HomeMy WebLinkAboutSLOANS LAKE MANAGED CARE THE SEGAL COMPANY - CONTRACT - RFP - P682 BENEFITSCity of Fort Collins
Administrative Services
Purchasing Division
PARTICIPATION
.L,
MEDICAL MANAGEMENT
AGREEMENT
CITY OF FORT COLLINS
AND
SLOANS LAKE MANAGED
CARE INC.
256 W. Mountain Avenue • P.O. Box 580 • Fort Collins, CO 80522-0580 • (970) 221-6775 • FAX (970) 221-6707
5.13 The Participating Plan acknowledges that all Participating Providers are contractually
required to submit all bills for Covered Services rendered to Covered Individuals directly
to SLMC. All claims received by SLMC which identify the insured to be a member of
the Participating Plan shall be sent to the Participating Plan's claim administrator. In
the event the Participating Plan's claim administrator does not identify the patient as a
Covered Individual, the Participating Plan agrees that its claim administrator shall either
return the claim to the Participating Provider or send the Participating Provider a notice
of denial.
5.14 The Participating Plan has contracted for access to the SLMC statewide network of
Participating Providers and understands that it cannot terminate any Participating
Provider from this Agreement.
5.15 The Participating Plan agrees that it shall not use the list of Participating Providers and/or
the Negotiated Rates on Exhibits A and B as a source for forming a network of preferred
providers or to contract directly with any Participating Provider. The obligations
contained in this Section 5.15 shall survive termination of this Agreement and continue
for a period of one year following the termination of this Agreement.
5.16 Participating Plan is solely responsible for ERISA compliance and reporting obligations,
SLMC shall not be deemed a fiduciary of Participating Plan for any purpose.
5.17 Participating Plan agrees to provide SLMC with the enrollment data listed on Exhibit C
upon execution of this Agreement and thereafter on an annual basis.
5.18 In order to assure that there will be no disruption of service to the Covered Individual or
the Participating Provider, Participating Plan agrees to contact its claim administrator to
ensure that they are taking the necessary steps to be Year 2000 compliant by December
31, 1999.
ARTICLE VI
INDEPENDENT RELATIONSHIP
6.1 The relationship of the parties hereto is only that of independent entities contracting with
each other at arm's length solely for the purpose of affecting the provisions of this
Agreement. None of the parties to this Agreement nor any of their respective affiliates or
employees shall be construed to be agents, employees, joint venturers or representatives
of the other.
6.2 Participating Plan shall not interfere with or otherwise influence the manner in which any
of the services or obligations of SLMC outlined in this Agreement are provided. SLMC
shall not interfere with or otherwise influence the relationship between Participating Plan
and its Covered Individuals. Participating Plan acknowledges that SLMC does not
9 PP017/PAR-WE-UR/Cr'Y OF Fr COLLINS/11.20.98/jg
EXHIBIT A
The Network Alliance
Page 8
Infusion - Continued
Prolastin Theraov Amount Code
Prolastin Therapy $ 75.00 + AWP PROT
Included in the per diem rate for Prolastin: Solutions, pharmacy compounding fees, standard medical supplies, delivery,
hazardous waste disposal and pharmacy management services.
Pumps
Amount
Code
Non -ambulatory pump
$ 7.00 per day
PUMPI
Ambulatory pump
$10.00 per day
PUMP2
Disposable pump
$10.00 per day
PUMP2
Desferal Therapy
Amount
Code
Desferal
$60.00 + AWP
DEFT
Pump, if required
$127.00 per month
DEFP
Heparin Theraov
Amount
Code
Heparin
$65.00 + AWP
HEPT
Pump, if required
$127.00 per month
HEPP
Catheter Care -
Amount
Code
Any catheter type
$7.00 per day
CATHC
Supplies necessary to maintain IV catheter patency are often needed with certain regimens.
Chronic Granulomatous Disease _
Amount
Code
Actimmune®
$50.00 + AWP
AYCS
Cystic Fibrosis
Amount
Code
Pulmozyme®
$50.00+ AWP
- PULM
Coaeulation & Memotoloeical Disorders
Amount
Code
Antihemophilk Factor VIII
Recombinate®
$0.98/A.U.
ANTI
Kogenate®
$0.98/A.U.
ANTI
Koate®HP
$0.65/A.U.
ANT2
Melate®
$0.65/A.U.
ANT2
Hemoftl®
$0.70/A.U.
ANT3
Monoclate®
$0.80/A.U.
ANT4
Profilate®OSD
$0.42/A.U.
ANTS
EXHIBIT A
The Network Alliance
Page 9
Infusion - Continued
Antihemophilic Factor IX
Amount
Code
Mononine®
$0.90/A.U.
ANT6
Alphanine ®SD
$0.89/A.U.
ANT7.__-
Proplex xT
$0.23/A.U.
ANT8
Konyne® 80
$0.32/A.U.
ANT9
ProfilnineORT
- $0.32/A.U.
ANT9
Autoplexn
FEIBA®VH
DDAVP
Humate®
Chronic Immune Globulin Intravenous
(WIG Therapy)
Gammagard®SD Sandoglobulin®
Gamimune®N 5% Venoglobulin®-1
Gamimune®N 10% Venoglobulina-S
Alpha Antitrypsin Deficiency/
Genetic Emphysema
Amount Code
$ 1.14/A.U.
ANT10
$ 1.10/A.U.
ANTll
$219.00 per vial
ANT12
$ 1.10/A.U.
ANT11
Amount Code
$50.00 + AWP IVIG
Polygam ®SD
Gatnmar®IV
Iveegam®
Amount Code
Prolastin® - — $75.00 + AWP PROT
Continuous Passive Motion for TNU
PPO Allowable
Continuous Passive Motion Device Rentals $ 46.20 per diem
Splints and Set -Up Charges
_ Splints _ $360.00 per diem _ --
Set-Up Charges - $ 67.50
Other Related Services 9% discount
Note: Routine services of the Rehabilitation Coordinator are included in the above charges.
EXHIBIT A
The Network Alliance
Page 10
Per Diem Rates
Routine Home Care
$108.00/day
Inpatient Care
$476.00/day
Continuous Care
$631.00/day
Respite Care
$109.00/day
PER DIEM RATES INCLUDE THE FOLLOWING:
" s� r it r1v 3 b
Admission Visit
Skilled Visit (RN or LPN)
MSW Admission Visit
MSW/Chaplain Visit -- --
CNA Routine Visit
Spiritual Admission Assessment
Spiritual Routine Visit
Per Visit Rates
$110.00/visit
$ 80.00/visit
$110.00/visit
---S 80.00/visit--- ---- -
$ 28.00/visit
$ 50.00/visit
$ 20.00/visit
1. Intermittent home visits by licensed nurses. -
2. Home visits by social workers/counselors.
3. Home visits by home health aides.
4. Home visits by volunteers.
5. Chaplaincy services.
6. Family counseling services to patients and family members while the patient is receiving hospice care.
7. Bereavement care and for family up to 13 months following the patient's death.
8. Palliative physical therapy (only when necessary).
9. Palliative occupational therapy (only when necessary).
10. Palliative speech therapy (only when necessary).
it. Dietary consultation.
12. Durable Medical Equipment (excluding ventilators) related to the terminal diagnosis.
13. Routine medical supplies related to the terminal diagnosis.
14. Palliative medications related to the terminal diagnosis.
15. In -home lab fees related to the terminal diagnosis.
EXCLUSIONS TO THE PER DIEM RATES:
1. Inpatient Hospitalizations.
2. Outpatient diagnosis tests and other procedures. -
3. Custodial care.
4. Blood transfusions. -
5. Experimental therapy. --
6. Physician fees.
7. Radiation and chemotherapy.
8. Total Parenteral Alimentation.
9. IV antibiotics.
10. Insertion of Epidermal Catheters, Port-a-Cath, Central Lines.
it. Specialty Beds(e.g., Climitron).-
12. Epidermal infusion (unless all other methods have been exhausted).
13. Ventilators.
HOLIDAY RATES:
All "per visit" rates will be billed at time and one half for the following recognized holidays:
New Years Day
Labor Day
Memorial Day
Thanksgiving Day
Independence Day
Christmas Day
Holiday rates begin at I I p.m. on the eve of the holiday through I p.m. on the actual date of the holiday.
provide professional healthcare services to Covered Individuals and that Participating
Providers are individually and solely responsible for the professional decisions and
actions made while providing Healthcare Services to Covered Individuals.
ARTICLE VII
INSURANCE
7.1 SLMC agrees to maintain at its expense during the term of this Agreement professional
liability insurance in the amount of one million ($1,000,000) per occurrence to one
million ($1,000,000) aggregate to cover any claims that could arise from the provision of
services under this Agreement. Each of the parties hereto shall, during the term of this
Agreement, maintain at its sole cost and expense all necessary insurance for its
employees, including but not limited to workers' compensation, unemployment insurance,
and any other insurance required by law. Either party will provide the other with
certification of such insurance upon request.
ARTICLE VIII
MEDICAL RECORDS
8.1 participating Plan grants to SLMC the right to review Covered Individuals' medical
records.
8.2 SLMC shall require Participating Providers to maintain appropriate medical records in
such form, containing such information, and preserved for such time period(s) as required
by state and federal law and SLMC. All medical records shall be and remain the property
of Participating Providers and shall not be removed or transferred from the premises of
Participating Providers except in accordance with applicable law.
8.3 SLMC and its Participating Providers shall only release medical records of Covered
Individuals with written authorization for the release of such records signed by Covered
Individual or another person legally authorized to consent to the release of Covered
Individual's medical records. When presented with an adequate authorization for the
release of medical records, SLMC and its Participating Providers shall permit
Participating Plan to inspect Covered Individual's medical records, and shall provide
copies of such records to Participating Plan upon reasonable request. Participating Plan is
responsible to pay for copies of medical records, whether requested by SLMC or
Participating Plan, in accordance with rates established by the State of Colorado,
Department of Health.
8.4 This Agreement does not oblige SLMC to disclose to Participating Plan internal SLMC
records, documents, minutes, correspondence or any other document or item related to
the credentialing of or peer review activities or committee meetings related to any
10 PPOMPAR-WE-UR/Cn'Y OF FT COLLINS/11.20.98/jg
particular Participating Provider. Participating Plan is entitled to review the SLMC
policies and procedures relating generally to credentialing and peer review.
8.5 SLMC represents and warrants that it will maintain the privacy and confidentiality of all
medical records or other medical information that SLMC obtains from any provider
including a hospital or physician concerning Covered Individuals. SLMC further agrees
it will utilize the medical information it obtains only for utilization review determinations
and case management services, and will not release such medical information to any third
parry without prior written consent of the patient and Participating Plan unless required to
release such medical information by court order. SLMC may develop and release
statistical compilations and comparisons for purposes of statistical reporting as long as
Covered Individuals are not identified by name.
ARTICLE IX
CONFIDENTIALITY
9.1 SLMC and Participating Plan shall hold and cause their respective affiliates, employees,
and other representatives and agents to hold, in strict confidence, Confidential
Information concerning the other parry or with respect to this Agreement unless
compelled to disclose by judicial or administrative process or by other requirements of
law. For purposes of this Agreement, "Confidential Information" shall mean all
information of a proprietary or confidential nature including any financial information
relating to SLMC or Participating Plan, their respective affiliates, employees, agents or
other representatives, or information otherwise prohibited from transmission by
contractual, legal or fiduciary obligations, including any credentialing and peer review
information regarding Participating Providers and any information clearly marked as
confidential. Exhibits A and B of this Agreement shall be considered Confidential
Information. Confidential Information shall not include information generally available to
the public, other than as a result of a disclosure by the party receiving such information
on a non -confidential basis or from a source other than SLMC or Participating Plan. The
obligations contained in this Section 9.1 shall survive termination of this Agreement and
continue for a period of five (5) years thereafter.
ARTICLE X
PARTICIPATING PROVIDERS LISTING
10.1 Participating Plan may list each Participating Provider's name, address(es), telephone
number(s) and a description of his/her Healthcare Services in Participating Plan's
marketing/promotional activities to Covered Individuals. However, such description
and/or material shall be subject to SLMC prior written approval.
11 PPOMPAR-WE-UR/CrrY OF Fr COLLINS/11.20.981J8
ARTICLE XI
TERM OF AGREEMENT
11.1 This Agreement shall continue for a period of twelve (12) months and it shall thereafter
be renewed for successive one-year periods effective each January 1st unless terminated
as set forth in Sections 11.2 and 11.3.
11.2 This Agreement may be terminated at any time by mutual consent of both parties. This
Agreement may also be terminated without cause, with or without providing reasons for
termination, by any of the parties hereto upon not less than sixty (60) days prior written
notice to the other party. Any such written notice shall designate the intended date of
termination. The fees outlined under Article IV shall remain in effect until the designated
date of termination.
11.3 This Agreement may be terminated by either parry due to the failure of a parry to
correct a breach of its obligations under the Agreement within thirty (30) days after
written notice from the other party; however, that if any such breach by a party cannot,
with due diligence, be corrected within such thirty (30) day period, cause for
termination shall exist only if such party fails to undertake and to diligently pursue
correction of said breach as soon as reasonably possible.
11.4 Termination shall have no effect upon the rights and obligations of the parties arising out
of any transactions occurring between the parties prior to the effective date of such
termination unless otherwise specifically stated in this Agreement. Termination of the
Agreement shall not affect Participating Plan's obligation to pay for Covered Services
provided after termination of the Agreement to a Covered Individual who was properly
admitted to Hospital(s) or received Healthcare Services from a Participating Provider
prior to such termination provided Covered Individual was otherwise entitled to benefits -
of Participating Plan.
ARTICLE XII
DISPUTE RESOLUTION
12.1 Mediation. If any dispute or claim arising out of or relating to this Agreement cannot be
settled through informal negotiation by the parties directly, the parties agree that they will
not proceed with any further dispute resolution procedures without first participating in
mediation. Mediation is a process whereby a neutral third party facilitates discussion
between the parties in an attempt to resolve the dispute or claim without formal litigation.
It is not arbitration. Either party may initiate mediation by notifying the other party, and
the other parry must attend at least one mediation session, and attempt, in good faith, to
resolve the matter. The mediation shall occur within ten (10) days of the request for
mediation. The parties shall share equally in the cost of mediation. This paragraph shall
not apply to discussions between the parties held in conjunction with contract renewal or
renegotiation.
12 PP017/PAR-WE-UR/CrrY OF FT COLLINS/11.20.98/ig
12.2 Disputes under $10,000. In the event the parties are unable to resolve any dispute or
claim arising out of or relating to this Agreement by the procedure outlined in Section
12.1, above, the parties agree that, if the reasonable value of the claim is $10,000 or less,
and a party wishes to proceed with formal litigation, the claim must be filed in the nearest
County Court which can assert jurisdiction and all simplified civil procedure rules shall
apply. The parties hereto waive any right to a jury trial to which they may have
otherwise been entitled.
12.3 Disputes in excess of $10,000. In the event the parties are unable to resolve any dispute
or claim arising out of or relating to this Agreement by the procedure outlined in Section
12.1, above, and the reasonable value of the claim is in excess of $10,000, either party
may elect to proceed to binding arbitration, which election shall be binding on the other
party. Such arbitration shall occur within the County of Denver, State of Colorado,
unless the parties mutually agree to have such proceeding in some other locale. The
arbitration shall be conducted by one arbitrator, appropriately experienced with the issues
presented by the dispute. The arbitrator shall have no power to award punitive or
exemplary damages or to ignore or vary the terms of this Agreement and shall be bound
by Governing Law as set forth in this Agreement. The arbitration shall be conducted in
accordance with the Colorado Uniform Arbitration Act, or, in the alternative, other
procedural rules if such rules are mutually agreed to by the parties. The decision of the
arbitrator shall be final and binding upon both parties and enforceable in any court having
jurisdiction thereof. In the event neither party elects to utilize arbitration, the dispute
shall proceed to formal litigation in the appropriate District Court. The non -prevailing
parry in such arbitration or litigation shall be liable to the other party for reasonable
attorneys' fees and reasonable costs to the prevailing parry.
ARTICLE IIIII
MISCELLANEOUS PROVISIONS
13.1 Notices. Any notice required to be given pursuant to the terms and provisions hereof
shall be in writing and shall be personally delivered or sent by certified mail, return
receipt requested, postage prepaid, or by generally recognized overnight delivery services
who keep records of such deliveries, to the following addresses:
Participating Plan: City of Ft. Collins
200 W. Mountain, Suite A
Fort Collins, CO 80522
SLMC: Sloan Lake Managed Care, Inc.
1355 S. Colorado Blvd., Ste. 902
Denver, CO 80222
Attn: Contracts/Marketing
13 PPOMPAR-WE-UR/CITY OF Fr COLLINS/11.20.98/jg
13.2 Assignment. No party shall assign or otherwise transfer this Agreement or any interest
herein without obtaining the prior written consent of the other party. Notwithstanding the
foregoing, each party shall have the right to assign the Agreement and to delegate all
rights, duties and obligations hereunder, whether in whole or in part to any parent,
affiliate, successor, subsidiary organization or company of the parties. SLMC may from
time to time subcontract with other parties for various services provided under this
Agreement without the written consent of the Participating Plan.
13.3 Governing Law. This Agreement shall be construed and governed in all respects by the
laws of the State of Colorado.
13.4 Waivers and Amendments. No term or provision hereof shall be deemed waived and no
breach excused, unless such waiver or consent shall be in writing and signed by the party
claiming to have waived or consented. No waiver of any rights under this Agreement by
any party shall operate as a waiver of any other rights, or of the same right with respect
to any subsequent occasion for its exercise. No waiver by any parry of any breach of this
Agreement shall be held to constitute a waiver of any other breach or continuation of the
same breach. This Agreement may not be amended except in writing signed by each of
the parties to the Agreement.
13.5 Headings. The headings of the articles and paragraphs in this Agreement are used as a
matter of convenience and for reference only, and they in no way define, limit or describe
the scope of this Agreement or the intent of any of its provisions.
13.6 Severability. If any term or provision of this Agreement shall, to any extent, be held
invalid or unenforceable, the remainder of this Agreement shall not be affected. Such
remaining portion shall be valid, enforceable and of full force and effect.
13.7 Third Party Beneficiary. The parties to this Agreement do not intend to create or confer
any benefits under this Agreement to any other person or legal entity other than the
parties. The rights and obligations of each parry to this Agreement shall inure solely to
the benefit of the parties hereto, and no person or entity, including any Covered
Individual or Participating Provider, shall be considered a third party beneficiary of this
Agreement.
13.8 Trade Name Trade Mark and COAVright. Nothing contained in this Agreement shall
confer upon either parry a license to use or ownership of : (i) the name of the other party
or any other name under which a party operates, or (ii) any trademark, service mark or
trade name owned by such parry. Upon termination of this Agreement, all use of names,
trademarks, service marks or trade names owned by one parry as described above by the
other party shall cease, except as may be otherwise expressly authorized in writing. Each
of the parties to this Agreement warrant that neither this Agreement nor the tangible or
intangible products produced as a result of it will infringe upon or violate any patent,
copyright, trade secret or other proprietary right of any third parry, and each party will
indemnify and hold the other harmless from and against any loss, cost, liability or
14 PPOITPAR-WE-UR/CITY OF FT COLLINS/11.20.98/j8
expense (including reasonable attorney fees) arising out of any breach, or claimed breach
of this warranty.
13.9 Legal Action. In the event of legal action by a person not a party to this Agreement
against a party to this Agreement, related to the obligations or performance outlined
herein, the other parry shall cooperate to the extent that no conflict of interest exists
between the parties. Such cooperation may include providing appropriate individuals for
depositions and/or testimony in court.
13.10 Advertising Restraints. Each party agrees that, without the other party's written consent,
it will not use the name, service marks, or trademarks of the other party or of any of its
affiliated companies or reveal the existence of this Agreement or the terms or conditions
thereof in any written advertising, publicity release, or sales representation.
13.11 Acknowledgment. Each party acknowledges that it has read this Agreement, understands
it and agrees to be bound by its terms and further agrees that it is the complete and
exclusive statement of the Agreement between the parties, and supersedes all proposals,
oral or written and all other communications between SLMC and Participating Plan
relating to the subject matter of this Agreement.
13.12 Counterparts. This Agreement may be executed in one or more counterparts, each of
which shall be deemed an original and all of which together constitute one and the same
instrument, notwithstanding that all of the parties are not signatory to any one
counterpart.
IN WITNESS WHEREOF, the undersigned have executed this Agreement as of the day
and year first written above.
Sloan Lake Managed Care,
BY:es
TITLE: ,
DATE:
BY:
TITLE:
DATE:
City of Ft. Collin
BY:_
TITLE
DATE:
BY:
TITLE:
DATE:
15 PPO17/PAR-WE-UR/CrrY OF Fr COLLINS/11.20.98/jg
EXHIBIT A
The following time frame for payment of claims shall apply to all Participating Providers listed
on the following Exhibit A pages. Any time frame language which may appear on a specific
Participating Provider's Exhibit A shall supersede this language.
TIME FRAME FOR PAYMENT OF CLAIMS:
The Participating Plan agrees that claims submitted on behalf of Covered Individuals shall be
considered for payment within the time frames listed below by their claim administrator. If
claims are not paid or applied to Deductible, Copayment and out-of-pocket amounts within the
time frame described below, the claim shall not be eligible for the Participating Provider's
Negotiated Rate and no discount will be taken on the claim by the Participating Plan's claim
administrator. If a claim is denied, the Participating Plan agrees that its claim administrator
shall notify the Participating Provider within the time frames described below.
A claim shall be considered received by the Participating Plan's claim administrator the day it
is physically and electronically delivered to their place of business. If the Participating Plan's
claim administrator does not record the actual day the claim is physically received at its place
of business, the received date shall be five (5) days from the date the claim was mailed to the
Participating Plan's claim administrator based on either the Participating Provider's or
SLMC's record of mailing.
1. For claims not requiring additional information the time frame shall be within thirty (30)
days of receipt of the claim by the Participating Plan's claim administrator.
2. For claims that require additional information to determine if they are reimbursable
according to the Participating Plan's benefit provisions, the time frame shall be within
thirty (30) days of receipt of the information by the Participating Plan's claim
administrator. _-
Participating Plan agrees that its claim administrator will acknowledge receipt of a
pending claim and notify the Participating Provider of its pending status within thirty (30)
days of receipt of the claim.
3. The Participating Plan agrees that all claim appeals properly submitted to SLMC for
consideration of the Participating Provider's allowable amount, which is based on
Exhibits A, shall be adjusted by the Participating Plan's claim administrator, if
applicable, within thirty (30) days of receipt of the claim appeal by the Participating
Plan's claim administrator. Participating Plan agrees that its claim administrator shall
maintain a Repricing quality of no less than ninety percent (98%). If claims are not
Repriced in accordance with Exhibits A and it results in an incorrect claim payment to
the Participating Provider, the Negotiated Rate shall not apply.
PPOMPAR-WE-UR/CITY OF FT COLLINS/10.13.98/ig
EXHIBIT A
Ambulatory Surgery Center of the
Colorado Springs Health Partners, P.C.
(Formerly Colorado Springs Medical Center, P.C.)
Tax ED #84-1129000
Ambulatory Surgery Center of -the Colorado Springs Medical Center, P.C. agrees to a discount
of seven percent (7%) off total billed charges.
EXHIBIT A
Arkansas Valley Regional Medical Center
Tax ID #84-0393987
Arkansas Valley Regional Medical Center agrees to an eight percent (8%) discount off of billed
charges for all inpatient and outpatient charges.
Sloans Lake Managed Care, Inc.
PARTICIPATION AND MEDICAL MANAGEMENT AGREEMENT
This Participation Agreement is effective the 1st day of January, 1999, by and between
City of Ft. Collins (hereinafter referred to as "Participating Plan") and Sloans Lake Managed
Care, Inc., a Colorado corporation, (hereinafter referred to as "SLMC").
PREMISES
1. SLMC has been formed for the purpose of entering into agreements with third parties
(such as insurance companies, self -insured multi -employer plans and governmental
entities) for the delivery of healthcare by SLMC Participating Providers to the employees,
members or other constituents of such third parties, as well as their dependents,
hereinafter referred to as "Covered Individuals".
2. SLMC maintains a network of contracted physicians, hospitals and providers of ancillary
services available for use by Covered Individuals of Participating Plan. SLMC can
provide, utilization review and case management services for Covered Individuals
enrolled in a health benefit plan offered by the Participating Plan, and
3. Whereas, SLMC shall establish, operate and continuously maintain utilization review and
case management programs acceptable to the Participating Plan and in accord with
protocols agreed upon by SLMC and the Participating Plan, and
4. Participating Providers will accept as full payment SLMC Negotiated Rates and cooperate
with SLMC policies.
5. Participating Plan is a self -insured plan and wishes to secure for its Covered Individuals
the SLMC network of physicians, hospitals and ancillary service providers and to secure
for itself the benefits of SLMC network system.
Therefore in consideration of mutual promises contained herein, the parties agree as follows:
ARTICLE I
DEFINITIONS
1.1 "Agreement" means this Participation Agreement between the parties.
1.2 "Coinsurance", "Copavment" and "Deductible" mean the portion of payment due to the
Participating Provider from the Covered Individual for Covered Services under the terms
of the Participating Plan.
I PPOMPAR-WE-UR/Cn'Y OF FT COLLINS/11.20.98/j8
EXHIBIT A
ASPEN HEALTH PLUS, INC.
Aspen Valley Hospital District
Tax ID #84-0720309_
Aspen Valley Hospital agrees to a ten percent (10%) discount off total billed charges for all
inpatient and outpatient care_
NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or
logo, the Aspen Valley Hospital is not obligated to accept the above Negotiated Rate.
EXHIBIT A
Avista Hospital (PorterCare Hospital - Avista)
Tax ID #84-0438224
Avista Hospital commits to the following discounts:
1. Inpatient Services - An eight
P g ()percent discount from billed charges shall apply to all
inpatient services rendered.
2. Outpatient Services - An eight (8) percent discount from billed charges shall apply to all
outpatient services rendered.
The Hospital will discount total billed charges by the above percentage when the
Participating_> Plan is primary carrier on a claim.
When the Participating Plan is not primary carrier on a claim the Hospital will discount,
by the above percentage, the remaining balance after subtraction of the primary carrier's
payment.
EXHIBIT A
Boulder Community Hospital
Tax ED#84-0175870
The Following Discount Includes Services At:
Boulder Community Hospital Community Medical Center
1100 Balsam Avenue 2000 W. South Boulder Road
P.O. Box 9019
Lafayette, CO 80026
Boulder, CO 80301-9019
Mapleton Center -Behavioral Health Services Miriam R. Hart Regional Radiation Therapy Center
311 Mapleton Avenue 905 Alpine Avenue
P.O. Box 9130 Boulder, CO 80304
Boulder, CO 80301-9130
Note: Billed under Boulder Community Hosp-MPL
Hospital agrees to a discount of ten percent (10%) off total billed charges for services rendered both
inpatient and outpatient at the above facilities.
The Following Discounts Include Services At: Mapleton Center -Rehabilitation Services
311 Mapleton Avenue
P.O. Box 9130
Boulder, CO 80301-9130
Note: Billed under Boulder Community Hosp-
MPL
Rehabilitation:
Inpatient $850.00 per diem
Outpatient 12%u off total billed charges
The Following Discounts Include Services From:
Boulder Community HomeCare
_..
311 Mapleton Avenue
P.O. Box 9130
Boulder, CO 80301-9130
Service:
Rate Per Visit:
Skilled Nursing
$63.50
Physical Therapy
$70.00
Occupational Therapy
$70.00
Speech Therapy
$70.00
Social Worker
$85.00
Home Health Aide
$10.00 hour
High Tech Skilled Nursing (IV)
$65.00
Certified Nurse Assistant (CNA)
$44.00
�W.
Boulder Medical Center Ambulatory Surgery Unit
Tax ID #84-0834835
Negotiated Rates
Boulder Medical Center commits to a ten percent (10%) discount off billed facili charges for
services rendered in Boulder Medical Center's Ambulatory Surgery Unit.
EXHIBIT A
Breckenridge Medical Center
Tax ID #84-1206844
Negotiated Rates
Breckenridge Medical Center agrees to a five percent (5 %) discount off total billed charges.
.1
EXHIBIT A
Centura Home Care and Hospice
This contract includes the following providers:
Centura Home Care
2420 W. 26" Avenue, Suite 200D
Denver, CO 80211
Phone: 303.56t.5000
Fax: 303.561.5050
TIN: 84-0438224
Centura Home Care - Avista
333 S. Boulder Road, Suite 5
Louisville, CO 80027
Phone: 303.665.3228
Fax: 303.665.2223
TIN: 84-0438224
Centura Home Care - Brighton
1295 Bridge Street, Suite 102
Brighton, CO 80601
Phone: 303.659.5798
Fax: 303.659.6247
TIN: 84-0438224
Centura Home Health
4815 List Drive, Suite 102
Colorado Springs, CO 80919
Phone: 719.528.6991
Fax: 719.528.5324
TIN: 84-0405257
St. Mary Corwin Home Health
3921 Outlook Boulevard
Pueblo, CO 81008
Phone: 719.543.9680
Fax: 719.543.8136
TIN: 84-0405257
St. Thomas More Home Health
1338 Phay Avenue
Canon City, CO 81212
Phone: 719.269.2286
Fax: 719.269.2161
TIN: 84-0405257
Mercy Home Health & Hospice
3801 N. Main Street
Durango, CO 81301
Phone: 970.382.2000 -- -
Fax: 970.382.2069
TIN: 84-0405515
Mercy Home Health & Hospice
95 S. Pagosa Boulevard
Pagosa Springs, CO 81147
Phone: 970.731.9190
Fax: 970.731.9196
TIN: 84-0405515
Porter Hospice
2420 W. 26" Avenue, Suite 200D
Denver, CO 80211
Phone: 303.561.5000
Fax: 303.561.5050
TIN: 84-0438224
Porter Hospice - Avista
333 S. Boulder Road, Suite 5
Louisville, CO 80027
Phone: 303.665.3228
Fax: 303.665.2223
TIN: 84.0438224
Porter Hospice at The Johnson
Center
5020 E. Arapahoe Road
Littleton, CO 80122
Phone: 303.694.3545
Fax: 303.694.5103
TIN: 84-0438224
Porter Hospice at High Street
2379 S. High Street
Denver, CO 80210
Phone:303.871.0502 —
Fax: 303.698.1851
TIN: 84-0438224
Centura Home Infusion -
North State
2420 W. 26" Avenue, Suite 200D
enver, R —
Phone: 303.561.5000
Fax: 303.561.5050
TIN: 84-0405257
Centura Home Infusion -
South State
4815 List Drive, Suite 102
Colorado Springs, CO 80919
Phone: 719.260-4507
Fax: 719.2604522
TIN: 84-0405257
Centura/American Home Patient
2422 S. Trenton Way, Suite H
Denver, CO 80231
Phone: 303.306.9055
Fax: 303.306.0818
TIN: 84-1420928
Centura Home Oxygen
4815 List Drive, Suite 102
Colorado Springs, CO 80919
Phone: 719.599.0202
Fax: 719535.0158
TIN: 84-0405257
TIy1E FRAME FOR CLAIMS PAYMENT:
Participating Plan agrees to remit payments due from them within ninety (90) days of receipt of Participating
Provider's billing by the Participating Plan's claims administrator for claims not requiring additional information for
processing of the claim or claims not involving coordination of benefits. For processing of a claim when the
Participating Plan is the secondary carrier, or when additional information is required, the Participating Plan agrees
to remit payments due from them within ninety (90) days of receipt of the information by the Participating Plan's
claims administrator required to process the claim. If claims are not paid within the time frame described above
Centura Home Care and Hospices' Negotiated Rates shall not apply and no discount will he taken on the claim
by the Participating Plan's claim administrator.
EXHIBIT A
Centura Home Care and Hospice
Page 2
HOME HEALTH VISITS
B.
Antibiotic Therapy
Based upon the dosage schedule:
Single Drug Regimens
Per Diem
AWP
Single Antibiotic
Q24
115.00
100%
Single Antibiotic
Q12
122.00
100%
Single Antibiotic
Q8
127.00
100%
Single Antibiotic
Q6
139.00
100%
Single Antibiotic
Q4
144.00
100%
Multiple Drug Regimens
Per Diem
AWP
Mult. Antibiotic
Q24
122.00
100%
Mult. Antibiotic —
Q12
127.00
100%
Mult. Antibiotic
Q8
139.00
100%
Mult. Antibiotic
Q6
144.00
100%
Mult. Antibiotic —
Q4
149.00
100%
C.
Catheter Care: Central Line Maintenance - The daily rates for central line catheter maintenance shall be in
requires no
other therapy except dressing changes and maintaining potency of the
effect whenever a patient
include all dressing supplies, syringes, needles, heparin flush, saline flush,
catheter. The monthly charges
shall
and injection caps.
Per Diem
Single Lumen
9.00
Multiple Lumen
9.00
D.
Chemotherapy
Per Diem
AWP
_
82.00 -
100%
E.
Enteral Therapy
Per Diem
AWP
Syringe
19.00
100%
Pump
_
19.00
100%
_
Gravity
19.00
100%
F.
Hydration Therapy
Per Diem
I Liter per Day
57.00
2 Liter per Day
70.00
3 Liter per Day
82.00
4 Liter per Day
84.00
EXHIBIT A
Centura Home Care and Hospice
Page 3
HOME INFUSION continued
G. Miscellaneous Therapies and/or Drugs - Any therapy not covered above, or other additives to hydration
therapy.
Per Diem
AWP
Dobutamine
79.00 -
100%
Continuous Heparin Infusion
79.00
100%
IVIG
79.00
Prolasdn
79.00
100%
Erythropoietin
13.00
100%
Neupogen -
21.00
100%
Anti -Hemophiliac
27.00
100%
Leuprolide
13.00
100%
Growth Hormone
13.00
100%
Iron Dextran
79.00
100%
Methylprednisolone
_
79.00
100%
Other intramuscular/
subcutaneous drugs
48.00
100%
Other miscellaneous
therapies &/or drugs
79.00
100%
H. Pain Management -
Per Diem
AWP
82.00
100%
I. Total Parenteral Nutrition
Per Diem
Standard 1 Liter per Day
158.00
Standard 2 Liter per Day
202.00
Standard 3 Liter per Day
233.00
Additive drugs:
- AWP
J. Line Insertion
Per Diem
PICC Supplies with insertion
315.00
Midline Supplies with insertion
189.00
DURABLE MEDICAL EQUIPMENT
HCPC
CODE EQUIPMENT.. TYPE
RENTAL ;.... PURCHASE
E0100
Cane - (all materials) arljastable or fixed
_
18.00
E0105
Cane - quad or three prong with tip
--
36.00
E0110
Crutch forearm - adj or fixed, pair w/tip & handgrip
18.00
80.00
Eol11
Crutch, forearm Incl. various materials, adj or fixed whips & handgrip
---
40.00
_E0112
Crutches - underarm, wood, adj or fix pr w/pads, tips, grips
12.00
20.00
E0113
Crutches - underarm, wood, adj or fix, w/pad tip grip -
-_
_ IS 00
E0114
Crutches - underarm, alum, adj or fix, w/ pad/tips/hdgrips
---
28 p0
E0116
Crutches - underarm, alum, adj or fix, w/pad/tip/grip
--
18.00
E013D
Walker - rigid (pick up) adjustable or fixed height
---
65.00
E0135
Walker - folding (pick up) adjustable or fixed height
20.00
55.00
E0141
Walker - wheeled without seat
25.00
84.00
E0142
Walker - rigid and wheeled with seat
---
135.00
E0143
Walker - folding wheeled without seat
---
100.00
E0145
Walker - wheeled with seat/cruich attachment
---
110.00
E0146
Walker - wheeled with seat
_-
110.00
E0147
Walker - variable wheel resistance
---
286.00
EXHIBIT A
Centura Home Care and Hospice
Page 4
HCPC
CODE EQUIPMENTTYPE
CRUTCHES, WALKERS, & ACCESSORIES continued
E0153
Platform attachment Forearm crutch
E0154
Platform attachment walker
E0155
Wheel attachment - rigid (pick up) walker
E0156
Seat attachment walker -
E0157
Crutch attachment walker
E0158
Leg extensions: walker -
BATHROOM ASSISTANCE DEVICES
E0160
Sitz type bath, portable, fits over commode seat
E0161
Sitz type bath, port fit over commode seat w/faucet attachment
E0163
Commode chair - stationary with fixed arms
E0164
Commode chair - mobile with fixed arms
E0165
Commode chair - stationary with detachable arms
E0166
Commode chair - mobile with detachable arms
E0167
Commode chair - pail or pan
E0175
Commode chair - foot rest
E0224
Commode seat (raised)
E0245
Tub stool or bench
ALTERNATING PRESSURE PADS & ACCESSORIES
E0180
Alternating pressure pad with pump
E0181
Heavy duty alternating pressure pad with pump -
E0182
Pump for alternating pressure pad -
_ A4640 -
Replacement pads
MISCELLANEOUS PRODUCTS
E0607
Home blood glucose monitor
E0720
TENS - two lead
E0730
TENS - four lead
E0776
IV pole
- E0935
Continuous passive motion machine, including set up
-
COMPRESSED GAS -STATIONARY
E0424
Oxygen regulator - stationarMstem -
E0441
Oxygen refill - stationary cylinder
_
COMPRESSED GAS -PORTABLE
E0432
Oxygen regulator - portable system with can
E0443
Oxygen refill - portable cylinder -
OXYGEN CONCENTRATORS
E1375
Oxygen suppl nebulizer portable
E1400
Oxygen concentrator less than 2 liters per minute
E1401
Oxygen concentrator 2-3 liters per minute
E1402
Oxygen concentrator 3-4 liters per minute
E1403
Oxygen concentrator 4-5 liters per minute
E1404
Oxygen cone - mfg spec now rate >5 liters per min at 85%
RENTAL PURCHASE
--- 81.00
... 97.00
--- 28.00
--- 23.00
--- 53.00
23.00
17.00
15.00
-- 69.00
-- 119.00
132.00
205.00
-- 5.00
- 57.00
30.00
_ 49.00
32.00
259.00
42.00
302.00
24.00
178.00
---
30.00
96.00
30.00
325.00
38.00
360.00
13.00
97.00
46.00
--
36.00 - --- _
-- 30.00
39.00 --
--- 11.00
32.00
178.00
180.00
2403.00
180.00
2403.00
180.00
2403.00
180.00
2403.00
180.00
2403.00
EXHBIIT A
Centura Home Care and Hospice
Page 5
HCPC
CODE
-
EQUIPMENT TYPE
_-
RENTAL
PURCHASE
OXYGEN CONCENTRATORS continued
Maint
Concentrator maintenance when purchased
-_
38.00
LIQUID OXYGEN SYSTEMS
E0439..
Liquidoxygen stationary reservoir _ _..
ss nn _
7140 00
E0434
Liquid oxygen portable system
30.00
1008.00
E0 42
Liquid oxygen per pound
-
0.85
RESPIRATORY PRODUCTS
E0450
Volume ventilator - stationary or portable
700.00
E0452
Intermittent assist device with CPAPBIPAP
230.00
...
E0453
Therapeutic ventilator - BIPAP - ST
432.00
---
E0460
Negative pressure ventilator - portable/stationary,
513.00
_..
E0480
Percussor, electric or pneumatic, home model
38_00
_-
E0500
IPPB machine - all types, with built-in nebulizer
76.00
E0565
Compressor air power source
48.00
470.00
E0570
Nebulizer - with compressor
25.00
I10.00
E0575
Nebulizer - ultrasonic
75.00 -
- 450.00
E0660
Suction pump - portable home model
38.00
286.00
E0601
CPAP device with set-up
100.00
850.00
(includes initial head gear, tubing, rnask,etc)
E0608
Apnea monitor - recording
205.00
-
E0608
Apnea monitor - non -recording
135.00
._
Pulse oximeter
243.00
.--
CPAPBIPAP REPLACEMENT SUPPLIES
-
K0183
CPAP mask
---
50.00
K0185
CPAP head gear
-
33.00
K0187
Hose
---
28.00
K0188
CPAP filters
5.00
K0184
Nasal pillows
29.00
WHEELCHAIRS & ACCESSORIES
-
E1070
Fully recline w/c, desk or full length, swing detach footrests
65.00
729.00
E 1084
-Hemi w/c, detach arms, desk/full len arms, swing detach elev legrests
49.00
675.00 _
E1085
Hemi w/c, fix full length arms, swing away, detach footrests
43.00
578.00
E1088
H/S Igtwgt w/c detach arms, desk/full len, swing detach elev leg
49.00
675.00
E 1090
H/S Igrwgt w/c detach arms, desk or full len swing detach footrests
49.00
626.00
E1130
Std w/c fix full length arms. fix or swing detach footrests
32.00
351.00
E1140
W/c, detach arms, desk or full length swing detach footrests
38.00
389,00
El 150
W/c detach arms, desk or full length swing detach elev legrests
49.00
626.00
El 160
W/c fix full-length arms, swing away, detach, elev legrests
43.00
578.00
El170
Amputee w/c fix full-length arms, swing detach elev legrests
65.00
826.00
E 1172
Amputee w/c detach arms, desk or full len w/o foot or leg rest
81.00
848.00
E1260
Lgrwgt w/c detach arms, desk/full len, swing detach footrest
59.00
589.00
KO(98
Elevating legrest, complete assembly
11.00
130.W
Amputee w/c anti -tipping device
5.00
---
1.3 "Covered Individuals" means those eligible employees, members or other constituents of
the Participating Plan as well as their eligible dependents.
1.4 "Covered Services" means Healthcare Services which are provided to Covered
Individuals for which health benefits are reimbursable by the Participating Plan. Covered
Services includes the portion of the fee not reimbursed due to applicable Coinsurance,
Copayments, and Deductibles for which payment is the responsibility of the Covered
Individual.
1.5 "Healthcare Services" means those services, supplies and facilities normally provided by
the Participating Provider and that are within the scope of the Participating Provider's
license and accreditation.
1.6 "Hospital" means any hospital (or hospitals) which is (are) duly licensed in the State of
Colorado and accredited by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) (the JCAHO accreditation requirement may be waived at the
discretion of SLMC if the Hospital is Medicare certified) and which contracts with SLMC
to provide Healthcare Services.
1.7 Negotiated Rate(s) refers to the amount the Participating Provider must accept as full
payment for Covered Services rendered to Covered Individuals pursuant to the terms
and conditions of the provider agreement in effect between SLMC and each
Participating Provider at the time Covered Services are provided.
1.8 "Non -Covered Services" means Healthcare Services provided to Covered Individuals
which are not covered as part of the Participating Plan or, if covered, are not payable
because of the Participating Plan's applicable penalty provisions, benefit maximums, and
utilization review standards for which payment is the responsibility of the Covered
Individual.
1.9 "SLMC" means the integrated system of a Participating Provider network, cost
management programs, Negotiated Rates, provider communications expertise, and
management information systems offered by SLMC.
1.10 "Participating Provider" means any Physician, Hospital, Provider of Ancillary Services,
or preferred provider organization which has contracted with SLMC to provide
Healthcare Services to Covered Individuals and who are specifically included in this
Agreement.
1.11 "Physician" means a duly licensed medical doctor or doctor of osteopathy who is legally
permitted to practice medicine and who has contracted with SLMC to provide Healthcare
Services to Covered Individuals.
1.12 "Provider of Ancillary Services" means any properly licensed and/or credentialed
provider of healthcare or other allied or related products or services which do not fit
2 PP017/PAR-WE-UR/CrrY OF Fr COLLINS/11.20.98/J9
EXHIBIT A
Children's Home Care
Tax ID Number: 484-0166760
Children's Home Care agrees to the following pricing schedule.
I. HOME HEALTH SERVICES
Home Health Services include the following:
* Nursing Care: RN, LPN * Physical Therapy
* Occupational Therapy
* Speech and Audiology Therapy * Palliative Care/Hospice Services
* Clinical Social Work
A. Intermittent Nursing (price per visit)
$70.00
Each nursing visit constitutes up to 2.5 hours per visit and includes assessments, infusion, teaching, wound
care, post -operative care, etc. _
B. Home Phototherapy (price per diem)
$115.00
Includes nursing, phototherapy lights, or wallaby blanket and bilirubin level.
C. Rehabilitation Therapies
$69.00
* Physical Therapy * Occupational Therapy * Speech & Audiology Therapy
D. Clinical Social Work
$89.00
Includes a three (3) hour visit
I1. HOURLY NURSING CHARGES _
Nursing charges are based upon day time hours of 7:00 a.m. to 7:00 p.m. and night time hours from 7:00 p.m. until
7:00 a.m. Holidays include the following:
* Christmas Day
* Memorial Day
RN (all shifts)
LPN (all shifts)
* New Years Day
* Labor Day
* Independence Day
* Thanksgiving Day
$34.00
$24.00
III. KIDSTREET (Center -Based Care for Medically Fragile Children)
The KidStreet Center is open 5 days per week from 6:00 a.m. to 6:00 p.m. Transportation is available to and from the
center via a specially equipped van with a lift gate for wheelchair dependent children. A nurse provides care during
transport. -
Note: Children's Home Care utilizes strict admission criteria for access to these services.
Center -Based Nursing Rate: $24.00/hour
(Includes hours at the center and nurse transport time)
Rehabilitation Therapies $65.00/visit
(Includes physical, occupational and speech/audiology therapies. Respiratory therapy is included in the hourly rates
for the center.)
EXHIBIT A
Children's Home Care
Page 2
Arena Testing $234.00/visit
(Includes periodic testing of the child's physical, occupational, speech and audiology skills and abilities in a group test
with parent, physician, nursing staff and therapists to chart and report progress and revise the care plan for the child's
rehabilitative development.)
IV. INFUSION THERAPY RATES -.----
Medications administration IV, Intramuscular of Subcutaneous are priced using either a per diem price or a fee plus
average wholesale price (AWP.) AWP reflects the rate quoted monthly in the First Data Bank drug formulary.
Supplies included are listed with each therapy, Any additional supplies will be charged at the Ancillary Supply rate
quoted. All medications include an EpiPen or Epinephrine Administration Kit for emergencies in the event of an
anaphylactic reaction. Benadryl is not included in the supplies unless specifically ordered by the physician and will be
charged separately.
Children's Home Care Return Goods Policy states that no credit will be given for supplies or medications returned due
to Federal regulations which prohibit the use of any returned medical supply or medications. Supplies are carefully
monitored with one week or less of supplies as indicated being provided at one time with the exception of enteral
supplies. The close monitoring will minimize the amount of supplies that may go unused.
The rates quoted for infusion include Pharmacy with Limited Nursing. This includes two intermittent nursing visits to
teach the family/caregivers the administration and maintenance of the medication/enteral therapy, supplies, infusion
pump and pole, and delivery.
Any additional nursing visits will be charged at a rate of $70.00 per visit
Infusion Therapies include, but are not limited to
• Antibiotic/ Antifungal/ Antiviral/ Antiemetic/ Antirejection/ Colony Stimulating/ IV Steroids
• Antihemophiliac Factor
•_ Blood Transfusions —
• Chemotherapy
• Enteral Nutrition
• Growth Hormone/ Leuprolide
• Hydration
• Immune Globulin
• Pain Management
• Total Parenteral Nutrition
• Multiple Drugs
• Other
• Ancillary Supplies
Specific supplies are included in the per diem of fee rates quoted in this list for infusion therapies. Following is a list
of those typical supplies according to the type of line of administration.
Parenteral Supplies:
Central Line Dressing Kit
Administration Kit w/Filter
Syringes
Needles
Alcohol Wipes
Tape
Gloves
Clamp
Huber Needles w/Extension Tubing
Povidine (Iodine)
Sharps Container
Sodium Chloride Flush
Tegaderm
Heparin Flush
Epi Pen or Epinephrine Kit
Injection Cap
Interlink Needleless Svstem
Cassette/tiled Bag if Chemo
EXHIBIT A
Children's Home Care
Page 3
Peripheral Line Supplies: -
IV Start Kits
Administration Kit w/ Filter
Sharps Container
Syringes
Sodium Chloride Flush
Needles
Alcohol Wipes
Herapin Flush
Tape _ -
_.. EpiPen. or. Epinephrine_ Kit
Gloves -
Injection Cap
Interlink Needleless System
Catheter
Intramuscular/Subcutaneous
Alcohol Wipes
Sharps Container
Gloves
Syringes
Needles _
EpiPen or Epinephrine Kit
Immune Globulin Supplies
Syringes
Sharps Container
Needles
Povidone(Iodine)
Swabs
Injection Ports
Tape
Herapin Flush
Tubing
Saline Flush
Catheters
Tourniquet
Extension Tubing
EpiPen or Epinephrine Kit
V. INFUSION THERAPIES
A. Antibiotic/ Antifungal/ Antiviral/ Antiemetic/ Antirejection/ Colony Stimulating/ IV Steroids
(Peripheral and Central Lines) _
Per Diem Includes compounding fee, supplies, ambulatory or stationary pump, pole, delivery and
Limited Nursing.
AWP = Price of drug according to First Data Bank formulary
Single Antbx $95.00 plus Drug at AWP minus 10%
Double Antbx $145.00 plus two Drugs at AWP minus 10%
Triple Antbx $153.00 plus all three Drugs at AWP minus 10%
$15.00 per diem Intramuscular or Subcutaneous Injections
plus drug at AWP minus 10% Includes Limited Nursing
Parenteral or Peripheral or Intramuscular/Subcutaneous supplies. (See supply lists above). Supplies not
included in infusion rates = 20%off billed charges.
B. BLOOD AND BLOOD PRODUCTS (Per Diem)
$75.00 Transfusion - Pharmacy only delivery of blood products
plus current procurement rate of whole supplies, administration supplies and set-up.
blood, PRBCs, Platelets, Cyroprecipitate
$190.00 Transfusion - Pharmacy and 4 hours of Nursing includes:
plus current procurement rate of whole first visit for tab draw to type and cross -match, a follow -
blood, PRBC's, Platelets. Cyroprecipitate up visit for CSC and travel time to obtain blood products,
patient training and assessment, education and clinical
management.
EXHIBIT A
Children's Home Care
Page 4
C.
Ia
$300.00 - Transfusion - Pharmacy and 7 hours of Nursing includes:
plus current procurement rate of whole first visit for lab draw to type and cross -match, a follow -
blood, PRBC's, Platelete, Cyroprecipitate up visit for CBC and travel time to obtain blood products,
patient training and assessment, education and clinical
management.
Blood Transfusion Supplies (Included in per diem rate)
Tourniquet -
Gloves
Dressings
Alcohol Wipes
Tape
EpiPen or Epinephrine Kit
CHEMOTHERAPY (Per Diem)
(Infused)
580.00
plus drug at AWP minus 10%
(IV Push)
$45.00
plus drug at AWP minus 10%
Sharps Container
Herapin Flush
Tubing
Povidine (Iodine)
IV Start Kit
Pump and Pole
Chemotherapy - Pharmacy and Limited Nursing
Chemotherapy - Pharmacy and Limited Nursing
Parenteral Supplies (listed above) included in per diem rate.
ENTERAL NUTRITION (Per Diem)
(pump feed or gravity feed)
531.00
plus drug at AWP minus 10%
Gravity Feed Supplies
Gauze
Irrigation Supplies
Gravity Bags and Tubing
-Anti-reflex Valves
Pump Feed Supplies
Ambulatory or Nonambulatory Pump
Pump Supplies
Tape
Syringe
Irrigation Supplies
Syringe Feed Supplies
Irrigation Supplies
Syringes
Tubes
Enteral Nutrition - Pharmacy and Limited Nursing
Tape
Adapters and Caps _
3 Nasogastric Tubes per month
Enteral Bag and Tubing
Feeding Tube Supplies
Adapters and Caps
Gauze
Anti -reflex Valves
Gauze
Tape
EXHIBIT A
Children's Home Care
Page 5
E. GROWTH HORMONE/ LEUPROLIDE (Per Delivery)
(Includes but is not limited to Humatrope, Protropin, Neutropin & Leuprolide)
$15.00 per delivery
plus drug at AWP minus 10%
Growth Hormone Supplies ( Included in per diem)
Growth Hormone - Intramuscular Injection or
SubQ. Includes pharmacy and limited nursing
Syringes _. Needles
Swabs Sharps Container
EpiPen of Epinephrine Kit
F. HYDRATION (Per Diem)
(Includes Pharmacy and Limited Nursing)
$30.00
Up to 1 Liter Solution and Electrolytes
$35.00
Up to 2 Liters Solution and Electrolytes
$37 00
Up to 3 Liters Solution and Electrolytes
$40.00
Up to 4 Liters Solution and Electrolytes
Parenteral Supplies (listed above)
G. IMMUNE GLOBULIN (Per Diem)
Includes compounding fee, supplies, ambulatory or stationary pump, pole and delivery. Price of drug
according to First Data Bank formulary.
$75.00 Immunoglobulin - Pharmacy only
plus drug at AWP minus 10%
H. PAIN MANAGEMENT (Per Diem)
(Central Line, Subcutaneous, Epidural, Intrathecal)
$85.00 Pain Management - IV or Epidural
._ plus drug at AWP minus 10% _ Includes Pharmacy and Limited Nursing - —
$15.00 Pain Management - Intramuscular or Subcutaneous
plus drug at AWP minus 10% Includes Pharmacy and Limited Nursing
Parenteral Supplies or Intramuscular/Subcutaneous Supplies (listed above) _
Included in per diem rate.
I. TOTAL PARENTERAL NUTRITION (TPN) (Per Diem)
(Includes Lipids and Additives)
Includes drug, compounding fee, supplies, ambulatory or stationary pump, pole and delivery and Limited
Nursing.
$135.00 Up to I liter TPN solution, nutritional combinations of dextrose, lipids, electrolytes. vitamins.
proteins, amino acids and heparin
EXHIBIT A
Children's Home Care
Page 6
$145.00 Up to 2 liters TPN solution, nutritional combinations of dextrose, lipids, electrolytes, vitamins,
proteins, amino acids and heparin
$175.00 Up to 3 liters TPN solution, nutritional combinations of dextrose, lipids, electrolytes, vitamins,
proteins, amino acids and heparin -
$195.00 Up to 4 liters TPN solution, nutritional combinations of dextrose, lipids, electrolytes, vitamins,
proteins, amino acids and heparin
Parenteral Supplies (listed above) included in per diem rate
J. DESFERAL (Per Diem)
$45.00 plus drug at AWP minus 10% Includes drug and nursing
Parenteral Supplies (listed above)
K. MULTIPLE THERAPIES
1. 100% of the most expensive per diem drug at AWP minus 10%
2. 50% of the second most expensive per diem plus drug at AWP minus 10%.
3. No charge on remaining per diems, plus drug at AWP minus 10%.
L. ANCILLARY SUPPLIES
Other supplies not included in the supply lists will be allowed at 20% off billed charges.
EXHIBIT A
The Children's Hospital
Tax ID #84-0166760
Inpatient Service Rates:
A ten percent (10%) discount from billed charges shall apply to all inpatient services except for those
listed below.
Outpatient Services:
A ten percent (10%) discount from billed charges shall apply to all outpatient services except for those
listed below.
Inpatient and Partial Day Treatment Child and Adolescent Psychiatry
Child Psychiatry Inpatient - $494.00 per day
Adolescent Psychiatry Inpatient - $515.00 per day
Child and Adolescent Partial Day (8 hours) - $247.00
Child and Adolescent Partial Day (4 hours) - $137.00
Child Resident Program - $315.00 per day
Transplant Services':
Heart Transplant $62,000 per case (Covers from day of transplant to 30 days beyond
transplant.) Inpatient days 31 and beyond and any pre -transplant
inpatient hospital days shall be paid at a per diem rate of $2,500.
Liver Transplant $110,000 per case (Covers from day of transplant to 30 days after day
of transplant.) Inpatient hospital days 31 and beyond and any pre -
transplant inpatient days shall paid at a per diem rate of $2,500.
Lung Transplant $110,000 per case (Covers from day of transplant to 30 days beyond
transplant.) Inpatient hospital days 31 and beyond and any pre -
transplant inpatient hospital days shall be paid at a per them of $2,500.
- Kidney Transplant - $36,000 per case (Covers from day of transplant to 30 days beyond day _
of transplant.) Inpatient hospital days 31 and beyond and any pre -
transplant inpatient hospital days shall be paid at a per diem of $2,500.
Bone Marrow - All bone marrow transplant services shall be paid at an eighteen
Transplant percent (18%) discount from billed charges.
Day Sureery Dental Procedures Requiring Anesthesia (Effective 11/1/98):
The day surgery case rate for dental procedures requiring general anesthesia is $1,100.00 per case.
This rate covers hospital services only and does not include fees for dentists, oral surgeons,
pediatric anesthesiologists or other professional fees.
EXHIBIT A
Clagett Memorial Hospital
Tax ID #84-0513889
Clagett Memorial Hospital agrees to a three percent (3%) discount off total billed charges for
both inpatient and outpatient services.
NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or
logo, Clagett Memorial Hospital is not obligated to accept the above Negotiated Rate.
EXHIBIT A
Cleo Wallace Center
Tax ID #84-0406820
To include services at: Cleo Wallace Center Cleo Wallace Center
8405 West 100th Avenue 2525 S. Hwy. 115
Westminster, -CQ. 80221 ._ ._ ___-Colorado-Springs, CO 80906
Adolescent Inpatient
Children Inpatient
Adolescent and Child Residential Care
$475.00
$475.00
$235.00
Adolescent and Child Partial Hospitalization $225.00
The above quoted rates exclude the following:
Individual psychotherapy performed by a physician or licensed member of the
medical staff.
Neuropsychological testing or other special procedures.
Cost of medication ordered by the attending physician.
Any and all necessary physical medicine, dental, and optical treatment.
Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or
(b) billed charges.
EXHIBIT A
Colorado Orthopedic
Services Provided by Donald R. Hardin
1,0100 Cerv, Cranio, Helmet Molded/Padent Model
LOl 10 Cerv, Craniostenosis, Helmet, -Non -Molded --
L0120 Cerv, Flexible, Non -Adjustable (foam collar)
L0130 Cerv, Flexible, Thermo Collar, Molded/Patiem
L0140 Cerv, Semi -Rigid, Adjustable (plastic collar)
-
L0150 Cerv, Send -Rigid, Adjustable Molded Chin Cup
L0160 Cerv, Semi -Rigid, Wire Frame Occi/Mand Support
L0170 Cerv, Collar, Molded to Patient Model
L0172 Cerv, Collar, Semi -Rigid Thermo Foam- 2 pc
L0174 Cerv, Collar, Semi -Rigid Thermo Foam- 2 pe w/thor
L0130 Cerv, Mtdt Post Collar, OcciMland Supports
L0190 Cerv, Malt Post Collar, Occi/Maud Supports
L0200 Cerv, Mult Post Collar, OccVMand Supports
Ur 10 Thoracic, Rib Belt, Custom Fitted
L0220 Thoracic, Rib Belt, Custom Fabricated
U)300 Thoracic, Lumbar-Sacral-Orthosis (TLSO) Flexible
L0310 TLSO, Flexible, Custom Fabricated
L0315 TLSO, Flexible, Elastic type
L0317 TLSO, Flexible, Hyperextension, Elastic type
L0320 TLSO, Anterior -Posterior Control, w/apron front
L0330 TLSO, Ant -Post -Lateral Control, w/apron from
L0340 TLSO, Anterior -Posterior -Lateral- Rotary Control
L0350 TLSO, Ant-Post-Lat-Rot Control, Flex Comp Jacket
LOW TLSO, Ant-Pon-Lat-Rot Control, Flex Comp Jacket
L0370 TLSO, Ant-Post-Lat-Rot Control, Hyperextension
- L0380 TLSO, Ant-Post-Lat-Rot Control, w/Extensions
L0390 TLSO, Ant-Post-Lat Control (Body Jacket)
L0400 TLSO, Am-Post-Lat Control (Body Jacket -molded)
L0410 TLSO, Ant-Post-Lat Control (Body Jacket-2 pc)
L0420 TLSO, Ant-Post-Lat Control (Body Jacket-2 pc)
L0430 TLSO, Ant-Post-Lat Cont(Body Jacket-w/interface)
L0440 TLSO, Ant-Post-Lat Cont (Body Jacket-w/overlap)
L0500 Lumbar-Sacral-Orthosis (ISO)- Flexible
L0510 LSO, Flexible, Custom Fabricated
L0515 LSO",,'lexible, Elastic Type w/Rigid Posterior
L0520 LSO, Ant-Post-Lat Control (Knight, Wilcox types)
L0530 LSO, Ant -Post Control (Macausland type)
L0540 LSO, Lumbar Flexion (Williams Flexion type)
L0550 LSO, Ant -Post -Lateral Control (Body Jacket)
L0560 LSO, Ant-Post-Lat Control (Body Jacket -molded)
_ L0565 - LSO, Ant-Post-Lat Cont (Body Jacketcusmm fit)
L0600 Sacroiliac, Flexible- Custom Fitted -
L0610 Sacroiliac, Flexible- Custom Fabricated
L0620 Sacroiliac, Semi -Rigid- w/apron front
L0700 Cervical-Thomcic-Lumbar-Sacral-Orthoses (CTLSO)
L0710 CTLSO, Anterior -Posterior -Lateral Control
L0810 Halo Procedure-Cery Halo incorp into Jacket
L0820 Halo Proc-Cery Halo imorp/plaster body jacket
L0830 Halo Proc-Cery Halo incorp into Milwaukee type
L0860 Addition to Halo Proc-Magnetic Reasonattce Image
L0900 Torso Support- Ptosis Support- Custom Fitted
L0910 Torso Support- Ptosis Support- Custom Fabricated
L0920 Torso Support -Pendulous Abdomen Support- Fined
L0930 Torso Support -Pend Abdomen Support -Fabricated
L0940 Torso Support -Post Surgical Support -Custom Fitted
L0950 Torso Support -Post Surgical Support- Fabricated
L0960 Torso Support -Post Surgical Support- Pads
Tax ID #84-1160260
424.63
L0972
LSO- Corset Front
72.55
__. 93.52 ._....
--1.0974-._-TLSO-TatCorser-
-
18.10
L0976
LSO- Full Corset
138.49
105.44
L0978
Axillary Crunch Extension
125.66
51.21
L0980
Peroneal Straps- Pair
11.33
71.71
L0982
Stocking Supporter Grips- Set of four
11.00
100.02
1,1000
CTLSO (Milwaukee)
1609.74
415.45
LI010
Addition no CTLSO
44.88
97.40
L1020
Add no CTLSO or Scoliosis Orthosis (Kyphosis pad)
57.59
233.73
L1025
Add to CTLSO/Scoliosis Orth- Kyphosis pad -floating
84.51
241.23
L1030
Add to CTLSO/Scoliosis Orth- Lumbar Bolster Pad
41.90
374.13
L1040
Add to CTLSO/Scoliosis Orbosis- Lumbar
50.53
372.95
L1050
Add to CTLSO/Scoliosis Orthosis. Sternal Pad
55.61
29.25
L1060
Add to CTLSO/Scoliosis Orthosis- Thoracic Pad
63.14
77.44
L 1070
Add to CTLSO/Scoliosis Orthosis- Trapezius Sling
59.58
115.64
L1080
Add to CT'LSO/Scoliosis Orthosis- Outrigger
47.22
218.01
L1085
Add to CTLSO/Scoliosis Orthosis- Outrigger- Bdat
100.00
172.49
L10%
Add to CTLSO/Scioiosis Orthosis- Lumbar Sling
61.87
272.69
L1100
Add to CTLSO/Sciolosis Orthosis- Ring_Flange
104.83
251.78
1,1110
Add to CTLSO/Scoliosis Orthosis- Ring Flange
168.90
301.50
L1120
Add to CTLSO/Scoliosis Orthosis- Cover for Upright
26.05
437.58
L1200
TLSO- Inclusive of Furnishing Initial
1296.15
703.05
L1210
Addition to TLSO- Lateral Thoracic Extension
240.59
1183.13
L1220
Addition to TLSO- Anterior Thoracic Extension
145.24
265.15
L1230
Addition to TLSO- Milwaukee Type Superstructure
485.95
425.92
L1240
Addition to TLSO- Lumbar Denotation Pad
50.02
1222.63
L1250
Addition to TLSO- Anterior Asis Pad
46.29
1358.32
L1260
Addition to TLSO- Anterior Thoracic Derotation Pad
48.76
1529.15
L1270
Addition to TLSO- Abdominal Pad
49.57
1582.30
L1290
Addition to TLSO- RIB Gasser- Elastic- each
55.57
1145.00
L1290
Addition to TLSO- Laterial Trochanteric Pad
50.12
744.85
L1300
Other Scol Proc-Body Jacket Molded, Patient Model
1444.11
88.44
L1310
Other Scol Pmc- Post -Operative Body Jacket
1491.36
177.80
L1500
Thor -Hip -Knee -Ankle Orth(THIC40)-Mobility Frame
1355.97
138.56
L1510
THKAO- Standing Frame
1027.70
274.16
L1520
THKAO-Swivel Walker
1487.44
356.67
L1600
Hip Orthosis (HO)- Abduction Comml/ Hip Jts
89.33
370.62
L1610
HO- Abduction Control/Hip Jts-Flex-fmjka Cover _.
28.62
1070.27
L1620
HO- Abduction ControVHip Jts-Flex-Pavlik Harness
88.26
1190.63
L1630
HO- Abduction Control/Hip Jts-Semi-Flex (VonRosen)
111.31
748.77
L1640
HO-Abduct Control/Hip Its -Pelvic Band/Spread Bar)
358.34
79.10
L1650
HO- Abduction Control/Hip Jts-.4dj- Custom Fitted
16724
169.90
L1660
-HO- Abduction Control/Hip Its -Plastic- Custom Fit
109.07
274.75
L1680
HO- Abduction Control/Hip Jts-Dynamic-Pelvic Cont
802.72
1323.25
L1685
HO- Abd Control/Hip Its -Post Op Hip Abd Type
757.26
1557.28
L1686
HO- Abduction Control/Hip Its -Post Op Custom
685.74
1677.11
L1700
Legg Perthes Orthosis- Tororuo Type
996.07
1423.34
L1710
Legg Perthes Orthosis- Newington Type
1159.26
2053.61
L1720
Legg Perthes Orthosis- Trilateral (Tachoijan type)
902.99
1093.09
L1730
Legg Perthes Orthosis- Scottish Rite type
739.21
107.89
L1750
Legg Perthes Orthosis- Sling (Sam Brown type)
127.42
220.33
L1755
Legg Perthes Orthosis- Patten Bottom type
1070.23
126.46
L1900
Knee Orthosis (KO)- Elastic w/stays
42.51
246.04
L1810
KO- Elastic w/joints
68.89
101.33
L1815
KO- Elastic w/Condylar Pads
63. 19
221.54
L1820
KO- Elastic w/Condylar Pads & Joints
97.93
44.95
L0970 TLSO- Corset Front 99.60
within the definition of a Hospital or Physician, and which contracts with SLMC to
provide Healthcare Services to Covered Individuals.
1.13 "Repricing or Reprice" means the recalculation of a claim based on the rates outlined in
Exhibits A and B.
ARTICLE U
NETWORK MANAGEMENT
2.1 SLMC shall contract with a network of Participating Providers to provide Healthcare
Services to Covered Individuals and shall require Participating Providers to accept as full
payment for Covered Services the SLMC Negotiated Rates as outlined in Exhibits A and
B, which are attached hereto and incorporated by reference herein. SLMC may add or
delete Participating Providers to or from this Agreement with written notice to the
Participating Plan or the Participating Plan's claim administrator. Such written notice,
for the addition of Participating Providers, shall include the Participating Provider's
Exhibit A or B. Further, SLMC may, from time to time, negotiate and provide to
Participating Plan or its claim administrator updated Exhibits A and B for Participating
Providers. Participating Plan shall pay claims in accordance with and otherwise abide by
such new and updated Exhibits A and B.
2.2 Participating Providers will collect from responsible Covered Individuals, in accordance
with their usual collection practices, amounts that are owed for Non -Covered Services
and portions of a Negotiated Rate not paid by the Participating Plan as a result of the
Participating Plan's Copayment, Coinsurance or Deductible provisions.
2.3 SLMC agrees to ensure that all new Participating Providers undergo a credentialing
process before participation in SLMC and shall provide peer review services with respect
to Physician Healthcare Services that are provided under this Agreement. The conduct of
the peer review functions under this Agreement shall be the sole responsibility of SLMC.
The rights of the Participating Plan or its Covered Individuals are not limited by this
function.
2.4 SLMC agrees to require all Participating Providers to maintain a current license or
certificate authorizing them to deliver Healthcare Services in the State of Colorado.
Hospitals must be properly licensed in the State of Colorado and accredited by the Joint
Commission on Accreditation of Healthcare Organizations (unless granted a waiver by
SLMC). Physicians must maintain staff privileges with at least one Hospital subject to
this Agreement, unless the Physician's practice does not require hospital usage.
2.5 SLMC agrees to require all Physicians to carry malpractice liability insurance in the
minimum amount required by Colorado State law. SLMC agrees to require all Hospitals
to carry malpractice liability insurance, or maintain a program of self funding of
3 PP017/PAR-WE-UR/CrrY OF Fr COLLINS/11.20.98fg
EXHIBIT A
Colorado Orthopedic
Page 2
L2260
Add/Lower Extremity -Reinforced Solid Stirrup
169.83
1.2265
Add/Lower Extremity-Lorig Tongue Stirrup
78.57
L1825
KO- Elastic Knee Cap
35.78
L2270
Add/Lower Extremity-Varus Valgus Correct
41.36
L1830
KO- Immobilizer- Canvas Longitudinal
63.60
L2280
Add/Lower Extremity -Molded Inner Boot
326.69
L1832
KO- Adjustable Knee Its- Rigid Support- Custom Fit
387.49
L2300
Add/Lower Extremity -Abduction Bar-Bilat Hip
172.07
L1834
KO- w/o Knee Jt- Rigid- Molded to Patient Model
534.33
L2310
Add/Lower Extrenmy-Abduction Bar -Straight
102.94
L1840
KO- Derotation- Medial -Lateral -Am Cmc Lig-Fitted
602.30
L2320
Add/Lower Extremity -Non Molded Lacer
136.31
L1845
KO- Double Upright -Thigh & Calf- Adj Flexion
555.74
L2330
Add/Lower Extremity -Lacer Molded/Padent Model
282.23
L1846
KO- Double Upright-Tbigh/Calf-w/adjust Flexion
688.11
L2335
Add/Lower Extremity -Anterior Swing Band
161.11
__. L1850
KO -Swedish type_.. - ---._ __ _-__
232.05_..
_L2340-__Add/Lower
Extremity -Pre Tibial.Sbell-Molded
7RR RR _..
L1855
KO- Molded Plastic -Thigh & Calf- doub upr knee jt
721.09
L2350
Add/Lower Extremity -Prosthetic Type -Molded
612.42
LI858
KO- Molded Plastic-Polycentric Knee it (knee pads)
893.78
L2360
Add/Lower Extremity-Ererded Steel Shank
38.75
L1860
KO- Modification/Supmcondylar Prosthetic Socket
749.04
L2370
Add to Lower Extremity- Patten Bottom
167.25
L1870
KO- Double Upright- Thigh & Calf Lacers- Molded
697.45
L2375
Add/Lower Extremity -Torsion Control -Ankle It
72.58
L1880
KO- Double Upright- Non molded Tbigh/Calf Lacers
483.55
L2380
Add/Lower Extrem-Tors CotmolStraight Knee It
104.67
L1900
Ankle -Foot Orthosis (AFO)- Spring W m
231.15
L2385
Add/Lower Extrem-Straight Knee Jt-Heavy Duty
119.60
L1902
AFO- Ankle Gauntlet- Custom Fitted
51.82
L2390
Add/Lower Extremity -Offset Knee Jt-ea jt
94.57
L1904
AFO- Molded Ankle Gauntlet- Molded/Patient Model
327.83
L2395
Add/Lower Extmnity-Offset Knee Jt-Heavy Duty
134.73
L1906
AFO- Multiligamentus Ankle Support
102.67
L2405
Add to Knee Jt/Dmp Lock- eajt
43.07
L1910
AFO- Post- Single Bar- Clasp Attach/Shoe Counter
201.07
L2415
Add to Knee Jt- Cam Lock (Swiss, French, Bait)
119.17
L1920
AFO- Single Upright w/Static or Adjus Stop
303.44
L2425
Add/Knee Jt- Disc or Dial Lock-Adj Knee Flexion
119.74
L1930
AFO- Custom Fitted - Plastic
164.43
L2435
Add/Knee Jt- Polycentrlc It- ea jt
108.03
L1940
AFO- Molded to Patient Model- Plastic
321.82
L2492
Add/Knee Jt- Lift Loop for Drop Lock Ring
79.66
L1945
AFO- Mold/Patient Model -Plastic -Rigid Am Fib Sect
620.69
L2500
Add/Lower Extremity -Thigh/ Weight Bearing
219.41
L1950
AFO- Spiral- Molded to Patient Model (IRM type)
548.35
L2510
Add/Lower Extremity-Thigh/Wt Bearing -Molded
476.91
L1960
AFO- Posterior Solid Ankle- Molded/Padem Model
362.99
L2520
Add/Lower Extremity-Thigh/Wt Bearing -Custom
328.35
L1970
AFO- Plastic Moded to Patient Model- Ankle Joint
498.06
L2525
Add/I.ower Extremity-ThighfWt Bearing-Ischial
898.17
L1980
AFO- Single Upright Free Plantar Dorsiflexion
267.38
L2526
Add/Lower Extremity-Thigh/Wt Bearing4schial
573.89
L1990
AFO- Double Upright Free Plantar Dorsiflexion
286.98
L2530
Add/Lower Extremity-Thigh/Wt Bear -Non Molded
197.62
L2000
Knee-Ankle-Foot-Orthoses (KAFO)- Single Upright
746.65
L2540
Add/Lower Extremity-Thigh/Wt Bear -Molded
305.52
L2010
KAFO- Single Upright- Thigh & Calf Bands
703.18
L2550
Add/Lower Extremity-Thigh/Wt Bear -High Roll Cuff
255.65
L2020
KAFO- Double Upright- Thigh & Calf Bands
754.91
L2570
Add/Lower Extremity -Pelvic Control -Hip Jt
307.55
L2030
KAFO-Doub UprightSolid Stirrup-Thigh/Calf Bands
665.13
L2580
Add/Lower Extremity -Pelvic Control -Pelvic Sling
360.10 ._.
L2036
KAFO- Full Plastic-Doub Upright. Free Knee -Mold
1530.34 -
L2600
Add/Lower Extrem-Pelvic Cont-Hip A-Clevis type
175.90
L2037
KAFO- Full Plastic -Single Upright -Free Knee -Mold
1078.23
L2610
Add/Lower Extrem-Pelvic Cont-Hip It -Thrust
191.11
L2038
KAFO- Full Plastic -w/o Knee Jt-Molded to Patient
939.78
L2620
Add/Lower Extrem-Pelvic Cont-Hip Jt-Heavy Duty
191.75.
L2040
Hip -Knee -Ankle -Ft Orthosis(HKAFO)-Torsion Cont
152.41
L2622
Add/Lower Extrem-Pelvic Cont-Hip Jt-Adjust Flex
203.61
L2050
HKAFO- Torsion Control- Bilateral Cables- Hip
386.22
L2624
Add/Lower Extrem-Pelvic Cont-Hip Jt-Adjust Flex
212.62 -
L2060
HKAFO- Tors Cont- Bilat Cables-Mlbear Hip It
438.41
L2627
Add/Lower Extrem-Pelvic Cont-Plastic.Molded
1358.21
L2070
HKAFO- Torsion Control- Unilateral Rotation Straps
87.38
L2628
Add/Lower Extrem-Pelvic Cont-Metal Frame
1301.74
L2080
HKAFO- Torsion Control- Unilat Torsion Cable -Hip
256.35
L2630
Add/Lower Extrem-Pelvic Cont-Band/BeR-Unilat
217.89
L2090
HKAFO- Torsion Control- Hnilat Torsion Cable -Ball
345.37
L2640
Add/Lower Extrem-Pelvic Cont-Band/Belt-Bilat
234.95
L2102
Ankle-Foot-Orthosis (AFO)- FX Orlhosis-Tibial FX_
310.89
L2650
Add/Lower Extrem-Pelvic/Thoracic Cont-Gluteal Pad
78.57
L2104
AFO- FX Orthosis-Tibial FX Cast Orthosis
327.12
L2660
Add/Lower Extrem-Thoracic Cont-Thoracic Band
155.07
L2106
AFO- FX Orthosis-Tibial FX Cast Ottlwsis-Thermo
437.27
L2670
Add/Low Extrem-Thoracic Cont-Paraspinal Upright
145.10
L2108
AFO- FX Orthosis-Tibial FX Cast Ortlmsis-Molded
908.35
L2680
Add/Low Extrem-Thoracic Cont-Iat Support Upright
133.50
L2112
AFO- FX Orthosis-Tibial FX Orth-Soft Custom Fit
316.89
L2750
Add/Lower Extrem-Orthosis-Plating Chrome -per bar
53.06
L2114
AFO- FX Orthosis-Tibial FX Orth-Semi-Rigid Fit
410.24
L2760
Add/Lower Extrem-Orthosis-Extension-per bar
52.33
L2116
AFO- FX Orthosis-Tibial FX Orth-Rigid Custom Fit
458.69
L2770
Add/Lower Extrem-Orthosis-Stainless Steel -per bar
50.15 _
L2122
Knce-Arai de -Foot- Orthosis (KAFO) FX Orthosis
531.33
- L2780
Add/Lower Extrem-Orthosis-Non Corrosive Finish
43.50
_
L2124
KAFO- FX Orthosis-Femoral FX Cast Orth-Synth
658.65
L2785
Add/Lower Extrem-Orthosis-Drop Lock Retainer, ea
20.62
L2126
KAFO- FX Orthosis-Femoml FX Cast Orth-Thermo
865.34
L2795
Add/Low Extrem-Orthosis-Knee Cont-Full Kneecap
55.74
L2128
KAFO- FX Orthosis-Femoral FX Cast Orth-Molded
1170.10
L2800
Add/Low Extrem-Orthosis-Knee Cont-Medial
69.89
L2132
KAFO- FX Orthosis-Fern FX Cast OrthSoft Fitted
- 621.98
L2810
Add/Low Extrem-Orthosis-Knee Cont-Condylar Pad
49.53
L2134
KAFO- FX Orth-Fem FX Cast Orth-Semi Rigid Fit
649.12
L2820
Add/Low Extrem-Orthosis-Soft Interface -Mold Platet
67.24
-
L2136
KAFO- FX Orth-Fem FX Cast Orth-Rigid Custom
847.96
L2830
Add/Low Extrem-Ordwsis-Soft Interface -Mold Plate
82.27
L2180
Add to Lower Extremity FX Orthosis-Plastic Shoe
90.97
L2840
Add/Low Extrem-Orthosis-Tibial Length Sock-FX
27.71
L2182
Add/Lower Extremity FX Orth-Drop Lock Knee it
60.62
L2850
Add/Low Extrem-Orthosis-Fenrmml Length Sock-FX
51.81
L2184
Add/Lower Extremity FX Orth-Limit Motion Knee It
85.39
L3215
Orthopedic Footwear -Ladies Shoes -Oxford
82.65
L2186
Add/Lower Extrem FX Ornh-Adjust Motion Knee It
111.43
L3219
Orthopedic Footwear -Mess Shoes -Oxford
105.32
L2188
Add/Lower Extrem FX Orth-Quadrilaterial Brim
191.42
L3650
Shoulder Onhosis (SO)- Figure of "8" Design
38.53
L2190
Add/Lower Extremity FX Orth-Waist Belt
59.66
L3660
SO -Figure of "8" Design-Abd Restrainer -Canvas
68.68
L2192
Add/Lower Extremity FX Orth-Hip Jt-Pelvic Band
236.71
L3670
SO-Acromio/Clavicular-Canvas & Webbing type
72.68
L2200
Add/Lower Extremity -Limited Aide Motion-eajt
39.09
L3700
Elbow Orthosis (EO)-Elastic w/smys
45.77
L2210
Add/Lower Extremity-Dorsilexion Assist
56.93
L3710
EO- Elastic w/Metal Joints
78.89
L2220
Add/Lower Extremity-Dorsiflexion & Plantar Flex
63.44
1.3720
EO- Double Upright/Forearm/Arm Cuffs
428.92
L2230
Add/Lower Extremity -Split Flat Caliper Stirrups
55.59
L3730
EO- Double Upright w/Fomarm/Arm Cuffs-Exten
574.61
L2240
Add/Lower Extremity -Round Caliper & Plate Attach
57.69
L3740
EO- Double Upright w/Forearm/Arm Cuffs -Adjust
676.38
1,2250
Add/Lower Extremity -Foot Plate, Molded to Patient
286.96
EXHIBIT A
Colorado Orthopedic
Page 3
L4055
Replace Non -Molded Calf Lacer
171.49
L4060
Replace High Roll Cuff •
282.72
L3800
Wrist-Hand-Finger-Orthoses{WHFO)Short Opponents
165.70
L4070
Replace Proximal/Distal Upright for KAFO
208.51
L3805
WHFO- Long Opponents- No Attachment
268.48
L4080
Replace Metal Bands KAFO- Proximal Thigh
67.30
L3810
WHFO- Add to Short/Long Opponens-Thumb Abd
55.78
L4090
Replace Metal Bards KAFO-AFO-Calf/Distal Thigh
62.46
L3815
WHFO- Add to Short/Long Opponensr2nd M P
51.58
L4100
Replace Leather Cuff KAFO- Proximal Thigh
69.46
L3820
WHFO- Add to Short/Long Opponents- I P Exten
83.78
L4110
Replace Leather Cuff KAFO- Calf/Distal Thigh
58.50
L3825
WHFO-.Add to Short/Long Opponens-MP Exten-Stop
53.80
L4130
Replace Pretibial Shell
331.45
L3830
WHFO-Add to Short/Long Oppon- MP Exten-Assist
65.68
L4310
Multi-Podus/Equal Orthotic Preparatory Mgmt
332.61
L3835
WHFO-Add to Short/Long Oppon- MP Spring
69.56
L4320
Add to AFO-Muld-Podus Orthotic Prep Mgmt
97.96
L3940
W 4PO-Add ioShort/Long Cppoh=Spring wivet
-45-03-
1,4350
Pneurname enk�nt-rol Splint-Aircast or Equal-- -- - -
58.71
L3845
WPIFO-Add to Short/Long Oppon-Thumb IF Extent
65.99
L4360
Pneumatic Walking Splint- Aircast or Equal
197.21
L3850
WHFO-Add to Short/Long Oppon-Action Wrist
80.29
L4370
Pneumatic Full Leg Splint-Aircast or Equal
134.93
L3855
WHFO-Add to Short/Long Oppon-Adjust MP -Flex
83.43
LA380
Pneumatic Knee Splint- Aircast or Equal
69.81
L3860
WHFO-Add to Short/Long Oppon-Adjust MP
116.44
L5000
Partial Foot -Shoe haert w/Longitudinal Arch
340.02
L3900
WHFO- Dynamic Flexor Hinge-Rec Wrist Exten
873.49
L5010
Partial Foot -Molded Socket- Ankle Height
1026.48
L3901
WHFO- Dynamic Flexor Hinge-Rec Wrist Exten
1156.64
L5020
Partial FootKMolded Socket- Tibial Tubercle HE
1807.31
L3902
WHFO- External Powered- Compressed Gas
1851.16
L5050
Ankle- Symes- Molded Socket- Bach foot
1751.76
L3904
WHFO- External Powered- Electric
2202.58
L5060
Ankle- Symes-Metal Frame -Molded Leather Socket
2293.58
L3906
WHFO- Wrist Gauntlet- Molded to Patient Model
2%24
L5100
Below Knee -Molded Socket- Skin- sach foot
1606.06
L3907
WHFO- Wrist Gauntlet- w/Thumb Spica
322.88
L5105
Below Knee -Plastic Socket -Its ru Thigh Lacer
2645.72
L3908
WHFO- Wrist Extension Control Cock -Up -Canvas
42.17
L5150
Knee Disarticuaton-Molded Socket-Ext Its
2735.46
L3910
WHFO- Swanson Design
290.41
L5160
Knee Disarticulation-Molded Socket -Bent Knee
2965.83
L3912
WIIFO- Flexion Glove w/ Elastic Finger Control
72.06
L5200
Above Knee- Molded Socket- Single Axis
2391.06
L3914
WHFO- Wrist Extension Cock -Up
55.24
L5210
Above Knee -Short Prosthe-No Knee It -Foot Blocks
1901.57
L3916
WHFO- Wrist Extension Cock -Up w/Outrigger
80.79
L5220
Above Knee -Short Prosthe-No Knee It -Articulated
2125.36
L3918
WHFO- Knuckle Render
50.45
L5230
Above Knee -for Proximal Femoral Focal Deficiency
3559.43
L3920
WHFO- Knuckle Bender w/Outrigger
63.13
_ 1.5250
Hip Disarticulation-Canadian type -Hip Jt
4368.74
L3922
WHFO- Knuckle Bender- 2 Segment to Flex Its
63.54
L5270
Hip Disarticulation-Tilt Table type -Locking It
4191.98
L3924
WHFO- Oppenheimer
69.02
L5280
Hemipelvectomy-Canadian type -Hip it
4577.49
L3926
WHFO- Thomas Suspension
60.36
L5300
Below Knee -Molded Socket-Sach Foot
1959.95
L3928
WHFO- Finger Extension w/Clock Spring
37.46
L5310
Knee Disarticulation- Molded Socket-Sach Foot
3345.10
L3930
WHFO- Finger Extension w/Wrist Support
40.44
L5320
Above Knee- Molded Socket-Sach Foot
2953.15
L3932
WHFO- Safety Pin- Spring Wire
29.94
L5330
Hip Disarticulation-Canadian type -Molded Socket
4854.58
L3934
WHFO- Safety Pin- Modified
31.24
L5340
Hcmipelvecmmy-Canadian type Molded Socket
5295.13
L3936
WHFO- Palmer
57.47
L5400
Immediate Post Surg/Early Fitting -Rigid Dressing
997.03
L3938
WHFO- Dorsal Wrist
59.35
L5410
Immediate Post Surgical or Early Fitting
289.92 -
L3940
WHFO- Dorsal Wrist w/Outrigger Attachment
_ 68.79
L5420
Immediate Post Surg/Early Fitring-Rigid Dressing
1279.05
L3942
WHFO-Reverse Knuckle Bender
48.95
L5430
Immediate Post Surg-Early Fitting-Initid Appli. -
346.05
L3944
WHFO- Reverse Knuckle Bender w/Outrigger
63.52
L5450
Immed Post Surg/Early Fitting -Non WE Bearing
368.57
L3946
WHFO- Composite Elastic
57.63
L5460
Immed Post Surg/Early Fitting -Application
491.89
L3948
WHFO- Finger Knuckle Bender
35.45
L5500
Initial -Below Knee PTB type Socket
1198.96
L3950
WHFO- Comb Oppenheimer w/Knuckle Bender
97.85
L5505
Initial -Above Knee- Ischial Level Socket
1491.50
L3952
WHFO- Comb Oppenheimer w/Rev Knuckle Bender
109.09
L5510
Preparatory Below Knee PTB type Socket-USMC
1253.35
L3954
WHFO- Spreading Hand
67.81
L5520
Preparatory Below Knee FTB type Socket-USMC
1086.42
L3960
Shoulder -Elbow -Wrist Hand Orthosis (SEWHO)
486.65
L5530
Preparatory Below Knee PTB type Socket-USMC
1516.23
L3962
SEWHO- Abduction Position- ERBS Palsey Design
450.96
L5535
-Preparatory Below Knee PTB type Socket-USMC
-1168.91
L3963
SEWHO- Molded w/Articulating Elbow Joint
1059.62
L5540
Preparatory Below Knee PTB type Socket-USMC
1589.96
L3964
SEWHO- Mobile Arm Support-Attach/wheelchair
479.22
L5560
Preparatory Above Knee-Ischial Level Socket
1783.27
L3965
SEWHO- Radial Am Support-Attach/wheelchair -
-759.66
L5570
Preparatory Above Knee-Ischial Level Socket
1878.97
L3966
- SEWHO- Mobile Arm Support -Attach wheelchair
596.57
L5580
Preparatory Above Knee-Ischial Level Socket
2173.47
L3968
SEWHO- Mobile Am Support-AMach/wheelchair
675.64
L5585
Preparatory Above Knee-Ischial Level Socket
2166.80
L3969
SEWHO- Mobile Am Supp-Monosuspen-AmAHand
493.67
L5590
Preparatory Above Knee-Ischial Level Socket
2225.66
L3970
SEWHO- Addition/Niobile Arm Supp-Elevate Amr
208.72
L5595
Preparatory- Hip Disarticulation-Hemipelvectomy-
2766.69
L3972
SEWHO- Addition/Mobile Arm Supp-Offset/Lat
167.42
L5600
Prep -Hip Disarticulation-Hemipelvecmmy-Pylon
3077.96
L3974
SEWHO- Addition/Mobile Arm Supp-Supinator-
106.27
L5610
Add to Lower Extremity -Above Knee-Hydracadence
1734.10
L3980
Upper Extremity FX Orthosis- Humeral
198.15
L5611
Add to Lower Extremity -Above Knee-Disarticulation
1353.08
L3982
Upper Extremity FX Orthosis- Radius/Ulnar
279.57
L5613
Add to Lower Extremity -Above Knee-Disarticulation
1930.75
L3984
Upper Extremity FX Orthosis- Wrist
266.73
L5616
Add to Lower Extremity -Above Knee-Univ Multiplex
1255.43
L3985
Upper Extremity FX Orthosis- Forearm/Hand
389.60
L5618
Add to Lower Extremity -Test SccketSymes
194.53
L3986
Upper Exrremiry FX Orthosis- Combination
361.48
L5620
Add to Lower Extremity -Test Socket -Below Knee
195.62
L3995
Add/Upper Extrem Orthosis- Sock FX or Equal
21.06
L5622
Add to Lower Extremity -Test Socket-Disarticulation
251.36
L4000
Replace Girdle for Milwaukee Orthosis
862.45
L5624
Add to Lower Extremity -Test Socket -Above Knee
273.61
L4010
Replace Trilateral Socket Brim
444.59
L5626
Add/Lower Extrem-Test Socket -Hip Disarticulation
329.89
L4020
Replace Quadrilateral Socket Brim- Molded
569.88
L5628
Add/Lower Extremity -Test Socket-Hemipelvectomy
333.44
L4030
Replace Quadrilateral Socket Brun- Comm Fit
330.13
L5629
Add/Lower Extremity -Below Knee -Acrylic Socket
216.80
L4O40
Replace Molded Thigh Lacer
284.18
L5630
Add/Low Extrem-Symes type -Expand Wall Socket
313.13
L4045
Replace Non -Molded Thigh Lacer
238.94
L5631
Add/Low Extrem-Above Knee -Acrylic Sock
299.97
L4050
Replace Molded Calf Lacer
274.39
EXHIBIT A
Colorado Orthopedic
Page 4
L5812
Add -Endo Knee -Shin Syst-Sing Axis -Friction Swing
515.01
L5816
Add -Endo Knee -Shin Syst-Poly-Meth Stance
772.53 --^-
L5632
Add/Low Extrem-Symes type-PTB Brim Design
201.47
L5818
Add -Endo Knee -Shin Syst-Poly-Friction Swing
889.99
L5634
Add/Low ExtremSymes type -Canadian Socket
278.90
L5822
Add -Endo Knee -Shin Syst-Sing Axis-Pneumat Swing
1492.30
L5636
Add/Low ExtremSymes type -Medial Open Socket
233.22
L5824
Add -Endo Knee -Shin Syst-Single Axis -Fluid Swing
1430.30
L5637
Add/Low Extrem-Below Knee -Total Contact
208.49
L5828
Add -Endo Knee -Shin Syst-Single Axis -Fluid Swing
2249.72
L5638
Add(Low Extrem-Below Knee -Leather Socket
447.02
L5830
Add -Endo Knee -Shin Syst-Single Axis -Pneumatic
1340.43
L5639
Add/Low Extrem-Below Knee -Wood Socket
1006.71
L5850
Add-Endoskeletal Syst-Above Knee or Hip Disart
114.60
L5640
Add/Low Extrem-Knee Disarticul-Leather Socket
585.25
L5910
Add -Endo Syst-Below Knee- Alignable system
328.41
L5642...
Add/Low Extrem-Above Knee:LeatheLSocket_-_ _._
___ 578.16_--_
t 5920
Add -Endo gyct-Above Knee or Hip Disarticularinn
487 75_..
L5643
Add/Low Extrem-Hip Disarticul-Flex Inner Socket
1346.53
L5940
Add-Endoskeletal Syst-Below, Knee -Ultra Lt Mat
466.64
L5644
Add/Low Extrem-Above Knee -Wood Socket
548.63
L5950
Add-Endoskeletal Syst-Above Knee -Ultra Lt Mat
535.38
L5645
Add/Low Extrem-Below Knee -Flex Inner Socket
721.60
L5960
Add -Endo Syst-Hip Disarticuladon-Ultra Lt Mat
679.53
L 5646
Add/Low Extrem-Below Knee -Air Cushion Socket
418.04
1.55%
All Lower Extremity Prostheses-FoodSach Foot
171.43
L 5647
Add/Low, Extrem-Below Knee Suction Cup
725.05
I.5972
AN Lower Extremity Prostheses -Flex Keel Foot
292.80
L5648
Add/Low Exttm-Above Knee- Air Cushion Socket
617.28
L5974
All Lower Extremity Prostheses -Foot -Sing Axis
174.62
L5649
Add/Low Extrem-Ischial Containment
1383.16
L5976
A0 Lower Extrem Prostheses -Energy Staring Foot
445.28
L 5650
Add/Low, Extrem-Total Contact -Above Knee -
465.11
L5978
All Lower Extrem Prostheses -Foot -Multiaxial
211.26
L5651
Add/Low Extrem-Above Knee -Flex Inner Socket
1120.34
L5980
All Lower Extrem Prostheses -Flex Foot System
3404.20
L5652
Add/Low Extrem-Suction Suspension -Above Knee
414.04
L5982
All Exo Lower Extrem Prostheses -Axial Rotation
550.45
L5653
Add/Low Extrem-Knee DisarxlcW-Expand Socket
545.28
L5984
AS Endo Lower Extrem Prostheses -Axial Rotation
419.49
L5654
Add/Low Extrem-Socket Insert-Symes
257.36
L5986
All Lower Extrem Prostheses -Multi Axial Rotation
557.97
L5655
Add/Low Extrem-Socket Insert -Below Knee
205.39
L6000
Partial Hand -Robin Aids -Thumb Remaining
930.08
L5656
Add/Low Extrem-Socket Insert -Knee Disarticulation
275.23
L6010
Partial Hand -Robin Aids -Little Wor Ring Finger
1081.72
L5658
Add/Low Extrem-Socket Insert -Above Knee
306.59
L6020
Partial Hand -Robin Aids -No Finger Remaining
994.73
L5660
Add/Low Extrem-Socket Insert-SymesSilicone Gel
406.44
L6050
Wrist Disart-Molded Socket -Flex Elbow Hinges
1483.57
L5661
Add/Low Extrem-Socket Ins-Multi-Duromerer Symes
418.07
L6055
Wrist Disart-Molded Socket w/Expand Interface
1982.76
L5662
Add/Low Extrem-Socket Ira -Below Kr=Sil Gel
431.71
L6100
Below Elbow -Molded Socket-Frex Elbow Hinge
1453.79
L5663
Add/Low Extrem-Socket Ins-Disarticl-Sil Gel
494.32
L6110
Below Elbow -Molded Skt(Muensner/Northwestem)
1540.63
L5664
Add/Low Extrem-Socket Ins -Above KneeSil Gel
467.20
L6120
Below Elbow -Molded Double Wall Split Socket
1737.63
L5665
Add/Low Extrem-Socket Ins-Multi-Duro-Below Knee
353.93
L6130
Below Elbow -Molded Dbl Wall Spt Skt-Stump Act
1921.58
L5666
Add/Low Extrem-Below, Knee -Cuff Suspension
46.97
L6200
Elbow Disarticidation-Outside Locking Hinge
2076.53
L5668
Add/Low Extrem-Below, Knee -Mold Distal Cushion
68.08
L6205
Elbow Disarticulation-Expandable Interface
2533.01 ..�.
L5670
Add/Low Extrem-Below, Knee -Molded Supracondylar
246.02
L6250
Above Elbow -Molded Dbl Wall Skt-Ira Lock Elbow
1960.48
M672
Add/Low Extrem-Below Knee -Rem Med Brim Susp
285.16
L6300
Shoulder Disarticulation-Molded Socket
2732.90
L5674
Add/Low Extrem-Below, Knee -Latex Sleeve Sop
49.73
L6310
Shoulder Disatvculation-Passive Rester -Complete
2099.66
L5675
Add/Low Extrem-Below Knee -Latex Sleeve Susp
65.58
L6320
Shoulder Disarticulation-Passive Rester -Cap only
1272.74
L5676
Add/Low Extrem-Below Knee -Knee Its -Single Axis
327.47
L6350
Interscapular Thomcic-Molded Socket
3378.91
L5677
Add/Low Extrem-Below, Knee -Knee Its-Polycentric
344.72
L6360
Interscapular Thoracic -Passive Restor-Complere
2184.59
L 5678
Add/Low Extrem-Below, Knee -It Covers -Pair
35.76
L6370
Interscapular Thoracic -Passive Restor-Cap only
1435.74
L.5680
Add/Low Extrem-Below Knee -Thigh Lacer
278.13
L6380
Immediate Post Surg/Early Fitting -Rigid
845.53
L5682
Add/Low Extrem-Below, Knee -Thigh Lacer-Gluteal
458.68
L6382
Immediate Post Surg/Early Firdarg-Rigid
1137.81
L 5684.
Add/Low Extrem-Below, Knee -Fork Strap
36.10
L6384
Immediate Post Surg/Early Fitting -Rigid
1526.79
L5686
Add/Low Extrem-Below Knee -Back Check
40.02
L6386
horned Post Surg/Early Fitting -ea add cast change
300.82
L5688
Add/Low Extrem-Below Knee -Waist Belt -Webbing
42.15
L6388
Intoned Post Surg/Early Fitting -Rigid Dressing only
396.17
L5690
Add/Low Extrem-Below Knee -Waist Belt -Padded
67.39
L6400
Below Elbow -Molded Socket-Endoskeletal Syst
2147.03
L 5692
Add/Low Ext-Above Knee -Pelt' Com Belt -Light
101.93
L6450
Elbow Disarticulation-Molded Socket -Endo Syst
2700.38
L5694
Add/Low Ext-Above Knee -Pelt' Com Belt -Padded
147.86
L6500
Above Elbow -Molded Socket -Endo Syst-Soft Prosth
2845.92
- L5695
Add/Low Extrem-Above Knee -Pelvic Control
137.63
L6550
Shoulder Disartindation-Molded Socket -Endo Syst
3418.45 -
L5696
Add/Low Extrem-Above Knee-Disart-Pelvic A
126.98
L6570
Interscapular thoracic -Molded Socket -Endo Syst _.
3624.73
L5697
Add/Low Extrem-Above Knee-Disart-Pelvic Band
55.46
-1.6580
Prep -Wrist Disart/Below Elbow -Plastic Socket
1344.38
L5698
Add/Low Extrem-Above Knee-DisanSilesian
72.77
L6582
Prep -Wrist DisartBelow Elbow -Single Wall Skt
1285.45
L5699
All Lower Extremity Prosthese"houlder Harness
127.73
L6584
Prep -Elbow Disart/Below Elbow -Plastic Socket
1426.56
L5710
Add- Exoskeletal Knee -Shin System -Single Axis
302.80
L6586
Prep -Elbow Disart/Above Elbow -Single Wall Ski
1392.76
L5711
Add-Exoskeletal Knee -Skin System -Single Axis
363.12
L6588
Prep -Shoulder DisaNlnterscapular Thoracic
1964.22
L5712
Add-Exoskeleal Kne"hin System -Friction Swing
320.23
L6590
Prep -Shoulder Disart/Interscapular Thoracic
1862.28
L5714
Add-Exoskeletal Knee -Shin System -Variable Friction
352.66
L6600
Upper Extremity Additions-Polycentric Hinge
128.68
L5716
Add-Exoskeletal Knee -Shin System-Polycentric-Meth
672.20
L6605
Upper Extremity Additions -Single Pivot Hinge
128.88
L 5718
Add-Exoskeletal Knee -Shin System-Poly-Frict Swing
845.01
L6610
Upper Extremity Additions -Flexible Metal Hinge
131.19
L5722
Add-Exo Knee -Shin Syst-Single Axis-Preumat Swing
765.22
L6615
Upper Extremity Add -Disconnect Locking Wrist Unit
126.99
L 5724
Add-Exo Knee -Shin Syst-Single Axis -Fluid Swing
1141.59
L6616
Upper Extremity Add-Discoruect Insert
44.92
L5726
Add-Exo Knee -Shin Syst-Single Axis-Ext Its
1224.21
L6620
Upper Extremity Add -Flexion Friction Wrist Unit
247.64
L5728
Add-Exo Knee -Shin Syst-Single Axis -Fluid Swing
2193,36
L6623
Upper Extremity Add -Spring Asst Rotational Unit
445.01
L.5780
Add-Exo Knee -Shin Syst-Single Axis -Pneumatic
839.89
L6625
Up Extrem Add -Rotation Wrist Union w/Cable Lock
357.07
L5785
Add-Exoskeleml Syst-Below Knee -Ultra Lt Mat
357.87
L6628
Upper Extrem Add -Quick Disconnect Hook Adapter
440.11 --..
L 5790
Add-Exoskeletal Syst-Above Knee -Ultra Lt Mat
498.66
L6629
Upper Extem Add -Quick Discon lamination Collar
133.80
L 5795
Add-Exoskeletal Syst-Hip Disart-Ultra Lt Mat
721.12
L6630
Upper Extrem Add-Staidess Steel -any Wrist
150.44
L5810
Add -Endo Knee-Shin-Syst-Single Axis -Manual Lock
399.46
L6632
Upper Extrem Add -Latex Suspension Sleeve
60.83
L5811
Add -Endo Knee -Shin Syst-Single Axis-Ultm Light
596.89
EXHIBIT A
Colorado Orthopedic
Page 5
L6900
Hand Restor (Casts, shading included) Partial Hand
1043.33
L6905
Hand Restor (Casts, shading, measurements inc)
1020.05
L6635
Upper Extremity Addition -Lift Assist for Elbow
152.29
L6910
Hand Restor (Casts, shading, measurement; inc)
1021.62
L6637
Upper Extremity Add -Nudge Control Elbow Lack
251.68
L6915
Haul Restor (Shading & Measurements inc)
431.58
L6640
Upper Extrem Add -Shoulder Abduction It -Pair
221.13
L6920
Wrist Disarticulation-Self Susp Inner Socket
5199.61
L6641
Upper Extrem Add -Excursion Amplifier -Pulley type
129.60
L6925
Wrist Disarticulation-Self Susp Inner Socket
5605.75
L6642
Upper Extrem Add -Excursion Amplifier -Lever type
149.96
L6930
Below Elbow-Ext Power -Self Susp Inner Socket
5593.49
L6645
Upper Extrem Add -Shoulder Flexion -Abduction It
219.93
L6935
Below Elbow-Ext Power -Self Susp Inner Socket
6I40.66
L6650
Upper Extrem Add -Shoulder Universal It
232.37
L6940
Elbow Disart-Ext Power -Molded Inner Socket
8112.35
L6655
Upper Extrem Add -Standard Control Cable
- L6945
Elbow Disart-Ext Power -Molded Inner Socket
8962.66
L6660
Upper Extrem Add -Heavy Duty Control Cable
_ _53.35
64.77
L6950
Above Elbow-Ext Power -Molded Inner Socket
- 9601.98
L6665
Upper Extrem Add -Teflon or Equal Cable Lining
31.14
L6955
Above Elbow-Ext Power -Molded Inner Socket
11418.15
L6670
Upper Extrem Add -Hook to Hand -Cable Adapter
32.56
L6960
Shoulder Disart-Ext Power -Molded Inner Socket
9897.06
L6672
Upper Extrem Add-Harness-Chest/Shoukler-Saddle
153.88
L6965
Shoulder Disart-Ext Power -Molded Inner Socket
11005.94
L6675
Upper Extrem Add -Harness -Figure "8" type -Single
80.42
L6970
Imterscap-Thorac-Ext Power -Molded Inner Socket
10969.32
L6676
Upper Extrem Add -Harness -Figure "8" type -Dual
103.69
L6975
Interscap-Thorac-Ext Power -Molded Inner Socket
11945.66
L6680
Upper Extrem Add -Test Socket -Wrist D'tsarticulation
180.23
L7010
Electronic Hard -Otto Bock-Steeper/Equal-Switch
2478.00
L6682
Upper Extrem Add -Test Socket -Elbow Disarriculation
194.74
L7015
Electronic Hand -System Teknik-Switch Controlled
4082.78
L6684
Upper Extrem Add -Test Socket -Shoulder Disart
255.74
L7020
Electronic Greifer-Otto Bock -Switch Controlled
2483.42
L6686
Upper Extremity Addition -Suction Socket
405.04
L7025
Electronic Hard -Otto Bock-Myoelectronicaily Cant
2435.18
L6687
Upper Extrem Add -Frame Skt-Below Elbow/Wrist
528.07
L7030
Electronic Hard -System Teknik-Myoelectron Cont
3994.80
L6688
Upper Extrem Add -Frame Skt-Above Elbow/Wrist
372.98
L7035
Electronic Grehfer-Otto Bock-Myoelecuon Cont
2515.33
L6689
Upper Extrem Add -Frame SiaShoulder Disar
571.14
L7040
Prehensile Acruamr-HosmerSwitch Controlled
1926.27
L6690
Upper Extrem Add -Frame Skit-Imerscapular-Thoracic
475.27
L7045
Electronic Hook -Child -Michigan -Switch Controlled
1067.51
L0691
Upper Extrem Add -Removable Insert- each
234.49
1.7160
Electronic Elbow-BosronSwitch Controlled
10328.77
L6692
Upper Extrem Add -Silicone Gel Insert
485.76
L7165
Electronic Elbow-Boston-Mycelectronicall-v Cant
12500.36
L6700
Terminal Device-Hook-Dorrance/Equal-Model #3
477.58
L7170
Electronic Elbow-Hosmer-Switch Controlled
4254.35
L6705
Terminal Device-Hook-Dorrance/Equal-Model #5
275.14
L7180
Electronic Elbow-Utah-Myoelectronically Cant
25018.55
L6710
Terminal Device-Hook-Dorrance/Equal-Model #5X
315.55
L7185
Electron Elbow-Adol- Variety Village -Switch Cont
4411.22
L6715
Terminal Device-Hook-Dorran ce/Equal-Model #5XA
321.32
L7186
Electronic Elbow -Child -Variety Vill-Switch Cont
8031.16
L6720
Terminal Device-Hook-Dormnce/Equal-Model #6
788.30
L7190
Electronic Elbow -Adolescent -Variety Village
5547.72
L6725
Terminal Device-Hook-Dorrance/Equal-Model #7
369.09
L7191
Electronic Elbow-Child-Variery Vilt-Myo Cont
7803.50
L6730
Terniml Device-Hook-Dorrance/Equal-Model #7LO
535.16
L7260
Electronic Wrsr Rotator -Otto Bock/&lual
1636.47
L6735
Terminal Device-Houk-Dorrance/Equal-Model #8
277.36
L7261
Electronic Wrist Rotator for Ural Arm
3073.58
L6740
Terminal Device-Hook-Dorrance/Equal-Model #8X
359.47
L7266
Servo Control- Steeper or Equal
693.62
L6745
Terminal Device-Hook-Dorrance/Equal-Model #88X
329.00
L7272
Analogue Control- UNB or Equal
1540.26
L6750
Terminal Device-Hook-Dorrance/Equal-Model #10P
321.21
L7274
Proportional Control-12 Volt-Utah/Equal
4556.58
L6755
Terminal Device-Hook-Dorrance/Equal-Model #10X
314.31
L7360
Six Volt Battery- Otto Bock or Equal -each
157.41
L6765
Terminal Device-Hook-Dorrance/Equal-Model #12P
302.23
L7362
Battery Charger- Six Volt- Otto Back or Equal
231.15
L6770
Terminal Device-Hook-Dorance/Equal-Model #99X
324.04
L7364
Twelve Volt Battery -Utah or Equal- each
278.20
L6775
Terminal Device-Hook-Dorrance/Equal-Model #555
355.94
L7366
Battery Charger -Twelve Volt- Utah or Equal
381.15
L6780
Term Device-Hook-Dortance/Equal-Model #SS555
380.43
L8000
Breast Prosthesis- Mastectomy Bra
25.41
L6790
Terminal Device -Hook -Attu Hook/Equal
340.29
L8010
Breast Prosthesis- Mastectomy Sleeve
54.07
L6795
Terminal Device-Hook-2 Load or Equal
901.30
L8020
Breast Prosthesis- Mastectomy Form
140.48
L6800
Terminal Device-Hook-APRL VC or Equal
864.90
L8030
Breast Prosthesis- Silicone or Equal
239.79
L6805
Terminal Device -Modifier Wrist Flexion Unit
263.66
L8300
Truss- Single w/Standard Pad
69.41
L6806
Terminal Device-Hook-TRS Grip -VC
914.34
L8310
Truss- Double w/Standard Pads --
113.43
L6807
Terminal Device-Hook-TRS Adept -Child -VC
906.72
L8320
Truss- Addition to Standard Pad- Water Pad
37.39
L6908
Terminal Device-Hook-TRS Adept-infant-FC
788.19
L8330
Truss- Addition to Standard Pad -Scrotal Pad
33,65
L6809
Terminal Device-Hook-TRS Super Sport -Passive
340.80
L840O
F stheric Sheath- Below Knee- each
11.08
L6810
Terminal Device -Pincher Tool-Dtm Bock/Equal
172.45
L8410
Prosthetic Sheath- Above Knee- each
16.90
L6825
Terminal Device -Hand- Dorance-VO
854.33
L8415
Prosthetic Sheath- Upper Limb -each
15.90
L6830
Terminal Device -Hand- APRL-VC
1246.31
L8420
Prosthetic Sock- Wool- Below Knee- each
13.56
L6835
Terminal Device -Hand- Siena-VO
1072.57
L8430
Prosthetic Sock- Wool- Above Knee- each
15.76
L6840
Terminal Device -Hard- Becker Imperial
685.03
L8435
Prosthetic Sock- Wool- Upper Limb- each
14.76
L6845
Terminal Device -Hand- Becker Lock Grip
600.32
L9440
Prosthetic Shrinker- Below Knee -each
28.86
L6850
Terminal Device -Hand- Becker Plylite
543.94
L8460
Prosthetic Shrinker- Above Knee- each
45.65
L6855
Terminal Device -Hand- Robin Aids- VO
744.81
L8465
Prosthetic Shrinker- Upper Limb- each
35.33
L6860
Terminal Device -Hand- Robin Aids- VO Soft
618.71
L8470
Smnhp Sock- Single Ply- Fitting- Below Knee -each
6.33
L6865
Terminal Device -Hand- Passive Hand
288.22
L8480
Stump Suck- Single Ply
8.51
L6867
Terminal Device -Hand- Detroit Infant Hard
662.80
L8500
Artificial Larynx- any type
460.35
L6868
Terminal Device -Hand- Passive Infant Hand
171.21
L8501
Tracheostomy Speaking Valve
81.61
L6870
Terminal Device -Hand- Child Mitt
197.62
L6872
Terminal Device -Hand- NYU Child Hand
846.36
L6873
Terminal Device -Hand- Mechanical Infam Hand
321.87
L6875
Terminal Device -Hard- Buck- VC
586.13
L6880
Terminal Device -Hand- Bock- VO
398.97
L6890
Terminal Device -Glove for above Hands -Production
133.22
L6895
Terminal Device -Glove for above Hands -Custom
445.66
Exhibit A
Colorado Orthopedic & Rehabilitation Equipment, Inc. (C.O.R.E.)
Tax ID #84-1039270
Equipment Pricing
All Rental Charges Include Standard Supplies
Two Months Rental May Be Applied To Purchase-
Monthly Rental Price Includes 30-Day Standard Pack of Electrodes
(Does not include specialized electrodes for pulsed galvanic stimulation, multiple site -use for special conditions).
PF.R
'MONTH"
BONE GROWTH STIMULATOR
Orthologic
Open Custom
N/A
N/A
E0747AP
$3,515.00
Standard
N/A
N/A
E0747BP
$3,080.00
Soft Pack Custom
N/A -
N/A
E0747CP
$4,180.00
EBI
N/A
N/A
E0747DP
$2,700.00
THERMAL THERAPY
Henley International Fluidotherapy -
FLUIDOR
$195.00
FLUIDOP
$1,650.00
Paraffin Bath
E0235R
$30.00
E0235P
$235.00
Paraffin #6-Wax
N/A
N/A
A4265P
$30.00
Cryocuff (knee) includes pad
N/A
N/A
A9270P
$150.00
Cryocuff (shoulder) includes pad
N/A
N/A
A9270EP
$150.00
Danninger T.T.U. Pump
A9270FR
$400.00
A9270FP
N/A
Pad(TTU)_
N/A
- N/A
E0249TP
$160.00
Danninger Surcool Pump/OTI Pump
N/A
N/A
E0237AP
$265.00
Pad (SURCOOL)
N/A
N/A
E0249SP
$60.00
Breg Polar Cub Pump - includes pad
N/A
N/A
E0237AP
$265.00
Seabrook Cool Aid - includes pad (knee or
shoulder)
N/A
N/A
E0237AP
$265.00
House Call Fee, if applicable (One time only)
N/A
N/A
A9270CP
$35.00
EXHIBIT A
C.O.R.E.
Page 2
'
!6sk
:,
CODE
,.
RENTAL
PER:...
MONTH
CODE
PURCHASE`'
SPECIALIZED FORM -FITTED
ELECTRODES (Purchase Only)
Knit Silver Fabric Sleeve
N/A
N/A
E0731AP
$120.00
Knit Silver Fabric Glove
N/A
N/A
E0731BP
$144.00
Knit Silver Fabric Sock
N/A
N/A
E0731CP
$160.00
Garment Kit (combination sock/glove w/wrap)
N/A
N/A
E0731DP
S300.00
CERVICAL TRACTION
Lossing
E0948AR
$125.00
E0948AP
$830.00
Lossing NecStep
E0948BR
$75.00
E0948BP
S495.00
Cervitrak
E0948CR
$75.00
E0948CP
S495.00
Saunders Hometrack
E0948DR
$125.00
E0948DP
$847.00
Pronex
E0948ER
$85.00
E0948EP
$500.00
Halter (if applicable)
N/A
N/A
E0942P
S42.35
LUMBAR TRACTION
Lossing 90/90 - —
E0947AR
$125.00
E0947AP
$980.00
Action Traction
E0947BR
$75.00
E0947BP
$625.00
Pelvic Belts
N/A
N/A
E0944P
$50.80
Bucks Traction
E0880R
$44.00
E0880P
S275.00
House Call Fee, if applicable (one time only)
N/A
N/A
N/A
$35.00
DYNAMIC SPLINTS & ORTHOTICS
.Many types and brands available
-
_
LMB Products
L3965R
$200.00
L3965P
$1,200.00
Knee Orthosis (Post Acl) Breg
N/A
N/A
N/A
$834.00
EXHIBIT A
Colorado Plains Medical Center, Inc.
Tax ID #93-0880990
Colorado Plains Medical Center agrees to a discount of three percent (3 %) off billed charges for both
inpatient and outpatient services.
EXHIBIT A
Colorado Professional Medical, Inc.
Tax ID #84-1189608
DEVICE MANUFACTURER PRICE SET UP/PATIENT HIT
Hand CPM
Toronto H-2
$22.00 daily
$45.00
Toronto H-3
$22.00 daily
S45.00
--
- -. -_. Richards 8080-._---_.___--_$22�00
Richards 8091
$22.00 daily
$45.00
Wrist CPM
Toronto W-1
$22.00 daily
$45.00
Knee CPM
Danninger 400i
$22.00 daily
S45.00
Danninger 450
$22.00 daily
$45.00
Danninger 460
$22.00 daily
$45.00
Danninger 500
$22.00 daily
$45.00
Shoulder CPhI
Artromot
$35.00 daily
$45.00
Invacare
$35.00 daily
S45.00
Richards 7081
$35.00 daily
S45.00
Elbow CPM
Richards 6080
$22.00 daily
$45.00
Ankle CPM
Toe CPM
Artromot sp-2
Jace
$22.00 daily
$22.00 daily
W.00
$45.00
DEVICE
TYPE
PRICE
SET UP/PATIENT HIT
Dynamic Splints Ankle
Elbow Extension
Elbow Flexion
Knee Extension
Knee Flexion
Wrist Extension
Wrist Flexion
LME Splints
$115.00 monthly
$25.00
$115.00 monthly
$25.00
$115.00 monthly-
$25.00
$115.00 monthly
$25.00
$115.00 monthly
$25.00
$115.00 monthly
$25.00
$115.00 monthly
$25.00
$115.00 monthly
$25.00
A twenty five percent (25%) discount off billed charges shall be applied to the purchase of the above splints.
Full rental cost shall be applied to the purchase of the splint. Rental shall not exceed purchase price.
Jobst Pumps
Int. Comp.
$76.50 monthly_
$25.00 -
-
Seq. Int. Comp.
$121.50 monthly
$25.00 -
Int. Comp. -
$598.50 purchase
N/A
Seq. Int. Comp.
$895.50 purchase
N/A
Full rental cost shall be applied
to the purchase of the pump. Rental shall not exceed purchase price.
Garments
Int. Comp. youth leg
$136.80 purchase
N/A
(sale only on garments)
Int. Comp. full leg
$144.00 purchase
N/A
Int. Comp. full arm
$144.00 purchase
N/A
Int. Comp. Hand/Wrist
$125.75 purchase
N/A
Seq. Comp. Arm
$197.90 purchase
N/A
Seq. Comp. Leg
$223.60 purchase
N/A
Circ Aid
Ready Fit Legging
$200.00 purchase
N/A
EXHIBIT A
Colorado Professional Medical, Inc.
Page 2
SERVICE CODES
DESCRIPTION
CHARGE
L0500
-Lumbar -Sacral_Orthosls¢SOI-Rexible________$
88.44 _
L0515
LSO, Flexible, Elastic Type w/Rigid Posterior
$ 138.56
L1686
HO-Abduction Control/Hip Jts-Post Op Custom
$ 685.74
L1800
Knee Orthosis (KO) -Elastic w/Stays
$ 42.51
L1810
KO -Elastic w/Joints
$ 68.89
L1815
KO -Elastic W/Condylar Pads
$ 63.19
L1820
KO -Elastic w/Condylar Pads & Joints
$ 97.93
L1825
KO -Elastic Knee Cap
$ 35.78
L1830
KO -Immobilizer -Canvas Longitudinal
$ 63.60
L1832
KO -Adjustable Knee Its. -Rigid Support -Custom Fit
$ 387.49
L1840
KO-Derotation - Medial -Lateral -Ant Ctuc. Lig. Fitted
$ 602.30
L1845
KO- Double Upright -Thigh & Calf- Adj. Flexion
$ 555.74
L1846
KO- Double Upright-Thigh/Calf-w/Adjust Flexion
$ 688.11
L1858
KO- Molded Plastic-Polycentric Knee Jt. (knee pads)
$ 893.78
L1902
AFO- Ankle Gauntlet- Custom Fitted
$ 51.82
L1906
AFO-Multiligamentus Ankle Support
$ 102.67
L2425
Add/Knee It. -Disc or Dial Lock-Adj Knee Flexion
$ 119.74 - —
L2435
Add/Knee Jt.-Polycentric Jt - ea It
$ 108.03
L2810
Add/Low Extrem-Orthosis-Knee Cont-Condylar Pad
$ 49.53
L2840
Add/Low Extrem-Orthosis-Tibial Length Sock-FX
$ 27.71
L3670
SO-Acromio/Clavicular-Canvas & Webbing Type
$ 72.68
L3700
Elbow Orthosis (EO)-Elastic w/Stays
$ 45.77
L3740
EO-Double Upright wlForearm/Arm Cuffs -Adjust
$ 676.38
L3914
WHFO-Wrist Extension Cock -Up
$ 55.24
L3936
WHFO-Palmer
$ 57.47
L3938
WHFO-Dorsal Wrist
$ 59.35 —
_
L3960
Shoulder -Elbow -Wrist Hand Orthosis (SEWHO)
$ 486.65
L3963
SEWHO - Molded w/Articulating Elbow Joint
$1,059.62
L3980
Upper Extremity FX Orthosis - Humeral
$ 198.15
Participating Healthcare Provider agrees to bill the above items using the appropriate Medicare code listed.
Effective February 1, 1998, Colorado Professional Medical, Inc. agrees to accept a twenty percent
(29%) discount off billed charges for services provided directly by them, that currently are not listed on this Exhibit A. —
I.
II.
Colorado Sports and Spine - Pain Program
Tax ID #84-0845658
Rates
Colorado Sports and Spine - Pain Program will accept from Participating Plan, for authorized
services, the following agreed upon Negotiated Rate, less any applicable Deductible, Copayment
or Coinsurance:
Description Code* Case Rate
Pain Program - Daily PAIND $ 600
Pain Program - Weekly PAINW $ 3,000
Scope of Service
The all inclusive rate includes all routine and specialized services provided by and performed by
Colorado Sports and Spine - Pain Program staff, including physical therapy, occupational therapy,
psychological groups and individual sessions, biofeedback and pool/water exercise, and weekly
team staffing with all providers. The rate does not include the initial evaluation to determine
whether the Pain Program is appropriate for the Covered Individual, nor does it include physician
_ visits.
For proper processing of claims, this code must be used on HCFA 1500 claim forms submitted for
Colorado Sports and Spine - Pain Program services.
insurance for malpractice liability insurance, in an amount deemed adequate by SLMC.
SLMC will require all other Participating Providers to carry professional liability
insurance in an amount determined adequate by SLMC to insure Participating Provider
and provider's employees against liability for damages directly or indirectly related to the
performance of Participating Provider's professional activities.
2.6 SLMC shall maintain an appropriate geographic and specialty distribution of Participating
Providers which have agreed to cooperate with the SLMC system.
2.7 SLMC agrees to periodically provide information to all Participating Providers and their
staff regarding Participating Plan and policies and procedures with respect to the
Participating Plan.
2.8 SLMC will publish annually a directory of the names of all Participating Providers,
their respective specialties and area of practice. Upon request and at no cost to the
Participating Plan, SLMC will provide sufficient copies of the directory to the
Participating Plan, for distribution to all eligible employees, on an annual basis.
Listings of additions, deletions, and other changes to Physicians and certain Providers
of Ancillary Services will be communicated to. the Participating Plan's claim
administrator in writing every thirty (30) days by SLMC. Listings of additions and
deletions to Hospitals and certain Providers of Ancillary Services will be communicated
to the Participating Plan or their claim administrator with a thirty (30) day advance
written notice.
2.9 The Participating Plan's claim administrator is authorized to Reprice claims. SLMC
shall provide the Participating Plan with Negotiated Rates that are listed in Exhibits A
and B, guidelines for repricing RNE, BR cpt codes, and unlisted procedures in the St.
Anthony Publishing Relative Value for physicians (RVP) so that the Participating Plan's
claim administrator can assume Repricing. Participating Plan acknowledges that in
order to Reprice Participating Provider claims according to Exhibit B, either the
Participating Plan or its claim administrator will need to purchase and maintain the St.
Anthony Publishing Relative Value for Physicians (RVP). SLMC reserves the right
and shall have sole authority to make all final determinations on Negotiated Rates.
SLMC shall have the right to audit the Participating Plan's or its claim administrator's
records, pertinent books, documents and papers as they relate to its Repricing
capabilities and accuracy. SLMC shall provide a fifteen (15) day advance written
notice to the Participating Plan or.its claim administrator prior to the start of such audit.
All individuals conducting such audits shall be required to treat all information made
available as a result of the audit confidential according to the terms of Section 9.1.
4 PPOMPAR-WE-UR/Cn'Y OF FT COLLINS111.20.98fg
Colorado Springs Eye Surgery Center
Tax ID #84-1069459
Colorado Springs Eye Surgery Center agrees to a discount of 10% off of billed charges.
EXHIBIT A
Colorado Springs Surgery Center
dba HealthSouth Surgery Center of Colorado Springs
Tax ID #84-1160450
When Covered Services are provided to a Covered Individual, the following discounts apply:
OUTPATIENT SERVICES:
Sterilization Procedures (Only): Twenty-five percent (25%) discount off of billed charges to a
maximum of $1,350.00 per date of service.
OTHER RELATED SURGERIES (those related procedures done at the time of sterilization
procedure):
Other Related Surgeries: Twenty-five percent (25%) discount off of billed charges to a maximum
of $400.00 per date of service included in the maximum of $1350.00 per date of service.
EXHIBIT A
Columbia Ambulatory Surgery Centers
See Tax ID numbers below
Columbia Ambulatory Surgery Centers include the following locations:
Columbia Centrum Surgical Center Columbia Lakewood Surgical Center
8200 E. Belleview, #300E 2201 Wadsworth Blvd.
Englewood, CO 80111 Lakewood, CO 80215
Tax ID # 75-2546712 Tax ID # 84-0887394
Columbia Midtown Surgical Center
1919 18th Ave.
Denver, CO 80206
Tax ID # 75-2548180
When Covered Services are provided to a Covered Individual, the following discount applies:
OUTPATIENT SERVICES:
Outpatient Surgery: Twenty percent (20%) discount off of billed charges to a maximum of
$1,200.00 per date of service.
EXHIBIT A
Columbia Homecare
(formerly Home HealthONE)
Tax ID #84-1321373
HOME HEALTH
General Nursing Visit
Pediatric Nursing Visit
IV RN Visit
Initial Start-up Visit
Follow-up Care
Extended Hour RN Visits
General Nursing Visits in excess
of two (2) hours
RN Pediatric visits in excess
of two (2) hours
Home Health Aide
HHA Private Duty visits in excess
of two (2) hours
Rehabilitation
Physical Therapy
Occupational Therapy
Speech Therapy
Medical Social Worker
Discount Rates
$ 72.00 per visit (2 hours)
$ 72.00 per visit (2 hours)
$ 75.00 first visit
$ 76-00 per visit
$ 36.00 per hour
$36.00 per hour
$ 34.00 per visit (2 hours)
$ 16.00 per hour
$ 75.00 per visit
$ 75.00 per visit
$ 75.00 per visit
$ 80.00 per visit
EXHIBIT A
Columbia Medical Center of Aurora and
Centennial Healthcare Plaza
(formerly Aurora Presbyterian Hospital & Aurora Regional Medical Center)
Tax ID #84-1321373
INPATIENT:
Includes services at Columbia Medical Center of Aurora
Medical
Surgical
ICU/CCU
Pediatrics
OB-Normal Delivery (Incl Level n
B-C/Section (Incl Level 1)
OB-One Day Stay (Incl Level I)
Level I Nursery (Boarder Baby)
Level 11 NICU
Psychiatric
Cardiovascular Surgery/Cardiac Cath/
Athrectomy/PTCA or any other Cardiac
Cath Lab procedure that results in admission.
Spinal Procedures (DRG's 496 through 500)
PER DIEMS
$1,015.00
$1,273.00
$2,045.00
$1,286.00
$1,427.00
$1,555.00
$1,946.00
$ 301.00
$1,365.00
$ 538.00
30% discount off billed charges
30 % discount off billed charges
STOPLOSS: In the event that total billed charges exceed $30,000.00, reimbursement will be calculated at
a thirty percent (30%) discount off total billed charges.
Payment of claims when per diem rates apply will be based on the lesser of (a) per diem rates, or (b) billed
charges. —
Includes services at Columbial Medical Center of Aurora and Centennial Healthcare Plaza.
Ambulatory Surgery 25 % discount off billed charges (EXCEPT for procedures
with Ambulatory Surgery Case Rates - listed on page two)
23 Hour Observation $51 per hour up to the Medical per diem rate
All Other Outpatient 25 % discount off billed charges
EXHIBIT A
Columbia Medical Center of Aurora and Centennial Healthcare Plaza
Page 2
AMBULATORY SURGERY CASE RATES
ICD.9 CODE PRINCIPAL PROCEDURE CASE RATE
04.43
Carpel Tunnel
$1,347.00
13.41
Cataract/ASP
$1,812.00
13.59
Extracap Lens Extraction
$2,314.00
20.01
Myringotomy w/Tubes
$ 992.00
21.88
Septoplasty
$1,396.00
22.20
Intranasal Antrotomy
$2,327.00
22.63
Ethmoidectomy
$1,709.00
28.20
Tonsillectomy
$1,432.00
28,30
Tonsillectomy/Adnoidectomy
$1,506.00
28.60
Adnoidectomy
$1,500.00
53.01-53.05
Unilateral Hernia
$1,531.00
53.10-53.17
Bilateral Hernia
$2,669.00
54.21
Laparoscopy
$1,763.00
57.32
Cystoscopy
$1,531.00
67.39
Cervical Lesion Removal
$1,837.00
69:01-69.09
D & C
$1,102.00
80.26
Knee Arthroscopy
$2,137.00
80.60
Knee Cartilage Removal
$2,572.00
82.21
Excision of Tendon Sheath
$1,378.00
(Lesion Hand)
85.12
Breast Biopsy
$ 992.00
85.21
Breast Lesion Removal
- $1,017.00
86.30
Skin Lesion Removal
$ 735.00
Payment of claims when ambulatory surgery case rates apply will be based on the lesser of (a) ambulatory surgery case
rates, or (b) billed charges.
MULTIPLE PROCEDURES:. If any Ambulatory Surgery Procedure is performed in conjunction with one of the
above principal procedures, payment will be at 125% of the case rate -listed above.
STOPLOSS: Payment will never be less than 50% of billed charges or greater than 100% of billed charges.
EXHIBIT A
Community Hospital
Grand Junction
Tax ID #84-0469270
Negotiated Rate
Community Hospital agrees to a 7.5 percent (7.5 %) discount off of total billed charges if a clean claim is
paid within thirty days.
EXHIBIT A
Conejos County Hospital
Tax ID #84-0522464
- ---
Conejos County Hospital agrees to a discount of fifteen percent (15%) off billed chazges for services
rendered inpatient and outpatient hospital.
EXHIBIT A
Craig Hospital
Tax ID #84-0404233
Hospital agrees to the following discounts:
INPATIENT:
Twelve percent (12%) discount off total billed charges for services rendered inpatient
OUTPATIENT:
Ten percent (10%) discount off total billed charges for services rendered outpatient
i pis
Delta County Memorial Hospital
Tax ID #84-0428757
Negotiated Rates
Delta County Memorial Hospital commits to the following discounts:
1. Inpatient Services - A two percent (2%) discount from billed charges shall apply to all inpatient
services rendered.
2. outpatient Services - A two percent (2%) discount from billed charges shall apply to all outpatient
services rendered.
The Hospital will discount total billed charges by the above percentage when the Participating Plan
is primary carrier on a claim.
When the Participating Plan is not primary carrier on a claim the Hospital will discount, by the
above percentage, the remaining balance after subtraction of the primary carrier's payment.
ARTICLE III
SLMC RESPONSIBILITIES
3.1 SLMC shall institute and maintain during the term of this Agreement the following
programs:
A. Precertification Inpatient:
1. Pre -Admission Review: prospective review for elective hospital
admissions involving a determination of whether admissions are medically
necessary through a review of the admitting diagnosis, applicable
secondary diagnoses, medical history and factual circumstances.
2. Review of Urgent/Emergent Admissions: medical review of indications
for urgent/emergent admissions.
3. Concurrent Review: determination of the continued need for hospital stay
based on review of patient status, including complications, by licensed
professionals at designated intervals per SLMC policy; discuss for less
intensive, alternate means of care.
B. Case Management: If the Participating Plan, their claims administrator or SLMC
through the utilization review process identifies a case which may benefit by case
management a request for evaluation to the case management manager can be
made. The final determination for case activation remains with SLMC.
1. Case Management: systematic approach to identifying high cost claim
situations, assessing potential opportunities to coordinate care, and
formulating cost effective quality care programs.
2. Criteria: criteria used to determine case appropriate referral includes
diagnosis, severity of illness and ability to negotiate alternative treatment
options.
3. Evaluation: an indepth assessment of the patient's condition which
includes dialogue with the physician, family and other health care
providers.
4. Review: case management program is reviewed monthly by the Medical
Director for quality assurance. Significant developments are discussed
with the Medical Director and the Participating Plan or its claims
administrator.
5 PPOMPAR-WE-UR/CITY OF FT COLLINS/11.20.98/k
Flatirons Osteoporosis Center
Tax ID #84-0926552
Flatirons _Osteoporosis Center agrees to the following rates for the professional and technical component
for the services listed below:
-- SERVICES
Single Beam Photon Scan CPT 78350 $104.00
Dual Photon Beam Scan CPT 78351 $125.00
These rates include both the professional and technical components.
Effective 1/1/99 Exhibit A
Gambro Healthcare Patient Services, Inc.
See Tax ID numbers below
Columbia Ambulatory Surgery Centers include the following loactions:
Gambro Healthcare
Colorado Springs
2361 E Platte Place
Colorado Springs, CO 80909
(719) 471 - 7273
TIN: 95-2977916
Gambro Healthcare
Denver Central
One Broadway, Bldg. A 100
Denver, CO 80203
(303) 765 - 1699
TIN: 62-1606070
Gambro Healthcare
Rocky Mountain Center
4600 Hale Parkway, Suite 120
Denver, CO 80220
(303) 320 - 6894
TIN: 62-1606070
Service Description
Revenue Code
MCR CPT or HCPC
Code
Contracted Rate
Hem odialysis-In center
821
90935
$366.00
Hemodialysis, Home Training _
841
90993
$283.00
CAPD, Home Training/Session
841
90993
$233.00
CCPD, Home Training/Session
851
90993
$283.00
CCPD, Incenter Backup Dialysis
821
90945
S235.00
Hemodialysis, In Center Home Back-
❑p _
CAPD, In -Center Back-up Dialysis
821
821
90935
90945
$235.00
-
$235.00
Home CCPD, Per Day
851
90945
$235.00
Home CAPD, Per day
841
90945
$235.00
• Rates include all laboratory services anu ruuunc pua..unoJI a� ����••��� �•• ••••�
• All non -routine pharmacy will be billed and allowed at AWP.
- — Rlnnd ondRlnndRPla}Pfl SP.NICPS
Description
Revenue
Code
MCR CPT or HCPC
Code
Contracted Rate*
Blood, Spin -Cooled -Filtered
380
P9022
S331.18
Blood, Lekopoor Red Blood Cells
385
P9016
$331.18
Blood, Platelets
384
P9019
$405.45
Blood, Packed Cells
381
P9021
$331.18
Blood, Other, Frozen RBCS
390
P9021
$344.18
* All blood charges include the following: blood products, type and crossmatch,
AB antibody ID, syphillis testing, blood typing, HIV/HTLV antibody, and supplies.
Exhibit A -Effective 1/1/99
Gambro Healthcare Patient Services, Inc.
Page 2
Included Laboratory Testing
Frequency in Center
TEST
HEMODIALYSIS & CCPD
CAPD
Hematocrit
Per TX
Monthly
Clotting Time Tests
Per TX
' No
Prothrombin Time
Weekly
No
Serum Creatinine
Weekly
Monthly
BUN
Weekly
Monthly
CBC
Monthly
No
Serum Calcium
Monthly
Monthly
Serum Chloride
Monthly
No
Serum Bicarbonate
Monthly
No
Serum Phospuorous
Monthly
Monthly
Serum Potassium
Monthly
Monthly
Serum Albumin
Monthly
Monthly
Serum Iron
Semi -Annual
Semi -Annual
Iron Binding Capacity
Semi -Annual
Semi -Annual
Total Protein
Monthly
Monthly
Alkaline Phosphatase
Monthly
Monthly
SGOT
Monthly
Monthly
LDH
Monthly
Monthly
Hemoglobin (HGB)
No
Monthly
Serum Magnesium
No
Monthly
Dialysate Protein
No
Monthly
Serum sodium
No
Monthly
Carbon Dioxide
No
Monthly
Hepatitis B Antigen & Antibody
Quarterly
Quarterly
Included Pharmacy
Pharmaceuticals
Albumin Benadryl Dextrose Glucose Heparin Mannitol
Plasminate Saline Sodium Chloride Categories
Pharmaceutical Categories
Anti-Arithymics Anti -Hypertensives. Pressure Drugs (i.e. High Blood Pressure)
All Antihistamines All Topical Anesthetics Self -Administered Drugs (e.g. Aspirin)
EXHIBIT A
Goodland Regional Medical Center
Goodland, Kansas
Tax ID #48-0725111
Goodland Regional Medical Center agrees to a six percent (6 %) discount off total billed charges for
services rendered inpatient and outpatient.
EXHIBIT A
HealthSouth Surgery Centers
HealthSouth Surgery Centers include the following locations:
HEALTHSOUTH AURORA
SURGERY CENTER
13701 E. Mississippi Ave., #200
Aurora, CO 80012
303-363-8646
Tax ID #62-1488744
HEALTHSOUTH DENVER WEST
SURGERY CENTER
13952 Denver W. Parkway
Building 53, Ste. 100
Golden, CO 80401
303-271-1112 —
Tax ID #62-1514638
HEALTHSOUTH PUEBLO
SURGERY CENTER
25 Montebello Road
Pueblo, CO 81001
719-544-1600
Tax ID #62-1488737
HEALTHSOUTH SURGERY CENTER
OF FORT COLLINS
1100 E. Prospect Road
Ft. Collins, CO 80525
970-493-7200
Tax ID #84-1183185
When Covered Services are provided to a Covered Individual, the following discount applies:
RATES:
Twenty percent (20%) discount off billed charges to a maximum of $1,200.00 allowable per date of
service.
SCOPE OF SERVICES:
The discounted rate includes all routine and specialized services provided by and performed by the _
facility's staff while at the facility.
The surgery center (facility) will accept as payment from Participating Plan, for any orthotic/prosthetic
case that exceeds $200.00, invoice cost plus five percent (5 %).
Heart of the Rockies Regional Medical Center
Tax ID #84-0631509
The allowable amount shall be billed charges. Heart of the Rockies Regional Medical Center has
agreed to establish the level of charges for their services at the beginning of each contract year (based on
the contract between SLMC and Heart of the Rockies Regional Medical Center) and guarantee such
charge levels for the remainder of that year.
EXHIBIT A
Hospice of Metro Denver, Inc.
Tax ID #84-0743121
Provider shall accept reimbursement for Covered Services rendered to Covered Individuals in accordance with the
following guidelines:
ALL-INCLUSIVE HOSPICE HOME OR RESIDENTIAL CARE $115.00 per diem
Includes all core staff services including bereavement, medical supplies, laboratory tests, DME, medications,
respiratory therapy, infusion services related to the terminal illness and ambulance transportation for acute care,
if needed.
ADDITIONAL SERVICES WITH PRE -AUTHORIZATION ONLY:
1. Room and Board - HMD Care Center $ 90.00 per diem *
Nursing Home $ 90.00 per diem *
(In addition to rate for all-inclusive or core services Hospice or Special Services care)
To provide respite or residential hospice care in inpatient hospice or in contract beds within the nursing
home setting for patients who can no longer remain at home.
2. All -Inclusive HMD Acute Inpatient Hospice Care $530.00 per diem *
(In lieu of hospitalization, if appropriate, for symptom control)
Includes inpatient staff services, terminal illness related supplies, equipment, tests and medications.
3. Supplemental Professional Nursing Care $ 31.00 per hour
(In lieu of hospitalization)
Limited extended hours of professional care at home for symptom control. ---
4. Supplemental Car4ver-Assistance _ $ 18.00 per hour
(In lieu of institutional care)
Certified Nurse Aide (CNA) to supplement caregiver in the home when patient does not have family or
friends available to meet all caregiving needs.
SPECIAL SERVICES HOME OR RESIDENTIAL CARE
$99.00 per diem *
Includes all core staff services, bereavement and DME related to the terminal illness. Does not include medical
supplies, tests, medications, oxygen and respiratory equipment or ambulance transportation.
* Per Diem rate is applicable every day that patient is in the program except for days that patient is hospitalized.
EXHIBIT A
Hospice of St. John
Tax ID #74-2254709
Per Diem Rates
Hospice of St. John Schedule of Per Diem Rates.
All Inclusive Inpatient Hospice Care $200.00
All Inclusive Home Care Hospice $ 95.00 *
Includes terminal illness related services, supplies, equipment, tests, medications and ambulance
transportation.
The above per Diem rates exclude physician services.
Hospice Care services do not include medications, treatments, equipment, transportation, hospitalization
or any type of care provided for a condition not related to the terminal illness for which they are receiving
hospice care.
Any portion of a claim due from a Covered Individual when per diem rates apply will be based on the
lesser of (a) per diem rates, or (b) billed charges. _
* Per Diem rate is applicable every day that patient is in the program from admission to discharge.
Exception: Per Diem charge is waived for days that patient —is hospitalized_
EXHIBIT A
Huerfano Medical Center —
Tax ID #84-6027322
Huerfano Medical Center agrees to the following discounts:
Inpatient - An eight percent (8%) discount off billed charges shall apply to all
inpatient services rendered.
Outpatient - An eight percent (8 %) discount off billed charges shall apply to all
outpatient services rendered.
EXHIBIT A
Learning Services Corporation
Tax I.D. # 03-0297705
Neurorehabilitation Per Diem: $ 576.00
_ Includes: Clinical case manager, physiatry consults, physical therapy, neuropsychology,
speech/language pathology, clinical psychology, occupational therapy, on campus training/educational
support groups, nursing services, life skills training, avocational services, family support services,
written monthly status report by case manager, verbal status reports by case manager as requested, up
to 24 hours LST staffing (7 days/week), semi -private room, bedding, linen, laundry, consumable
hygiene and grooming materials, balanced diet monitored by a nutritional specialist, first aid supplies,
all non-prescription/ over-the-counter medications, including vitamins, therapeutic recreation,
transportation to follow-up appointments and to program activities.
Not included: Admission Physical, CBC, Urinalysis, Dental and Vision exams, wheelchairs, adaptive
and assistive devices and equipment, any one-on-one Attendant care, Physician charges and any outside
medical treatment or consultations, laboratory services, x-rays, prescription medications, prescription
medical supplies, special education, off campus classes, drivers' education, transportation for
therapeutic leaves from the Learning Services campus.
Day Treatment Neurorehabilitation Per Diem: $ 531.00
Includes: Clinical case manager, physical therapy, neuropsychology, speech/language pathology,
clinical psychology, occupational therapy, on campus training/educational support groups, nursing
services, life skills training, avocational services, family support services, written monthly status
report by case manager, verbal_ status reports by case manager as requested, up to 10 hours LST
staffing (7 days/week), balanced diet monitored by a Nutritional Specialist, customary first aid supplies
(on campus), all non-prescription/ over-the-counter medications, including vitamins (on campus),
therapeutic recreation, transportation to program activities. _
Not included: Admission Physical, CBC, Urinalysis, Dental and Vision exams, wheelchairs, adaptive
and assistive devices and equipment, any one-on-one Attendant care, Physician charges and any outside
medical treatment or consultations, laboratory services, x-rays, prescription medications, prescription
medical supplies, special education, off campus classes, drivers' education, transportation for
therapeutic leaves from the Learning Services campus, or from home to campus, including the return
trip. -
Partial Day Treatment Neurorehabilitation - Per Diem: $ 350.00
Partial Day Treatment Neurorehabilitation represents up to one half day of campus directed
programming per day and includes and excludes the same services as listed in "Day Treatment
Neurorehabilitation". Basic Transportation is not included in this program, and is subject to daily
charges.
5. SLMC shall determine which cases will be managed under the case
management program. Typical medical conditions that frequently result in
but are not limited to case management are:
AIDS/HIV +
Malignant Neoplasm
Bums (Full Thickness)
Organ Transplantation
CVA, Severe, Complicated
Preterm Labor
Cystic Fibrosis
Progressive Neurological Diseases
High -Risk Infant
Spinal Cord Injury
Major Head Trauma
Traumatic Amputation
3.2 SLMC shall perform utilization review services for Covered Individuals who receive care
outside and within its service area.
3.3 SLMC shall monitor the practice and utilization patterns, including specialty referrals, of
the providers.
3.4 SLMC shall provide the Participating Plan with utilization reports for utilization review
services performed. Such reports shall be provided quarterly. SLMC further agrees to
comply, within a reasonable time, with Participating Plan's reasonable request for
changes in the frequency of such reports.
3.5 When an adverse decision is made through the SLMC utilization review or case
management processes as defined above, SLMC will establish and provide a mechanism
for reconsideration, expediated appeal and standard appeal of that decision. This
procedure will meet applicable Colorado statute. The next level of appeal will be the
responsibility of the Participating Plan.
ARTICLE IV
COMMUNICATIONS
4.1 SLMC agrees to notify all Participating Providers of this Agreement's effective date.
SLMC agrees to make reasonable efforts to answer questions regarding directory and
network information which arise from Covered Individuals. All questions from Covered
Individuals regarding eligibility and Covered Services shall be directed to the
Participating Plan's claim administrator.
ARTICLE V
PARTICIPATING PLAN'S OBLIGATIONS
5.1 The Participating Plan agrees to pay SLMC one hundred dollars ($100.00) per hour for
case management services as described in Section 3.1 (B). These services shall be billed
on a monthly basis. The Participating Plan shall remit such fees no later than 30 days
following the receipt of the billing statement. Each billing statement shall explain the
I
6 PPO17/PAR-NE-UR/Cn'Y OF FT COLLINS/11.20.9a/jg
EXHIBIT A
Life Care Centers of America
This exhibit sets forth the payment methodology and rate for Covered Services, as authorized by
applicable Participating Plan and rendered by Life Care Centers to Covered Individuals. The fees listed
below shall be reduced by the amount of any applicable Copayment, Coinsurance or Deductible charges
which are directly to the Covered Individual.
Yarn<�rnr
Services Available:
• Semi -private room
• Meals (including specialized dietary orders)
• Skilled nursing care (up to 3 hours of nursing care per 24 hour period)
• Routine respiratory care
• Radiology services
• Laboratory services- —
• In-house medical supplies
• Standard medical equipment (walker, wheelchair, trapeze, commode, feeding pumps)
• Social services
• Wound care (stages I & 2)
• Insulin dependent diabetic care
• Colostomy care
• Traction & positioning
• NG or G tube feeding
• Discharge planning assistance
• Other services as mutually agreed upon between Sloans Lake Managed Care and facility
LEVEL TWO —
Per Diem: $325
Services available include those offered in Level One, plus the following:
• More intense nursing services (up to 4 hours of nursing care per 24 hour period)
• Oxygen or respiratory treatment that is intermittent
• Pharyngeal aspiration
• One physical therapy evaluation, one occupational therapy evaluation and one speech therapy
evaluation per admission
• Up to one hour of total therapy each day (PT, OT or Speech)
• Tracheostomy supplies and treatment not to exceed more than 3 treatments per 24 hour period
• Whirlpool treatments (lower extremity or full body) for any skin problems
• Other services as mutually agreed between Sloans Lake Managed Care and facility
EXHIBIT A
Life Care Centers of America
Page 2
LEVEL THREE'
Per Diem: $425
Services available include those offered in Level Two, plus the following:
• More intense nursing services (5 hours of nursing care per 24 hour period)
• Wound care (necrotic, including debridement)
• Up to two hours of total therapy each day (PT, OT or Speech)
• Tracheostomy supplies & treatments exceeding 3 treatments per day
• Other services as mutually agreed between Sloans Lake Managed Care and facility
LEVEL FOUR
Per Diem: $500
Services available include those offered in Level Three, plus the following:
• More intense nursing services (6 hours or more of nursing care per 24 hour period)
• Patient controlled anesthesia pumps (SQ or IV)
• Traumatic brain & spinal cord care
• Up to three hours of total therapy each day (PT, OT or Speech)
• Other services as mutually agreed between Sloans Lake Managed Care and facility
LEVEL FIVE
Per Diem: $675
Services include those offered in Level Four, plus the following:
• Ventilator care
- SERVICES NOT INCLUDED IN PER DIEM AMOUNTS:
• -Additional therapy (OT, PT or Speech) as authorized, at $85.00 per hour
• Total Parenteral Nutrition at an all inclusive per diem of $160.00 (Includes: All additives common to
TPN formulations, solutions, pharmacy compounding fees, standard medical supplies, stationary
pump, delivery, hazardous waste disposal and pharmacy management services)
EXHIBIT A
Life Care Centers of America
Page 3
PARTICIPATING FACILITIES
Alamosa 1 Carbondale
Evergreen Nursing Home
60 beds Heritage Park Care Center
1991 Carroll Avenue
1200 Village Road
Alamosa, CO 81101
Carbondale, CO 81623
(719) 589-4951 (Office)
(970) 963-1500 (Office)
(719) 589-5651 (Fax)
(970) 963-9507 (Fax)
Tax ID #62-1644855
Tax ID #62-1644855
San Luis Care Center 60 beds
240 Craft Drive
Alamosa, CO 81101
(719) 589-9081 (Office)
(719)589-9083 (Fax)
Tax ID #62-1644855
Aurora
Denver
118 beds
Berkley Manor Care Center 118 beds
735 South Locust Street
Denver, CO 80224
(303) 320-4377 (Office)
(303) 355-6289 (Fax)
Tax ID #62-0963862
Garden Terrace 120 beds
Briarwood Health Care Center 201 beds
Alzheimer's Center of Excellence
1440 Vine Street
1600 South Potomac Street
Denver, CO 80206 - —
Aurora, CO 80012
(303) 399-0350 (Office)
(303) 750-8418 (Office)
(303) 3994276 (Fax)
(303) 750-0021(Fax)
Tax ID #62-0963862 -
Tax ID #62-1263545
—
Hallmark Nursing Center 145 beds
Life Care Center of Aurora 94 beds
3701 W. Radcliff Avenue
14101 East Evans Avenue
Denver, CO 80236
Aurora, CO 80014 -
(303) 794-6484 (Office)
(303) 751-2000 (Office)
(303) 797-8781 (Fax)
(304) 751-0026 (Fax)
Tax ID #62-1246424
Tax ID #62-1542993
Evergreen
Canon City
Canon Lodge Care Center 78 beds
Life Care Center of Evergreen 118 beds
905 Harding Avenue
2987 Evergreen Parkway
Canon City, CO 81212
Evergreen, CO 80439
(719) 275-4106 (Office)
(303) 674-4500 (Office)
(719) 275-2895 (Fax)
(303) 674-8436 (Fax)
Tax ID #62-1644855
Tax ID #84-1147138
EXHIBIT A
Life Care Centers of America
Page 4
Fort Morgan
Valley View Villa 120 beds
815 Fremont Avenue
Fort Morgan, CO 80701
(970) 867-8261 (Office)
(970) 867-8192 (Fax)
Tax ID #62-1624822
Pueblo
Life Care Center of Pueblo
2118 Chatalet Lane
Pueblo, CO 81005 .
(719) 564-2000 (Office)
(719) 564-7741 (Fax)
Tax ID #62-1354006
180 beds
University Park Care Center 180 beds
Greeley
945 Desert Flower Blvd.
Pueblo, CO 81001
Life Care Center of Greeley 120 beds
(719) 545-5321 (Office)
4800 25" Street
(719) 545-0096 (Fax)
Greeley, CO 80632
Tax ID #62-1246424
(970) 330-6400 (Office)
(970) 506-1370 (Fax)
Salida
Tax ID #84-1349423
Columbine Manor Care Center 112 beds
Lakewood
530 West 16" Street
Salida, CO 81201
Villa Manor Care Center 240 beds
(719) 539-6112 (Office)
7950 W. Mississippi Avenue
(719) 539-6510 (Fax)
Lakewood, CO 80226
Tax ID #62-0963862 —
(303) 986-4511 (Office)
(303) 914-9427 (Fax)
- Westminster
Tax ID #84-0921561
-
Life Care Center of Westminster 120 beds
Western Hills Health -Care Center 140 beds
7751 Zenobia Court
1625 Carr Street
Westminster, CO 80030
Lakewood, CO 80215 _
(303) 412_9121 (Office)
(303) 232-6881 (Office) -
(303) 412-9187 (Fax)
(303) 232-1927 (Fax)
Tax ID #62-1605722
Tax ID #62-0963862
Longmont
Life Care Center of Longmont 187 beds
2451 Pratt Street
Longmont, CO 80501
(303) 776-5000 (Office)
(303) 776-7661 (Fax)
Tax ID #62-1381523
EXHIBIT A
Keefe Memorial Hospital —
Tax ID 484-1071323
Hospital agrees to a five percent (5%) discount off total billed charges.
EXHIBIT A
Kidney Stone Center
of the Rocky Mountains
Taal ID #84-1013285
Negotiated Rates
Kidney Stone Center of the Rocky Mountains commits to a fifteen percent (15%) discount off billed
charges:
EXHIBIT A
Kit Carson County Memorial Hospital
Tax ED#84-6002430
The allowable amount shall be billed charges. Kit Carson County Memorial Hospital has agreed to
establish the level of charges for their services at the beginning of each contract year (based on the
--^^tracts Carson County Memorial Hospital) and guaranteesuchcharge-levels-. — ---.---
for the remainder of that year.
EXHIBIT A
Kremmling Memorial Hospital
Tax ID #84-0676212
Kremmling Memorial Hospital agrees to a discount of six percent (6 %) off billed charges for both
inpatient and outpatient services.
EXFHBTT A
Lincoln Community Hospital
Tax ID #84-0484566
---Lincoln Ce . , HospiW agrees to a dig o= offive- percent (5 %)--off billed- charges for -services- --- --
rendered inpatient and outpatient.
Littleton Day Surgery Center
Tax ID #23-2731319
Littleton Day Surgery Center has agreed to the following discounts for Covered Services rendered to
Covered Individuals:
Outpatient Surgical Facility Fees
CPT Code
PRI-M
a�•
Description
15 % off each billed cpt code to maximum allowable
of: $1,200 for the primary procedure and $600 for
each subsequent procedure. The two exceptions
are:
Arthroscopy w/partial acromioplasty
Arthroscopy aided anterior cruciate
ligament repair
Discount
20 % off billed charges
20% off billed charges
The maximum allowables listed above do not apply to these procedures. All outliers do apply to
these procedures.
OUTLIERS:
MultipleProcedures: Primary procedure allowed at 100% of the discounted amount.
-- (i.e. billed charge x discount -= primary procedure allowable)
Any and —all subsequent procedures allowed at 50% of the discounted
amount.
(i.e. billed charge x discount = allowable x 50% = any and all subsequent procedures' allowable)
Implants: Implants and/or devices will be allowed at 20% off billed charges.
Flouroscopy: Flouroscopy services will be allowed at 20% off billed charges.
basis of calculation of this fee. The Participating Plan agrees to pay SLMC a fee of four
dollars and sixty-five cents ($4.65) per employee per month for all other services
provided pursuant to this Agreement. Such fees shall be based on the number of
employees covered under this Agreement on the first day of each month and due no later
than the last day of the month. Participating Plan shall provide SLMC with a statement
listing the number of employees covered under this Agreement no later than forty-five
(45) days following the execution of this Agreement and, thereafter on a monthly basis.
This statement shall accompany each payment of the above fee. Participating Plan shall
remit the fees directly to Sloans Lake Managed Care at:
Sloan Lake Managed Care, Inc.
1355 South Colorado Blvd., Ste. 902
Denver, CO 80222
Attn: Finance Dept.
Late payment charges will be computed at the rate of one and one half percent (1.5 %) of
the overdue amount per month or the maximum lawful amount, whichever is less.
Participating Plan will also be liable for all costs to collect any past due amounts,
including any collection agency or attorneys' fees. _ Each payment shall include a
statement explaining the basis of calculations of this fee in a format mutually agreed upon
by the parties. SLMC retain the right to request independent verification of the number
of employees covered under this Agreement for any given month. Participating Plan
shall respond to a request for independent verification of covered employee lives within
thirty (30) days of the request
5.2 The Participating Plan agrees to remit payments due to Participating Providers, for
Covered Services rendered to Covered Individuals, within the time frames and in the
amounts specified in Exhibits A and B, less any applicable Deductible, Copayment,
Coinsurance, or Non -Covered Services. Participating Plan, or its claim administrator,
shall submit to SLMC, no later than the fifteenth (15') of each month a claims report, to
include total claims received, paid and denied and the time frame for turning around such
claims for the prior month, in a format mutually agreeable to the parties.
5.3 The Participating Plan agrees to remit payments directly to the Participating Provider,
without the necessity of the Participating Provider obtaining a signature from the Covered
Individual for the assignment of benefits.
5.4 The administration of all claims is solely the responsibility of the Participating Plan. The
Participating Plan shall be solely responsible for determination of all question concerning
claims, payment, and the eligibility of any individual who benefits from the Participating
Plan.
5.5 Payment or denial of payments to a Participating Provider shall be accompanied by an
explanation of benefit (EOB). A copy of the EOB shall be sent to the Participating
Provider whether a payment is issued or not. The EOB shall list separately each dollar
7 PP017/PAR-WE-UR/CrrY OF Fr COLLINS111.20.98/k
EXHIBIT A
Longmont Surgery Center, LCC
Tax ID #84-1295365
When the Covered Services are provided to a Covered Individual, the following discounts apply:
OUTPATIENT SERVICES:
Outpatient Surgery: Twenty-five percent (25 %) discount off of billed charges to a
maximum of $1,300.00 per date of service.
CONVALESCENT SERVICES:
Convalescent Services: $300.00 per diem up to twenty-four (24) hours of stay (incorporated
into the outpatient services maximum listed above).
IMPLANTS ORTHOTICS. PROSTHETICS:
Ten percent (10%) discount off of billed charges (to allow no less than 110% of invoice -
charges).
Longmont United Hospital
Tax ID #84-0460697
Negotiated Rates
Longmont United Hospital agrees to the following discounts:
1. Inpatient Services - A ten percent (10%) discount from billed charges shall apply to all inpatient
services rendered.
2. Outpatient Services - A fifteen percent (15%) discount from billed charges shall apply to the
following list of outpatient services:
Phvsical Medicine
Physical Therapy
Occupational Therapy
Speech Therapy
Cancer Care Center
Therapeutic
Other Outpatient Services
Including but not limited to:
Emergency Services_
Laboratory
Surgery
Radiology
Home Health
Registered Nurse
Physical Therapy
Speech Therapy
Occupational Therapy
Medical Social Services
Home Health Aides
Other Services
Psychiatry
Adult
Adolescent
Detox
The Hospital will discount total billed charges by the above percentage when the Participating
Plan is primary carrier on -a claim--
- When the Participating Plan is not primary carrier orra claim the Hospital will discount, by the -
above percentage, the remaining balance after subtraction of the primary carrier's payment.
EXHIBIT A
Loveland Ambulatory Surgery Center, LLC
dba Mountain View Surgery Center
Tax ID #84-1389436
T. Rates: Mountain View Surge Center has _agreed to -accept the following agreed upon
discounted rate, less any applicable Deductible, Copayment or Coinsurance:
15% discount to a maximum allowable of $1,300 per date of service
II. Scope of Service: The all inclusive rate includes all routine and specialized services provided
by and performed by Mountain View Surgery Center staff while at Mountain View Surgery
Center.
III. Exceptions:
• Mountain View Surgery Center will accept as payment from Participating Plan, for any
orthoticfprosthetic device not already included in a given procedure, invoice cost plus five
percent (5 %).
• Mountain View Surgery Center will accept as payment from Participating Plan, for any
implant not already included in a given procedure, invoice cost plus five percent (5 %).
• The following procedures will be allowed at the lesser of billed charges or the listed case
rate:
Description - CPT Code Case Rate
Laparoscopic chole 56340 $2,000
with cholelangiogram 56341 $2,500
Shoulder Reconstruction 23455 $2,000
including Bankart procedures 23420 $2,000
_ Anterior Cervical Fusion (ACF) - 22554 $3,000
22845 - $3,000 —
20938 $3,000
Knee Arthroscopy with ACL reconstruction 29888 $2,000
29889 $2,000
Mastectomy (with or without reconstruction) 19160 $2,000
19162 $2,000
19180 $2,000
19240 $2,000
EXHIBIT A
Matria Healthcare, Inc.
(Formerly Healthdyne Maternity Management)
Tax ID #58-2205984
OBSTETRICAL HOME CARE SERVICES
Fee Schedule
PRETERM LABOR MANAGEMENT SERVICES
Fetal Fibronectin - Patient Reportable Result
Fetal Fbronectin - Service Program - Initial 12 Days
Preterm Labor Program
Preterm Labor Program - With Oral Tocolytics
Pretem Labor Program - With Multiple Transmissions
Subcutaneous Tocolytic Therapy
OBSTETRICAL HYPERTENSION MANAGEMENT
Preeclampsia Critical Pathway
Blood Pressure Monitoring
DIABETES IN PREGNANCY MANAGEMENT
Perinatal Clinician Diabetic Home Visit
ANTICOAGULATION THERAPY
Heparin Therapy Subcutaneous Administration
Heparin Therapy 1V Administration
HYPEREMESIS THERAPY
Hyperemesis Metoclopramide Therapy
OTHER OBSTETRICAL HOME CARE SERVICES
Skilled Nursing Visit - Follow Up
Dietary Analysis
FETAL ASSESSMENTS
Non -Stress Test - One Fetus
Non -Stress Test - Two Fetuses
Self Administered Non -Stress Test (SAFHR)
Skilled Nursing Visit - NST'sOnly _
HOME INFUSION THERAPY
Hydration Therapy - I Liter
Hydration Therapy - 2 Liters
Hydration Therapy - 3 Liters
Hydration Therapy - 4 Liters
Betamethasone Injection
Nurse Visit for Betamethasone Injection
Price
$203.00 per test
$185.00 per patient/test
$ 70.00 per diem
$ 81.00 per diem
$ 81.00 per diem
$287.00 per diem
$135.00 per diem
$ 35.00 per diem
$150..00 per diem
$125.00 per diem
$125.00 per diem
$155.00 per diem
$ 80.00 per visit
$ 90.00 per analysis
$ 75.00 per test
$105.00 per test
- $100.00 per test
$ 45.00 per visit
$ 65.00 per diem
$ 70.00 per diem
$ 75.00 per diem
$ 80.00 per diem
$ 40.00 per injection
$ 45.00 per visit
DWI0 i� :3Ur�
Mediplex Rehab
Per Diem Rates
patient Services - Tax ID #85-0370802: — —
General Rehabilitation
$700 per day
Traumatic Brain Injury
$800 per day
Ventilator/Pulmonary
$950 per day
Extended Rehab Unit
$500 per day
Acute Coma
$900 per day
Behavioral Rehab
$875 per day
Spinal Cord
$950 per day
Bridge Recovery Unit
$600 per day
Exclusions - The following items are specifically excluded from the per diem rate:
- Non -Routine Lab Work
- Physician Charges
- Special Orthopedics, Prosthetic or Other External Adaptive or Durable Medical
Equipment, Including Ventilator Rental
- Behavior Management Sitter -
- Out -of -Facility Services
- Specialized Treatment, such as: IV Antibiotics, and Hyperalimentatioa-
Any portion of a claim due from a Covered Individual when per diem rates apply will be based
on the lesser of (a) per diem rates, or (b) billed charges. —
EXHIBIT A
The Memorial Hospital
Tax ID #84-0399209
The Memorial Hospital agrees to a five percent (5 %) discount_ off total billed charges for both inpatient
and outpatient care.
EXHIBIT A
Mercy Medical Center, Durango
Tax ID #84-0405515
----Merc _ ga agrees to a fifteen percent (15%-) discountofftotal billed charges
for all inpatient and outpatient care.
ANCILLARY HOSPITAL SERVICES:
Home Health:
IV RN Visits
$
85.00
General Nursing Visits
$
85.00
HHA Visit
$
50.00
Rehabilitation:
PT
$
85.00
OT
$
85.00
ST
$
85.00
Medical Social Worker
$
100.00
ED Cards. If the Participating Plan's ID card does not clearly show the SLMC name and/or logo,
the Hospital is not obligated to accept the Negotiated Rates. _
The above discounts shall not be taken by the Participating Plan's claims administrator, if the
Participating Plan's benefit design does not offer a financial incentive to use a Participating
Provider. (i.e. differential in benefit reimbursement between an in network and out of network
provider)
Effective 1/1/99 EXHIBIT A
MidValley Ambulatory Surgery Center, LLC
Tax ID #84-1454222
When Covered Services are provided to a Covered Individual, the following discounts apply: ____ __
OUTPATIENT SERVICES:
Outpatient Surgery: Ten percent (10%) discount off of billed charges to a maximum of
$4,000.00 per date of service.
EXCEPTIONS:
Codes listed below to be paid at a Ten percent (10%) discount not to exceed the following rates.
CPT Code
Description
Reimbursement
20680
Hardware Removal
$2,250
23420
Shoulder Rotator Cuff Repair
$5,400
23455
Shoulder Dislocation
$4,500
29822
Arth. Shoulder —
$4,700
29881
Arth. Knee Menisectomy
$3,500
29877
Arth, Knee Debridment
$3,500
29882
Arth. Men. Repair
$4,000
29826
Arth. Shoulder Dec.
$4,000
29888
Arth. ACL
$6,100
29909
Arth. Unlisted
$4,300
64721
Carpal Tunnel
$2,500
SCOPE OF SERVICES:
The discounted rate includes all routine and specialized services provided by and performed 5y the
facility's staff while at the facility.
EXHIBIT A
Montrose Memorial Hospital
Tax ID #84-6002707
Negotiated Rates — — - -- -
Montrose Memorial Hospital commits to the following discounts:
1. Inpatient Services - A 4.75 % discount from billed charges shall apply to all inpatient services
rendered.
2. Outpatient Services - A 4.75 % discount from billed charges shall apply to all outpatient services
rendered.
NOTE: If the Participating Plan's ID card does not clearly show the SLMC name and/or logo,
Montrose Memorial Hospital is not obligated to accept the above Negotiated Rates.
EXHIBIT A
Mount San Rafael Hospital
Tax ID #84-0586742
1. The following discounts apply as long as the total number of SLMC participating Covered Individuals in the Las
Animas County are less than 500 lives:
Inpatient and Outpatient Services: - - — - --
Hospital has agreed to establish the level of charges for their services at the beginning of each fiscal year and
guarantee such charge levels for the remainder of that year. Allowable charges for Inpatient and Outpatient
services shall be actual billed charges except for those services listed below.
Phvsical Therapy and Home Health Services:
Hospital agrees to a discount of three percent (3 %) off total billed charges.
NIRI:
MRI - $850.00 case rate (all inclusive)
The above mentioned case rate shall be paid at the lesser of the Negotiated Rate or billed charges.
2. Once the total number of SLMC participating Covered Individuals reaches five hundred (500) lives in Las Animas
County the Hospital agrees to the following discounts:
Inpatient and Outpatient:
A discount of two percent (2%) off total billed charges for services rendered Inpatient and Outpatient except for
these services listed below.
Physical Therapv and Home Health Services:
Hospital agrees to a discount of three percent (3 %) off total billed charges.
IS19$
MRI - $850.00 case rate (all inclusive)
The above mentioned case rate shall be paid at the lesser of the Negotiated Rate or billed charges.
NOTE: Currently there are less than 500 SLMC participating Covered Individuals in Las Animas
County therefore, the Participating Plan MUST follow the discounts outlined in #1 above. SLMC
will notify the Participating Plan's claims administrator when the number of SLMC participating
Covered Individuals in Las Animas County reach 500 lives and the discounts outlined in #2 can be
applied.
amount for. Copayment, Coinsurance, Deductible, and Non -Covered Service amounts
taken or applied on each claim, and shall explain the reason for each exclusion. The EOB
shall also list separately the discount amounts taken based on the Negotiated Rates
specified in Exhibits A and B.
5.6 Participating Plan agrees to cooperate and assist all parties in the coordination of benefits
5.7 SLMC acknowledges that Covered Individuals are responsible for Non -Covered Services,
Copayments, Coinsurance, and Deductibles as defined by Participating Plan and are
ultimately responsible for payment to the Participating Provider for such items.
Participating Plan acknowledges if Covered Services are not paid by the Participating
Plan's claim administrator within the time frames specified in Exhibits A and B, then a
discount based on the Participating Provider's Negotiated Rate may not apply and
payment of Covered Services is ultimately the responsibility of the Covered Individual.
The Covered Individual will then need to seek reimbursement from the Participating Plan.
5.8 In the event a Participating Provider seeks oral or written verification of a Covered
Individual's eligibility or information regarding the level of benefits of the Participating
Plan, the Participating Plan shall require its claim administrator to confirm such eligibility
or provide the information requested by the provider.
5.9 The parties agree that if a participating Physician believes the amount paid is in error,
he/she shall have ninety (90) days after receipt of payment to question the accuracy of
such amount. After such time, the amount paid shall be binding on the participating
Physician as the full amount due to Physician.
5.10 Upon request, Participating Plan agrees to provide SLMC with a copy of their plan
document. Participating Plan shall immediately notify SLMC in writing of any
amendments or material changes in its schedule of benefits payable to Participating
Providers. Participating Plan agrees that it will provide SLMC with at least thirty (30)
days advance notice of benefit revisions affecting reimbursement to Participating
Providers.
5.11 The Participating Plan shall be responsible for the printing and distribution of
identification cards to all Covered Individuals participating in this health benefit option.
The identification cards shall include both SLMC's and the Participating Plan's name
and/or logo. The identification card shall also include the group number SLMC assigns
to the Participating Plan. Participating Plan is obligated to provide Covered Individuals
with information and/or material on the appropriate use of the identification card.
5.12 The Participating Plan agrees to exclusively use the SLMC preferred provider network in
the State of Colorado. The Participating Plan shall not contract directly with any hospital
or other healthcare provider in the State of Colorado without SLMC's written consent.
8 PPO17/PAR-WE-UR/CrrY OF FT COLLINS/11.20.981J9
1.
I�
EXHIBIT A
Mountain Crest Hospital
Tax ID #84-1275549
Rate Schedule by Service
PSYCHIATRIC
- Adult Inpatient
- Adolescent Inpatient
- Adult Day Treatment (> =4 hrs)
- Adolescent Day Treatment (> =4 hrs)
- Child Day Treatment (> =4 hrs)
- Adult Afternoon/Evening Treatment (< 4 hrs)
- Adolescent Afternoon/Evening Treatment (<4 hrs)
- Child Afternoon/Evening Treatment (< 4 hrs)
- Adolescent Intensive Outpatient Dual Diagnosis
SUBSTANCE ABUSE
- Adult/Adolescent Detoxification
- Adult Inpatient -
- Adolescent Inpatient
- Adult Day Treatment (> = 4 hrs)
- Adolescent Day Treatment (> = 4 hrs)
- Adult Afternoon/Evening Treatment (<4 hrs)
- Adolescent Afternoon/Evemng Treatment (<4 hrs)
Per Diem/Fee (1)
$490
$515
$245
$255
$255
$145
$155
$155
$ 30/hr
$500
$425 _
$515
$245 _
$255
$145
$155
Adult Intensive Outpatient * - — $ 30/group
Adult Intensive Outpatient Family Program $125/session
Adult Intensive Outpatient Relapse Track * $ 30/group
Adolescent Intensive Outpatient Dual Diagnosis $ 30/hr
* Relapse guarantee: If any patient has completed the entire Adult Intensive Outpatient or Adult
Intensive Outpatient Relapse Track program, and if that patient relapses within one year of
completing treatment, then the adult can complete the Adult Intensive Outpatient Relapse Track
at no cost. This guarantee is valid as long as HHG of Colorado is operating out of Mountain
Crest Hospital.
EXHIBIT A
Mountain Crest Hospital
Page 2
(1) The per diem for treatment is inclusive and includes the following treatment components when
required by the attending physician and provided by Mountain Crest Hospital employees:
- Room and Board Charges - Adjunctive Therapy
- Nursing - Art Therapy
- Lab - Group Therapy
- Psych000cial Therapy - Family Therapy performed by MCH staff
- Recreational/Occupational Therapy - Medications
- Rope Therapy - Patient Supplies and Materials
- Adolescent Schooling
- Aftercare Groups, for one year (provided at Hospital)
The per diem for treatment does not include the following components:
Attending physician fees are billed by the attending physician.
Services performed that are physical rather than psychological in nature, including, but
not limited to:
(1) CAT Scans
(2) - X-rays
(3) MRI's
_ (4) ECT -
(5) History & Physical
Psychological testing that has been ordered by the attending physician and is crucial to
diagnosis and treatment planning. Psychological testing may be provided by a Sloans
Lake clinician/provider if they have applied for and have been granted privileges at
Mountain Crest Hospital.
Biofeedback when ordered by the attending physician and is crucial to the patient's
treatment.
- - ECT when ordered by the attending physician and is crucial to the patient's treatment.
EXHIBIT A
National Jewish Medical & Research Center
Tax ID #74-2044647
OUTPATIENT SERVICES:
Time out for Asthma Outpatient Clinic: Adults & Pediatrics' _ $900.00 Per Diem'
This is a multi -day outpatient program of evaluation, observation and therapy tailored for patients with
moderate to severe asthma. The results are an optimal management regimen that improves patient quality of
life, reduces the frequency and severity of exacerbations and reduces long-term costs.. The package prices are
all inclusive (all facility and professional fees, billed on a UB92 claim form).
Time Out for Asthma Day Treatment Program: Adults & Pediatrics" $1,100.00 Per Diem' -
Day Treatment is an evaluation and treatment program that provides an intermediate level of care for difficult
to manage patients that are refractory to outpatient management, yet do not meet criteria for inpatient
hospitalization. This is an eight to twelve hour per day outpatient pediatric and adult program with a facility
component. Patients are those who do not require inpatient supervision yet need a more intensive evaluation
and treatment period than can be provided in outpatient clinic appointments. The package prices are all
inclusive (all facility and professional fees, billed on a UB92 claim form).
Outpatient SleeD Studv Codes
CPT
95805
95807
95808
95810
PPO Allowable
$ 292.00
413.00
450.00
613.00
Other Outuatient Clinic/Day Treatment Programs: 20% discount off Billed Charges
Evaluation and treatment of chronic respiratory and immune disease in a clinic or day treatment setting.
National Jewish provides successful programs for a broad range of chronic illnesses such as,
COPD/Emphysema, Tuberculosis, Allergies, Interstitial lung disease, Occupational/Environmental lung and
skin diseases, Autoimmune diseases such as Lupus, Sleep disorders, Chronic fatigue syndrome, and Juvenile
rheumatoid arthritis.
Outpatient Ancillary Services: 20% Discount off Billed Charges
Diagnostic and therapeutic procedures (bronchoscopy, laryngoscopy, pulmonary physiology) and radiology.
INPATIENT SERVICES:
Inpatient Care: $1,500.00 Per Diem'
Charges cover inpatient diagnostic and therapeutic procedures including pharmacy, inhalation therapy,
discharge planning, PT, OT, ST, rehab services, radiology testing, laboratory testing, health education, and
inpatient psychiatric services. Reimbursement includes professional and technical services.
1 Case Management Review as requested.
2 Case Management Review as requested.
3 Reimbursement is based on the lesser of billed charges or the per diem
EXHIBIT A
The Network Alliance
Tax ID #84-1278733
Healthcare Services Fee Schedule
Intermittent Visits: (0-2 Hourll Code: . Discount Rates
Registered Nurse (hi -tech)
SRHV
$ 74.00
Registered Nurse (primary nursing)
RNHV
$ 69.00
Licensed Practical Nurse
LPHV
$ 40.00
Mental Health Worker
MHWV
$ 34.50
Home Health Aide
HHAV
$ 28.00
Physical Therapy
SRHH
$ 72.00
Occupational Therapist
OTHV
$ 72.00
Speech Pathologist
STHV
$ 72.00
Medical Social Worker
MSWV
$ 85.00
PICC Line Placement (including supplies)
PICC
$225.00
Midline Placement (including supplies)
MIDL
$175.00
Hourly Visits
Registered Nurse (hi -tech)
SRH
$ 36.00
Registered Nurse (primary nursing)
RNH
$ 32.00
Licensed Practical Nurse -
LRH
$ 18.00
Mental Health Worker
MHW
$ 15.00
Home Health Aide _
HHA
$ 12.00
Personal Care Giver
PCHP
$ 10.00
Companion
COMP
$ 10.00
Holiday Rates
All rates will be billed at time and one-half for the following recognized holidays:
New Years Day _ Labor Day
Memorial Day Thanksgiving Day
Independence Day Christmas Day
Holiday rates are in effect from 7:00 p.m. on the eve of the holiday through 11:00 p.m. on the actual date
of the holiday.
EXHIBIT A
The Network Alliance
Page 2
For products not listed on pages 2 through 5 under the following headings, "Respiratory Services", "Rehabilitation
Equipment & Wheelchairs Rental and Retail", "Miscellaneous" and "Enteral Therapy Service and Supplies", The Network
Alliance offers a 20% discount off of the customary rate for supply and 25% discount off the customary rate for rentals.
Respiratory Services
HCPC Codes - Oxygen Stationary
Liquid Oxygen
E0492
$ 0.85
$85.00 per month
w/portable
H Cylinders
E1399A
$ 11.00 ea.
E Cylinders
E2399B
$ 7.00 ea.
Oximetry
E1399B
$50.00/test
HCPC CODES
Rental Per Month
Purchase
Cylinder & Regulator
E0431
$ 40.00
Concentrators
E1400
$185.00
$1700.00
CPAP
E0601
$110.00
$800.00
CPAP supplies subsequent to inital set up
respronic head gear
K0185
Included in Rental Price
$35.00
tubing 61
K0187
Included in Rental Price
$30.00
soft series mask
E1399
Included in Rental Price
$35.00
respironic mask
E1399
Included in Rental Price
$55.00
gel mask
E1399
Included in Rental Price
$70.00
Service maintence every 6 months E0601MS
Included in Rental Price
$50.00
BiPAP
E0450
$240.00
Compressor Nebulizer
E0570
$ 25.00
$110.00
Nebulizer Kits (month supplies)
E0580
- -
$ 3.75
Ultrasonic Nebulizer
E0575A
$ 75.00
Portable Nebulizers
E0575B
$ 75.00
$450.00
Environmental/Purif/Humid.
E0550
$250.00
Suction Machine
E0600A
$ 50.00
Gastric Intermittent Suction
E0600B
$ 65.00
W/C Oxygen Cylinder Holder--
K0104
$ 49.50
Cylinder Portable Cart
E1355A
$ 10.00
Phototherapy Units
E0202
$ 55.00 (daily)
Ventilator
_ E0450 -
$700.06
H Stand
E135513
$ 10.00
A complimentary supply of cannulas, masks, humidifiers and oxygen tubing is provided to all oxygen patients.
All oxygen/respiratory patients are set up by a trained respiratory personnel.
Routine follow-ups by trained respiratory personnel are performed every 60-75 days; more frequently if needed or requested
by a physician.
Respiratory personnel are available 24 hours per day.
EXHIBIT A
The Network Alliance
Page 3
Rehabilitation Equipment & Wheelchairs - Rental and Purchase
HCPC Codes
Alter. Press. Pump w/Matt E0182
Blood Pressure Monitor (Automatic)
Automatic digital blood pressure kit
Digital wrist monitor -automatic blood pressure
Blood Pressure Monitor (Manual)
Sphygmomanometer no stop -adult blood pressure
Blood pressure monitor manual child w/cuff
Canes
Standard adjustable cane
Aluminum adjustable cane round handle
Black wood adult cane
Quad Canes
Cervical Pillows
Cervical neck roll pillow
Cervical pillow -standard
Stress -Ease support pillow
Commode Pail
Compression Hosiery
Compression hose -thigh
Compression hose -calf closed toe
CPM (all joints except TMJ)
Crutches
Crutches -Forearm
Half calf forearm adult crutches
Aluminum forearm adult crutches (pair)
-Forearm crutches royal bronze finish adult
Eggcrate Mattresses
Twin eggcrate pad 2"
Twin eggcrate pad 3"
Queen eggcrate pad 4"
Gerri Chairs
Glucose Monitor
One -touch II glucometer
Glucose Strips (per box)
Grab Bars
12" grab bar chrome
16" grab bar chrome
24" grab bar chrome
Hospital Beds
Manual hospital bed w/matt. (side rails included)
Semi -elect. hosp. bed w/matt. (side rails included)
Full elect. hosp. bed w/matt. (side rails included)
Hoyer Type Patient Lift
Inflatable Basin w/Shampoo
Lancets (per box)
A4670
E1399
A4660A
A4660B
EO I OOA
EOl00B
EOl00C
E0105
E0943A
E0943B
E0943C
E0167
LOTSA
LOTSB
E0935
UNIES
EO110A
EOl10B
E0110C
EO179
EO179
E0199B
K0002A
E0607
A4253
E0241A
E0241A
E0241C
E0250
E0260A
E0260B
E0630
E1399
A4259
Rental Per Month
$ 45.00
$ 18.00
Purchase
$ 107.00
$ 140.00
$ 25.00
$ 25.00
S 10.50
$ 10.50
S 20.00
$ 8.70
$ 8.70
$ 26.50
$ 425
$ 39.50
$ 22.00
$ 30.00 per day plus a
$ 50.00 one time set up fee
$ 20.00
$ 58.83
$ 99.92
$ 80.00
S 12.47
$ 12.47
$ 41.25
$ 85.00 $ 500.00
_ 5 185.00
$ 42.50
S 14.50
$ 14.50
$ 17.00
$100.00
$145.00
$170.00
$180.00
$ 19.30
$ 20.00
EXHIBIT A
The Network Alliance
Page 4
Rehabilitation Equipment & Wheelchairs - Rental and Purchase - Continued
HCPC Codes Rental Per Month Purchase
Lift Chairs
2-position lift chair
E0627A
3-position lift chair
E0627B
Luxury 3-position lift chair —
E0627C
Overbed Table
E0274
$ 30.00
Parabath, Oil and Wax
A4265
$ 37.50
Platform Attach.
E0153
$ 20.00
Scooters
Standard 3-wheel, rear drive scooter
E1230A
Carrette 3-wheel, rear drive scooter with charger
E 1230B
Side Rails
E0310
$ 20.00
Toilet Seats
Raised toilet seat molded plastic
E0244A
EZ-lock elevated toilet seat
E0244B
EZ-lock elevated toilet seat with arm
E0244C
Traction Units (over door)
E0860
Transfer Boards
Plastic transfer board
K0103A
Wood transfer board
K0103B
Wood transfer board (thicker)
K0103C
Trapeze —
Trapeze
E0910
$ 25.00
Free standing trapeze bar
E0190
$ 45.00
Walkers
Walkers
E0135
$ 20.00
Walkers (w/wheels) _
E0155
$ 25.00
Wheelchairs
_
Standard
K0001
$ 70.00
Hemi
K0002B
$ 80.00
Lt. Weight
K0003
$ 90.00
Heavy Duty
K0006
$125.00
Pediatric Custom Equipment
charges —.
Wheelchair Cushions
Foam wheelchair cushion
E0192A
Jay basic wheelchair cushion
E0192B
Jay 2 pressure relief wheelchair cushion
E0192C
Stimulite pressure relief wheelchair cushion
E0192D
Roho pressure relief wheelchair cushion
E0I92E
Wheelchair Maintenance & Repair -Labor Charge
$ 600.00
$ 708.00
$ 817.00
$1980.00
$3019.00
$ 15.00
$ 36.00
$ 55.00
$ 17.50
$ 29.00
$ 38.00
$ 56.00
15% off billed
$ 10.00
$ 50.00
$375.00
$350.00
$385.00
$ 40.00/per hour
EXHIBIT A
The Network Alliance
Page 5
Miscellaneous
HCPC Codes
Price
Bed pan (each)
E0275
$ 4.64
Bed pan -fractured (each)
E1399
$ 4.44
Gloves -non -sterile (100)
A4927A
$10.00
Gloves-powderless latex (100)
A4927B
$10.00
Gloves-safeskin non -sterile (100)
A4927C
$ 6.25
Gloves -Sterile (50 pr.)
A4927D
$20.00
Sphygmomanometer -adult cotton cuff
A4660A
$24.87
Sphygmomanometer -infant cotton cuff
A4660B
$22.55
Staple removal kit
E1399A
$ 7.63
Stethoscope (each)
E1399B
$ 5.40
Stethoscope-sprague rappaport type
E1399C
511.38
Suture removal kit
E1399D
$ 1.08
Thermometer covers -digital (50)
E1399E
$ 1.23
Thermometer covers -oral (50)
E1399F
$ 3.53
Thermometer covers -rectal (50)
E1399G
$ 5.01
Thermometers -digital
A9270
$ 5.02
Thermometers -oral (each)
E1399H
$ 2.00
Thermometers -rectal (each)
E1399I
$ 2.00
Enteral Therapy Service and Supplies I
Oral Supplements HCPC Codes Price per Case
Oral Supplements HCPC Codes Price per Case
Attain
B4150A
$23 25
Jevity
B4150E
$32.45
Citrisource
B4155A
$35.55
Osmolite
B4150F
$30.00
Fibersource
B41-53
$50.10
Advera
B4155B
$93.25
Isosource
B4152
$4130
Isocal*
B4150G
$26.00
Comply*
B4150B
$23 25
Nepro
B4154
$75.50
Ensure*
B4150C
$28.38
Promote
B4150H
$35.85
Ensure w/Fiber*
B4151A
535.00
UltraCal
B4155C
$29.50
Ensure Plus*
B4150D
532.40
Pediasure
B4156
$35.86
Ensure Puddings
B4100
$56.46
Pediasure w/Fiber
B4151B
$37.66
* Available in flavors.
Enteral Pumps: B9002
Total Parenteral Nutrition (TPN)
1 liter of TPN solution
1.1 - 2.0 liters of TPN solution
2.1 - 3.0 liters of TPN solution
$75.00 rental per month
Lipids
Non -Standard Additive Therapy
TPN CONTINUED ON NEXT PAGE...
Amount Code
$140 per day
TPNOI
$160 per day
TPN02
$175 per day
TPN03
$20.00 per day
LIPID
AWP minus t0%.
ADDI
EXHIBIT A
The Network Alliance
Page 6
Infusion - Continued
Total Parenteral Nutrition (TPN) - Continued:
Included in the per diem rate for total parenteral nutrition: All additives common to TPN formulations, solutions, pharmacy
compounding fees, standard medical supplies, stationary pump, delivery, hazardous_ waste_disposal_and _pharmacy
management services.
Antibiotic. Antiviral, Antifungal Therapy
One dose every 24 hours
One dose every 12 hours
One dose every 8 hours
One dose every 6 hours
Amount Code
$ 75.00+AWP - 10%
ANT24
$ 87.00 + AWP - 10%
ANT12
$ 92.00 + A WP - 10%
ANT8
$110.00+AWP- 10%
ANT6
Included in the per diem rate for antibiotic, antiviral and antifungal therapy: Solutions, pharmacy compounding fees,
standard medical supplies and equipment, delivery, hazardous waste disposal and pharmacy management services. For
multiple drugs, each additional drug will be charged at $20.00 per drug + AWP minus 5%.
Hydration Theranv
Up to 3000 ml/day
Amount Code
$ 70.00 per diem HYD3
Included in the per diem rate for hydration therapy: Solutions, pharmacy compounding fees, standard medical supplies and
equipment, delivery, hazardous waste disposal and pharmacy management services.
Pain Management
Pain Management
Amount
$ 70.00+AWP- 10%
Code
— PMGT
Included in the per diem rate for pain management: Solutions, pharmacy compounding fees, standard medical supplies, PCA
pump, delivery, hazardous waste disposal and pharmacy management services. --
Chemotherapy
Chemotherapy
Amount Code
$ 80.00 + A WP CHEMO
Included in the per diem rate for chemotherapy: Solutions, pharmacy compounding fees, standard medical supplies and
equipment, delivery, hazardous waste disposal and pharmacy management services.
Immunoglobulms
Immunoglobulin
Amount Code
$70.00+AWP IMMU
Included in the per diem rate for immunoglobulins: Solutions, pharmacy compounding fees, standard medical supplies and
equipment, delivery, hazardous waste disposal and pharmacy management services.
EXHIBIT A
The Network Alliance
Page 7
Steroid Therapy
Infusion - Continued i
Amount
Code
Steroid Therapy $70.00+AWP STET
Included in the per themratefor steroid therapy: Solutions, pharmacy-compounding-fees,-standard-rnedica"upplie--and--- _
equipment, delivery, hazardous waste disposal and pharmacy management services.
Iron Binding Therapy Amount Code
Iron Binding Therapy $ 65.00 +AWP IBTH
Included in the per diem rate for iron binding therapy: Solutions, pharmacy compounding fees, standard medical supplies,
delivery, hazardous waste disposal and pharmacy management services.
Dobutamine Therapy
Dobutamine Therapy
Amount Code
$95.00+AWP DOBT
Included in the per diem rate for dobutamin therapy: Solutions, pharmacy compounding fees, standard medical supplies and
equipment, delivery, hazardous waste disposal and pharmacy management services.
Iniectibles
Neupogen, epogen, interferon, etc.
Amount Code
$55.00+AWP NEUP
Included in the per diem rate for injectibles: Standard medical supplies, delivery, hazardous waste disposal and pharmacy
management services.
Aerosolized Pentamidine
Aerosolized Pentamidine
Amount Code
$ 90.00 + AWP AREO
Included in the rate for aerosolized pentamidine: Pharmacy compounding fees, standard medical supplies, nebulizer,
delivery, hazardous waste disposal and pharmacy management services.
Enteral Therapy
Amount
Code
Enteral Therapy $ 20.00 +AWP — ENTT
Included in the per diem rate for enteral therapy: Standard medical supplies, stationary pump, delivery, hazardous waste
disposal and pharmacy management services.
Human Growth Hormone Amount Code
5 mg vial AWP+ 10% HGH5
Included in the per diem rate for human growth hormone: Medical supplies, equipment, delivery, hazardous waste disposal
and pharmacy management services.