Section
|
Description
|
Implementation Date
|
7.1
|
Automated Adjudication of Claims
|
5/2/05
|
7.2
|
Increased Intranet and Clearinghouse Functionality
|
|
a
|
Investments/Requirements
|
Effective Date + 90 days
|
b
|
Electronic Transactions
|
Effective Date + 90 days
|
c
|
Website Access-Facilitator/Medical Societies
|
9/7/05
|
7.3
|
Availability of Fee Schedule/CPT Code Inquiries
|
Effective Date + 120 days
|
7.4
|
Provider Relations Investment
|
5/2/05
|
7.5
|
Reduced Pre-certification Requirements/ Disclosure
|
|
a
|
Reduced Pre-certification Requirements
|
11/6/05
|
b
|
Disclosure of Pre-certification Requirements
|
11/6/05
|
c
|
Disclosure of Customized Pre-certification List
|
11/6/05
|
7.6
|
Material Adverse Charge Notice
|
7/9/05
|
7.7
|
Initiatives to Reduced Claims Resubmissions
|
11/6/05
|
7.8
|
Disclosure of Commitments Concerning Claims Payment Practices
|
|
a
|
Consistency of Claim Payment Practices
|
The later of the Effective Date or 12/31/05
|
b
|
Certain Claims Bundling Logic
|
Effective Date + 90 days
|
c
|
Request for Clinical Information
|
Effective Date + 90 days
|
d
|
Claims with Modifiers 25 and 59
|
The later of the Effective Date or 12/31/05
|
e
|
Updates
|
The later of the Effective Date or 12/31/05
|
7.9
|
Physicians Advisory Committee
|
Effective Date
|
7.10
|
New Dispute Resolution Process for Physician Billing Disputes
|
Effective Date
|
7.11
|
Medical Necessity/Experimental-Investigational Determinations
|
Effective Date
|
7.12
|
ERA/EFT
|
12/31/05
|
7.13
|
Participation in Company's Network
|
|
a
|
Credentialing
|
Effective Date + 90 days
|
b
|
"All Products" Clauses
|
7/9/05
|
c
|
Termination Without Cause
|
7/9/05
|
d
|
Rights of Class Members to Refuse to Accept New Patients
|
Effective Date
|
7.14
|
Fee Schedule Changes
|
|
a
|
Notice
|
Effective Date
|
b
|
Payment Rules for Injectibles, DME, etc.
|
Effective Date
|
c
|
Appeals of R&C Determinations
|
Effective Date
|
7.15
|
Recognition of Assignments of Benefits
|
9/7/05
|
7.16
|
Application of Clinical Judgment
|
|
a(1)
|
Medical Necessity Definition
|
7/9/05
|
a(2)
|
External Review Statistics
|
Effective Date
|
b
|
Policy Issues Involving Clinical Judgment
|
7/9/05
|
c
|
Consideration of Administrative Exemption Program
|
Effective Date
|
7.17
|
Billing and Payment
|
|
a
|
Timing of Claim Submissions 120-day requirement
|
12/31/05
|
b
|
Claims Submissions (acceptance of certain forms and submissions of Clinical Information)
|
12/31/05
|
7.18
|
Timelines for Processing and Payment of Complete Claims
|
|
a
|
Logging of Receipt Date and Attempt to Require 24-Hour Transmission by Clearinghouses
|
The later of the Effective Date + 6 months or 10/1/06
|
b
|
Payment of Simple Interest
|
The later of the Effective Date + 6 months or 10/1/06
|
7.19
|
No Automatic Downcoding of Evaluation and Management Claims
|
5/10/05
|
7.20.a.i
|
Modifications to Payment Policies
|
The later of the Effective Date + 6 months or 10/1/06
|
7.21
|
Modification of Language in EOBs and Remittance Forms
|
Effective Date + 120 days
|
7.22
|
Overpayment Recovery Procedures
|
Effective Date + 90 days
|
7.23
|
Efforts to Improve Accuracy of Eligibility Information
|
5/10/05
|
7.24
|
Response to Physicians Inquiries
|
5/10/05
|
7.25
|
Confirmation of Medical Necessity
|
7/9/05
|
7.26
|
Electronic Connectivity
|
Effective Date + 90 days
|
7.27
|
Physician Information on Website
|
Effective Date + 90 days
|
7.28
|
Capitation and Physician Organization Issues
|
|
a
|
Capitation Reporting
|
Effective Date
|
b
|
PCP Assignment
|
Effective Date
|
7.29
|
Miscellaneous
|
|
a
|
No "Gag Clauses"
|
7/9/05
|
b
|
Ownership of Medical Records
|
7/9/05
|
c
|
Arbitration Fee Limits
|
Effective Date + 60 days
|
d
|
Impact on Physician Agreements
|
Obligations and commitments to be incorporated into physician contracts (where required) as they commence pursuant to this Exhibit A
|
e
|
Impact of this Agreement on Covered Services
|
5/10/05
|
f
|
Privacy of Records
|
5/10/05
|
g
|
Physician Risk Pools
|
5/10/05
|
h
|
"Stop Loss"
|
5/10/05
|
i
|
Pharmacy Provisions-Disclosures re: Formulary; Maintenance of Exception Process; Coverage for Off-Label Uses
|
5/10/05
|
j
|
Restrictive Endorsements
|
5/10/05
|
k
|
Scope of Responsibilities
|
Obligations and commitments to be incorporated into physician contracts (where required) as they commence pursuant to this Exhibit A
|
l
|
Provision of Contract Copies
|
7/9/05
|
m
|
State and Federal Laws
|
5/10/05
|
n
|
Modification of Means of Disclosure
|
5/10/05
|
o
|
Participating Physicians Status and Limits on Obligations on Non-Participating Physicians
|
Effective Date
|
p
|
Limitation on Rental Networks
|
Effective Date + 60 days
|
q
|
Most Favored Nations Clauses
|
7/9/05
|
7.30
|
Compliance with Applicable law and Government Contracts
|
Obligations and commitments to be incorporated into physician contracts (where required) as they commence pursuant to this Exhibit A
|
7.31
|
Value of Section 7 Initiatives
|
5/10/05
|
7.32
|
Force Majeure
|
5/10/05
|
7.33
|
Mental Health Provisions
|
Effective Date + 120 days
|