Practice Contracting Standards
FEE-FOR-SERVICE REIMBURSEMENT / Practice Standard
Standard Schedule – Indicate the minimum rate your practice requires for a payor contract based upon the following standards:
% Current Year Resource Based Relative Value Schedule (Commercial/PPO Plans) / % / 140
% Medi-Cal Fee Schedule (State Sponsored Managed Care Plans) / % / 150
% Billed Charges / % / 70
No RVU Codes – Assuming a payor fee schedule based upon Medicare Relative Value Units (RVU), indicate the minimum rate your practice requires for those CPT codes that have no RVU value (e.g. no codes):
% Billed Charges / % / 70
% Usual & Customary / %
CREDENTIALING
ChildNet Delegate Credentialing - Does your practice require a payor to delegate credentialing services to ChildNet Medical Associates for your participation in an Agreement (Yes/No) / Y/N / Y
CLAIMS SUBMISSION & PAYMENT DISPUTES
Timely Submission
Indicate your minimum requirement for days from the date of service to submit a claim before Payor may deny payment to you for untimely claim(s) submission.
(CaliforniaState law requires a minimum 90 days from the date of service) / days / 90
Overpayment
Payors may recover overpayments made to your practice by offsetting such amounts from later payments, including making retroactive adjustments to payments for errors and omissions relating to data entry errors and incorrectly submitted claims or incorrect
A. Indicate your minimum requirement for days advance notice a payor must provide to your practice of their intent to offset such amounts prior to deduction of any monies due. / days / 90
B. Indicate your minimum requirement for days you shall have to either refund said overpayment or request review of the notice following receipt of the aforementioned notice (A) from payor to avoid automatic deductions. / days / 90
C. Indicate the maximum period in days that a payor may make such retroactive adjustments from original date of payment.
(CaliforniaState law dictates a maximum of 365 days from the original payment date) / days / 365
Payment Dispute
Indicate your minimum requirement for days from the date of service your practice has to dispute a denial of payment or the payment amount for services rendered.
(CaliforniaState law requires a minimum of 365 days from the date of service) / days / 365
TERM & TERMINATION OF AGREEMENT
Contract Term – Indicate the maximum initial term in months of a new payor contract. / Months / 12
Termination Without Cause – Indicate if you require a terminate without cause clause in health plan agreements. (Yes/No) / Yes/No / Y
Termination Without Cause – Indicate the maximum number of days that either party must provide written notice to terminate the agreement without cause. / Days / 90
Termination For Non Payment – Once you serve a payor notice of your intent to terminate the agreement due to non payment of covered services, indicate the maximum number of days that a payor has to cure the nonpayment to avoid termination. / Days / 30
Practice name: / Women’s Imaging Specialists in Healthcare
Signature:
Print Name:
Date:
Exhibit 3.2.2
ChildNet Medical Associates
Specialists
Contracted Health Plans
Acceptance List
Listed below are the contracts available to you through ChildNet Medical Associates. Please indicate which plans you wish to participate in and return the form to ChildNet. The form may be sent electronically to , mailed to ChildNet 9300 Valley Children’s Place M/S PC20, Madera, CA93636 or faxed to (559)353-5184, attention: ChildNet Coordinator.
I / We wish to participate in the fee-for-service plans indicated below:
Health Plans/ PPO Brokers/ Managed Medi-Cal Contracts:
No Aetna (PPO)
__ N/A ___Blue Cross Medi-Cal Managed Care
YesCalViva/HealthNet Managed Medi-Cal
YesCentral CaliforniaAlliance for Health (CCAH)
YesCoventry Care Network (CCN)/First Health
No Cigna (PPO)
YesEmanuel Employee Benefit Plan
YesEmployee Health Systems (EHS - Managed Care)
No Great West HealthCare (PPO)
YesHealth Plan of San Joaquin
No Interplan
YesKern Family Healthcare (KernCounty)
YesLaSalle Medical Associates
No Multiplan
YesNetworks By Design
IPAs/Medical Groups:
YesAllCare IPA (Stanislaus & Merced Counties)
YesCentral Valley Medical Group (CVMG)
YesGEMCare/Delano IPA (Kern & Tulare Counties)
YesHill Physician Medical Group (San JoaquinCounty)
YesOmni/Medcore Medical Group IPA
YesMosaic/Key Medical Group IPA (TulareCounty)
No Sante Medical Providers IPA
YesSutter Gould Medical Group (StanislausCounty)
Practice/Group Name: Women’s Imaging Specialists in Healthcare
Tax ID#: 20-3510131
I, , have been delegated with the authority to authorize participation in the above listed contracts.
Signature:
Date: