Organ Transplant Network Access and Transreview Agreement
CITY OF DUBUQUE, IOWA
MEMORANDUM
June 2, 1999
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT:
Organ Transplant Network Access and Transreview Agreement
Human Services Manager Randy Peck is recommending that the City amend its
health care plans by expanding the organ transplant coverages and entering into a
Network Access and Transreview Agreement with United HealthCare Services, Inc.
The Health Care Committee concurs in the recommendation.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
MCVM/j
Attachment
cc: Barry Lindahl, Corporation Counsel
Tim Moerman, Assistant City Manager
Randy Peck, Human Services Manager
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CITY OF DUBUQUE, IOWA
MEMORANDUM
May 27, 1999
TO: Michael C. Van Milligen, City Manager
FROM: Randy Peck, Personnel Manager fB
SUBJECT: Organ Transplant Network Access and Transreview Agreement
On May 26, 1998, the Health Care Committee approved expanding the organ
transplant coverages offered by the health plans. Under the HMO Plan, the
transplant coverages would be expanded to include heart/lung, pancreas and
kidney/pancreas. The Indemnity Plan was expanded to include kidney/pancreas
transplant coverages. The attached Network Access and Transreview Agreement
is an addendum to our stop-loss contract and will grant the City of Dubuque
access to the United Health Care Service's network of transplant centers. This
agreement has been reviewed by Corporation Counsel Barry Lindahl.
I recommend that the agreement be approved. The Health Care Committee has
reviewed the agreement and concur in my recommendation. The requested action
is for the City Council to pass a motion approving the agreement and authorizing
you to sign the agreement.
If you have any questions, please feel free to call.
RP/dd
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NETWORK ACCESS AND TRANSREVIEW AGREEMENT
(hereinafter" Agreement")
To: United HealthCare Services, Inc.
Minneapolis, MN
From: City of Dubuque
Dubuque, Iowa
In consideration of United HealthCare Services, Inc. (hereinafter "OOS") granting City of Dubuque
(hereinafter "Payor") access to it's network of transplant centers, Payor agrees as follows with regard to
the above referenced Contracts.
.
1.1 Payor agrees that it is responsible for making payment for Transplant Services (as defmed herein)
rendered by providers who have entered into agreements (hereinafter "Participating Providers") with OOS
on behalf of its division, United Resource Networks (hereinafter "URN"). Payor acknowledges that its
access to the OOS network of Participating Providers is made available by Payor's relationship with its
excess liability carrier (hereinafter "Carrier") and Payor's participation in the Special Alternatives
TransplantCare Program.
1.2 For purposes of this Agreement, a "Covered Person" is an individual properly enrolled for coverage
under a "Benefit Contract," defined as a benefit plan which includes health care coverage and contains the
terms and conditions of a Covered Person's coverage. "Transplant Services" shall mean the transplant-
related health care services and supplies covered under a Covered Person's Benefit Contract and provided
at or under the supervision of a Participating Provider pursuant to such Participating Provider's agreement
with OOS.
1.3 If a Covered Person begins receiving Transplant Services from a Participating Provider before this
Agreement is effective, this Agreement will not apply to the Transplant Services that Covered Person
receives through the duration of the Covered Person's treatment. If a Covered Person begins receiving
Transplant Services before this Agreement, Carrier's agreement with UHS, or Payor's relationship with
Carrier ends, the Participating Provider will continue to provide Transplant Services to the Covered
Person in accordance with the terms of this Agreement, and Payor wili continue to pay for such services
in accordance with the terms of this Agreement.
.
.
.
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NETWORK ACCESS AND TRANSREVIEW AGREEMENT (cont.)
IA.a. Payor shall pay to UHS the Scheduled Amount set forth below for each transplant for which Payor
or Payor's claims administrator signs a Transplant Benefit Approval form. The Transplant Benefit
Approval form identifies the transplant procedure and the transplant recipient (hereinafter "Approved
Transplant"). Such payment shall be due within 30 days of the date UHSsends the invoice.
Scheduled Amounts
Bone Marrow
Autologous, all diagnoses
Less than II Days
II or more Days
Allogeneic, related or unrelated donor
Heart
Lung
Simultaneous heartllung
Liver
Kidney
Simultaneous kidney/pancreas
$ 5,000
$ 7,500
$ 7,500
$ 7,500
$ 7,500
$ 7,500
$ 7,500
$ 2,000
$ 2,000
For the purposes of determining autologous bone marrow transplant fees, a "Day" is a Covered Person's
consecutive 24-hr period of inpatient stay at a Participating Provider. The total number of days will be
counted, whether consecutive or nonconsecutive, beginning with the first day the Covered Person begins
receiving protocol-specific chemotherapy and/or radiation immediately before the autologous bone
marrow transplant and ending at 12 midnight on the 30th calendar day after the infusion of the
transplanted bone marrow.
l.4.b. If one or more ofthe following events occurs before a Covered Person receives an Approved
Transplant, UHS will invoice an amount equal to the lesser ofthe above Scheduled Amount or 35% of the
difference between billed charges and the contract charges to which the Participating Provider agreed in
its agreement with UHS: (1) a Covered Person is not accepted into a Participating Provider's transplant
program; (2) the Covered Person dies; or (3) the Covered Person's coverage under a Benefit Contract
ends.
Payment to UHS under these circumstances is in lieu of the Scheduled Amount and is due within 30 days
of the date the invoice is sent.
IA.c. In the event a replacement of an Approved Transplant is required, Payor shall pay UHS an amount
equal to 50 percent of the Scheduled Amount for each replacement of an Approved Transplant. Such
payment shall be due within 30 days of the date UHS sends its invoice.
1.5 Payor or Payor's claims administrator shall be solely responsible for verifying benefits accurately and
approving eligibility for all Covered Persons before Transplant Services are provided pursuant to this
Agreement. Benefit Contracts covering Transplant Services must provide, or Payor must otherwise
guarantee, payment for at least $500,000 in major medical coverage during a Covered Person's lifetime
and must not require copayments, coinsurance or deductibles from a Covered Person in excess of a
combined total of $10,000 for Transplant Services during any 12-month period. Nothing in this
Agreement shall be deemed to obligate Payor to direct any Covered Person to Participating Providers.
Any dispute about benefit coverage or eligibility of covered Persons is solely between Covered Person
and Payor. Payor agrees that neither UHS nor Carrier, nor their affiliates, has any responsibility of any
kind for the interpretation of Benefit Contracts regarding the coverage or denial of benefits.
NETWORK ACCESS AND TRANSREVIEW AGREEMENT (cont.)
.
1.6 Payor or Payor's claims administrator must execute the Transplant Notification form and Transplant
Benefit Approval form before a Covered Person begins receiving Transplant Services in order to ensure
that this Agreement will apply to the applicable transplant. Such forms will be provided to Payor by
Carrier. After the Participating Provider receives the executed Transplant Benefit Approval form, Payor
must pay the Participating Provider for the Transplant Services that it renders for Approved Transplants.
Payor must make payment in accordance with the terms of the Participating Provider's agreement with
UHS, including the terms about when and in what amount payment is due. Payor agrees that payment for
Transplant Services is solely the obligation of Payor and not that of UHS or of Carrier.
1. 7 To the extent Payor has an agreement with a Participating Provider that covers the delivery of
Transplant Services for the same types of transplants covered in UHS's agreement with that same
Participating Provider, UHS's agreement supersedes Payor's agreement unless payor elects below to
exclude such Participating Provider at the time this Agreement is executed or when written notification is
received by Payor that a new Participating Provider has been added to the UHS transplant network. Once
a Participating Provider is listed as being excluded, Payor will have no access to the terms ofUHS's
agreement with that excluded Participating Provider throughout the duration of Payor's relationship with
Carrier.
1.8 During the term of this Agreement and for one year after it ends, Payor will not renew or directly
enter into a new agreement with any Participating Provider, except Participating Providers which have
been excluded as described in section 1.7 above, for the provision of Transplant Services covered in that
Participating Provider's agreement with UHS as of the date this Agreement ends. However, Payor may
access contracts with Participating Providers through vendors providing similar Transplant Services as
those provided by UHS, whereby Payor would not directly contract with Participating Providers.
. 1.9 Payor will not disclose the provisions ofUHS's agreements with Participating Providers, including
but not limited to the payment amounts and terms set forth therein, to any third party without Carrier's
prior written approval, except to a third party that acts as a paying agent for Payor and that has agreed in
writing to maintain the confidentiality of the information.
1.10 Payor agrees that this Agreement creates direct obligations of Payor to Participating Providers for
Transplant Services and, in the event Payor fails to perform an obligation to a Participating Provider as
described in this Agreement, such Participating Provider shall have a direct cause of action against Payor.
1.11 Any dispute between Payor and a Participating Provider that relates to UHS' s agreement with the
Participating Provider will be resolved in accordance with the dispute resolution process described in that
agreement.
1.12 UHS may terminate Payor's access to Participating Providers through this Agreement with cause
upon 30 days' written notice to Payor, except that termination will be effective immediately upon written
notice to Payor if (1) Payor fails to pay any Participating Provider as required; or (2) Payor's relationship
with Carrier or Carrier's agreement with UHS terminates; or (3) Payor breaches this Agreement.
.
.
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NETWORK ACCESS AND TRANSREVIEW AGREEMENT (cont.)
2. TRANSREVIEW SERVICES PROVISION
2.1 At the request of Payor, UHS will provide TransReview Services to Payor. For the purposes of this
Agreement, "TransReview Services" shall mean the review and assessment ofa Covered Person's
medical record information and the preparation of a written, professional opinion about the medical
appropriateness of a transplant that is proposed as a method of treatment for that Covered Person. UHS' s
medical directors who are involved in providing TransReview Services will be, or will consult directly
with, a currently licensed physician who practices transplant medicine and who has the appropriate
experience to assess the Covered Person's medical condition.
2.2 To request TransReview Services, Payor or Payor's claims administrator will complete the
TransReview Services Request form provided by Carrier. Payor will provide UHS with any information
necessary to complete the TransReview Services written opinion. Payor is responsible for the cost of
obtaining Covered Person's records or information necessary for UHS to provide TransReview Services.
2.3 Payor will pay UHS for TransReview Services as follows:
$1850 for one written opinion
$2450 for three written opinions
If Payor forwards to UHS additional information that was anticipated and noted by the author of the
original opinion and received by UHS within four months of the date the original written opinion was
completed, the additional information will be reviewed at no extra charge. For a review and written
opinion about any other additional information, Payor will pay UHS an additional fee of $1000 for one
opinion or $1800 for three opinions. All payments to UHS are due within 30 days of the date the invoice
is sent.
2.4 To the best of its ability, UHS will provide Payor with access to a reviewer to participate in litigation
if the review indicates in the written opinion that the proposed transplant is not medically appropriate, the
Payor thereafter denies coverage, and the denial results in litigation. Payor and the reviewer will
negotiate the reviewer's fees for participation in such litigation.
2.5 Within one year of receiving TransReview Services, Payor will not solicit a reviewer retained by
UHS to work as an employee or independent contractor to perform medical appropriateness review
services without UHS' s prior written consent.
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NETWORK ACCESS AND TRANSREVIEW AGREEMENT (cont.)
3. GENERAL PROVISIONS
3.1 a. Payor agrees that neither UHS nor Carrier, nor their affiliates, has any responsibility of any kind for
the medical outcomes "Of the quality or competence of any physician, facility or other provider rendering
Transplant Services or TransReview Services.
3.1.b. Payor will assist, or will instruct its claims administrator, to assist Carrier as needed in obtaining
and transferring to third parties information about a Covered Person's medical experience or other
information necessary for the performance of utilization review, quality assessment, research analyses or
the duties under the agreement between UHS and Participating Providers. When Covered Person's
consent is needed to obtain and transfer such information, Payor will use its best efforts to obtain such
consent.
3.2 Payor will obtain Carrier's prior written approval before preparing and distributing any materials that
refer, directly or indirectly, to UHS, URN, Participating Providers or UHS's agreements with
Participating Providers.
3.3 Any dispute between Payor and UHS will be resolved by binding arbitration in accordance with the
rules of the American Arbitration Association.
3.4 Payor shall deliver or cause this Agreement to be delivered to Carrier. Upon such delivery, Carrier
shall be authorized to distribute copies of this Agreem ent to UHS or its delegee for distribution to any
and all Participating Pro . e UHS shall r be authorized to include Payor in its client lists but will
not otherwise des' te :{ public refe to Payor without Payor's prior written consent.
Signed by: LL
Title:
City Wa~d;?!
Date: