HomeMy WebLinkAboutTouchPoint Agreement W/ City Article
I.
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VII.
VIII.
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TOUCHPOINT HEALTH PLAN, INC.
ADMINISTRATIVE AGREEMENT
WITH
CITY OF OSHKOSH ~
Table of Contents
Page
DEFINITIONS ................................................................................. 1
DUTIES OF TOUCHPOINT HEALTH PLAN ........................................... 2
DUTIES OF GROUP .......................................................................... 4
PAYMENT FOR COVERED SERVICES AND TOUCHPOINT
HEALTH PLAN ADMINISTRATIVE FEES ............................................. 4
CONFIDENTIALITY ......................................................................... 6
EXCLUSIVITY ................................................................................ 7
RESPONSIBILITY FOR TREATMENT OR SERVICE ................................ 7
TERM AND TERMINATION .............................................................. 8
MISCELLANEOUS ........................................................................... 9
Independent Contractor Status .............................................................. 9
Insurance ....................................................................................... 9
Indemnification ............................................................................... 9
Notice ......................................................................................... 10
Dispute Resolution .......................................................................... 10
Third-Party Beneficiaries ................................................................... 11
Advertising ................................................................................... 11
Books and Records .......................................................................... 11
Governing Law / Severability ............................................................. 12
Entire Agreement / Amendment .......................................................... 12
Assignment and Delegation ................................................................ 12
Force Majeure ............................................................................... 12
Waiver ........................................................................................ 12
Authority ...................................................................................... 12
Survival of Provisions ...................................................................... 12
TOUCHPOINT HEALTH PLAN
ADMINISTRATIVE AGREEMENT
WITH
CITY OF OSHKOSH
This Agreement is entered into this __ day of ,2003, and
effective as of the 1st day of January 2002 (the "Effective Da te") by and between City of
Oshkosh ("Group"), and Touchpoint Health Plan, Inc. ("Touchp0 int Health Plan") for its
preferred provider organization, Touchpoint Preferred.
WHEREAS, Touchpoint Health Plan is a managed care company operating a
preferred provider organization (" PPO") in the State of Wisconsin for the purpose of
delivering competitively priced health care services from local providers to Covered
Persons (as hereinafter defined); and
WHEREAS, Group sponsors a self-funded medical indenmity benefit plan (Plan)
desires to develop an agreement to establish a PPO option for its Covered Employees (as
defined in the plan) to access Touchpoint Preferred Participating Providers (as hereinafter
defined) within the identified Service Area (as hereinafter defined).
NOW, THEREFORE, in consideration of the promises and mutual covenants of the
parties to this Agreement and other good and valuable consideration, the sufficiency of
which is hereby acknowledged, it is mutually covenanted and agreed as follows:
ARTICLE I
DEFINITIONS
1.1 Covered Services means the health care service to which a Covered Person
(as defined in the Plan) and Group is obligated to pay pursuant to the Plan.
PPO Group Administrative Agreement - 08/01 Page 1
1.2 Covered Person means the Employee and his/her Family Members for
which Group provides coverage under Plan.
1.3 Participating Providers means the hospitals, physicians, and other health
care providers who are duly credentlaled by Touchpoint Health Plan, if applicable, and
who have entered into an agreement with Touchpoint Health Plan to provide Covered
Services to Covered Persons.
1.4 Participating Provider Agreement means the contract entered into between
a Participating Provider and Touchpoint Health Plan for the provision of Covered Services
to Covered Persons.
1.5 Plan means the self-funded medical indemnity benefit plan offered by Group
pursuant to which Covered Persons are entitled to receive Covered Services.
1.6 Service Area means the Wisconsin counties set forth in Schedule 1.7
attached hereto.
1.7 Employee means an individual whose position as an employee of the group,
creates eligibility for the individual and his/her Family Members, as specified in the Plan,
to be enrolled in the Plan.
1.8 Third Party Administrator means the company or organization that
administers the Group' s Plan.
1.9 Touchpoint Preferred means the PPO product offered by Touchpoint Health
Plan.
ARTICLE II
DUTIES OF TOUCItPOINT HEALTH PLAN
2.1 Participating Providers. Touchpoint Health Plan has entered into
Participating Provider Agreements with licensed providers. Participating Providers are
required to meet Touchpoint Health Plan credentialing criteria, as established from time to
time by Touchpoint Health Plan.
2.2 Participating Provider Agreements. Touchpoint Health Plan shall obtain
from Participating Providers agreement to accept the amounts specified in the Participating
Provider Agreement as payment in full for Covered Services rendered to Covered Persons
and to bill Covered Persons only for: (1) applicable deductibles, co-payments, and/or
coinsurance, or (2) services not covered under the Plan.
PPO Group Adminisa'ative Agreement - 08/0I Page 2
2.3 Insurance. Participating Provider Agreemems require that Participating
Providers maintain professional liability insurance with minimum limits of $1,000,000 per
occurrence and $3,000,000 aggregate, or limits that meet or exceed the requirements of
applicable Wisconsin statutes, as the case may be. Participating Providers shall also give
Touchpoint Health Plan prior notice of the cancellation or non-renewal of such insurance.
2.4 Participating Provider Agreements on File. Touchpoint Health Plan shall
keep current Participating Provider Agreements on file.
2.5 Provider Directories. Touchpoint Health Plan shall provide quarterly PPO
Directory updates to Group's Third Party Ad ministrator.
2.6 Claims Submission. Participating Provider Agreements require Participating
Providers to submit claims for Medically Necessary Covered Services to the address
identified on the Covered Person's identificati on card, unless otherwise instructed by
Touchpoint. Touchpoint Health Plan will request that Participating Providers make all
reasonable efforts to submit claims and any information necessary for Third Party
Administrator to process said claims no more than thirty (30) days from the date of service
or discharge of the Covered Person.
2.7 Medical Management. If Group selects Touchpoint Health Plan to perform
utilization management services in addition to PPO panel access and repricing of claims,
Touchpoint Health Plan shall establish and implement a utilization management program to
include the review and recommendation on prospective and retrospective bases of the
Medical Necessity of services provided to Covered Persons. Touchpoint Health Plan shall
provide a copy of the utilization management program description in effect at the time of
execution of this Agreement in the attached Schedule 2.7.
2.8 Disputed Claim. Group agrees to cooperate with the utilization management
program implemented by Touchpoint Health Plan with respect to Covered Persons. If
Group disputes payment of a claim for services from a Participating Provider on the basis
that the provision of the service was inconsistent with the utilization management program,
Group shall notify Touchpoint Health Plan immediately and the issue shall be resolved
pursuant to the procedures established by Touchpoint Health Plan for resolution of
utilization management program disputes. Notwithstanding such dispute resolution
procedures, the parties recognize that any utilization management activities performed by
Touchpoint Health Plan are only recommendations to Group. Group retains full authority
and responsibility with respect to the benefits payable for any claims and for deciding
disputed claims. In the event of a dispute regarding the Medical Necessity of a claim, the
parties reserve the right to refer the claim to an independent medical review organization
for determination of Medical Necessity, and the parties shall share in the cost of such
review as mutually agreed.
PPO Group Administrative Agreement - 08/01 Page 3
ARTICLE III
DUTIES OF GROUP
3.1 Plan. Touchpoint Health Plan shall have no responsibility for the design or
implementation of the Plan, such responsibility being solely the Group's. Touchpoint
Health Plan shall have no power to interpret ambiguities or conflicts that may exist in any
provision of the Plan, but shall abide by the decisions of the Group on all questions of
substance and procedure respecting the Plan. Group's Plan shall con tain financial
incentives with at least a ten percent (10%) differential in the coinsurance and deductible
levels between Participating and non-Participating Providers.
3.2 Identification Cards. Group shall arrange to issue standard identification
cards to Subscribers specifying information set forth on Schedule 3.2. Group will provide
Touchpoint Health Plan with a "ca mera ready" copy of the approved Touchpoint Preferred
Identification Card for internal communication purposes prior to the Effective Date.
3.3 Eligibility Verification. Group shall provide a telephone number for
eligibility verification. The number must be visible on the Identification Card.
Participating Providers will have the right to rely on this information to determine whether
or not an individual is eligible to receive health care services under the Plan.
3.4 Eligibility Reports. Group shall arrange to provide a monthly PPO
Eligibility/Reconciliation Report to Touchpoint Health Plan in the format specified by
Touchpoint Health Plan. See Schedule 3.4 attached for the current format specified by
Touchpoint Health Plan.
3.5 Compliance with Law. Group shall comply with all relevant federal, state
and local laws which are applicable to Group and to this Agreement.
3.6 Grievances. Group shall, in cooperation with Third Party Administrator and
Touchpoint Health Plan, establish and manage a system for the receipt and resolution of
Covered Persons' complaints and grievances.
ARTICLE IV
PAYMENT FOR COVERED SERVICES AND
TOUCHPOINT HEALTH PLAN ADMINISTRATIVE FEES
4.1. Process Payment for Claims. Group ensures that Third Party Administrator
shall process payment for claims and coordinate payment by Group of that portion of the
Touchpoint Health Plan Participating Provider reimbursement that: (a) exceeds the
copayment, deductible and coinsurance amounts specified in the Plan; and (b) is not
PPO Group Administrative Agreement - 08/01 Page 4
otherwise excluded or limited by the Plan. The parties acknowledge that Group is solely
responsible for the payment of claims.
4.2 Copayment, Deductible, and Coinsurance. Touchpoint Health Plan shall
require Participating Providers: (a) to accept payments made to Participating Providers
hereunder as full payment for Covered Services furnished to Covered Persons, except to
the extent of deductibles, coinsurance, and/or copayments; (b) not to bill Covered Persons
for any balance attributable to Covered Services other than deductibles, coinsurance, and
copayments; and (c) to seek payment for any such deductibles, coinsurance, and/or
copayments. Participating Providers may seek payment from Covered Persons for non-
Covered Services.
4.3 Payment by Covered Persons. A Participating Provider shall have the right
to bill Covered Persons for services rendered to Covered Persons which have been
excluded in Plan design reductions or which have been determined not to be Medically
Necessary under the applicable utilization management programs. Group and/or Third
Party Administrator shall provide Covered Persons with prior notification of such services
which are not covered under the Plan.
4.4 Claims Processing Guidelines. Group and Third Party Administrator agree
to process Participating Provider claims without applying usual and customary fee edits.
4.5 Timely Payment of Claims. Group, through its Third Party Administrator,
shall pay Participating Provider claims within thirty (30) days following receipt of
complete claims. Group agrees to remain responsible for payment to Participating
Providers, in accordance with the terms of this Agreement. Touchpoint Health Plan shall
not be responsible for payment for health care services rendered by Participating
Providers. Failure to pay a claim in the required time frame may result in the forfeiture of
the discount.
4.6 Coordination of Benefits and Subrogation. Group shall cause Third Party
Administrator to coordinate benefits with other group health plans in accordance with
applicable state law. Participating Providers have agreed to cooperate with Third Party
Administrator in the effective implementation of coordination of benefits and subrogation
programs.
4.7 Remittance Advice / Explanation of Benefits. Group shall cause Third Party
Administrator to provide a remittance to the Participating Provider that includes the
information set forth in Schedule 4.8 attached hereto. In addition, Third Party
Administrator shall provide a sample Explanation of Benefits to Touchpoint Health Plan for
internal communication purposes.
PPO Group Adminis~-ative Agreement - 08/01 Page 5
4.8 Administrative Fees. Group shall pay Touchpoint Health Plan an
administrative fee in accordance with the formula set forth on Schedule 4.9 attached
hereto. Such fee is in consideration for access to and maintenance of Touchpoint's
preferred provider panel. Third Party Administrator shall pay such administrative fee
within fifteen (15) business days of the end of the month, during the term of this
Agreement.
Group shall have the right to request a retroactive adjustment from Touchpoint
Health Plan for an overpayment of fees through the provision of credits in an amount equal
to the overpayment of such fees, provided, however, that any such request shall be made
by Group within three hundred sixty-five (365) days after the date of the overpayment.
4.9 Late Claims. Group shall not be responsible for payment of claims
submitted more than one hundred eighty (180) days after the date that services were
rendered to a Covered Person, or the discharge date, whichever is later.
ARTICLE V
CONFIDENTIALITY
5.1 Proprietary or Confidential Information. Except as otherwise required by
law, or with the prior written consent of the other party, Group or Touchpoint Health Plan
shall not, during the term of this Agreement or thereafter, disclose to any third party any
proprietary or confidential information concerning the other party. For purposes of this
Agreement, "proprietary and confidentia 1 information" will include, without limitation, all
internal business practices and business records, including, but not limited to, information
concerning products, pricing, contracts, claims, accounting, utilization management, data
processing procedures, or other policies and procedures, or business methods, in any form
whatsoever, not including information otherwise available to the public.
5.2 Medical Records. Touchpoint Health Plan and Group agree that medical
records of Covered Persons are confidential and both parties shall comply with all
applicable federal and state laws regarding such records.
PPO Group Adminis~ative Agreement - 08/01 Page 6
5.3 HIPAA Compliance. The parties agree to negotiate and amend this
Agreement to incorporate the requirements of 45 C.F.R. §164.504(e)(1) ("Business
Associate Contracts") of the final "Standards for Privacy of Individually Identifiable
Health Information" and the requirements of 45 C.F.R. §162 (" Standards for Electronic
Transactions") and other applicable provisions in the yet to be published final security and
electronic signature standards.
5.4 Trading Partner Agreement. Notwithstanding anything to the contrary
herein, the parties to this Agreement hereby agree that nothing herein is intended nor
should be interpreted as (1) changing the definition, Data Condition, or use of a Data
Element or Segment in a standard, (2) adding any Data Elements or Segments to the
maximum defined Data Set, (3) using any code or Data Elements that are either marked
"not used" in the standard's implementation specification or are not in the standard's
implementation specification(s), or (4) changing the meaning or intent of the standard's
implementation specification(s), as such capitalized terms are defined in the Standards for
Electronic Transactions, 45 C.F.R. {}162.103.
5.5 Business Associate Compliance. The parties hereby agree that any and all
actions taken or authorized by a Business Associate regarding a Transaction shall comply
with all applicable law pertaining to Standards for Electronic Transactions, including those
set forth in the Health Insurance Portability and Accountability Act of 1996 and all rules
promulgated thereunder ("HI PAA"), and that the Business Associate shall require any
agent or subcontractor to comply with such applicable law. Upon the request of a Covered
Entity, the Business Associate will provide appropriate documentation of its agent's or
contractor's compliance with such requirement s. All capitalized terms used in this
subsection are as defined in HIPAA.
ARTICLE VI
EXCLUSIVITY
6.1 No "Dual Cho ice". Group shall not offer to its Covered Persons a choice
between Touchpoim Preferred and any other PPO for the same Plan year within the same
Service Area.
6.2 Touchpoint Health Plan Contracting. Touchpoint Health Plan shall not be
precluded from entering into agreements similar to this Agreement with any other persons.
PPO Group Administrative Agreement - 08/01 Page 7
ARTICLE VII
RESPONSIBILITY FOR TREATMENT OR SERVICE
7.1 Participating Providers solely shall be responsible to Covered Persons for
treatment or service. Nothing in this Agreement is intended to create nor shall it be
construed to create any rights for Touchpoint Health Plan or Group to intervehe in any
manner by which any Participating Provider renders treatment or service to Covered
Persons. No provision contained in this Agreement shall be construed to make Touchpoint
Health Plan responsible for or in any way liable by reason of the provision of clinical
services by any Participating Provider.
ARTICLE VIII
TERM AND TERMINATION
8.1 Tern~. The term ("Term") o f this Agreement shall be for one (1) year
commencing on the Effective Date and automatically renewing for additional one (1)-year
terms unless terminated by law or pursuant to Section 8.2.
8.2 Termination. This Agreement shall terminate in any of the following
circumstances:
(a)
(c)
(d)
at the option of a party, exercisable by written notice to the other, if the
other party becomes insolvent, becomes the subject of voluntary or
involuntary bankruptcy or other like proceeding which is not dismissed
within thirty (30) days of commencement thereof, makes an assignment for
the benefit of creditors or consents to the appointment of a trustee, a receiver
or other fiduciary for all or a substantial part of its assets;
at the option of a party, exercisable by written notice to the other, if the
other party is in material breach or default of any of its obligations under this
Agreement and has not remedied such breach or default within thirty (30)
days following written notice of such breach or default;
at the option of a party, exercisable by written notice to the other, if any
applicable statute, regulation, interpretation thereof or enfomement activity
related thereto indicate, in the opinion of the party's legal counsel, that any
part of this Agreement may violate any such statute or regulation, provided
that the parties are unable to agree within thirty (30) days upon modifications
to this Agreement as may be necessary to comply with said statute or
regulation;
at any time upon the written agreement of the parties; or
PPO Group Adminisn:ative Agreement - 08/01 Page 8
(e)
at the option of a party, exercisable by at least ninety (90) days prior written
notice to the other.
8.3 Rights and Obligations Upon Termination. Upon termination of this
Agreement for any reason, the parties agree that:
(a)
Each party shall remain entitled to full performance of the duties and
responsibilities of the other party arising prior to the effective date of
termination;
(b)
Each party shall promptly return to the other all proprietary and confidential
information concerning the other party, both originals and copies thereof, as
described in Section 5.1; and
(c)
No termination of this Agreement shall affect any payment due to
Touchpoint Health Plan Participating Providers for any Covered Person
undergoing treatment at the time of termination.
ARTICLE IX
MISCELLANEOUS
9.1 Independent Contractor Status. Group, Touchpoint Health Plan, Third Party
Administrator, and Participating Providers are each independent entities. Nothing in this
Agreement shall be construed or deemed to create a relationship of employer and employee
or principal and agent, or any relationship other than that of independent entities
contracting with each other solely for the purpose of carrying out the terms and conditions
of this Agreement. In addition, Group acknowledges that Touchpoint Health Plan and each
of the Participating Providers are independent from each other and nothing in this
Agreement shall be construed or deemed to create a relationship other than that of
independent entities contracting with each other by way of Participating Provider
Agreements.
9.2 Insurance. Group and Touchpoint Health Plan shall ~each maintain policies
of liability insurance during the term of this Agreement with adequate coverage insuring
and protecting each party's respective interests against liability relating to the services
contemplated by the parties' relationship. Upon request, both parties agree to provide
certification from such party's insurer of the insurance coverage in compliance with the
provisions of this Agreement.
9.3 Indemnification.
(a)
Group shall hold harmless and indemnify Touchpoint Health Plan from any
claims, losses, damages, liabilities, costs, expenses, or obligations arising
PPO Group Adminisecative Agreement - 08/01 Page 9
out of or resulting from the negligence or willful misconduct of Group
and/or Third Party Administrator, or their agents, its officers and employees
in the performance of their respective obligations under this Agreement or
otherwise.
(b)
Touchpoint Health Plan shall hold harmless and indemnify Group from any
claims, losses, damages, liabilities, costs, expenses, or obligations arising
out of or resulting from the negligence or willful misconduct of Touchpoint
Health Plan, its officers and employees in the performance of Touchpoint
Health Plan's obligations under this Agreement.
9.4 Notice. Any and all notice required to be given pursuant to the terms of this
Agreement must be given by United States mail, postage prepaid, return receipt requested,
and forwarded to the following address or such other address as either party may in writing
submit:
For Touchpoint
Health Plan:
For Group:
Touchpoint Health Plan, Inc.
Attn: President
5 Innovation Court
Appleton, WI 54914
City of Oshkosh
Attn: John Fitzpatrick
215 Church Street
Oshkosh, WI 54902
9.5
(a)
(b)
Dispute Resolution.
Good Faith Negotiation. In the event of any dispute, claim, question or
disagreement arising out of or relating to this Agreement or the breach
thereof, the parties hereto shall use their best efforts to settle such dispute,
claim, question or disagreemem. To this end, they shall consult and
negotiate with each other, in good faith, and, recognizing their mutual
imerests, attempt to reach a just and equitable solution satisfactory to both
parties.
Mediation / Arbitration. In the event such efforts do not resolve the dispute
within sixty (60) days from the date the parties first met or conferenced to
discuss it (or sooner if agreed between the parties), then the parties shall
submit the disputed matter to informal mediation before a mediator mutually
agreed upon. If the parties are unable to agree upon a mediator, or if after
mediation, the parties are still unable to settle the dispute, then, upon notice
PPO Group Administrative Agreement - 08101 Page I0
by either party to the other, the dispute shall be finally settled by arbitration
administered by the AHLA Alternative Dispute Resolution Service or a
comparable nationally recognized dispute resolution body that is mutually
agreed to by the parties, unless otherwise set forth herein, and judgment on
the award rendered by the arbitrator(s) may be entered in any court having
jtirisdiction thereof. The parties may bypass mediation and proceed with
arbitration if they mutually agree to do so. All fees and expenses of the
mediation/arbitration shall be borne by the parties equally. However, each
party shall bear the expense of its own counsel, experts, witnesses, and
preparation and presentation of proofs.
(c)
Procedures. The mediation/arbitration hearing shall be held in Appleton,
Wisconsin, unless otherwise agreed by the parties. With respect to the
method of appointment, all mediator(s)/arbitrator(s) shall be mutually agreed
upon by the parties and selected from a panel of persons having experience
with and knowledge of the health insurance industry and managed care
issues, unless such qualification is waived in writing by both parties. The
arbitration shall be heard by a panel of three (3) arbitrators, unless the
parties agree otherwise. In rendering the award, the arbitrator(s) shall
determine the rights and obligations of the parties according to the
substantive and procedural laws of the State of Wisconsin. The arbitrator(s)
shall have no authority to award punitive or exemplary damages, or to ignore
the terms of this Agreement. Neither party nor the mediator(s)/arbitrator(s)
may disclose the existence, content or results of any mediation/arbitration
hereunder without the prior written consent of both parties, except to the
extent such disclosure is necessary to enforce an award or judgment. This
provision shall not be construed to prohibit Touchpoint Health Plan or Group
from impleading the other into a legal or administrative action commenced
by a Covered Person or another person on his or her behalf.
9.6 Third-Party Beneficiaries. It is not the intention of Touchpoint Health Plan
or Group that anything in this Agreement be construed or deemed to create any rights or
remedies in any third party, including, but not limited to, a Covered Person, Third Party
Administrator, or Participating Provider, nor is it the intention that such individuals occupy
the position of intended third-party beneficiaries of the obligations assumed by either party
to this Agreement, and no such individual shall have the right to enforce any such
obligation.
9.7 Advertising. Neither party shall cause or permit the use of the name or logo
of the other party in any advertisement or publicity material without the prior written
consent of the other party. Group agrees that Touchpoint Health Plan may indicate in its
promotional material the fact that it is affiliated with Group.
PPO Group Administrative Agreement - 08/01 Page 11
9.8 Books and Records. Each party agrees to retain a copy of this Agreement
for the duration of this Agreement and for not less than six (6) years after the termination
of this Agreement. Each party retains the right to inspect, review and audit in accordance
with applicable law and during normal business hours and after reasonable notice, any and
all books and records maintained by the other with respect to the provision of Covered
Services and the submission and payment of claims and fees hereunder.
9.9 Governing Law / Severability. This Agreement shall be governed by and
construed in accordance with the laws of the State of Wisconsin and further construed
without regard to any presumption or rule requiring construction against the party causing
the agreement to be drafted. The invalidity or unenforceability of any provision of this
Agreement shall not affect the validity and enforceability of the remainder of this
Agreement.
9.10 Entire Agreement / Amendment. This Agreement with its Schedules and
Addenda constitutes the entire agreement of the parties with respect to the subject matter of
this Agreement. Group agrees that Touchpoint Health Plan may, upon ten (10) days'
written notice to Group, amend the terms of this Agreement so long as such amendment is
made solely for the purpose of complying with regulations and guidelines established by
regulatory bodies governing Touchpoint Health Plan. Any other amendments to this
Agreement shall be in writing and signed by duly authorized officers of the parties.
9. i 1 Assignment and Delegation. This Agreement may not be assigned or
transferred, nor may duties hereunder be delegated, in any manner without the prior
written consent of the other party, which consent shall not be unreasonably withheld. All
terms, provisions and obligations of this Agreement shall be binding upon and shall inure
to the benefit of the parties hereto and their respective heirs, representatives, and permitted
successors and assigns.
9.12 Force Majeure. In the event either party is unable to perform its duties and
responsibilities under this Agreement due to causes beyond its control, such party shall be
excused from its obligation to perform while and to the extent so prevented, provided that
such party provided to the other party prompt written notice of the cause(s) for such failure
or delay. Such party shall resume and complete performance of its duties and
responsibilities after removal or cessation of the cause(s) of said failure to perform.
9.13 Waiver. The waiver by either party of a breach or violation of any provision
of this Agreement shall not operate as or be construed to be a waiver of any subsequent
right to exercise that or any other such term or condition. No term or condition of this
Agreement may be waived except in writing by the party charged with the waiver.
9.14 Authori _ry. The persons signing this Agreement warrant that they have full
authority to do so and their signatures shall bind the parties for which they sign.
PPO Group Administrative Agreement - 08/01 Page 12
9.15 Survival of Provisions. In addition to specific terms herein regarding
survival of certain provisions, Articles V (Confidentiality), Article IX, Sections 9.3
(Indemnification), 9.5 (Dispute Resolution), and 9.7 (Advertising), and this Section 9.15
shall survive the termination or expiration of this Agreement.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement
intending to be bound from the Effective Date set forth above.
CITY OF OSHKOSH
Name:~ Richard A. Wollanqk
Title: City Manager
10/03/03
Date
TOUCHPOINT HEALTH PLAN, INC.
~ l~ulkgrson, President
Date
Name: Pamela R. Ubr~q'/'
Title: City Clerk
10/03/03
Date
Narr~:~-~y~X~ A. LoreX~ ~v
Title: Asst. City Attorney
10/03/03
Date
I hereby certify that the necessary provisions
have been made to pay the liability which will
accrue under this contract.
................
City'Comptrol ler ff
PPO Group Admin/strative Agreement - 08/01 Page 13
SCI-IEDULE 1.7
SERVICE AREA
The Service Area shall be the Wisconsin counties of Brown, Calumet, Door, Fond du Lac,
Green Lake, Kewaunee, Manitowoc, Marquette, Marinette, Oconto, Outagamie, Portage,
Shawano, Waupaca, Waushara, and Winnebago.
PPO Group Administrative Agreement - 08/01
SCHEDULE 2.7
UTILIZATION MANAGEMENT PROGRAM DESCRIPTION
PPO will not be performing Utilization Management services for this group.
PPO Group Administrative Agreement - 08/01
SCHEDULE 3.2
TOUCHPO1NT PREFERRED
IDENTIFICATION CARD SPECIFICATIONS
To assure easy recognition of Covered Persons to providers, as well as making information
to utilize the Plan identifiable, the following identification card requirements must be
adhered to:
The Touchpoint Preferred logo must be present on the identification card.
Copayment amounts must appear on the identification card.
The appropriate Claims Submission address(es) (in-plan, out-of-plan) must
be present on card. If claims are to be sent directly to Touchpoint Preferred
for repricing, the following address should be identified on the identification
card:
Touchpoint Preferred
P.O. Box 1871
Appleton, WI 54912-1871
The Third Party Administrator's telephone number shall be on t he
identification card informing Covered Persons and providers where to call
for eligibility and/or benefit guidelines.
If Touchpoint Preferred is performing provider verification, the following
toll-free number shall be displayed on the identification card:
1-877-236-5255.
PPO Group Administrative Agreement - 08/01
SCHEDULE 3.4
ELIGIBILITY/RECONCILIATION REPORT
In order for Touchpoint Health Plan to reconcile Covered Personship, the following
information is required from the Group or the Third Party Administrator on a monthly
basis.
Electronic "flat" files containing certain Covered Person identification data (Covered
Person Data") and Covered Person eligibility effective dates. The Third Party
Administrator shall report Covered Person Data to Touchpoint Health Plan no later than
ninety (90) calendar days following the eligibility effective date of such Covered Person
Data.
For the purposes of this Schedule 3.4, "Co vered Person Data" shall mean:
Covered Person's name
Covered Person's Social Security number
Covered Person's date of birth
Covered Person's gender
Covered Person's addr ess
Total # of Covered Persons.
Monthly Access Fee: Based on above information.
Covered Person Demographic information* should include the following:
Covered Person Social Security Number
Covered Person Name (Last, First)
Covered Person Address (City, State, Zip)
Covered Person Date of Birth
Covered Person Gender Relationship (M, F)
Covered Person Effective Date
Covered Person Term Date
*(Note: Covered Person Demographic information is required to facilitate claims
repricing. Inaccurate Covered Person information will result in claims being returned to
the provider of services for further clarification.)
PPO Group Administrative Agreement - 08/01
SCHEDULE 4.8
REMITTANCE ADVICE INFORMATION
1. Patient's name
2. Insured's name
3. Insured's Social Security Number
4. Employer Name
5. Employer Contract Number
6. Name of Provider
7. Date of Service
8. Total Charges
9. Excluded Amount
10. Amount of Copay
11. Amount Applied to the Deductible
12. Total Allowance
13. An indication that it is a Touchpoint Preferred PPO Claim.
In addition, Third Party Administrator will provide Touchpoint Health Plan with a sample
Explanation of Benefits for internal communication purposes.
PPO Group Administrative Agreement - 08/01
SCHEDULE 4.9
CALCULATION OF ADMINISTRATIVE FEE
Group shall pay Touchpoint Health Plan a fee equal to Two dollars and Seventy-Five cents
($2.75) perEmployee, per month.
PPO Group Administrative Agreement - 08/01