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Provider Agreement - 2009 !---- -t, BlueCross BlueSbield of Kansas " 1133 SW Topeka Boulevard Topeka, Kansas 66629-0001 In Topeka - (785) 291-7000 In Kansas - (800) 432-0216 Web site: www.bcbsks.com September 21, 2009 City of Salina EMS P.O. Box 736 Salina, KS 67402 200KS00365AO 1 72663 Dear Provider: TriWest Healthcare Alliance (TriWest), and Blue Cross and Blue Shield of Kansas are pleased to announce that TriWest Healthcare Alliance was awarded the contract for the TRICARE West Region by the Department of Defense (DoD) on July 13,2009. TriWest has been a Managed Care Support Contractor for the DoDsince 1997 and looks forward to continuing to provide access to health care for the 2.7 million TRICARE beneficiaries in the 21-state West Region. On behalf of the TRICARE beneficiaries, we would like to thank you for your hard work and dedication. Your commitment to providing quality health care helps ensure that active duty service members, military retirees and their families are well served. Your continued participation in this network serving the men and women of America's military family is greatly appreciated. f( TriWest is determined to build on its successes and continue to focus on delivering superior customer service to our provider network and to the TRICARE beneficiaries. TriWest is engaging a number of enhancements to improve the provider experience, including greater availability and easier access to information on its Web site. Enclosed is an amendment to your current TRICARE Provider Agreement, effective February 1,2010. The amendment updates your current provider agreement to align with the new Department of Defense TRICARE West Region contract. No action is required by you at this time in order for you to continue serving America's military family as a network provider in the West Region. For your convenience, a summary of the TRICARE Provider Agreement changes is enclosed. If you have any concerns about this amendment, please call before November 21, 2009. Additional information and resources are available at www.triwest.com. Information about the TRICARE program is also available at www.tricare.mil. If you have any questions, please contact your local network representative at 1.800.432.3587. Thank you for continuing to serve all ofthose who so selflessly serve all of us! Sincerely, Douglas R. Scott Director Professional Relations Enclosures: Contract Amendment Summary of Contract Changes "An Independent Licensee of the Blue Cross and Blue Shield Association. .,. 'i TRICARE PROFILE SHEET W9ILEGAL BUSINESS NAME City of Salina EMS FEDERAL TAX ID # 486017228 PRIMARY PHYSICAL ADDRESS P.O. Box 736 LINE 1 PRIMARY PHYSICAL ADDRESS LINE 2 PRIMARY PHYSICAL CITY Salina KS 67402 STATE ZIP PRIMARY CONTACT PERSON PRIMARY PHONE/FAX PRIMARY EMAIL BILLING ADDRESS LINE 1 BILLING ADDRESS LINE 2 BILLING CITY STATE ZIP BILLING CONTACT PERSON BILLING PHONE/FAX BILLING EMAIL 200KS00365AO 1 Page 1 of 4 ~ , AMENDMENT TO TRICARE ANCILLARY CONTRACT This amendment to the TRICARE Ancillary Contract (this "Amendment") is entered into effective as of 2/1/2010, ("Effective Date") by and between Blue Cross Blue Shield of Kansas , a Kansas nonprofit corporation, ("Network Subcontractor") and City of Salina EMS ("Provider") (jointly referred to as the "Parties" or individually as a "Party"). This Amendment amends the TRICARE Ancillary Contract (the "Agreement") between the Parties as follows: 1. The following shall be added to the Recitals: "TriWest is contracted by the Department of Defense to administer the TRICARE program in the West Region." 2. Section I, Definitions: The definition "West Region Contract" shall be deleted in its entirety. 3. Throughout the Agreement the phrase "TRICARE benefiCiaries and/or Active Duty personnel" shall be removed and replaced with "TRICARE beneficiaries." 4. Section III, Provider Responsibilities: The following provisions shall be added: . "Provider shall provide Network Subcontractor prompt written notification of Provider's employment of an individual who, at any time during the twelve (12) months preceding such employment, was employed in a managerial, accounting, auditing, or similar capacity by an agency or organization which is responsible, directly or indirectly, for decisions regarding Department of Defense payments to provider." "Provider shall refer TRICARE Beneficiaries only to providers with which Provider does not have an economic interest, as defined in 32 C.F.R. ~ 199.2." 5. Section III, Provider Responsibilities: The following provisions shall replace, in their entirety, those provisions in the Agreement covering similar terms and conditions: "Provider shall collect applicable Copayments from TRICARE Beneficiaries. Except as otherwise provided in this Paragraph B., Provider may not bill TRICARE Beneficiaries for any service that is non-covered or disallowed. Provider shall not routinely waive Copayments. Except for Copayments, Provider agrees that in no event (including, but not limited to, nonpayment or breach of this Agreement by TriWest or TriWest's insolvency) shall Provider bill or collect for Covered Services from a TRICARE Beneficiary, and this provision shall survive termination of this Agreement. Provider shall not require payment from a TRICARE Beneficiary for any excluded or excludable service that the TRICARE Beneficiary received unless the TRICARE Beneficiary has been properly informed that the services are excludable and has agreed in advance of receiving the services, in writing, to pay for such services. A TRICARE Beneficiary who is informed that care is potentially excludable and proceeds with receiving the potentially excludable service shall not, by receiving such care, be construed 200KS00365AO I Page 2 of 4 ,- .,. ,I to have entered into an agreement to pay. Provider acknowledges that payment shall not be allowed for a non-Covered Service unless the TRICARE Beneficiary (with the exception of Active Duty personnel) is properly informed and agrees in a separate writing. Any waivers must be specific as to the details of the excluded or non-Covered Service. General agreements to pay, such as those signed by the TRICARE Beneficiary at the time of service, are not evidence that the TRICARE Beneficiary knew specific services were excluded or excludable or that the TRICARE Beneficiary agreed to pay. Notwithstanding any contrary provision herein, Provider shall not bill or collect payments from Active Duty personnel for non-Covered or excludable services. " "Provider agrees to being reported to the Department ofVeteraI)s Affairs (DV A) as a TRICARE Network Provider. To the extent TriWest and DV A enter into an agreement, Provider agrees to see Veterans Administration (VA) patients and shall accept reimbursement for these patients at the rates set forth in Exhibit 1 to the Agreement. In the event Provider has an existing agreement in effect to provide health care services to the Department of Veteran Affairs patients such VA agreement shall control for any services provided to VA patients." "Provider agrees to being reported to the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPV A) as a TRICARE Network Provider. To the extent TriWest and CHAMPV A enter into an agreement Provider agrees to see CHAMPV A patients and shall accept reimbursement for these patients at the rates set forth in Exhibit 1 to this Agreement. In the event Provider has an existing agreement in effect to provide health care services to CHAMPV A patients such CHAMPV A agreement shall control for any services provided to CHAMPV A patients." "Provider agrees to provide copies of medical records to TriWest within ten (10) business days of TriWest's request, to permit TriWest to conduct peer review, quality assurance and utilization review. At the Provider's request TriWest will'reimburse Provider for the cost of photocopying and postage using the same reimbursement as Medicare." "Provider shall provide and maintain policies of general and professional liability (malpractice) coverage to insure Provider against any claim for damages arising by reason of personal injury or death resulting directly or indirectly from the performance of this Agreement. Such coverage shall be subject to the approval of Network Subcontractor and be in an amount equal to the greater of the highest amount required by law or in the absence of such law, the community standard for such coverage. Provider shall provide Network Subcontractor with a certificate of such coverage upon execution of this Agreement, entitling Network Subcontractor to receive thirty (30) days' prior notice of any change in coverage or termination or expiration of coverage. If coverage is on a claims-made basis, Provider shall obtain or seek verification from employed physicians proof of Tail Insurance satisfactory to Network Subcontractor upon any termination of coverage and containing an extended reporting endorsement for a period of not less than three (3) years after the termination of this Agreement." 200KS00365AO I Page 3 of 4 .... ., 6. Section IV, Provider Directory: The following provisions shall replace, in their entirety, those provisions in the Agreement covering similar terms and conditions: "TriWest may periodically include Provider's name, gender, work address, work fax number and work telephone number, whether the Provider is accepting new patients, specialty or sub- specialty and willingness to accept VA and CHAMPV A beneficiaries in a directory of Network Providers. " 7. Section VII, General Provisions: The following provision shall replace, in their entirety, those provisions in the Agreement covering similar terms and conditions: "All amendments to this Agreement or any of its Addenda proposed by Provider must be agreed to in writing by Network Subcontractor in advance of the effective date thereof. Any amendment to this Agreement, including any of its Addenda, proposed by Network Subcontractor shall be effective 30 days after Network Subcontractor has given written notice to Provider of the amendment, and Provider has not notified Network Subcontractor in writing of Provider's rejection of the requested amendment within that timeframe." "Amendments required because of legislative, regulatory or legal requirements, including without limitation any and all changes made to TRICARE reimbursement or the TRICARE program and policies, do not require the consent of Provider and will be effective immediately on the effective date thereof'. If any provision of this Amendment is deemed illegal, unenforceable or in conflict with any law of a Federal, state or local government having jurisdiction over this Agreement, the validity of the remaining sections and of the Agreement shall not be affected. This includes, without limitation, a change in TRICARE law or policy which is inconsistent with any provision of . this Amendment. Except as amended hereby, all of the terms and conditions of the Agreement remain in full force and effect -- Signature Not Required -- This Amendment addresses changes in the TRICARE program or TriWest's contract to administer the TRICARE program and, therefore, do not require signature. If Provider fails to object to this amendment prior to its Effective Date, Provider waives any provision in the Agreement that requires signature of the Parties to amend the Agreement. 200KS00365AO I' Page 4 of 4 ~ ~ 3!!l. (I)::C 3 ~ cr=- !Il :T ~ a Q.(I) >> IL~~ ~ m ~ .. 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