Healthcare HMO Contract

HEALTHCARE HMO CONTRACT

Parties and Administrative Information

This Contract is entered into by and between Plan Name: , hereinafter referred to as "Plan", and Provider Name: , hereinafter referred to as "Provider". Effective Date: .

Recitals and Definitions

Recitals: The Plan administers a health maintenance organization offering managed care to enrolled Members. Provider represents that Provider is duly licensed, credentialed, and qualified to provide covered services to Members and desires to render such services to Members under the terms of this Contract. Capitalized terms not otherwise defined herein shall have the meanings given in Appendix A: Definitions.

Term, Renewal and Termination

Term: This Contract shall commence on the Effective Date and continue for an initial term of years unless earlier terminated in accordance with this Contract. Thereafter the Contract shall automatically renew for successive one-year terms unless either party provides written notice of non-renewal at least days prior to the end of the then-current term.

Termination for Cause: Either party may terminate immediately for cause upon written notice if the other party materially breaches this Contract and fails to cure such breach within days after receipt of written notice. Immediate termination may occur for fraud, willful misconduct, loss of license, or exclusion from federal or state health care programs.

Scope of Services and Provider Obligations

Provider shall provide covered health care services to Members in accordance with applicable Plan policies, evidence-based clinical guidelines, and state and federal law. Provider shall maintain current licensure, accreditation, and malpractice insurance as required below and shall not discriminate in access to services.

Compensation and Billing

Reimbursement Method: Provider shall be compensated per the fee schedule and methodology set forth in Appendix B. Select applicable reimbursement arrangement(s):

Capitation per member per month as specified in Appendix B.    Fee-for-service based on Plan fee schedule.    Other:

Compliance, Confidentiality, and HIPAA

Compliance with Law: Each party shall comply with all applicable federal, state, and local laws, rules, and regulations, including those governing fraud, waste and abuse, anti-kickback statutes, and program exclusions. Provider shall not employ or contract with any individual or entity excluded from participation in federal or state health care programs.

Confidentiality and PHI: The parties shall maintain the confidentiality of Protected Health Information in accordance with applicable privacy laws. Provider shall implement administrative, physical, and technical safeguards to protect PHI and shall report any unauthorized disclosures or breaches to Plan within hours of discovery.

Quality Assurance, Credentialing and Audit Rights

Credentialing: Provider acknowledges that participation is contingent upon completion of Plan credentialing. Provider attests that all information provided for credentialing is true, accurate, and complete and will notify Plan within days of any material change.

Audit Rights: Plan shall have the right to audit Provider records relevant to claims and compliance, upon reasonable notice, and Provider shall retain records for a minimum of years following the date of service.

Indemnification and Insurance

Indemnification: Provider agrees to indemnify, defend and hold harmless Plan and its officers, directors, employees and agents from and against any and all claims, liabilities, damages, losses and expenses, including reasonable attorneys' fees, arising out of or relating to Provider's acts or omissions, breach of this Contract, or negligent performance of services.

Recordkeeping, Reporting and Data Exchange

Provider shall submit timely and accurate encounter data, claims, and required quality reports in the format and frequency specified by Plan. Provider shall cooperate with Plan's quality improvement activities, utilization review, and pay-for-performance initiatives.

Dispute Resolution and Governing Law

Parties agree to negotiate in good faith to resolve disputes. Unresolved disputes shall be resolved by binding arbitration under the rules mutually agreed upon by the parties. This Contract shall be governed by and construed in accordance with the laws of the state where Plan is domiciled, without regard to conflict of law principles.

Notices

All notices required or permitted by this Contract shall be in writing and delivered to the addresses set forth below (or such other address as a party designates by written notice). Notices are effective upon receipt.

Miscellaneous

Assignment: Provider shall not assign or subcontract this Contract or its duties without the prior written consent of Plan, except that Provider may assign receivables. Any attempted assignment without such consent shall be void.

Entire Agreement: This Contract, including appendices and attachments, constitutes the entire agreement between the parties and supersedes all prior agreements and understandings relating to the subject matter hereof.

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