Loading...
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 ~ ..\.....~ 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 . < . .\ Illcdkal case manaj.:ement service Ilf Lincllln :\arional 'lanaj.:clllcnt Scrviccs Inc. . 1700 :'\lagnavox Way' P.O. Box nS5 . Fort Wayne:. I\; -l"XO I 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. . . . . 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. . . . . 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. . . . 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: