I. INTRODUCTION:
To the extent of any conflict between the Agreement and this State-Specific Provisions (“SSP”) Addendum, this SSP Addendum shall supersede, govern and control to the extent required by federal and/or state law and to the extent that
Zelis Network Solutions, LLC, on behalf of itself and its subsidiaries and affiliates, including all entities under common ownership or control (“Zelis”), Network Provider and/or Customer(s) are subject to such federal or state law.
II. DEFINITIONS:
Depending upon the specific form of the Agreement, the following terms may be utilized in the Agreement and are intended to be defined as provided for in the Agreement:
(i) billed charges may be referred to as billing rates;
(ii) Customer(s) may be referred to as Zelis’ owners, subsidiaries, affiliates, payors employers, employer groups, third party administrators, Taft Hartley Funds, insurance companies including those authorized to obtain health care services for work-related injuries and automobile accidents, limited liability plans, individuals, insurance, health savings accounts and those who may be directly or indirectly engaged by such Customers to obtain access to Zelis.
(iii) Contract Rate may be referred to as billed charges;
(iv) Covered Services may be referred to as health care services;
(v) Participant may be referred to as covered individual; and
(vi) Benefit Program may be referred to as contract.
For purposes of this Addendum, the term Network Provider is a health care provider duly licensed, certified or otherwise duly authorized to practice health care in the state indicated above.
III. FEDERAL LAW COORDINATING PROVISIONS:
If applicable, this Agreement is subject to the terms of the laws governing health benefits for Federal Employees.
Federal Employees Health Benefits (“FEHB”) Plan. The parties agree that any and all claims or disputes relating to such benefits under a FEHB Plan will be governed exclusively by the terms of such federal government contract and federal law, whether or not such terms and laws are specified in this SSP Addendum or elsewhere in this Agreement.
IV. LAW COORDINATING PROVISIONS:TEXAS
For any Agreement involving the delivery of health care services in the State of Texas, the provisions noted below shall apply.
Where the term Customer is used Customer shall mean only those Customers that are subject to the specific law(s) cited below:
1. As required by 28 TAC §3.3703 (11), Customer shall comply with all applicable statutes and rules regarding the prompt payment of Clean Claims, including the applicable provisions of 1301.101 et seq. of the Texas Insurance Code and
§§21.2801-21.2826 of the Texas Administrative Code.
2. As required by 28 TAC §3.3703 (12), Network Provider shall comply with the continuity of care provisions in accordance with §§1301.152 to .154 of the Texas Insurance Code.
3. As required by 28 TAC §3.3703 (18), in the event Network Provider voluntarily terminates this Agreement, Network Provider shall provide reasonable notice to Participants and Customer shall provide assistance to Network Provider in
accordance with §1301.160 of the Texas InsuranceCode.
4. As required by 28 TAC §3.3703 (19), in the event Network Provider is terminated, Zelis shall provide written notice to Network Provider. If Network Provider is a physician or practitioner, the notice shall include the right of such physician or practitioner to request a review in accordance with §3.3706(c) of the Texas Administrative Code.
5. As required by §1301.136 of the Texas Insurance Code and 28 TAC §3.3703 (20), Zelis shall, within thirty (30) days of receipt of a request, provide the applicable Contract Rates to Network Provider. Customer shall, within thirty (30) days of receipt of a request, provide the additional information required by 28 TAC §3.3703 (20) to Network Provider. Network Provider may terminate this Agreement upon written notice to Zelis within thirty (30) days of receipt of the information requested in this section. Network Provider may only disclose the information requested and received
pursuant to this section in accordance with 28 TAC§3.3703(a)(20(G).
6. As required by §1301.136 of the Texas Insurance Code, Customer or Zelis, as applicable, shall provide notice of changes to the coding guidelines and fee schedules that will result in a change of payment to the Network Provider not later than the 90th day before the date the changes take effect and will not make retroactive revisions to the coding guidelines and fee schedules.
7. As required by 28 TAC §3.3703 (15), in the event Zelis participates in quality assessments as defined by §1301.059 of the Texas Insurance Code, Zelis shall conduct such activities through the use of a panel consisting of at least three (3)
physicians who are Network Providers.
8. As required by 28 TAC §3.3703 (25), Network Provider shall comply with the applicable requirements of §1661.005 of the Insurance Code, which relates to refunds of overpayments from Participants.
9. As required by 28 TAC §3.3703 (26), if Network Provider is a facility, such Network Provider must give notice to Zelis as soon as reasonably practicable, but no later than the fifth business day following the termination of a contract between such Network Provider and a facility-based physician group that is also a Network Provider.
10. As required §1301.062 of the Texas Insurance Code, in the event Network Provider is a Doctor of Podiatry, such Doctor of Podiatry may, practicing within the scope of the law regulating podiatry, furnish x-rays and nonprefabricated orthotics covered by Participant’s BenefitProgram.
11. As required by 28 TAC §21.2803, Network Provider may request a Participant’s eligibility by contacting the Customer.
12. As required by 28 TAC §21.2806, Network Provider shall submit claims for payment within ninety-five (95) days of furnishing health care services.
13. As required by 28 TAC §21.2818, within one hundred and eighty (180) days of Network Provider’s receipt of original payment, Customer may recover an overpayment made to Network Provider if (i) Customer provides written notice to
Network Provider, including the basis and specific reasons for such request and (ii) Network Provider does not appeal a request for a refund or make arrangements for the repayment to Customer within forty-five (45) days of receipt of the notice
requesting the refund of the overpayment. Customer shall allow Network Provider the opportunity to appeal such request for the recovery of an overpayment.
14. As required by the TX Health and Safety Code §76.001 et seq., regarding Discount Card participation, including ValuePoint Program participation, Network Provider will not charge ValuePoint Program Participants and Discount Card
Participants more than the Contract Rates for Covered Services rendered. Network Provider shall promptly notify Zelis if Network Provider loses the authority to provide services to discount card Participants, including by suspension or revocation of the Network Provider's license.
15. As required by 28 TAC §3.3704 (e)(9) and (10), Network Provider shall be available and accessible to Participants (i) for urgent care, as defined by 28 TAC §3.3702 (23), within 24 hours for medical and behavioral health conditions; (ii)
within three weeks for medical condition; and (iii) within two weeks for behavioral health conditions.
V. GEOGRAPHIC EXCEPTIONS COORDINATINGPROVISIONS: TEXAS
1. Professional Liability Insurance. As allowed by Zelis, if Network Provider is an individual practitioner or group provider, such Network Provider will maintain through a policy of insurance or a self-funded arrangement coverage for professional liability insurance at minimum levels of $100,000 per occurrence and $300,000 in the aggregate.
2. Professional Liability Insurance. As allowed by Zelis, if Network Provider is an urgent care center, such Network Provider will maintain through a policy of insurance or a self-funded arrangement, coverage for professional liability at minimum levels of $200,000 per occurrence and $600,000 in the aggregate.
3. Professional Liability and Comprehensive General Liability Insurance. As allowed by Tex. Civ. Prac. & Rem. Code Ann. §101.001 et seq., if Network Provider is governmental unit, as defined by Tex. Civ. Prac. & Rem. Code Ann. §101.001, such Network Provider will maintain professional liability insurance and comprehensive general liability insurance in accordance with Tex. Civ. Prac. & Rem. Code Ann. §101.023. Pursuant to Tex. Civ. Prac. & Rem. Code Ann. §101.027, Zelis and Network Provider acknowledge and agree that if Network Provider is a unit of state government, as defined by Tex. Civ. Prac. & Rem. Code Ann. §101.001, such Network Provider may only maintain professional liability and comprehensive general liability insurance if authorized or required to do so by law. In the event such Network Provider, who is also a unit of state government, is authorized or required by law to maintain professional liability and comprehensive general liability insurance, such Network Provider will maintain professional liability insurance and comprehensive general liability insurance in accordance with Tex. Civ. Prac. & Rem. Code Ann.§101.023.