You are the new CFO, of UMUC Medical Center, a 120 multi-skilled level three (3) healthcare facility. You have summoned a team of healthcare and business experts to assist with the process of contract

S A MP LE MA NAGED C ARE C ONTR ACT P H YSIC IA N A G REE M EN T T H IS A GREEM EN T is en te re d in to by an d betw een __ __ ________ ___ , In c., a __ __ _________ _ c o rp or atio n , ( " N etw ork ") a n d _ _ __ _______ _________ , M .D . ( " P hysic ia n" ). W HER EA S, th e N etw ork is d ev elo p in g a p ro vid er n etw ork c o nsis tin g o f p h ysic ia n s, in stitu tio nal fa cil it ie s, a n d p ro vid ers o f a n cilla ry h ealth; a n d W HER EA S, P hysic ia n wis h es to b e a P arti c ip ati n g Physic ia n in N etw ork . N OW , T H ER EFO RE, in c o nsid era tio n of th e m utu al p ro m is e s c o nta in ed here in , th e p artie s a g re e a s f o llo w s:  M ak e s u re th e c o n tr a ct c le a rly d esc rib es w hat p ro du ct lin e(s ) th is c o n tr a ct is f o r.  W hen is th e c o n tr a ct e ff e ctiv e?  E xa m ple - T his A gre em ent a ppli e s o nly t o P aye r’s C om m erc ia l H M O, b ut n ot to P aye r’s M edic a re H M O. I . D EFIN IT IO NS 1 .1 “ B en efit P la n” m ean s th o se h ealth c a re se rv ic es w hic h a re in clu d ed a s h ealth c are b en efits p urs u an t to M em ber’s B en efit P la n .  M ak e s u re th at B en efit P la n s a re o n ly in th ose P ro d u ct lin es y o u h ave a gre ed to c o n tr a ct.  E xa m ple - B enefit P la n s w il l b e li m it e d to C om merc ia l H M O, a nd n ot M edic a re H M O .

1 .2 " C overe d S erv ic e s" m ean s m ed ic a l a n d oth er h ealth c a re s e rv ic es th at a re c o vere d u n der a H ealt h Ben efit P la n e sta b lis h ed b y a P ay er a n d w hic h a re d eem ed M ed ic all y Necessa ry b y P ay er o r N etw ork .  W ho is th e P ayer? L ook f o r a d efin itio n o f P ayer. 1 .3 " E m erg en cy" m ean s th e su d den a n d u nex pecte d o nse t o f a c o nd iti o n o r sy m pto m s re q uir in g m ed ic al o r s u rg ic al c a re to s c re e n a n d/ or tr e at th e M em ber, a n d w hic h is s e cu re d im m ed ia te ly a fte r th e o n se t ( o r a s s o o n t h ere afte r a s th e c a re c a n be m ad e a v aila b le ), a n d is o f s u ch im med ia te n atu re th at th e M em ber's lif e o r h ealt h m ig h t b e je o p ard iz ed if h e o r s h e is n o t tr e ate d as s o o n a s p oss ib le . 1 .4 “ F ee S ch ed u le ” m ean s th e m ax im um a m ou nt w hic h N etw ork w ill p ay f o r a s p ecif ic s e rv ic e .  A nd w hat e x actl y is th at? 1 .5 " M ed ic all y N ecess a ry " o r " M ed ic al N ecess it y " m ean s th ose s e rv ic es o r s u pp lie s w hic h , u nd er th e te rm s a n d c o nd itio ns o f th is A gre e m en t, a re d ete rm in ed to b e: a p p ro pr ia te a n d necessa ry f o r th e s y m pto m s, d ia g n osis o r t r e atm en t o f th e m ed ic al c o n ditio ns o f th e M em ber; p ro vid ed f o r th e d ia g n osis o r d ir e c t c a re a n d tr e atm en t o f t h e m ed ic al c o nd iti o n o f th e M em ber; w ith in s ta n d ard s o f m ed ic al p ra ctic e w ith in th e c o m munity; a n d n ot p rim arily f o r th e c o nv en ie n ce o f th e M em ber, th e M em ber's p hy sic ia n o r a n oth er p ro vid er. 1 .6 " M em ber" m ean s a n y p ers o n e lig ib le to re ce iv e C overe d S erv ic es a n d w ho se B en efit P la n h as a ccess to th e N etw ork .  M ak e s u re th at M em ber is o n ly in th ose P ro du ct lin es y o u h ave a gre ed to c o n tr a ct.  E xa m ple - M em ber w il l b e li m it e d to C om m erc ia l H M O, a nd n ot M edic a re H M O. 1 .7 " P artic ip atin g H osp it a l" m ean s a d u ly lic en se d h osp ita l w hic h h as e n te re d in to a n a g re e m en t w ith N etw ork to p ro vid e C overe d S erv ic es to M em bers . 1 .8 " P artic ip atin g P hysic ia n" m ean s a p h ysic ia n w ho h as e n te re d in to a n a g re e m en t w ith N etw ork to p ro vid e C overe d S erv ic es to M em bers .  W hat P hysic ia n s a n d H osp ita ls a re p arti c ip a tin g? 1 .9 " P ay er" m ean s a n o rg an iz atio n , fir m , o r g ov ern m en ta l e n tity , in clu d in g b ut n o t lim ite d to a se lf -in su re d e m plo yer, em plo y er co alit io n , health in su ra n ce purc h asin g co o pera tiv e, in su re r, health m ain te n an ce o rg an iz ati o n o r p re fe rre d p ro vid er o rg an iz atio n , th at h as c o ntr a c te d w it h N etw ork to a rra n ge f o r th e p ro vis io n o f h ealth c a re s e rv ic es to its m em bers .  T he P ayer a n d th e N etw ork y o u a re c o n tr a ctin g w it h a re n ot n ecess a ril y th e s a m e. T he P ayer m ay p a y th e N etw ork to access p ro vid ers in th e N etw ork . I n th ese s itu ati o n s, th e P ayer is o b lig ate d to p ay th e c la im n ot t h e N etw ork .  N etw ork w arr a nts th at it s c o ntr a cts w it h P aye rs re quir e P aye rs to c o m ply w it h a ll P aye r re quir e m ents a nd re sp on sib ili t ie s d escrib ed in th is A gre em ent, a nd th at s u ch c o ntr a cts a ls o re quir e P aye rs to a ckn ow le dge th at th ey w ill n ot b e a llo w ed to p artic ip ate in th e n egotia te d r a te s a nd o th er te rm s o f th is A gre em ent if th ey fa il t o c o m ply w it h s u ch r e qu ir e m ents .  N etw ork a gre es th at e ach a gre em ent w it h a ny P aye r s h all p ro vid e fo r a d if f e re ntia l fo r in -n e tw ork v e rs u s o ut- o f- n etw ork c o ve ra ge fo r P hys ic ia n S erv ic e s of a t le ast 1 0 % . T he fo re goin g d is c o unt s h all a ls o b e a pp li e d to th e M em be r’s out- o f- p ock e t c o sts , i. e . C opaym ents o r D eductib le s.  N etw ork a gre es t o p ro vid e a q uarte rly li s t o f c o ntr a cte d P aye rs . 1 .10 " P rim ary C are P hysic ia n" m ean s a P artic ip ati n g P hysic ia n w ho is d esig nate d b y th e N etw ork a s a p ro vid er o f p rim ary c a re s e rv ic es, a n d w ho is p rim arily r e sp onsib le f o r m an ag in g a n d c o o rd in ati o n th e o v era ll h ealt h ca re n eed s o f th e M em ber. 1 .11 “ P hysic ia n M an ual” m ean s th e m an u al w hic h h as b een p re p are d b y N etw ork a n d s e ts fo rth a ll p oli c ie s a n d p ro ced ur es g ov ern in g P hysic ia n ’s p artic ip atio n in N etw ork .  M ak e s u re y o u g et a c o py o f th is a n d r e a d it . 1 .12 " S pecia lt y C are P hysic ia n" m ean s a P artic ip ati n g P hysic ia n w ho is d esig nate d by th e N etw ork a s a p ro vid er o f s p ecia lty s e rv ic es o th er th an p rim ary c are s e rv ic es. 1 .13 " U til iz atio n R ev ie w /Q ualit y A ssu ra n ce P la n" o r " U R/Q A P la n" m ean s th e p ro gr am o r p ro gr am s a d o pte d b y t h e N etw ork , a n d c a rrie d o u t b y P arti c ip atin g P ro vid ers w ith N etw ork w hic h a u th o riz es a n d m onito rs th e u tiliz ati o n o f P ro vid ers o ffe re d to M em bers .  B efo re e x ecu tin g th e c o n tr a ct, o b ta in c o p ie s o f th e P ayer ’s P ro vid er H an dbo ok/ UR/U M M an u als a n d P ro to co ls . U nders ta n d th e A pp ea ls , G rie va n ce , U R/Q A , a n d A uth oriz a tio n P ro cess e s. D ete rm in e w hic h s e rv ic es n eed p re a u th oriz a ti o n a n d n otif ic a tio n a n d w ho c a n r e q u est a u th oriz a tio n s – P C P, S C P o r b o th . A re r e tr o -a u th oriz a tio n s c o n sid ere d f o r m ed ic a l n ece ssity ? A ddit io n al D efin itio ns to in clu d e:  “ C le an C la im ” m eans a c la im fo r p aym ent fo r a C ove re d S erv ic e th at c a n b e p ro ce sse d w it h out o bta in in g a ddit io nal in fo rm atio n f r o m th e p ro vid er o f th e s e rv ic e o r fr o m a th ir d p arty . It in clu des a c la im w it h e rro rs o rig in atin g in P aye r's c la im s p ro ce ssin g s y ste m . It d oes n ot in clu de a c la im u nder r e vie w fo r m edic a l n ece ssit y .  “ C la im ” m eans a b ill s u bm it te d b y P hysic ia n to N etw ork fo r P hys ic ia n s e rv ic e s p ro vid ed to a M em be r u sin g a b il li n g fo rm c o nta in in g e quiv a le nt in fo rm atio n.  “ N on-C ove re d S erv ic e s” m ea ns s e rv ic e s, s u pplie s, p ro ducts a nd a cco m modatio ns th at N etw ork is n ot r e quir e d to p ro vid e to M em bers p urs u a nt to a G ro up C on tr a ct, in clu din g b ut n ot li m it e d to s e rv ic e s w hic h a re n ot a uth oriz e d b y N etw ork a s p a rt o f th e U tili z a tio n R evie w p ro gra m . I I . P H YSIC IA N R ESP O NSIB IL IT IE S 2 .1 P hysic ia n a g re es to p ro vid e to M em bers th ose C overe d S erv ic es to th e s a m e e x te n t a n d a v ail a b il ity , a n d w ith t h e s a m e d eg re e o f c a re , a s P hysic ia n norm all y pro vid es s u ch s e rv ic es to th e g en era l c o m m un ity . 2 .2 P hysic ia n sh all m ain ta in re aso nab le o ffic e h o urs in a lo catio n c o n ven ie n t to M em bers , a n d a g re es to b e a ccessib le to M em bers e it h er p ers o nally o r b y a rra n gin g f o r c o vera g e b y a n oth er P artic ip ati n g P hysic ia n o r b y a n oth er q uali f ie d p hy sic ia n a p pro ved b y N etw ork . P hysic ia n sh all a ssis t N etw ork in e n su rin g th at th e c o verin g p hy sic ia n c o m pli e s w ith th e U R/Q A p la n s e sta b lis h ed b y N etw ork a n d b y P ay ers , a n d th at h e c o m plie s w it h t h e c o m pen sa tio n te rm s o f th is A gre e m en t.  M ak e s u re y o u c a n c lo se p ra ctic e to o n e p ro du ct lin e a n d n ot a n oth er. 2 .3 I f P hysic ia n a rra n ges w ith e ith er a p artic ip atin g o r n on -p arti c ip atin g P hysic ia n to c o ver M em bers fo r h im /h er i n h is /h er a b se n ce , it w ill b e th e P hysic ia n ’s re sp onsib ili ty to a sc e rta in th at th e c o verin g P hysic ia n w ill : (a ) a ccep t c o m pen sa ti o n fr o m N etw ork a s fu ll p ay m en t fo r c o vere d s e rv ic es in a cco rd an ce w ith th e a p p lic ab le N etw ork c o m pen sa tio n sc h ed u le (b ) n ot b ill th e M em ber d ir e c tly e x cep t fo r a n y a p pli c ab le c o p ay m en t, c o in su ra n ce , o r d ed ucti b le s; (c ) o b ta in a p pro val a s d esig nate d b y N etw ork , p rior to a ll n o n-e m erg en cy h osp it a liz atio ns a n d n o n-e m erg en cy r e fe rra ls o f M em bers ; a n d (d ) c o m ply w ith a ll N etw ork ru le s, p ro to co ls , p ro ced ur es, a n d p ro gr am s.  T his p ro vis io n m akes it th e P hysic ia n ’s r e sp on sib ly to e d u ca te n on -p a rtic ip ati n g c o verin g p h ysic ia n s. 2 .4 P hysic ia n s h all m ain ta in a d eq uate m ed ic al r e c or ds f o r M em bers a n d s h all r e ta in a n d p re se rv e s u ch r e c or ds f o r t h e fu ll p erio d o f ti m e re q uir e d b y sta te a n d fe d era l la w . P hysic ia n a n d N etw ork sh all m ain ta in th e c o nfid en ti a lity of M em bers ' m ed ic al r e cor ds in a cc o rd an ce w ith a ll a p pli c a b le la w s a n d r e g ula tio ns. S ub je ct to s u ch re q uir e m en ts , th e P hysic ia n w ill m ak e th e M em ber's m ed ic al re cor ds re a d ily av ail a b le to an y P arti c ip atin g P hysic ia n o r o th er h ealt h p ro fe ssio nal w ho n eed s th e r e cor ds in o rd er to tr e at th e M em ber, a n d u po n r e aso nab le r e q uest, s h all m ak e th e r e c or ds a v aila b le f o r r e v ie w b y Netw ork , P ay er, o r th eir d esig n ee f o r q uali ty a ss u ra n ce/u ti liz a tio n purp ose s o r f o r o th er r e aso nab le a n d n ecessa ry p urp ose s.  N etw ork w ill r e im burs e P hys ic ia n th e c o st o f p re parin g, c o pyin g, a n d d eli v e rin g r e co rd s . 2 .5 N etw ork o r it s d esig n ee sh all h av e th e rig ht to in sp ect an d au d it , an y o f th e P hysic ia n 's acc o un tin g , a d m in is tr a tiv e, m ed ic al r e cor ds a n d o pera tio ns.  T his p ro vis io n a llo w s th e P ayer to in sp ect a n y o f y o u r f in an cia l r e co rd s.  A ny re vie w w ill b e li m it e d to M em bers a nd C ove re d S erv ic e s. P aye r s h all c o nta ct P hysic ia n a t le ast fif te en (1 5) d ays in a dva nce o f a ny r e vie w to s ch edule a m utu al a gre eab le tim e fo r th e r e vie w .  N etw ork m ay n ot r e que st o r h ave a ny a cc e ss to P hys ic ia n's n on-p ublic fin ancia l d ata , r e co rd s, o r in fo rm atio n, w hic h th ey fe el t o b e c o nfid entia l. 2 .6 P hysic ia n r e pr ese n ts th at th e in fo rm ati o n pro vid ed in th e n etw ork a p p lic ati o n is c o rre ct. I n a d d iti o n , P hysic ia n w arra n ts th at h e is ( a ) lic en se d to p ra c tic e m ed ic in e o r o ste o path y in th e S ta te (s ) o f C ali f o rn ia : ( b ) h as m et a ll q uali f ic atio ns a n d s ta n d ard s f o r a p p oin tm en t to th e m ed ic a l s ta ff o f a t le ast o n e P artic ip atin g; ( c ) w ill h av e a n d m ain ta in , w here ap pro pr ia te , a c u rre n t a n d u nre str ic te d n arc o tic s n u m ber is s u ed th e D ru g E nfo rc em en t A dm in is tr a ti o n (" D EA "); ( d ) h as s p ecia liz ed tr a in in g in th e a re a in w hic h h e p ra ctic es.  W atc h th e S ta te lo ca tio n r e fe re n ced in th e c o n tr a ct. 2 .7 P hysic ia n s h all r e p or t a n y r e p or ta b le o ccu rr e n ce s in clu din g , b u t a re n o t li m ite d to , a n y a ctio n , in vestig atio n , o r p ro ceed in g in itia te d o r ta k en b y a n y p ro fe ssio n al s o cie ty o r o rg an iz atio n , b y a n y f a cili ty , b y a n y m ed ic al g ro up o r p ra ctic e , b y an y lic en su re o r certi f ic ati o n ag en cy , b y an y re im bur se m en t en tity o r m an ag ed care o rg an iz ati o n , o r b y a n y s im ila r e n tity o r o rg an iz atio n , to re v oke, s u sp en d , re str ic t, o r o th erw is e a d v ers e ly a ffe ct h is p riv ile g es, lic en se , c e rtif ic atio n , o r p ro fe ssio nal s ta n d in g o r m em bers h ip . T he P hysic ia n a g re es to n otif y th e N etw ork im m ed ia te ly o f a n y s u sp en sio n , re d uctio n , o r te rm in ati o n o f h is li a b il ity in su ra n ce , o r o f a n y la w su it file d ag ain st h im alle g in g m alp ra c tic e o r n eg lig en ce an d re q uestin g d am ag es in ex cess o f $ 5 ,00 0.0 0 . 2 .8 P hysic ia n , s h all p ro vid e a n d m ain ta in p ro fe ss io nal li a b ili ty in su ra n ce , in a m oun ts o f $ 25 0 ,00 0 p er c la im a n d $ 75 0 ,00 0 a n nu al a g gre g ate d u rin g th is A gre e m en t.  D o y o u h ave th is c o vera g e? 2 .9 P hysic ia n a g re es th at N etw ork s h all n o t b e r e sp onsib le f o r a n y cla im s, a ctio ns, lia b ili ty or d am ag es a ris in g o u t o f th e a cts o r o m is sio n s o f P hysic ia n o r th e a cts o r o m is sio ns o f a n y n on -p artic ip atin g p h ysic ia n w ho c o vers M em bers f o r th e P hysic ia n .  T his p ro vis io n o n ly p ro te cts th e N etw ork .  N etw ork a gre es th at P hysic ia n a nd P hysic ia n’s em plo ye es, s e rv a n ts , d ir e cto rs , o r o ff ic e rs sh all n ot b e li a ble o r r e sp onsib le fo r a ny a nd a ll a cts o r o m is sio ns o f N etw ork r e la tin g to ( i) a ny a nd a ll d ete rm in atio ns b y N etw ork o f M edic a l N ece ssit y ; ( ii ) a ny a nd a ll d ete rm in atio ns by th e N etw ork a s to w heth er o r n ot a tr e atm ent, s e rv ic e , o r p ro duct is a C ove re d S erv ic e ; a nd ( iii) a ny and a ll d ete rm in atio ns b y Netw ork a s to w heth er o r n ot a ny p ers o n is , o r is n ot, a M em ber o r B enefic ia ry . N etw ork s h all h ave th e d uty to m ake d ecis io ns a t le ast a cco rd in g to in dustr y s ta ndard s a nd a t le ast w it h d ue a n d a ppro pria te c a re a nd d il ig e nce . N etw ork sh all in dem nif y a nd h old P hysic ia n a nd P hys ic ia n’s e m plo ye es, s e rv a nts , d ir e cto rs , a nd o ffic e rs h arm le ss a gain st a ny a nd a ll c la im s, a ctio ns, p ro ce e din gs, d em ands, s e ttle m ents , li a bili t ie s, e xp ense s, o r d am age s a sse rte d a gain st P hys ic ia n o r P hysic ia n’s a gents , e m plo ye es, a nd o ffic e rs to t h e e xte nt s u ch th in gs r e su lt fr o m o r a ris e o ut o f a ny a ct o r o m is s io n o f N etw ork ; p ro vid ed h ow eve r, th is in d em nif ic a tio n s h all n ot in clu de a ny c la im s o r h arm re su lt in g fr o m , a nd to th e e xte n t o f, a ny lia bili t y a ris in g o ut o f th e p ro vis io n o f h e alt h c a re s e rv ic e s b y P hysic ia n o r P hys ic ia n’s e m plo ye es, s e rv a n ts , d ir e cto rs , a nd o ff ic e rs . 2 .10 T he P hysic ia n a g re es to c o o pera te w ith m ark eti n g p ro gr am s e sta b li s h ed o r a p p ro ved b y N etw ork , a n d a g re es t o allo w th e N etw ork an d P ay ers to lis t th e P hysic ia n 's n am e, sp ecia lty , ad dre ss , te le p h on e n um ber, w il lin gn ess to a c cep t a d ditio nal M em bers , a n d o th er re le v an t in fo rm ati o n in P arti c ip atin g P ro vid er d ir e c to rie s a n d s im ila r in fo rm atio nal m ate ria ls .  N etw ork s h all d is tr ib ute id entif ic a tio n c a rd s id entif y in g N etw ork to a ll m em bers ; e ach c a rd s h all in clu d e a to ll- fr e e n um ber th at P hysic ia n m ay u se d urin g n orm al b usin ess h ours to v e rif y e li g ib ilit y o f c o ve ra ge, to o bta in g enera l c o ve ra ge in fo rm atio n a nd to o bta in a uth oriz a tio ns. A c o py of a ny ca rd (s ) o f a d esig n n ot p re vio usly se en b y Phys ic ia n s h all b e p ro vid ed to P hysic ia n p rio r t o d is tr ib utio n o f c a rd s to M em bers . I V . U TIL IZ A TIO N R EV IE W , Q UALIT Y M ANA G EM EN T A ND A DM IN IS T R ATIO N 4 .1 T he N etw ork w ill esta b lis h crite ria an d g oals fo r esta b lis h in g an d m on ito rin g th e M ed ic al N ecessit y , a p pro pr ia te n ess , a n d q u alit y o f s e rv ic es p ro vid ed by P artic ip atin g Pro vid ers .  W hat a re th ey? 4 .2 P hysic ia n a g re es to c o op era te w ith a ll N etw ork r u le s, p ro to co ls , p ro ce d ure s, a n d p ro gr am s in e sta b lis h in g its u tiliz ati o n re v ie w , q uali ty m an ag em en t, b en efit m an ag em en t, d en ia ls o f a d m is sio ns o r c o n tin ued s ta y , o r o th er p ro gr am s th at m ay b e e sta b li s h ed to m an ag e th e c o st a n d u til iz ati o n o f m ed ic al s e rv ic es.  E xce pt fo r E m erg en cy S erv ic e s, P hys ic ia n s h all c o nfir m M em ber s ta tu s a nd s e cu re p rio r a uth oriz a tio n b efo re re nde rin g s e rv ic e s. U pon th e re quest fo r M em ber tr e atm ent b y a p artic ip atin g p hys ic ia n, P hys ic ia n s h all c o nta ct N etw ork to c o nfir m M em ber s ta tu s a nd to v e rif y th at th e p ro pose d tr e atm en t is a pp ro ve d a s a C ove re d S erv ic e . N etw ork s h a ll p ro vid e th e r e queste d v e rif ic a tio ns w it h in _ __ h ou r( s ) o f P hysic ia n 's in it ia l r e qu est, u nle ss P hysic ia n f a il e d to p ro vid e in fo rm atio n n eeded to m ake th e e li g ib ili t y d e te rm in a tio n. U pon s u ch v e rif ic a tio n, N etw ork s h all g iv e to P hys ic ia n a n a uth oriz a tio n c o de in dic a tin g a pp ro va l u pon w hic h P hysic ia n m ay c o nclu siv e ly re ly fo r th e d eliv e ry o f a uth oriz e d s e rv ic e s to th e M em ber. If P hys ic ia n o bta in s s u ch v e rif ic a tio n, N etw ork s h all n ot r e tr o activ e ly d eny p aym ent if N etw ork la te r d ete rm in es th at M em ber is n ot e li g ib le o r th at th e s e rv ic e a uth oriz e d a n d r e nd ere d is n ot a C ove re d S erv ic e .  N etw ork sh all p ro vid e P hysic ia n w it h a t le ast th ir ty ( 3 0) c a le ndar d ays p rio r w rit te n n otic e o f a ny m odif ic a tio n o r a m en dm ent o f t h e U til iz a tio n R evie w p ro gra m . If P hysic ia n o bje cts to s u ch m odif ic a tio n o r a m end m en t, P hysic ia n m ay te rm in ate th is A gre em ent b y p ro vid in g n otic e t o N etw ork w it h in s u ch th ir ty ( 3 0) d ay p erio d. 4 .3 P hysic ia n a g re es to re fe r M em bers to o th er P arti c ip atin g P ro vid ers w hen h e/s h e is u n ab le to p ro vid e th e r e q uir e d s e rv ic es a n d w hen c o nsis te n t w ith s o u nd med ic al ju d gm en t.  M ak e s u re y o u a re p ro vid ed w ith u p-to -d ate P ro vid er D ir e cto rie s.  P hysic ia n w il l u se h is /h er b est e ffo rts to r e fe r M em bers to o th er P artic ip atin g P ro vid ers w hen h e/s h e is u nable to p ro vid e th e r e quir e d s e rv ic e s a nd w hen c o nsis te nt w it h s o und m edic a l ju dgm ent. 4 .4 P hysic ia n a g re e s th at f a ilu re to co op era te w ith Netw ork r u le s, p ro to co ls , p ro ced ur es, a n d p ro gr am s m ay re su lt i n p en altie s a s s e t f o rth b y th e N etw ork a n d in clu d ed in th e P hysic ia n s’ o ffic e m an u al.  P E N ALTIE S!!  R evie w t h e P hysic ia ns’ o ffic e m anual c a re fu lly . 4 .5 P hysic ia n a g re e s to c o o pera te w ith a n y a p p lic ab le N etw ork g rie v an ce p ro ced ur e a n d d ecis io n s. 4 .6 P hysic ia n s h all c o m ply with a ll d ete rm in atio ns r e n dere d b y th e U R/Q A P la n pro gr am .  U pon s u ch v e rif ic a tio n, N etw ork s h all g iv e to P hys ic ia n a n a uth oriz a tio n c o de in dic a tin g a ppro va l u pon w hic h P hysic ia n m ay c o nclu siv e ly re ly fo r th e d eliv e ry of a uth oriz e d s e rv ic e s to th e M em ber. If H osp it a l o bta in s su ch v e rif ic a tio n, N etw ork sh all n ot r e tr o a ctiv e ly d eny p a ym ent if N etw ork la te r d ete rm in es th a t M em ber is n o t e lig ib le o r th at th e s e rv ic e a uth oriz e d a nd r e ndere d i s n o t a C ove re d S erv ic e .  N oth in g in th is A gre em ent s h all b e c o nstr u ed to in te rfe re w it h o r a ffe ct in a ny w ay th e e xe rc is e o f th e in dep endent m edic a l j u dgm ent o f P hysic ia n o r P hysic ia n’s e m plo ye es in re nderin g h ealt h c a re s e rv ic e s to M em bers . S pecif ic a lly , b ut n ot in l im it a tio n, th e P hysic ia n o r P hysic ia n’s e m plo ye e s s h all b e p erm it te d to c o m munic a te w it h M em bers c o nce rn in g ( i) a ll m att e rs n ece ssa ry o r a ppro pria te fo r th e d eliv e ry o f h ealt h c a re s e rv ic e s, (ii ) tr e atm ent a lt e rn ativ e s re gard le ss o f th e p ro vis io ns o r l im it a tio ns o f c o ve ra ge, a nd ( iii ) th e r e im burs e m ent a rra ngem ents u nde r w hic h th e P hys ic ia n is c o m pensa te d. V . C O M PE N SA TIO N 5 .1 F or C overe d S erv ic es p ro vid ed to m em bers , P hysic ia n s h all b e c o m pen sa te d in a cco rd an ce w ith E xhib it A .  I s th ere a n E xh ib it A ? D oes is c le a rly d esc rib e r e im bu rse m en t b y p ro d u ct lin e? 5 .2 P hysic ia n a g re e s to lo ok s o le ly to N etw ork f o r p ay m en t f o r C overe d S erv ic es.  P hysic ia n h as th e r ig ht t o b il l M em ber f o r a ll n on -c o ve re d s e rv ic e s. N o c o ntr a ctu al d is c o unt w il l a pply . 5 .3 N etw ork m ay o ffs e t o v erp ay m en ts a g ain st f u tu re p ay m en ts to P hysic ia n .  N etw ork a gre es th at re co ve ry o f o ve rp aym ents w ill n ot b e ta ke n fr o m fu tu re p aym ents , b ut w ill b e b il le d to P hysic ia n w it h a pp ro p ria te d ocu m enta tio n to s u bsta ntia te th e r e co ve ry .  N etw ork w ill n otif y P hysic ia n w it h in fif te en ( 1 5) c a le ndar d ays o f r e ce ip t o f c la im , o f a ny c la im p ended fo r r e vie w o r a udit .  N etw ork m ust n otif y th e P hysic ia n o f s u sp ecte d o ve rp aym ents n o la te r th an tw elv e (1 2) m onth s fr o m th e d ate H ea lt h P la n m ade th e p aym ent to th e P hysic ia n t o b e e li g ib le to r e co ve r s u ch a m ounts . 5 .4 P hysic ia n a ck n ow le d ges th at th e c o vera g e p ro vid ed a n d th e a u th oriz ati o n(s ) re q uir e d fo r m ax im um b en efits , f o r p arti c u la r C overe d S erv ic es m ay v ary u n der d if fe re n t H ea lth B en efit P la n s. U nder c e rta in H ealth B en efit P la n s n o c o v era g e is a v aila b le if th e C overe d S erv ic e h as n ot b een p re a u th o riz ed . P hysic ia n a g re es to c o nsu lt t h e P hysic ia n ’s o ff ic e m an u al, M em ber se rv ic es a n d o th er N etw ork m ate ria ls in o rd er to d ete rm in e if a C overe d S erv ic e is c o vere d , a n d if so , to o bta in th e n ecessa ry a u th o riz atio n(s ) in o rd er fo r th e C overe d S erv ic e to r e c eiv e th e m ax im um b en efit . 5 .5 I f P hysic ia n b ills N etw ork , s u ch bill m ust b e s u bm itte d no la te r th an nin ety ( 9 0) d ay s a fte r th e d ate o f s e rv ic e . N etw ork s h all n o t b e o b lig ate d to p ay a n y su ch b ill s s u b m it te d a fte r th e n in ety ( 9 0 ) d ay p erio d .  T ry to r e m ove th is p ro vis io n .  C om ple te c la im s th at a re n ot p aid w it h in th ir ty d ays w ill b e p aid a t P hysic ia n’s b il le d c h arg es. 5 .6 P hysic ia n a g re es to c o op era te w ith N etw ork C O B re q uir e m en ts a n d in th e re co very o f c la im s fro m o th er i n su re rs a n d th ir d p arty p ay ers .  P hysic ia n w il l c o op era te w it h N etw ork in im ple m entin g P aye r’s c o ord in atio n o f b en efit s p ro gra m . W here th e N etw ork is p rim ary u nder a pplic a ble c o ord in atio n o f b enefit ru le s, th e N etw ork s h all p ay th e re im burs e m ent ra te s d ue u nder th is A gre em ent a s pro vid e d in A tta ch m ent. If s u ch p aym ent d oes not c o ve r a ll b il le d c h arg es, P hysic ia n m ay su bm it c la im s to th e s e co ndary c a rrie r.  W here th e N etw ork is o th er th an p rim ary u nder c o ord in atio n o f b en efit r u le s re fe rre d to a bove , th e N etw ork s h all p ay th ose a m ounts whic h , w hen a dded to a m ounts ow ed to th e P hys ic ia n fr o m o th e r s o urc e s, p urs u ant to th e a ppli c a ble c o ord in atio n o f b en efit r u le s, s h all n ot e xce ed o ne h undre d p erc e nt ( 1 00% ) o f th e a m ount b il le d. H ow eve r, p aym ent b y Netw ork to P hysic ia n s h all n ot e xc e ed o ne h u ndre d p erc e nt ( 1 00% ) o f th e r a te s s e t fo rth in th is A gre em ent.  I f th e p rim ary c a rrie r d oes n ot p ay P hysic ia n w it h in fo rty -fiv e ( 4 5) c a le nda r d ays o f P hys ic ia n’s b il li n g, th en N etw ork s h all p ay P hysic ia n a t th e ra te s s e t fo rth in th is A gre em ent a nd s e ek re im burs e m ent fr o m th e p rim ary c a rrie r. If N etw ork s o p ays P hysic ia n, P hysic ia n s h all p ro m ptly re m it to N etw ork su ch a m ount o f a ny paym ent h ere afte r r e ce iv e d fr o m th e p rim ary c a rrie r s u ch t h at N etw ork s h all n ot h ave p a id to P hys ic ia n a ny m ore th an it w ould h ave p aid u nder th is A gre em ent.  T he P hys ic ia n s h ould n ot a gre e to a ny p ro vis io n th at w ould lim it it s r e co ve ry o f fu ll c h arg es if m em bers s u bro gate th eir r ig hts to t h e h ealt h p la n.  N etw ork M em ber in elig ib il it y d ete rm in atio ns s h a ll b e lim it e d to ( 3 0) t h ir ty d ays a ft e r M em ber w as c o nsid ere d e li g ib le .  I f N etw ork d is a gre es w it h th e le ve l o f p a ym ent d ue p hysic ia n, N etw ork w ill s e nd w rit t e n n otic e to P hys ic ia n s p ecif y in g r e aso n f o r d is a gre em ent. N etw ork a nd P hysic ia n w il l w ork to re so lv e d is a gre em ent. If d is a gre em ent c a nnot b e re so lv e d to P hysic ia ns r e a so nable s a tis fa ctio n, P hysic ia n m ay te rm in a te th is A gre em ent u pon t h ir ty d ays n otic e t o N etw ork . V I. T ER M A ND T ER M IN A TIO N 6 .1 T his A gre em en t s h all b e e ffe ctiv e a s o f _ __ _____ __ , 1 9 9_ __ , a n d s h all c o ntin u e f o r a te rm o f th re e ( 3 ) y ea rs f ro m th at d ate . U nle ss o th erw is e te rm in ate d a s s e t f o rth b elo w , th e A gre e m en t s h all a u to m atic all y be r e n ew ed f o r s u b se q u en t o ne-y ea r te rm s. R en eg o tia tio n s o f A gre e m en t s h all o nly ta k e p la ce n in ety d ay s p rior to th e e n d o f th e te rm o f th e A gre em en t.  W atc h th e te rm o f th e c o n tr a ct a n d w hen y o u c a n r e n eg oti a te .  T he te rm o f th is A gre em ent s h all b e _ ___ y e ars , b egin nin g a s o f _ ______ _ __, _ _ __ a nd e ndin g a t m id nig ht o n _ _____ __ _ __ , _ ___, s u bje ct to e arli e r te rm in atio n b y Netw ork o r P hysic ia n a s h ere afte r p ro vid ed. T his te rm m ay b e e xte nde d w it h th e c o nse nt o f b oth p artie s in w rit in g. 6 .2 . E ith er p arty m ay te rm in ate th is A gre em en t, w ith o r w ith o ut c au se , a t a n y tim e u p on o ne h un dre d a n d e ig h ty ( 1 80 ) d ay s' p rior w ritt e n notic e to th e o th er p arty .  C are fu lly r e vie w th e t e rm in atio n p e rio d. 6 .3 E ith er p arty s h all h av e th e r ig ht to te rm in ate th is A gre em en t u p on th ir ty ( 3 0) d ay s' p rior w ritte n n o tic e to th e o th er p arty if th e p arty to who m s u ch noti c e is g iv en is in b re a ch o f a n y m ate ria l p ro vis io n o f th is A gre e m en t. S uch n otic e s h all s e t fo rth th e fa cts u n derly in g th e a lle g ed b re a ch . If th e b re ac h is c u re d w it h in th e n o tic e p erio d , th en th e A gre em en t s h all c o nti n u e in e ffe ct fo r its re m ain in g te rm , s u b je ct to a n y o th er p ro vis io n o f t h is A gre em en t.  M ak e s u re th e tim e f r a m e f o r b re ech is u nders to o d . 6 .4 I n a d dit io n , N etw ork m ay te rm in ate th is A gre em en t im m ed ia te ly u po n (i) th e re v ocati o n , su sp en sio n , o r r e str ic tio n o f P hysic ia n 's lic en se to p ra c tic e m ed ic in e; (ii) th e re v ocati o n , su sp en sio n , o r re str ic tio n o f P hysic ia n 's li c e n se , c e rtif ic atio n , re g is tr a ti o n , p erm it o r a p pro val re q uir e d fo r th e la w fu l a n d re aso nab le c o nd uct o f h is p ra cti c e a n d th e p ro vis io n o f C overe d S erv ic es to M em bers ; ( iii ) P hysic ia n 's f a ilu re to main ta in g en era l a n d p ro fe ssio n al lia b ili ty in su ra n ce a s re q uir e d u n der th is A gre em en t; (iv ) re v ocati o n , s u sp en sio n , o r r e str ic tio n o f P hysic ia n 's m ed ic al s ta ff a p p oin tm en t o r th e n ecessa ry c li n ic al p riv il e g es re q uir e d to p ro vid e C overe d S erv ic es a t a P artic ip atin g H osp it a l o r a n y o th er h osp ita l; (v ) N etw ork 's d ete rm in atio n th at a n y M em ber w ou ld b e e n d an gere d o r im pair e d b y th e c o n tin uatio n of th is A gre em en t. 6 .5 I n th e e v en t o f a n y m ate ria l c h an ges in la w s a ffe ctin g th e s tr u ctu re o f th e N etw ork , o r a ffe cti n g th e p ro vis io n o r r e im bur se m en t o f h ealth c are s e rv ic es s im ila r to th o se p ro vid ed h ere u nder, th e p artie s a g re e to n eg o tia te in g oo d f a ith to am en d th is A gre em en t to co nfo rm w ith ap p lic ab le la w . I n th e e v en t th at s u ch ch an ges a d v ers e ly a ffe ct e ith er p arty , s u ch p arty m ay te rm in ate th is A gre em en t u p on s ix ty ( 6 0) d ay s w ritte n n o tic e if th e p artie s a re u nab le to r e n eg otia te th e A gre e m en t o n m utu ally ag re eab le te rm s w it h in s u ch 6 0-d ay p erio d . 6 .6 I n th e e v en t o f te rm in atio n o f th is A gre em en t, N etw ork a n d P hysic ia n s h all u se th eir b est e ffo rts to a rra n ge f o r a n o rd erly tr a n siti o n o f p atie n t c a re , c o n sis te n t w ith a p p ro pr ia te m ed ic al s ta n dard s, f o r M em bers w ho hav e b een o r a re a t th e tim e u nd er th e c a re o f P hysic ia n , to th e c a re o f a n o th er p hy sic ia n s e le cte d b y M em ber o r P ay er, b ut f o r n o lo n ger th an ( 1 ) o ne y ea r. S uch s e rv ic es s h all b e p ro vid ed a c co rd in g to th is A gre e m en t.  T his p ro vis io n s ta te s th at e v en th ou gh y o u h ave te rm in ate d th e A gre em en t y o u m ay s ti ll b e r e c eiv in g th e r e im bu rse m en t f o r a y e a r.  U pon te rm in a tio n o f th is A gre em ent P hysic ia n s h all c o ntin ue to p ro vid e C ove re d S erv ic e s to M em bers th en in pa tie nts o f th e P hysic ia n a nd e ntit le d to s e rv ic e s p urs u ant to H ealt h B enefit P la ns u ntil s u ch M em bers a re (i) d is c h arg ed o r tr a nsfe rre d c o nsis te nt w it h s o und m edic a l p ra ctic e ; o r ( ii ) th ir ty ( 3 0) c a le ndar d ays fr o m th e e ffe ctiv e d ate o f te rm in atio n.  N etw ork s h all p ay P hys ic ia n in a cco rd ance w it h A tta ch m en t fo r s e rv ic e s re nde re d b y P hysic ia n to s u ch M em bers . If a t th e r e quest o f th e N etw ork , P hysic ia n p ro vid es C ove re d S erv ic e s to M em ber a dm it te d to P hys ic ia n a fte r th e e ffe ctiv e d ate o f t e rm in atio n o f th is A gre em ent.  N oth in g w it h sta ndin g a ny p ro vis io n o f th is A gre em ent to th e c o ntr a ry , N etw ork a nd P hysic ia n s h a ll c o ntin ue to fu lf ill th e ir o blig atio ns u nder th is A gre em ent w it h re sp ect to : (i) p aym en ts d ue P hys ic ia n; (ii ) re co rd s m ain te nance re qu ir e m ents ; (iii) i n su ra nce r e quir e m ents ; a n d ( iv ) c o nfid entia lit y r e q uir e m ents . V II . M IS C ELLA NEO US 7 .1 A ll N etw ork bus ine ss , m edi ca l a nd ot he r r e co rd s a nd a ll inf orm ati on ge nera te d by o r r e la ti n g to N etw ork o r it s m ana gement inf orm ati on s ys te m s s ha ll be a nd r e m ain the s ol e p ro p erty of N etw ork . P hys ic ia n a g re es t o ke ep s uc h inf orm atio n s tr ic tly c onf ide ntia l. 7 .2 T he pa rtie s a re inde pende nt c ont ra cto rs , a nd ne ithe r is o r s ha ll r e p re se n t it s e lf a s the e m ploye r, e m ploye e, pa rtn er, a ge nt, p rin cipa l, o r joi nt ve nture of the ot he r. T he P hys ic ia n unde rs ta n ds a nd a g re es tha t in the p ro vis io n of m edi ca l c a re s e rv ic es, the P hys ic ia n a cts a s a n inde pende nt e nt ity a nd tha t the phys ic ia n- pa ti e nt r e la tio ns hip s ha ll in no w ay be a ff e c te d . 7.3 A ny not ic e or com munic ati on r equ ir e d, pe rm itt e d or de sir e d t o be giv en h ere u nd er s hall be de em ed e ffe ctiv ely g iv en or m aile d, addr esse d on t he sig n atur e pa ge.  P re fe rre d n otic e s e nt c e rtif ie d m ail. 7 .4 T he w aiv er b y e ith er p arty o f a b re ach o r v io la tio n o f a n y p ro vis io n o f th is A gre em en t s h all n ot o p era te a s o r b e c o n str u ed to b e a w aiv er o f a n y s u b se q uen t b re ach here o f. 7 .5 T his A gre em en t s h all b e g ov ern ed b y a n d c o nstr u ed in a cco rd an ce w ith th e la w s o f th e s ta te o f C ali f o rn ia .  T his A gre em ent h as b een e xe cu te d a nd d eliv e re d, a nd s h all b e in te rp re te d, c o nstr u ed a nd e nfo rc e d in a cc o rd ance w it h th e l a w s o f t h e S ta te o f F lo rid a, w it h o ut r e gard to a ny c o nflic t o f la w p ro vis io ns c o nta in ed th e re in . 7 .6 T his A gre em en t m ay b e am en d ed b y N etw ork u po n th ir ty (3 0) d ay s w ritte n n otic e o f su ch p ro pose d a m en dm en t. F ailu re o f P hysic ia n to p ro vid e w ritte n o bje ctio n to s u ch a m en d m en t w it h in th e th ir ty (3 0) d ay p erio d s h all c o n stitu te P hysic ia n 's a p pro val o f s u ch a m en dm en t.  T his A gre em ent, in clu d in g a ll a tta ch m ents , m ay n o t b e a m ended o r c h ange d in a ny o f it s p ro vis io ns e xce p t b y a s u bse quent w rit t e n a gre em ent s ig ne d b y d u ly a uth oriz e d r e pre se nta tiv e s o f N etw ork a nd H osp it a l. 7 .7 T he in v alid ity o r u nen fo rc e ab il ity o f a n y te rm o r c o nd iti o n h ere o f sh all in n o w ay a ffe ct th e v alid ity o r e n fo rc e ab ilit y of a n y o th er te rm o r p ro vis io n . 7 .8 P hysic ia n m ay n ot a ssig n th is A gre em en t w it h o ut N etw ork ’s p rior w rit te n co nse n t.  T his A gre em ent c a n no t b e a ssi gne d w it h o ut th e w rit te n c o n se nt o f th e o th er p a rty. 7 .9 N etw ork a n d P hysic ia n ag re e to su bm it to b in d in g arb it r a tio n an y d is p u te o r c la im a ris in g o ut o f th e i n te rpr eta tio n of o r p erf or man ce u nd er th is A gre em en t w hic h c an no t b e s e ttl e d b y in fo rm al m ea n s.  T he p artie s s h a ll a tte m pt to re so lv e a ny d is p ute , c o ntr o ve rs y o r c la im a ris in g o u t o f o r re la tin g to th is A gre e m en t o r th e p re para tio n o f th is A gre em ent, in clu din g b ut n ot li m it e d to th e p aym ent o r n on-p aym ent o f a c la im , th e e lig ib il it y o f a M em ber, t h e d ete rm in atio n o f C ove re d S erv ic e s, o r th e d ete rm in atio n o f m edic a lly n ece ss a ry p ro ce dure s, b y m utu al c o opera tio n. N oth in g in th is A gre em ent s h all p re clu de N etw ork o r P hysic ia n fr o m e xe rc is in g, a t a ny tim e, t h e r ig ht to s e ek r e so lu tio n th ro ugh l e gal r e m edie s a s th e la w m ay p ro vid e.  I f a ny ju dic ia l p ro ce e din g is nece ssa ry to e nfo rc e o r in te rp re t th e te rm s of th is Agre em ent, th e p re va il in g p arty sh all b e e ntit le d t o re a so nable a tto rn eys’ fe es, c o sts a n d e xp ense s fr o m th e o th e r p arty , in a d dit io n to a ny o th er r e lie f to w hic h s u ch p arty is e ntit le d. I f th e p artie s m utu all y a g re e to th e u se o f a rb it r a tio n, th e d ecis io n o f t h e a rb it r a to r s h all n ot b e b in din g in a c o urt o f la w .  T his Agre em ent s h all b e b in din g u pon , a nd s h all in ure to th e b enefit o f, th e p artie s here to a n d th eir s u cce sso rs a nd p e rm it t e d a ssig nees.  T his Agre em ent s u pers e des a ny prio r a gre em ents , p ro m is e s, n egotia tio ns or r e pre se nta tio ns, e it h er o ra l o r w rit t e n, r e la tin g to t h e s u bje ct m atte r o f th is A gre em ent. T his A gre em ent m ay n ot b e a m ended e xce pt in w rit in g d uly e xe cu te d b y b oth p artie s.  N otw it h sta ndin g a ny p ro vis io n o f th is A gre e m en t to th e c o ntr a ry , th e s e ctio ns o f th is A gre em ent re la tin g to p aym ent, c o nfid entia lit y , in su ra nce , a nd r e co rd s r e qu ir e m ents s h a ll s u rv iv e a ny te rm in atio n o f th is A gre em ent.  T he fa ilu re o f N etw ork o r P hysic ia n to o bje ct to o r to ta ke a ff ir m ativ e a ctio n w it h r e sp ect to a ny c o nduct o f th e o th er w hic h is a b re ach o f th is A gre em ent s h all n ot b e c o nstr u ed a s a w aiv e r o f th at b re ach o r o f a ny p rio r o r f u tu re b re ach es o f th is A gre em ent R eim burse m en t E xh ib it P hys ic ia n s ha ll bi ll N etw ork a nd N etw ork s ha ll pa y f o r M edi cally ne cessa ry C ove re d S erv ic es p ro vid ed by P hys ic ia n to M em be r the le ss e r of ( 1) N etw ork ’s P hys ic ia n F ee S che dul e m inus a ppl ic abl e C opa ym ent s, C oi ns ura n ce , a nd D ed uc ti bl es, o r ( 2) u sua l a nd c us tom ary c ha rg es m inus a ppl ic abl e C opa ym ent s, C oi ns ura n ce , a nd D ed uc tibl es.  T he r a te s p ro vid ed fo r in th is c o ntr a ct m ay b e r e ne gotia te d b y e it h er p arty . If n ew r a te s h ave n ot b een a g re e d to b y th e p artie s w it h in th ir ty ( 3 0) d ays o f th e w rit te n r e quest fo rm th e P hysic ia n th en a n a uto m atic in cre ase o f te n p erc e nt ( 1 0% ) o r th e c h ange i n th e a nnual P hys ic ia n a nd M edic a l S erv ic e s C onsu m er P ric e In dex, w hic h eve r is g re ate r, s h all b e a pplie d to th e c u rr e nt r a te s.  S tr ik e “ u su al a nd cu stom ary c h arg e s” a nd r e pla ce w it h “ P hysi cia n ’s Bille d C ha rg es. ”