Healthcare PCP Contract

HEALTHCARE PCP CONTRACT

Parties and Identifying Information

This Primary Care Provider Contract ("Agreement") is entered into as of between:

Recitals and Definitions

WHEREAS, the Plan administers health benefits for enrolled Members and delegates to the Provider the performance of primary care services in accordance with the terms and conditions set forth below; and WHEREAS, Provider represents and warrants that Provider meets the credentialing, licensing and insurance requirements set forth in this Agreement.

Term; Renewal; Termination

Term: This Agreement shall commence on the Effective Date set forth above and shall continue for a period of years, unless earlier terminated as provided herein. Automatic renewal for successive one-year periods shall occur unless either party provides written notice of non-renewal at least days prior to the then-current term expiration.

Scope of Services

Provider shall furnish medically necessary primary care services to Members assigned to Provider, including preventive care, episodic and chronic care management, coordination of referrals to specialists, and maintenance of medical records in accordance with accepted standards of care. Provider shall comply with Plan policies for prior authorization, referral management, and continuity of care for enrolled Members.

Credentialing, Licensure and Insurance

Provider certifies that Provider and all clinicians furnishing services under this Agreement hold current and unrestricted licenses, board certifications where applicable, and are credentialed per Plan requirements. Provider shall maintain professional liability insurance with limits no less than $ per claim and $ aggregate, and shall provide certificates of insurance upon Plan request.

Compensation; Fee Schedule; Payment Terms

Plan shall compensate Provider as set forth below and in any attached Fee Schedule incorporated herein. Payments are conditioned upon timely and accurate submission of claims and member eligibility verification.

Claims Submission and Records

Provider shall submit claims in accordance with Plan requirements and accepted industry standards. Provider shall maintain legible medical records for each Member sufficient to document care and support claims and shall retain such records for a minimum of years or as required by law, whichever is longer. Plan or its authorized representatives may audit records upon reasonable notice and during normal business hours.

Quality Measures, Performance and Reporting

Provider agrees to participate in Plan quality programs, data collection and reporting consistent with the Plan's quality measures. Provider shall submit requested quality and utilization data within the timelines specified by Plan. Failure to meet performance metrics after an opportunity to remediate may result in corrective action or financial reconciliation as specified in the Fee Schedule.

Confidentiality; HIPAA Compliance

Provider and Plan shall comply with applicable federal and state privacy and security laws, including the privacy and security requirements applicable to Protected Health Information. Provider agrees to use and disclose Member information only as permitted by this Agreement and applicable law and to execute any required business associate agreement.

Indemnification; Liability

Provider shall indemnify, defend and hold Plan harmless from and against any claims, losses or liabilities arising out of Provider's breach of this Agreement or the negligent acts or omissions of Provider or its personnel. Plan shall indemnify Provider for claims arising from Plan's gross negligence or willful misconduct in administering benefits or assigning Members.

Audit and Inspection

Plan shall have the right to audit Provider's claims, billing and clinical records relating to Members and reimbursement under this Agreement. Provider shall cooperate with audits and provide access to requested records within business days of written request. Adjustments resulting from audits shall be paid or recouped in accordance with Plan policy.

Representations and Warranties

Provider represents that Provider has the authority to enter into this Agreement, that all services will be performed in a professional manner consistent with applicable standards, and that Provider will comply with all applicable laws, rules and regulations governing the provision of medical services.

Dispute Resolution; Governing Law

Any dispute arising under this Agreement shall first be addressed through good faith negotiation between senior representatives of the parties. If unresolved within days, disputes shall be resolved by binding arbitration in the county where the Plan's principal place of business is located, governed by the laws of the state selected below.

Notices

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below by certified mail, courier, or other nationally recognized delivery service, or by hand delivery with proof of receipt.

Amendments; Entire Agreement; Severability

This Agreement, including all attachments and Fee Schedules expressly incorporated herein, constitutes the entire agreement between the parties. Any amendments must be in writing and signed by authorized representatives of both parties. If any provision is found invalid, the remaining provisions shall remain in full force and effect.

Attachments and Additional Terms

Certifications and Signatory Authority

Each party represents and warrants that the individual signing this Agreement on its behalf is duly authorized to bind the party to the terms and conditions set forth herein. Each party certifies that all statements and information provided for purposes of credentialing and contracting are true, complete and accurate to the best of the signer's knowledge.

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