HomeMy WebLinkAboutAurora Health Care 2004
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SERVICE AGREEMENT
THIS AGREEMENT ("Agreement") is made and effective this 1st of January, 2004 by
and between The CITY OF OSHKOSH and AURORA HEALTH CARE, INC., a Wisconsin
corporation ("AHC").
WITNESSETH:
WHEREAS, AHC has established a network of health care providers through affiliation
agreements or other contractual relationships with various providers; and
WHEREAS, AHC arranges for the provision of health care services by such network
providers to certain individuals;
WHEREAS, Employer is desirous of having AHC arrange for the provision of health
care servic~s by the network providers to Employer's employees and other persons who are
covered by Employer's medical plan; and
WHEREAS, Employer understands that there are health care providers participating in
the network who are not owned or employed by AHC or an affiliate of AHC, and understands
that these non-AHC providers have been selected to ensure that AHC can offer all necessary and
appropriate health care services to individuals covered by Employer's medical plan; further,
Employer desires to provide individuals covered by Employer's medical plan with access to
these non-AHC providers, and desires that these non-AHC providers be included in the AHC
network of providers. .
NOW, THEREFORE, AHC and Employer hereby agree as follows:
1.
Definitions. The terms used in this Agreement are defined as follows:
1.1.
Actual Charges: shall mean the amount of each Provider's normal billed charges
as determined by the Provider for Covered Services.
1.2.
AHC Network: shall mean the network of Providers, including AHC Providers,
that AHC has established to provide Covered Services to Participants.
1.3.
AHC Providers: shall mean physicians, hospitals and any other provider of health
care or other allied or related products or services who are owned or employed by
AHC or an affiliate of AHC.
1.4.
Participants: shall mean all employees of Employer, retirees of Employer, their
respective dependents, and any other persons who are entitled to have their health
care for Covered Services paid for under the Plan, subject to the terms and
conditions of the Plan (including those persons eligible under COBRA) within the
Service Area.
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1.5.
1.6.
1.7.
1.8.
1.9.
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Coordination of Benefits: shall mean the process by which payment for health
care benefits rendered to a Participant is sought from another insurer, service plan,
or government or other third party payor which has primary responsibility for the
cost of that Participant's health care.
Covered Services: shall mean the health care services that are medically
necessary and are reimbursable under the terms of the Plan.
Employer: shall mean the City of Oshkosh and its subsidiaries and affiliates.
Medically Necessary: means those health care services or supplies which, under
the provisions of this Agreement, are determined to be: a) appropriate and
necessary for the symptoms, diagnosis or treatment of the medical condition; b)
provided for the diagnosis or direct care and treatment of medical condition; c)
within standards of appropriate medical practice within the organized medical
community; d) not primarily for the convenience of the Participant or the
Provider; and e) an appropriate and efficient level of service or supplies which
can be safely provided to the Participant. The decision as to whether a service or
supply is Medically Necessary for the purposes of payment rests with AHC or
Payor, as the case may be.
Payor: shall mean Employer's third party administrator which has an obligation
to process payments, on Employer's behalf, for Covered Services provided to a
Participant pursuant to the Plan, and to oversee all required elements of Plan
administration.
1.10. Plan: shall mean the health care benefit plan established by Employer for
Participants covered by and in compliance with this Agreement.
1.11. Provider: shall mean physicians, hospitals and any other provider of health care
or other allied or related products or services who have entered into an agreement
with AHC to provide Covered Services to Participants or are an AHC Provider.
1.12.
Service Area: represents the following counties within the State of Wisconsin:
Brown, Dodge, Door, Fond du Lac, Kenosha, Kewaunee, Manitowoc, Marinette,
Milwaukee, Oconto, Outagamie, Ozaukee, Racine, Sheboygan, Walworth,
Washington, Waukesha, and Winnebago.
2.
AHC Responsibilities.
2.1.
001.1404121.
Provider Responsibilities. AHC agrees that each Provider shall agree to:
2.1.1. Provide Covered Services to Participants at the payment rates set forth in
Exhibit A attached hereto and incorporated herein;
2.1.2. Accept the rates or charges set forth in Exhibit A applicable to such
Provider as payment in full for the Covered Services provided to
Participants, and not bill the Participants for any amount, except for: (i)
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Yf~"""""'--"
2.2.
001.1404121.
copayments and deductibles permitted under the Plan, such copayments
and deductibles constituting a part of and not in addition to the rates and
Actual Charges set forth in Exhibit A (it being understood that any
applicablecopayments and deductibles shall be billed and collected by the
Provider); (ii) charges for the provision of services which are not Covered
Services; (iii) charges which may exceed benefit limits for a particular
service under the Plan; (iv) charges for services which are determined by
Employer or its designee not to be medically necessary or otherwise are
not preauthorized and as a result are not payable under the Plan; and (v)
charges for the provision of Covered Services which are not paid by Payor
within thirty (30) days of Payor's receipt of Provider's invoice for
Covered Services rendered;
2.1.3. Provide and maintain, at its expense, the facilities, equipment, and
professional and other personnel necessary to provide Covered Services to
Participants in the same manner and with the same quality as it provides
health care services to other patients;
2.1.4. Provide the organizational and administrative capabilities to carry out its
duties hereunder;
2.1.5. Maintain all governmental approvals, licenses, certifications and consents,
as applicable, necessary to provide Covered Services, operate in
compliance with all State and Federal laws, and maintain certification
under Title XVIII and XIX of the U.S. Social Security Act;
2.1.6. Cooperate with Employer in responding promptly to any complaint of a
Participant concerning the provision of Covered Services;
2.1. 7. Obtain and maintain professional liability insurance in amounts sufficient
to qualify for participation in the State of Wisconsin Patients
Compensation Fund, and maintain comprehensive general liability
insurance in a reasonable amount as determined by each Provider
consistent with industry standards; and
2.1.8.
Maintain credentials pursuant to this Agreement and the AHC
credentialing policy at all times. AHC shall perform credentialing of all
Providers pursuant to NCQA or similar industry standards, at no expense
or cost to Employer. AHC shall provide Payor an EDI file of all
credentialed Providers on a monthly basis.
Administrative Responsibilities. AHC shall provide the following administrative
services:
2.2.1. Care Management. AHC shall provide care management services to
Participants in accordance with AHC's Care Management Program set
forth in Exhibit B attached hereto and incorporated herein, as such
Program may be revised by AHC from time to time.
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"'-'--------,
2.2.2.
Provider Directori~s. AHC shall provide Employer with an adequate
supply of Provider directories (in a format agreed to prior to the effective
date) and Employer shall pay to AHC the actual cost paid by AHC for the
printing of such directories within seven (7) days of receipt of an invoice
therefor from AHC.
2.2.3. AHC Services. In addition to providing Employer with access to the
AHC Network, AHC shall also provide Employer with access to related
products and services. Employer shall remit a monthly fee for such
related products and services as set forth in Exhibit C attached hereto and
incorporated herein.
2.2.4.
Utilization Reports. Upon Payor's submission of claims data to AHC in
a format acceptable to AHC, AHC shall provide Employer with quarterly
utilization reports. In no event shall such claims data submitted by Payor
include any data regarding the Actual Charges of Providers other than
AHC Providers.
2.2.5. Operational Meetings. AHC agrees to meet quarterly with Employer
and/or Payor to ensure the operational effectiveness of this Agreement in
all areas.
2.2.6. Designate a Contact Person. AHC shall designate one person as the
contact person for purposes of this Agreement. Such contact person shall
be the representative of AHC with whom Employer shall consult in all
matters relating to the terms of this Agreement.
2.2.7.
Communication Materials. AHC shall assist with the design and
creation of Participant educational materials relating specifically to the
implementation of the Plan and annual enrollment campaigns. AHC may
also prepare and distribute to Providers summary materials setting forth a
list of payors/employers with then-current contracts with AHC, the rates
agreed to by each payor/employer, the duration of the contracts with AHC,
and such other information deemed appropriate by AHC.
2.2.8. AHC Network Composition and Utilization of AHC Providers. AHC
shall use all commercially reasonable efforts to provide a comprehensive
network of Providers to Employer such that there are no material service
types excluded from the AHC Network. AHC may in its sole discretion
contract with non-AHC Providers to fulfill specific needs. The parties
agree that all Providers shall be available to render Covered Services to
Participants, and in no event shall Employer "carve-out" or exclude
services from its Plan, including but not limited to behavioral health,
DME, home health, lab, transplants, chiropractic, physical therapy or
phannacy. Specifically with respect to pharmaceutical services, Employer
shall utilize a Pharmacy Benefits Manager ("PBM") that includes Aurora
Phannacies as participating providers. In addition, in the event Employer
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001.1404121.
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001.1404121.
purchases "Stop Loss" coverage, AHC Providers shall be considered
transplant providers for any services covered under such Stop Loss policy
and will match any existing transplant network rates as communicated to
AHC as outlined in Exhibit H.
3.
Employer Responsibilities.
3.1.
3.2.
Plan Requirements. Employer shall have two options in offering the AHC
Network to Participants:
3.1.1. Option One: Employer may offer the AHC Network as an exclusive Plan
offering in the AHC service area as an exclusive provider organization
("EPO") or point-of-service ("POS") product. If offered as an EPO
product, Employer shall not provide coverage for services provided
outside of the AHC Network. If offered as a POS product, Employer shall
provide financial incentives to encourage AHC utilization, including
deductibles and at least a thirty percent (30%) differential in coinsurance,
an out of pocket maximum of at least $3,500 single and $7,000 family, as
well as a 50% more favorable employee contribution. .
3.1.2. Option Two: Employer may offer the AHC Network as an EPO or POS
product (including the above requirements) alongside a broad PPO
network product which must include all AHC Providers. Employer shall
provide financial incentives of at least thirty percent (30%) differential in
employee contributionlbenefit design between the AHC EPO or POS
products and the broad PPO product, in favor of the AHC EPO or POS
products.
3.1.3. The option selected by Employer shall be set forth in Exhibit D attached
hereto and incorporated herein. Exhibit D includes a description of the
specifications of Employer's Plan.
Notwithstanding the foregoing, the parties expressly acknowledge and agree that
the only PPO plan that may be offered with Option Two above is Touchpoint
Preferred. In addition, the parties express acknowledge that the Plans approved
by the Employers Joint Healthcare Committee are acceptable to AHC, however
do not meet the benefit design and employee contribution differentials as outlined
in 3.1.2 above. AHC has expressly waived this Section for 2004, however in the
event Employer does not comply with this Section regarding benefit plan design
and employee contribution, AHC in its sole discretion may terminate this
Agreement with ninety days notice at the end of the third calendar year.
Required Inclusion of Aurora Care Management Activities and Other AHC
Services. Employer agrees that it shall utilize all of the AHC Care Management
programs as described in Exhibit B (including but not limited to care
management, EAP, teleservices and occupational medicine) and agrees not to
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3.3.
3.4.
3.5.
3.6.
3.7.
001.1404121.
//
contract with or otherwise utilize any similar non-AHC programs. The
specifications and fees related to such Care Management programs are set forth
on Exhibitc.
Participant Eligibility. Employer shall ensure that AHC shall be provided with
accurate Participant eligibility information on a monthly basis in a format as
specified in Exhibit E attached hereto and incorporated herein. Payor shall
respond directly to Providers with respect to Participant eligibility inquiries.
Plan Information. Employer shall provide AHC with a copy of Employer's
Planes) to assist AHC in performing any included care management activities.
Employer shall coordinate with AHC's Medical Management team to ensure that
the schedule of benefits set forth in the Planes) is consistent with AHC's care
management objectives as set forth in Exhibit B.
Payor shall be solely responsible for administering the Plan, including but not
limited to identifying participating Providers for Participants and. other
participating Providers pursuant to the EDI files transmitted to Payor as set forth
in Section 2.1.8 above. .
Claims Information. Employer shall ensure that Payor shall comply with the
AHC data' specifications as outlined in Exhibit F attached hereto and
incorporated herein, and shall provide claims and other data to AHC on a monthly
basis; provided, however, that in no event shall Employer or Payor submit
information to AHC regarding the Actual Charges of non-AHC Providers. The
parties agree that they will review all data and medical cost history annually,
employing sound actuarial assumptions, to compare the Plan's experience and
determine performance of the Planes). Payor shall work with Providers directly to
resolve any claims related inquiries.
Identification Cards. Employer or Payor shall furnish an identification card to all
eligible Participants, and such card is to be presented upon each instance of
Covered Services being rendered to Participants by Providers. Employer shall
ensure that Payor shall comply with the AHC identification card specifications
which require the AHC logo to be prominently displayed on the front of the card.
No other logos shall appear on the front of the card other than Employer's logo.
See Exhibit G attached hereto and incorporated herein for a sample card. Copies
of the form of identification cards must be provided to AHC prior to effective date
of this Agreement. If EmployerlPayor is unable to comply with the standards set
forth above, AHC shall provide the identification cards to Employer at
Employer's sole expense.
Designate a Contact Person. Employer shall designate one person as the contact
person for purposes of this Agreement. Such contact person shall be the
representative of Employer with whom AHC shall consult in all matters relating
to the terms of this Agreement.
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3.8.
3.9.
Identification of Providers. Employer or Payor shall distribute Provider
directories and education materials prepared by AHC or Employer to all
Participants, at Employer's sole expense.
Payor shall be solely responsible for administering the Plan, including but not
limited to identifying participating Providers for Participants and other
participating Providers pursuant to the EDI files transmitted to Payor as set forth
in Section 2.1.8 above.
AHC Network Composition. In no event shall Employer supplement or add
health care providers to the Planes) utilizing the AHC Network by directly or
indirectly contracting, renting or otherwise including any provider who is not a
"Provider" hereunder, without the express prior written consent of AHC. The
foregoing shall not preclude Employer from obtaining Covered Services on a
case-by-case basis from providers who are not "Providers" hereunder in the event'
such Covered Services are not available from a Provider.
4.
Payment for Covered Services.
4.1.
4.2.
4.3.
001.1404121.
Invoices. Each Provider shall submit invoices based on Actual Charges to Payor
for payment for Covered Services rendered to Participants.
Payment by Payor. Employer shall ensure that Payor pays each Provider directly
at the rates set forth in Exhibit A within thirty (30) days of receipt by Payor of
Provider's invoice for Covered Services rendered pursuant to this Agreement.
Overpayments. In the event of an overpayment to a Provider, Payor shall recoup
the amount of the overpayment within sixty (60) days of receipt by Provider of
the following information: Participant's name and identification number, service
provided, date service provided, invoice number upon which erroneous charge
appears, specification and documentation of the error, and the erroneous amount.
Employer agrees that recoupment or any other adjustment of an overpayment
from Payor must be requested by Payor within one (1) year of the date of service
with respect to outpatient services and within one (1) year of the date of discharge
with respect to inpatient services
4.4.
Coordination of Benefits. In the event the Participant has another insurance
policy protecting the Participant against the cost of Covered Services provided
under the Plan, and such insurance policy and the Plan provide for the
Coordination of Benefits, the order of payment shall be determined as follows:
4.4.1. In the event Employer is the primary payor for Covered Services, Provider
shall be reimbursed by Payor as provided in this Agreement without
regard to any payments made by any other payor.
4.4.2. In the event Employer is the secondary payor for Covered Services, Payor
shall pay to Provider only those amounts which, when added to amounts
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4.5.
4.6.
received by Provider from other payors, is equal to the reimbursement
payable pursuant to Exhibit A.
Acknowledgment. Employer acknowledges that AHC is not a payor, an insurer
or guarantor of payment, nor a provider of Covered Services.
Claims Audits. AHC shall provide access to AHC Providers' records in order for
Employer to audit high cost claims (i.e., claims over $30,000), provided that any
such audits shall be conducted in accordance with the AHC audit policy. AHC
shall provide a claims liaison to answer minor questions from Employer or Payor
regarding claims; however, in the event such questions, in the sole discretion of
AHC, become material, Employer and/or Payor will be required to follow the
AHC audit policy. In the event Payor denies claims for lack of information,
Provider shall collect any monies owed from the responsible party.
5.
Term and Termination.
Term. The term of this Agreement shall be for a period of three (3) years commenèing as
of January 1, 2004 and shall automatically renew for additional one (1) year terms
thereafter, unless terminated earlier as provided herein.
5.1.
5.2.
5.3.
001.1404121.
Termination. This Agreement may be terminated in any of the following events:
5.2.1. Either party may terminate this Agreement, with or without cause, upon
written notice to the other party not less than ninety (90) days prior to the
end of the then-current term of this Agreement.
5.2.2. In the event either party provides written notice at any time to the other
party of a material breach of a provision of this Agreement (which notice
shall specify the breach), and such breach is not cured to the reasonable
satisfaction of the non-breaching party within thirty (30) days after written
notice is given to the breaching party, then the non-breaching party shall
have the right to terminate this Agreement upon ten (10) days prior written
notice to the breaching party, which notice shall specify the failure to cure
the breach. If the breaching party, prior to expiration of the thirty (30) day
period, has either cured the breach to the reasonable satisfaction of the
non-breaching party or taken all reasonable steps necessary to effect a
cure, this Agreement shall remain in effect, and the non-breaching party
shall be limited to specific performance as its exclusive remedy.
Continuation of Obligations. Upon termination of this Agreement as provided
above:
5.3.1. AHC agrees that each Provider shall continue to provide such Covered
Services as are customarily provided to inpatients of such Provider to any
Participant who was admitted to such Provider prior to termination of this
Agreement, and who remains an inpatient after said termination. Payor
shall pay for all such inpatient services rendered to Participants by
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Providers subsequent to termination of this Agreement until the
Participant is discharged in accordance with the rates as set forth in
Exhibit A in effect on the date of termination;
5.3.2. Each Provider may continue to provide such Covered Services as are
customarily provided to outpatients of such Provider to any Participant
who was an outpatient of such Provider prior to termination of this
Agreement, and who continues to require outpatient care after said
termination. Payor shall pay for all such outpatient services rendered to
Participants by Providers subsequent to termination of this Agreement in
accordance with such Provider's Actual Charges; and
5.3.3. Employer agrees to notify its Participants of the effective date of
termination of this Agreement not less than thirty (30) days prior to such
effective date. A copy of said notice shall also be delivered to AHC and
each Provider not less than thirty (30) days prior to the effective date of
termination. Failure to provide such notification to AHC, Providers and
Participants shall cause Employer to be liable for all services provided by
Providers to Participants, at Provider's Actual Charges, between the
effective date of said termination and the period ending thirty (30) days
after the delivery of said notification to AHC, Providers and Participants.
6.
Precertification and Preauthorization.
AHC agrees that each Provider shall cooperate with the prenotification requirements of
Employer under the Plan applicable to Participants. Such requirements are set forth on
Exhibit D, and shall not be modified during the term hereof without the prior written
consent of AHc. Once the provisions of the Plan set forth on Exhibit D are met and a
Covered Service is provided, if payment is denied for alleged error or defect in meeting
the provisions of the Plan, or if a Participant fails to identify himself or herself as a
Participant by presenting an identification card, Provider may bill Participant for services
rendered. In the event payment is denied retroactively or payment is . withheld as
described herein, the terms of Section 4.2 shall apply.
7.
Confidentiality and Advertising.
7.1.
Patient Records. AHC and Employer shall comply (and shall require their
respective agents to comply) at all times with all applicable state and federal laws
and regulations concerning the confidentiality of patient records.
7.2.
Advertising. AHC and Employer agree that neither party shall advertise or
publicly disclose the existence of this Agreement or advertise using the name of
the other party as a contracting entity, except as permitted herein, without the
prior written approval of the other party.
7.3.
Confidentiality. Unless otherwise provided herein, in no event shall Employer
disclose any of the terms or conditions of this Agreement. The foregoing shall
9
001.1404121.
not prohibit Employer from disclosing terms of this Agreement to Payor for the
administration of this Agreement. .
8.
Relationship Between the Parties.
The relationship of the parties hereto is that of independent contractors. Nothing
contained herein is intended or shall be construed to create the relationship of
employer/employee or of a joint venture. Neither of the parties hereto, not any of their
respective employees, shall be construed to be the agent, employee or representative of
the other.
9.
Indemnification.
9.1.
By Employer. Employer agrees to defend, indemnify and hold AHC and each
Provider, and their respective officers, directors, employees and agents, harmless
from and against any cost, damage, expense or settlement costs arising from any
claim, suit or proceeding, whether proven or not, relating to the failure of
Employer or its agents, including but not limited to Payor, to fulfill any of its or
their obligations under this Agreement or the negligent or wrongful performance
of any such obligations.
9.2.
By AHC. AHCagrees to defend, indemnify and hold Employer, and its officers,
directors, employees, and agents, harmless from and against any cost, damage,
expense or settlement costs arising from any claim, suit or proceeding, whether
proven or not, relating to the failure of AHC or its agents to fulfill any of its or
their obligations under this Agreement or the negligent or wrongful performance
of any such obligations.
10.
Maintenance of Records.
AHC agrees that each Provider shall maintain records of the Covered Services provided
to Participants pursuant to this Agreement for a period of at least (5) years from the date
of the Covered Service. Employer shall obtain and provide to AHC and Providers, as
necessary, all patient consents and releases from Participants prior to Employer
requesting to review any such records. To the extent required by state or federal law,
AHC agrees that each Provider shall permit designated state and federal officers access to
all such records upon request. AHC and Employer agree, to the extent permitted by law,
to coordinate the exchange of all information necessary to the administration of this
Agreement. Provider shall be reimbursed by requesting party at Provider's usual charge.
Severability .
If any provision of this Agreement shall be held or declared to be invalid, illegal or
unenforceable under any law applicable thereto, such provision shall be deemed deleted
from this Agreement without impairing or prejudicing the validity, legality and
enforceability of the remaining provisions hereof.
11.
Notice.
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001.1404121.
'"
Any notice or approval required or permitted under this Agreement shall be given in
writing and shall be sent by courier or mail, postage prepaid, to the address specified
below or to any other address that may be designated by prior notice. Any notice or
approval sent by courier shall be deemed received one (1) day after the date of posting.
Any notice or approval sent by mail shall be deemed to have been received three (3) days
following deposit in the U.S. Mail:
To AHC at:
Aurora Health Care, Inc.
3000 W. Montana St.
Box 343910
Milwaukee, WI 53234-3910
Attn: Executive Vice President & Chief Financial Officer
To Employer at:
City of Oshkosh
215 Church Avenue
P. O. Box 1130
Oshkosh, VVI54903-1130
Attn:
City Manager
12.
Assignment; Amendment.
This Agreement may not be assigned by either party without the prior written consent of
the other party hereto. This Agreement may be amended only in a writing signed by the
parties hereto.
13.
Governing Law.
This Agreement and all exhibits hereto shall be governed by and construed in accordance
with the laws of the State of Wisconsin and applicable federal laws. The venue for any
dispute or proceeding hereunder shall be in the Wisconsin Circuit Court for Milwaukee
County or Winnebago County.
14.
Entire Agreement.
This Agreement sets forth the entire understanding between Employer and AHC with
respect to the matters covered herein. No prior agreement or understanding not
specifically mentioned herein shall have any effect upon this Agreement.
15.
Waiver.
The waiver or failure of any party to enforce any provision hereof shall not preclude or
waive the right of such party from later seeking enforcement of such provision or be
deemed a waiver of any subsequent breach of the same or any other provision.
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001.1404121.
16.
Construction of Headings.
The captions or headings of this Agreement are for convenience only and in no way
affect the construction or effect of any of the terms, covenants and conditions hereof.
IN WITNESS WHEREOF, the parties hereto have caused their duly authorized
representatives to execute this Agreement as of the date and year first above written.
EMPLOYER:
CITY OF OSHKOSH
AURORA HEALTH CARE, INC.
By:
k) ~() A. V~
ame: Warren P. Kraft
Thle: Acting City Manager
By:
~~ /}/Ylß~
Name: Donald J. NestöÍ
Title: Executive Vice President &
Chief Financial Officer
Date: ~ -3-('7
Date:
2/25/04
Date:
2/25/04
12
001.1404121.
EXHIBIT A
PAYMENT RA TES
Employer shall pay Providers as follows:
A.
Except as set forth in Section C below, in the event Employer offers the
AHC Network as an exclusive provider organization ("EPO") or point-of-
service ("POS") product, then Employer shall pay to each Provider an
amount equal to such Provider's Actual Charges less the discounts
outlined below:
Discounts:
30% - All AHC Providers
I
10% - Children's Hospital & Children's Medical Group
15% - All no~-AHC Providers (other than CMG/CHS)
[fJote; AHC is in the process of re-contracting the
AHC 'Network, and will use reasonable efforts to
obtain discounts which are anticipated to be in the
25% ~ 30% range.]
Except as set forth in Secti~m C below, in the event Employer offers the
AHC Network as an EPO or POS product alongside a broad PPO network
I .
product, then Employer sh(ÛI pay to each ProvIder for such Broad PPO
product at the rates set fortq in AHC's then-current Agreement with such
broad PPO network product.
I
B.
C.
I
In the event Employer offers transplant services as part of its Plan,
Employer shall pay AHC Broviders (specifically only St. Luke's Medical
Center) for transplant serv~ces at AHC's then-current Global Transplant
reimbursement rates (incluQing physician services) which AHC offers to
commercial payors pursuant to Section 2.2.8 .
Exhibit A
001.1404121.
Exhibit A
001.1404121.
EXHIBIT B
AURORA CARE MANAGEMENT PROGRAM
Set forth below is a general summary of the Aurora Health Care, Inc. Care Management
Program. AHC has the right to revise, amend or modify the Care Management Program from
time to time, in any manner deemed necessary or desirable by AHC.
A.
001.1404121.
General. Participants shall be responsible for obtaining all necessary precertification or
preauthorization required by Employer's Plan, although hospital Providers shall use
reasonable efforts to inform Employer or its designee of any inpatient admission of a
Participant within 24 hours or the next business day, whichever is later. Physician
Providers shall use reasonable efforts to act as gatekeepers and shall assist Participants
when applicable with any precertification or preauthorization requirements in accordance
with Employer's Plan. In no event shall AHC or Providers be liable to Participants or
Employer for the failure to precertify or preauthorize covered services
AHC's Medical J.\tlanagement Services (Episodic. Chronic and Catastrophic Disease
Management). The AHC Medical Management Team provides a different scope of
review activities depending upon the employer under contract, the product, and the
contractual relationship for delegated activities. The Medical Management Team works
with Employer and Participants to understand and appropriately manage their benefits
under Employer's Plan. The following is a brief description of the functions of the
Medical Management Team:
B.
1.
Certification for inpatient admissions/outpatient procedures: The Medical
Management Team screens and authorizes inpatient admissions and outpatient
procedures to ensure that the individual's condition/treatment warrants the
service, the individual is an eligible Participant, the planned services are covered,
and the most appropriate setting is used for the service. Options such as home
health care and outpatient services are utilized whenever medically appropriate.
2.
Ambulatory/Specialist referral management: If a Participant's benefit plan is
designed as a gatekeeper model, the Medical Management Team will screen and
authorize amþulatory/specialist referrals.
3.
Concurrent review: The Medical Management Team, or its designee, performs
concurrent review on certified inpatient admissions and as necessary for
outpatient services. This process verifies and documents the continued need for
hospitalization/outpatient services and ensures AHC's prompt awareness of any
potential need for post-discharge alternative care services. When possible, the
concurrent review process is accomplished on site. In the hospitals affiliated with
the Aurora Health Care Metro, Inc. region, the concurrent review is performed by
Outcome Facilitation Teams ("OFTs"). The OFTs implement and monitor best
practice, care pathways, and care management initiatives, and apply InterQual
ISD and M&R guidelines where appropriate to ensure timely and appropriate
utilization of services. The OFTs are multidisciplinary and outcome focused.
Exhibit D, Page 1
4.
c.
001.1404121.
The OFTs consist of the primary RN, social worker, patient care manager, clinical
nurse specialist, and other disciplines as pertinent to the Participant's case
including the community-based case manager, catastrophic case manager and
managed care specialist if necessary. Each Participant's care is reviewed.
Physicians may be contacted on a periodic basis to obtain additional information.
Periodic treatment plan updates are necessary to assess the discharge planning
needs of the Participant and to facilitate activities that meet these needs.
Catastrophic case management: Nurse catastrophic case managers
telephonically plan, organize, and sequence activities with the Participant, family,
and care providers along the continuum of care to enhance the quality of the
outcome of catastrophic illness or trauma.
5.
Community-based case management: Community-based nurses and social
work case managers are assigned to physicians with Participants who have been
identified as high risk. The community-based case managers develop a care
coordination plan with the physicians, ensure that high-risk Participants in the
community are following through with physician recommendations, and provide
community support linkages where needed.
6.
Chiropractic review: In the event that a Plan does not limit chiropractic services,
the Medical Management Team screens and authorizes chiropractic services to
ensure that the individual's condition/treatment warrants the service, the
individual is an eligible Participant, the planned service is covered, and the most
appropriate setting is used for the service.
Other AHC Services:
1.
Plan Design Consultative Support: The Medical Management Team works with
Employer to advise and provide support regarding Plan design. This service is
based on extensive experience with various plans and current knowledge of
medical standards of care.
2.
Teleservices (Wellness & Health Promotion, Episodic and Chronic Disease
Management): The Aurora Teleservices unit provides advanced telephone-based
patient risk assessment and management, and physician referral. This program
enhances Participant health education and assists Participants with selecting
appropriate health services. This program also provides early identification of
serious conditions which may avoid costs of delayed or inappropriate care.
3.
Aurora Call-A-Nurse: The Call-A-Nurse program is a demand management
center that is also used by preventive services, wellness management, case
management and care management programs to make outbound calls.
(a)
Registered Nurses are currently available 24 hours a day, 7 days a week at
the Aurora Call-A-Nurse Unit. The trained Registered Nurses endeavor to
Exhibit D, Page 2
4.
001.1404121.
(b)
identify needs and levels of urgency among callers. The Registered
Nurses also have access to a translation line that allows them to assist
Participants regardless of the language spoken.
If desired, Participants can receive printed information regarding their
particular question or issue. This information explains in layman's terms
what the particular illness is, how it occurs, how it is diagnosed, how it is
treated, how long the effects will last and how the Participant can
administer self care. This written documentation serves to reinforce the
verbal information given by the Registered Nurse. Through employee
mailings, AHC can also supply wallet cards and refrigerator magnets, as
well as instructions on the use of the Call-A-Nurse line.
Clinical Preventive Care Recommendations (Wellness & Health Promotion):
The Care Management Quality Council of AHC has developed a set of clinical
prevention recommendations for primary care providers. The recommendations
are based on the guidelines developed by the United States Preventive Services
Task Force and are intended for healthy low-risk patients. These guidelines may
be implemented for Employer's Plan, and payment differentials can be
implemented to encourage Provider use of these recommendations.
(a)
(b)
5.
Preventive guidelines serve as evidence-based recommendations regarding
the appropriateness and frequency of various screening and preventive
services for individuals and populations. They are proven interventions to
decrease the rate at which "well" Participants become diseased.
In order to implement these guidelines, all Participants receive a copy of
the focused preventive care guidelines. When a Participant detects a
variation from the preventive care guidelines, the Participant is
encouraged to make an appointment with the Participant's primary care
physician. The primary care physician will assess the Participant's
medical history for compliance with the preventive care recommendations
and will provide or order services that are necessary.
(c)
Aggregate information about Participant compliance with the preventive
care guidelines can be analyzed and made available to primary care
. physicians, Participant and Employer.
Health Risk Assessment-Total Health (Wellness & Health Promotion): The
purpose of the AHC Risk Assessment Program is to identify and quantify health
issues contributing to the risk that "well" individuals or "well" groups will
become "sick". These programs provide consultation and education to groups and
individuals as deemed necessary from the risk areas identified. AHC
recommends that all Participants be assessed for health risks. Participants will
provide information to Health Risk Assessment Professionals through a
standardized, confidential questionnaire. The Health Risk Assessment
Exhibit D, Page 3
6.
001.1404121.
Professionals will analyze the information and provide Participants with the
opportunity for consultation and education.
Occupational Health (Wellness & Health Promotion and Episodic Disease
Management): Aurora Occupational Health Services is the AHC provider of
occupational health services for Eastern Wisconsin employers and employees.
Services include treatment and management of work place injury and illness,
wellness and prevention programs, rehabilitation, and exams and screenings
required by federal and state regulations. Aurora Occupational Health Services
provides a comprehensive approach to reducing unnecessary health and safety
costs and offers three types of services: (a) Care and prevention of work related
injury and illness, (b) Direct Client Services, and (c) Occupational Health
Servi ces/ Consul tati on.
7.
Employee Assistance Program (Wellness & Health Promotion): The AHC
Employee Assistance Program ("EAP") is a worksite program designed to
identify and resolve personal and family problems that may adversely affect a
individual's well-being or job performance. The EAP gives employees a
confidential resource to turn to, 24 hours a day. Standard services include:
Assessment and referral; 24 hour crisis intervention services; management
consultation; supervisory/union steward training, utilization reports; program
promotion; family connections, a referral resource for child and elder care;
financial management consultation; legal consultation; quality improvement
surveys; educational and personal enrichment seminars; convenient locations; and
substance abuse professionals.
8.
Managed Behavioral Health Services (Episodic and Chronic Disease
Management): To complement the Episodic Disease management program,
Aurora Behavioral Health Services provides a comprehensive provider network
and Care Management program to manage the behavioral health needs of the
Participants.
(a)
Aurora Behavioral Health Services brings a managed care focus to the
field of behavioral health care. By integrating all programs and assigning
trained case managers to each patient, nonessential duplication of services
is avoided and close monitoring and coordinated care throughout each
stage of recovery is possible. Practice guidelines and clinical standards
are applied, resulting in generally consistent treatment.
(b)
Aurora Behavioral Health Services provides a wide array of services to
ensure that individuals receive the least restrictive and most appropriate
level of care. These services include, but are not limited to, the following:
. Employee Assistance Programs
. Evaluation, Assessment and Referral Services
. Outpatient Programs
Exhibit D, Page 4
(c)
(d)
001.1404121.
Access.
(1)
(2)
. Partial Hospital Programs
. Crisis Stabilization Programs
. Inpatient Hospital Services
. Aftercare Programs
. Family Programming
. Home Based Programs
. Residential Programs
. Other programs as needed to serve specific client groups.
Participants are provided a toll-free number to call when they have
questions about to behavioral health issues. The Care Management
Center is staffed with Masters level therapists and/or Registered
Nurses trained in behavioral health. The Care Management Center
assesses the severity of the call as either emergent, urgent or
routine. Based upon specific assessment criteria, the caller is then
directed to the appropriate level of care or provided the
information he/she is seeking.
If treatment: is required, a care management specialist coordinates
services for each Participant and, if appropriate, communicates
information to family members, Employer, Employee Assistance
Program professionals, and/or to the Participant's primary care
physician.
Outcome Monitoring.
(1)
(2)
The Care Management Center specialists coordinate services for
patient populations with common problems, such as depression,
through the use of clinical protocols and pathways. By examining
defined populations with common symptoms and socio-
demographic needs, Aurora Behavioral Health Services is able to
offer programs which obtain measurable clinical outcomes for
patient-specific groups.
The goal of the Aurora Behavioral Health Services Care
Management Center is to provide a coordinated approach to the
management of behavioral health services that is easily accessible
and provides the appropriate care when needed. Aurora Behavioral
Health Services Care Management Center strives to ensure its
services are understood by the customers who use those services
and to achieve measurable outcomes that can be monitored and
continually improved.
Exhibit D, Page 5
EXHIBIT C
RELATED PRODUCTS AND SERVICES
INCLUDED FEE
Network Access YES No Fee
Occupational Health YES Pursuant to RFP response rate.
Care Management (as YES No Fee
defined in ExhibitB) .
CBCM YES No Fee
Health Link YES No Fee
Employee Communication YES No Fee
Provider Directories YES Actual cost paid to vendor for printing
EAP YES Pursuant to RFP response rate.
Behavioral Health YES No Fee
Management
Health Risk Assessments YES No Fee
Self Care Book YES No Fee
Aurora Experts YES No Fee
Complementary Medicine YES 30% discount on Chiropractic
Services services, 20% discount on Massage
Therapy services, 10% discount on all
other services
Exhibit C
001.1404121.
EXHIBIT D
OPTION SELECTED AND PLAN SPECIFICATIONS
A.
Option Selection:
xx
Option One: Employer may offer the AHC Network as an exclusive
Plan offering in the AHC service area as an exclusive provider
organization ("EPO") or point-of-service ("POS") product. Primary care
physician designation is required at the time of Participant enrollment. If
offered as an EPO product, Employer shall not provide coverage for
services provided outside of the AHC Network. If offered as a POS
product, Employer shall provide financial incentives to encourage AHC
utilization, including deductibles and at least a thirty percent (30%)
differential in coinsurance, an out of pocket maximum of at least $3,500
single and $7,000 family, as well as a 50% more favorable employee
contribution.
Option Two: Employer may offer the AHC Network as an EPO or P~S
product (including the above requirements) alongside a broad PPO
network product which must include all AHC Providers. Employer shall
provide financial incentives of at least thirty percent (30%) differential in
employee contributionlbenefit design between the AHC EPO or POS
products and the broad PPO product, in favor of the AHC EPO or POS
products.
B.
Plan Specifications: EPO
In-Plan:
Annual Deductible
Covered Percentage:
N/A
100% ot Eligible Expense,
specified
Out-ot-Pocket Limit N/A
Maximum Policy Benefit: $1,000,000
Benefit/Service Description
In-Plan Member Responsibility
No Out-or-Plan Coverage
No Out-or-Plan Coverage
Wel/ness/Preventive Health Services
Periodic Physical Exams
Well Child Care Exams
Immunizations
$15 Office Visit Co-Pay
$15 Office Visit Co-Pay
No Charge
Physician & Practitioner Services
Physical Examinations, Office
Visits & Procedures
Surgery/Anesthesiology Services
001.1404121.
No Out-or-Plan Coverage
$15 Co-Pay per visit
No Charge
Exhibit D
Diagnostic Testing - Non-Invasive
Physical Speech, Occupational Therapy
Laboratory & X-ray
Skilled Nursing Facility Visits
Chiropractic Office Visits, Manipulations
No Charge
$15 Co-Pay per visit
No Charge
No Charge
$15 Co-Pay per visit
Hospital Services
Inpatient Hospital
Inpatient Skilled Nursing Facility
(limited to 60 days per admission)
Outpatient Hospital Services
No Out-or-Plan Coverage
$100 Co-Pay then 100%
$100 Co-Pay then 100%
$50 Co-Payment then 100%
Emergency/Urgent Care Services
Emergency Room
Urgent Care Clinic Setting
No Out-or-Plan Coverage
$50 Co-Pay per visit, waived if admitted
$15 Co-Pay per visit
A medical condition constitutes an emergency when the acute symptoms would lead a prudent person to reasonably
conclude that immediatè medical attention is needed to avoid serious jeopardy or impairment to health.
Follow-up care must be directed by a NHP physician and must have prior authorization from NHP. The
co-payment will be waived if admitted for the same condition 24 hours.
Prescription Drugs*
Prescription drugs dispensed through a
Network Health Plan designated
pharmacy & prescribed by a Network
Health Plan physician, up to 1-month
supply.
Prescription drugs dispensed through a
Network Health plan mail-order pharmacy
and prescribed by a Network Health Plan
physicians; up to 3-month supply. Mail-
order prescription available See your
Member Handbook packet.
No Out-or-Plan Coverage
*Preferred Drug List
$5 Co-Pay per prescription or refill for
Expanded Preferred generic drugs.
$10 Co-Pay per prescription or refill for
Expanded Preferred brand name drugs.
$25 Co-Pay per prescription or refill for
Non-Preferred drugs.
$10 Co-Pay per prescription or refill for
Expanded Preferred generic drugs.
$20 Co-Pay per prescription or refill for
Expanded Preferred brand name drugs.
$50 Co-Pay per prescription or refill for
Non-Preferred drugs.
Supplies for Diabetes
No Out-or-Plan Coverage
001.1404121.
No charge, except a $10 Co-Pay per
prescription or refill for insulin (31-day supply)
Exhibit D, Page 2
EXHIBIT E
P ARTICIP ANT ELIGIBILITY
Employer shall provide AHC with monthly eligibility information as requested by AHC
regarding all Participants who are covered by Employer's Plan, including but not limited to the
following information:
Name
Employee Number
Date of Birth
Eligibility date span.
Exhibit E
001.1404121.
EXHIBIT F
DATA SPECIFICATIONS FOR CLAIMS INFORMATION
DATA EXCHANGE FORMATS
Version 01/2003
SERVICE FILE
service detail informacion
provider informacion
LAB FILE
PatientFnameLnameDOB
CODESET FILE
code description
Claim - This file contains claim level information for a specified time period of paid claims,
usually the prior month. The data elements contained in the file are those needed to create
edits and perform a variety of medical management and care management activities. In order
to reduce the size of the file and eliminate redundancy, the service, member and provider
information is stored in separate files linked with appropriate keys. It is expected that the
sum of associated service lines will tie to the total values stored in the claim record.
Adjustments should include the negation of the prior claim and then the corrected addition of
the new data. Therefore any adjustment will have three lines: the original, the back out, and
the corrected line.
Service - This file contains the service line detail information. The data elements contained
in the file are those needed to create service edits and perform a variety of medical
management and care management activities. It is very important that standard codes are
used. The SrvClmNbr should link back to the ClmNbr of the claim file. As with the claim
file, it is expected that any adjustments will include the negation of any prior service lines
and then the corrected additions of the new data. Therefor any adjustment will have three
lines: the original, the back out, and the corrected line.
Exhibit F
001.1404121.
Enrollment - This file contains one record per member eligibility span for any member who
has been effective in the past two years. This data will be used to provide medical
management with eligibility lists, calculate various PMPM and age/sex breakdowns, and to
perform various care management activities. All the fields in the member file are important
for data cleaning tasks such as joining member information from multiple sources using
various memberids. When available, the mbpcpid field should link to one unique providerid
in the provider file. Full history files are required to accurately reflect retroactive changes.
Provider - This file contains one record per provider id referenced in any of the other files.
Entity type providers will not have values in the fields for person type providers. This data
will be used to perform various care management activities.
Pharmacy - This file contains prescription drug information. This data will be used to
perform various care manag~ment activities
Lab - This file contains lab test results. This data will be used to perform various care
management activities
Codeset - This file contains a cross-reference to code descriptions for fields that store code
values. An example would be the PrvSpec field of the provider file will link to the codeset
file to obtain specialty descriptions.
Exhibit D, Page 2
001.1404121.
Claim File Layout
Version 01/2003 (234 bytes)
Field Name
Datatype
Sourceid This will be an identifier assigned to the Character 005 001 - 005 TPA01 R
supplier of data by Aurora.
Rundate This is the file create date ccyymmdd. Character 008 006 - 013 19970101 R
Filetype Type of data in the file: CL - Claim Character 002 014 - 015 Cl R
ClmNbr Claim number. Unique identifier for the claim Character 016 016-031 CL 123456789 R
ClmRecv Date claim was received: ccyymmdd, Character 008 032 - 039 19970101 R
CIri1Paid Date claim was paid: ccyymmdd. Character 008 040 - 047 19970101 R
ClmMbrlO Unique member id that will link to the Character 016 048 - 063 39786715501 R
accompanying member data file containing the
member demographic data.
ClmBiIIPrvlO Unique servicing/billing provider id that will link Character 016 064 - 079 W153324 R
once to the accompanying provider file
containing the provider demographic data.
ClmPayPrvlO Unique pay to provider id that will link once to Character 016 080 - 095 W187654 0
the accompanying provider file containing the
provider demographic data.
ClmRefPrvlO Unique referring provider id that will link once to Character 016 096 - 111 TMPOOO01 0
the accompanying provider file containing the
provider demographic data. For hospital data
this field contains the admitting provider id.
ClmBegOOS Eariliest date on this claim. ccyymmdd. Character 008 112-119 397972345 R
ClmEndOOS Latest date on this claim. ccyymmdd. Character 008 120 -127 19940805 R
ClmAmtBILLEO Claim amount billed (include sign.decimal) Character 010 128 - 137 +2100.00 R
ClmAmtPAIO Claim amount paid (include sign.decimal) Character 010 138-147 -10.00 R
ClmAmtCOB Claim amount COB (include sign.decimal) Character 010 148 - 157 +580.33 R
ClmAmtCOPAY Claim amount copay (include sign.decimal) Character 010 158 -167 -10.00 R
ClmAmtDEOUCT Claim amount deduct (include sign, decimal) Character 010 168 -177 +134.55 R
ClmAmtOTHER Claim amount other (include sign. decimal) Character 010 178-187 +134.55 0
CimOiag1 Primary ICO-9 diagnosis code. Use only valid Character 006 188 - 193 5990 R
ICO-9 codes. (do not include decimal)
CimOiag2 Secondary ICO-9 diagnosis code. Use only Character 006 194-199 5990 0
valid ICO-9 codes. (do not include decimal)
CimOiag3 Secondary ICO-9 diagnosis code. Use only Character 006 200 - 205 5990 0
valid ICO-9 codes. (do not include decimal)
CimOiag4 Secondary ICO-9 diagnosis code, Use only Character 006 206-211 5990 0
valid ICO-9 codes. (do not include decimal)
CimProc1 Primary ICO-9 principal procedure code Character 006 212-217 V999 R
ClmProc2 Secondary ICO-9 principal procedure code Character 006 218 - 223 V999 R
ClmAdmStat UB92 Admit code (req on hospital claims) Character 002 224 - 225 01 0
Exhibit D, Page 3
001.1404121.
Indicates (I)n network or (O)ut of network
Character
Character
002
006
226 - 227
228 - 233
01
000143
0
0
ClmDisStat
ClmDRG
UB92 Discharge code (req on hospital claims)
DRG on hospital claims
Character
ClmlONet
001
234 - 234
0
1. UNIQUE RECORD FOR EACH CLAIM
2. ALL CHARACTER VALUES ARE UPPER CASE
3. ALL DOLLAR VALUES INCLUDE DECIMAL POINTS WITH LEADING SIGN
4. ALL DATE ARE IN CCYYMMDD FORMAT
5. ALL PROCEDURE AND DIAGNOSIS CODES SHOULD BE INDUSTRY STANDARD CODES
6. ALL OPTIONAL FIELDS ARE FILLED IN IF THE DATA IS AVAILABLE
7. REQUIRES ACCOMPANYING SERVICE FILE WITH SERVICE INFO
8. REQUIRES ACCOMPANYING MEMBER FILE WITH MEMBER INFO
9. REQUIRES ACCOMPANYING PROVIDER FILE WITH PROVIDER INFO
10. REQUIRES ACCOMPANYING AUDIT REPORT WITH RECORD COUNTS AND DOLLAR TOTALS
Exhibit D, Page 4
001.1404121.
"
.Service File Layout
Version 01/2003 (\04 bytes)
Field Name
Datatype
Sourceid This will be an identifier assigned to the Character 005 001 - 005 TPAO1 R
supplier of data by Aurora.
Rundate This is the file create date ccyymmdd. Character 008 006 - 013 19970101 R
Filetype Type of data in the file: SE - Service Character 002 014 - 015 SE R
SrvClmNbr Claim number. Used to link to claim file and Character 016 016 - 031 CL 123456789 R
together with SrvLine to uniquely identify a
service.
SrvLineNbr Line number of claim. Used together with Character 004 032 - 035 0001 R
SrvClmNbr to uniquely identify a service.
SrvFromDate Earliest date of this service. ccyymmdd Character 008 036 - 043 19940715 R
SrvThruDate Latest date of this service. ccyymmdd. Character 008 044 - 051 19940805 R
SrvServPlace Place of Service code. Character 002 052 - 053 11 R
SrvProvlD Unique servicing provider id that will link once Character 016 054 - 069 W153324 R
to the accompanying provider file containing
the provider demographic data.
SrvProcCode AMA CPT-4, UB92, ICD-9, HCPCS procedure Character 005 070 - 074 74410 R
code.
SrvMod1 Procedure code modifier. (required if present) Character 002 075 - 076 26 O.
SrvMod2 Procedure code modifier. Character 002 077 - 078 26 0
SrvUnits Units of the service. (include sign) Character 006 079 - 084 +0001 R
SrvAmtBILLED Service amount billed (include sign,decimal) Character 010 085 - 094 +2100.00 R
SrvAmtPAID Service amount paid (include sign,decimal) Character 010 095 -104 +580.33 R
1. UNIQUE RECORD FOR EACH SERVICE LINE OF A CLAIM
2. ALL CHARACTER VALUES ARE UPPER CASE
3. ALL DOLLAR VALUES INCLUDE DECIMAL POINTS WITH LEADING SIGN
4. ALL DATES ARE IN CCYYMMDD FORMAT
5. ALL OPTIONAL FIELDS ARE FILLED IN IF THE DATA IS AVAILABLE
6. REQUIRES ACCOMPANYING CLAIM AND PROVIDER FILES
7. REQUIRES ACCOMPNAING AUDIT REPORT WITH RECORD COUNTS, CLAIM COUNTS, AND DOLLAR TOTALS
Exhibit D, Page 5
001.1404121.
Enrollment File Layout
Version 01/2003 (410 bytes)
Field Name
Sourceid This will be an identifier assigned to the Character 005 001 - 005 TPAO1 R
supplier of data by Aurora.
Rundate This is the file create date ccyymmdd. Character 008 006 - 013 19970101 R
Filetype Type of data in the file: EN - Enrollment Character 002 014-015 EN R
MbrSSN Patient's social security number Character 009 032 - 040 387657777 R
MbrFName Patient's first name Character 020 041 - 060 TOM R
MbrLName Patient's last name Character 020 061 - 080 JONES R
MbrMI Patient's middle initial Character 001 081 - 081 L 0
MbrSex Patient's gender. M - Male, F - Female Character 001 082 - 082 M R
MbrBirth Patient's date of birth. Ccyymmdd Character 008 083 - 090 19570426 R
MbrRel Patient's relation to contract holder. Character 002 091 - 092 01 R
01 - Contract HOlder 02 - Spouse
03 - Dependent 04 - Dependent Student
05 - Ex spouse 99 - Other
MbrPCPID Patient's PCP id that links to provider file Character 016 093-108 Wl87666 .0
MbrEff Date patient information effective Character 008 109 - 116 19970101 R
MbrTerm Date patient information terms Character 008 117 - 124 19971231 R
SubFName Contract holder's first name Character 020 141 -160 TOM R
SubLName Contract holder's last name Character 020 161-180 JONES R
SubMI Contract holder's middle initial Character 001 181-181 F R
SubBirth Contract holder's birth date Character 008 182 - 189 19650401 R
SubSex Contract holder's gender. M - Male. F- Female Character 001 190 -190 M R
SubEmployer Contract holder's employer Character 030 191 - 220 KODAK CORP R
Sublnsurance Contract holder's primary insurance Character 030 221 - 250 AURORA R
SubGroup Contract holder's group name Character 030 251 - 280 HMO - BENEFIT2 R
MbrAddr1 Member's mailing address line 1 Character 036 281-316 1234 LAKE DRIVE R
MbrAddr2 Member's mailing address line 2 Character 036 317-352 0
MbrCity Member's mailing address city Character 036 353 - 388 MILWAUKEE R
MbrState Member's mailing address state Character 002 389 - 390 WI R
Exhibit D, Page 6
001.1404121.
MbrZip
MbrPhone
Member's mailing address zip
Member's phone
391 - 400
401 - 410
53185-1111
4146476350
R
R
" ., ", ' ,,', ,", "",," ..
,....'.".'.",". . End Of Record , ',' ,'," .."""..'. "",.~)<"
. ' ',' '.
. , ' , ' , ," " /, ' "
Rules for File:
1. ONE RECORD FOR EACH MEMBER IN PLAN PER EFFECTIVEJEND SPAN FOR PAST TVVO YEARS
2. ALL CHARACTER VALUES ARE UPPER CASE
3. ALL DATE ARE IN CCVYMMDD FORMAT
4. ALL OPTIONAL FIELDS ARE FILLED IN IF THE DATA IS AVAILABLE
5. MBRPCP REFLECTS MEMBERS' CURRENTLY ACTIVE PCP NOT NECESSARILY PCP AT TIME OF SERVICE
Exhibit D, Page 7
001.1404121.
Provider File Layout
Version 01/2003 (233 bytes)
Field Name
Sourceid This will be an identifier assigned to the Character 005 001 - 005 TPA01 R
supplier of data by Aurora.
Rundate This is the file create date ccyymmdd. Character 008 006 - 013 19970101 R
Filetype Type of data in the file: PR - Provider Character 002 014-015 PR R
Prvld Unique provider id (links to claims) Character 016 016 - 031 P123456789 R
PrvTaxid Provider's billing tax id Character 010 032-041 234555555 R
PrvWholeName Providers Entire Name Character 060 042 - 101 ST LUKES HOSP R
PrvFName Provider's first name or first 30 characters of Character 030 102-131 JOHN R
entity name.
PrvLName Provider's last name or remaining 30 Character 030 132-161 JACOBS R
characters of entity name.
PrvMI Provider's middle initial Character 001 162-162 R .0
PrvSex Provider's gender Character 001 163 - 163 M .R
PrvBirth Provider's date of birth. Ccyymmdd Character 008 164 - 171 19570426 .0
PrvSpec Provider's primary specialty code which will link Character 002 172 -173 FP .R
to a unique entry in an accompanying codeset
file containing a description.
PrvStatelicNbr Provider's state license number Character 010 174 - 183 541111 .0
PrvSSN Provider's social security number Character 010 184 - 193 333445555 .0
PrvUPIN Provider's UPIN number Character 010 194-203 FP .0
PrvMedicarelD Provider's Medicare number Character 010 204 - 213 .0
PrvMedicaidlD Provider's Medicaid number Character 010 214 - 223 ME .0
PrvDEANbr Provider's Drug number Character 010 224 - 233 SCHOO01 .0
1. ONE RECORD PER UNQIUE PROVIDER ID
2, .FIELDS ARE ONLY FOR PERSONS NOT FOR FACILITIES OR VENDORS
3. ALL CHARACTER VALUES ARE UPPER CASE
4. ALL DATE VALUES ARE IN CCYYMMDD FORMAT
5. ALL OPTIONAL FIELDS ARE FILLED IN IF THE DATA is AVAILABLE, MINiMALLY REQUIRE ONE GOVERNMENT PROVID
6. REQUIRES ACCOMPANYING CODESET FILE FOR SPECIALTY CODES
7. DEA NUMBER IS REQUIRED IF SUBMITTING PHARMACY CLAIMS
8. THE SPECIALTY FIELD FOR ANY FACILITY OR NON-PERSON ENTITY SHOULD BE .XX"
Exhibit D, Page 8
001.1404121.
Pharmacy File Layout
Version 01/2003 (311 bytes)
Field Name
Datatype
Sourceid This will be an identifier assigned to the Character 005 001 - 005 TPA01 R
supplier of data by Aurora.
Rundate This is the file create date ccyymmdd. Character 008 006 - 013 19970101 R
Filetype Type of data in the file: RX - Pharmacy Character 002 014-015 RX R
RxPharmlD Unique pharmacy id assigned by the carrier Character 016 016-031 1234'5678'9. R-
linking to the provider id in the accompanying
provider file.
RxPharmTaxlD Unique pharmacy id assigned by the Character 010 032 - 041 3999999999 R
government linking to the PrvTaxid in the
accompanying provider file.
RXPharmName Full Name of Pharmacy Character 060 042-101 WALGREENS 27m R
RXDeaNbr DEA number of physician writing the script Character 010 102 - 111 AA3975501 R
linking to the PrvDEANbr in the accompanying
provider file,
RXNbr Unique claim number associated with the Character 016 112-127 RX12345 R
transaction.
RXFillSeq Prescriptions fill sequence number indicating Character 002 128 - 129 01 R
the current fill/refill number.
RXDays Number of days the prescription is for Character 003 130 - 132 030 R
RXQuantity Quantity of drug (include sign) Character 005 133 -137 +0060 R
RXNDC NDC Code for drug Character 016 138 - 153 0511110001010 R
RXLabel Drug name printed on label Character 030 154 - 183 ZANTAC R
RXGenBrand (G) eneric or (B)rand indicator Character 001 184-184 G R
RXWritten Date perscription was written Character 008 185 -192 19970101 R
RXFilled Date perscription was filled Character 008 193 - 200 19970102 R
"
RXAmtBilied Amount Billed (include sign, decimal) Character 010 201 - 210 +134.55 R
RXAmtPaid Amount Paid (include sign, decimal) Character 010 211-220 +134.55 R
RXPatPaid Amount Patient Paid (include sign, decimal) Character 010 221 - 230 +10.00 R
RXDiag1 Primary ICD-9 diagnosis code. Use only valid Character 006 231 - 236 5990 0
ICD-9 codes. (do not include decimal)
RXMbrlD Unique Patient identification. Character 016 237 - 252 34756723302 R
RXMbrSSN Patient's social security number Character 009 253 - 261 387657777 R
RXMbrFName Patient's first name Character 020 262 - 281 TOM R
RXMbrLName Patient's last name Character 020 282 - 301 JONES R
RXMbrMI Patient's middle initial Character 001 302 - 302 L 0
RXMbrSex Patient's gender. M - Male, F - Female Character 001 303 - 303 M R
RXMbrBirth Patient's date of birth. Ccyymmdd Character 008 304 - 311 19570426 R
Exhibit D, Page 9
001.1404121.
End Of Record" " . "',.". ".",,'.'~~~
. ' . .
Rules for File:
1. UNIQUE RECORD FOR EACH PERSCIPTION DRUG FILLED
2. ALL CHARACTER VALUES ARE UPPER CASE
3. ALL DOllAR VALUES INCLUDE DECIMAL POINTS WITH LEADING SIGN
4. ALL DATE ARE IN CCYYMMDD FORMAT
5, ALL OPTIONAL FIELDS ARE FILLED IN IF THE DATA IS AVAILABLE
6. REQUIRES ACCOMPANYING PROVIDER FILE WITH PROVIDER INFO
7. REQUIRES ACCOMPANYING AUDIT REPORT WITH RECORD COUNTS AND DOLLAR TOTALS
Exhibit D, Page 10
001.1404121.
'-
. ~
LAB File Layout
Version 0112003 (297 bytes)
Field Name
Sourceid This will be an identifier assigned to the Character 005 001 - 005 TPA01 R
supplier of data by Aurora.
Rundate This is the file create date ccyymmdd. Character 008 006 - 013 19970101 R
Filetype Type of data in the file: LA - LAB Character 002 014 - 015 LA R
LabTranslD Unique identifier for the lab transaction Character 016 016-031 CL 1234- 56.78:9" R-
LabTaxlD Billing Tax id for the LAB Character 010 032 - 041 399010101 R
Lab Name Full Name of the LAB Character 030 042 - 071 ACL R
LabMbrlD System Patient identification Character 016 072 - 087 34756723302 R
LabMbrSSN Patient's social security number Character 009 088 - 096 387657777 R
LabMbrFName Patient's first name Character 020 097 - 116 TOM R
LabMbrLName Patient's last name Character 020 117 -136 JONES R
LabMbrMI Patient's middle initial Character 001 137-137 L 0
LabMbrSex Patient's gender. M - Male, F - Female Character 001 138 -138 M R
LabMbrBirth Patient's date of birth. Ccyymmdd Character 008 139 -146 19570426 R
LabOPrvlD Ordering Provider ID Character 016 147 - 162 399876677 R
LabOPrvTaxlD Ordering Provider's Tax ID Character 010 163-172 399999999 R
LabOPrvFName Ordering Provider's First Name Character 030 173 - 202 MIKE R
LabOPrvLName Ordering Provider's Last Name Character 030 203 - 232 JONES R
LabOPrvMI Ordering Provider's Middle intial Character 001 233 - 233 M 0
LabTestCode Lab code for test being done Character 010 234 - 243 LDL R
LabTestName Lab description of test being done Character 020 244 - 263 LDL R
LabTestDate Date of test Character 008 264 - 271 19970101 R
LabTestResult Results of test Character 010 272 - 281 17.0 R
LabTestOther Other test information Character 010 282 - 291 XXXXX 0
LabDiag1 Primary ICD-9 diagnosis code. Use only valid Character 006 292 - 297 5990 0
ICD-9 codes. (do not include decimal)
,."~ /"...' ....,'. "...,',"'...,...,' ,"EndOfRecord..,..',.','~.',,',.""",",L,',
Rules for File:
1. UNIQUE RECORD FOR EACH LAB TEST
2. ALL CHARACTER VALUES ARE UPPER CASE
3. ALL DATE ARE IN CCYYMMOO FORMAT
4. ALL OPTIONAL FIELDS ARE FILLED IN IF THE DATA IS AVAILABLE
5. REQUIRES ACCOMPANYING AUDIT REPORT WITH RECORD COUNTS BY TEST CODE
Exhibit D, Page 11
001.1404121.
" ~
Codeset File Layout
Version 0112003 (80 bytes)
Field Name
Datatype
Sourceid This will be an identifier aSsigned to the Character 005 001 - 005 TPA01 R
supplier of data by Aurora.
Rundate This is the file create date ccyymmdd. Character 008 006 - 013 19970101 R
Filetype Type of data in the file: CO - Codeset Character 002 014 - 015 CO R
, ' , Provider Information ' " ,""<
, ,c' ",
CsField Name of field using code vallie character 010 016 - 025 SP" EC R"
CsValue Code value being referenced character 006 026 - 031 FP R
CsDescription Code description of value being referenced character 049 032 - 080 FAMILY PRACTICE R
, ' "'" "
End Of Record " " , ", ,
, ' ,
, " ' " '," ,
, " ,"
Rules for File:
1. ONE RECORD PER UNQIUE FIELDNALUE COMBINATION
2. ALL CHARACTER VALUES ARE UPPER CASE
Exhibit D, Page 12
001.1404121.
,., ,-.
ID Card:
Front:
.
~
...--
EXHIBIT G
SAMPLE ID CARD
City of Oshkosh Medical Benefit Plan
a self-funded Indemnity plan with
an Exclusive Provider Network
Group: «Group»
Member Nam.: «FIrst Name. «LastName»
Member Number. «SSN»
Coverage: «MedlcaICoverage»
~
--c..r--
Out of State Wrap Network
800-877.1444
www.b8echslreet-oom
-= Aurora Health Care.
001.1404121.
Back:
IMPORT ANT: P~ertillcatJon required. You are responsible to oan or
have your Doctor call Aurora Medical Management:
. Hospital admissions and certain outpatient procedures you must call
800-251-0838 (Aurora Medical Management), Emergency hospital
admissions must be reportød within 24 hou18 or on the next busines:;
day.
. Home ca/O. DME and hospice cate you must call Aurora Home
MecUcaVVNA at 800-882-2201.
. MontaVnervoua and substance aou8Ø treatment you must call
800-236-3231 (Aurora Behavioral Health).
Ellglblll1y. Claims or Benefits Questions: 800-615-7020
Send III-claims to: ~. Prairie State. Enterprises, Ine.
P.O. Box 23
Sheboygan. WI 53082-0023
Submit Electronlo Claims To: pralrl..tate..cli
Exhibit G