HomeMy WebLinkAboutAGREEMENT WITH CORVEL- ONE YEAR RENEWAL- ACTING AS THIRD PARTY ADMINISTRATOR TO PROVIDE WORKER COMPENSATION CLAIMS ADMINISTRATION SERVICES TO AUGUSTA, GA AMENDMENT NUMBER 2
This Amendment 2 ("Amendment")dated February 28, 2018 by and between CorVel Enterprise Comp,
Inc.,("CorVel")and Augusta Georgia Consolidated Government("Customer").
WHEREAS, CorVel and Customer entered into the Services Agreement with an Effective Date of
February 1, 2015 as amended (the "Agreement") pursuant to which CorVel agreed to provide Customer
certain third party claims administration services and bundled managed care services.
WHEREAS, CorVel and Customer agree to amend the pricing during Renewal Terms as described
hereunder.
Now, therefore, in consideration of the mutual promises and covenants contained herein, the parties
hereby amend the Agreement as follows:
• Renew the Agreement pursuant to Section 8A ("Term") for the first of two Optional
Renewal Terms of one(1)year effective February 1,2018 through January 31,2019.
• Amend Exhibit A of the Agreement adding the attached Exhibit A Rider attached
hereunder to this Amendment as Exhibit A Rider with updated Schedules.
• Remove Section 5 "Billing and Payment for Pharmacy Program"of Exhibit B ("Fees") of
the Agreement in its entirety.
• Remove Section III(a)(vi)of Exhibit A of the Agreement in its entirety.
• Amend Exhibit B ("Fees") adding language regarding Billing and Payments for Case
Management as described hereunder in in the Exhibit A to this Amendment.
Billing and Payments for Case Management. CorVel will invoice Customer monthly for all fees related to
Case Management Services. Billing for Case Management is based on actual time per activity. Activity is
based on ten(10)minute, a sixth(.17)of an hour,units. Time billed that exceeds the base billing unit
multiple, i.e., 10 minutes,20 minutes, etc.,will be converted to the next billing unit.
All other terms and conditions of the Agreement shall remain in full force and effect.
IN WITNESS WHEREOF, CorVel and Customer have caused this Amendment #2 to be executed by
the persons authorized to act in their respective names.
AUGUSTA GEORGIA CONSOLIDATED CORVEL ENTERPRISE COMP,INC.
GOVERNMENT l /
Axx��,,By: _ B : f'"C�1 lf/�df
A6"l y
/r.
3/,fic Print lame: �l RR0aM� ..U/t S�~J Print Name:_ Xe.,4 a c.. ve
Title: a 0: ' ( to�•-.....1C If ... "zt Title: 144J1-1 �
f / s,, i /&Aee : ed:�f=., ", � ,` , .,/.Li:. : ; Date Signed: Z
1 0 . ro `" kat , 0
This document cgrttaInsionf s' r , v ie info natio of the Parties and may not be disclosed or duplicated without the prior written
consent of the Pazifirf,,@® ' k, it CV?
oES r
/0
August' eorgia ns ed` bvet�x'lent when nt 2(Renewal Pharmacy and Network Solutions Updates)
11-3-1vii,
Ilk li ORG1t` ,? '.
x
:CORVEL
EXHIBIT A RIDER
Pharmacy Benefit Program
Terms and Conditions
I. DESCRIPTION OF SERVICES.
(a) CorVel shall be the provider of a Pharmacy Program inclusive of a PBM and a Provider
Network representing Participating Pharmacy Providers that are obligated upon and after
identification of a participant within CorVel's PBM to:
a. Accept a contracted rate, and
b. Apply mandated processes and CorVel's Formulary and Concurrent Drug
Utilization Review program at point-of-service before dispensing prescribed
medications.
(b) In addition, CorVel provides pharmacy audit, review and payment services.
II. DEFINITIONS.
(a) "AWP" shall mean the Average Wholesale Price for a Brand or Generic Drug Product.
CorVel bases Customer pricing off of the reported AWP value from Medi-Span and the
date of service.
(b) "AWP Discount" shall mean the PBM discounts CorVel applies, per Customer's
negotiated rates, to Covered Brand and Generic Drug Products, Compound Drugs and
Specialty Meds.
(c) "Brand Drug" shall mean a Covered Drug defined as a brand name drug in PBM
proprietary Generic Code Conversion ("GCC") logic. In the adjudication process,
CorVel applies Customer's negotiated Brand Drug discount rate to the AWP value of
Covered Brand Drugs.
(d) "Compound Drugs" shall be systematically identified when processing through the PBM
via the Formulary. In the adjudication process, Compound Drugs require Customer's
approval, and are priced at the lessor of:
i. Customer's AWP Discount pricing by ingredient plus the dispensing fee, or
ii. CorVel's Acquisition Price plus a management and dispensing fee.
(e) "Concurrent Drug Utilization Review" ("DUR") shall mean the algorithm systematically
applied at a Participating Pharmacy before dispensing that considers the Presenting
Drug's safety and efficacy in context with other drugs that have been dispensed. In
addition, the algorithm includes applicable protocols and guidelines based on the
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
2
CORVEL
Presenting Drug and specific claim history, such as the time period from the last fill of
the same Drug.
(f) "Covered Drug" shall mean the Drug Product that is processed through CorVel's PBM.
(g) "Emergency Fill" see Good Samaritan Fill, subsection(1) below.
(h) "First Fill" shall mean a prescription filled by a Participating Pharmacy for a limited
supply of Covered Drugs for a claim that is not, at the time, eligible. First Fill
transactions follow CorVel's First Fill Formulary. Customer is responsible for payment
of drug charges processed through its First Fill Program; CorVel assumes no liability.
(i) "Formulary" shall mean drug/drug class and brand/generic specific triggers
systematically applied at a Participating Pharmacy before dispensing a Presenting Drug
that prompts the pharmacy through its adjudication system to either: dispense the
Presenting Drug, convert from brand to generic, attain approval to dispense, or deny the
Presenting Drug outright.
(j) "Generic Drug" shall mean a Covered Drug, whether identified by its chemical,
proprietary, or non-proprietary name, that (i) is accepted by the FDA as
therapeutically equivalent and interchangeable with drugs having an identical amount of
the same active ingredient; and (ii) defined as a generic drug in PBM proprietary Generic
Code Conversion ("GCC") logic. In the adjudication process, CorVel applies
Customer's negotiated Generic Drug discount rate to the AWP value of Covered
Generic Drugs. Notwithstanding the foregoing, for Single Source Generic Drugs,
Customer's Brand Drug AWP Discount may be applied.
(k) "GCC" refers to PBM proprietary Generic Code Conversion logic. GCC logic converts
Medi-Span codes to the brand and generic codes used for claims adjudication.
(1) "Good Samaritan (Emergency) Fill" shall mean a limited supply of Covered Drugs that
are outside of the Formulary and typically dispensed outside of normal business hours
(overnight, weekends or holidays) by a Participating Pharmacy without Customer's or
CorVel's approval in order to meet, in the pharmacist's professional judgment, an
immediate or urgent need. Customer is responsible for payment of drug charges
processed through Good Samaritan Fills; CorVel assumes no liability.
(m) "Mail Order Program" or "Home Deliver Program" shall mean the managed program
from which Covered Drugs are dispensed and billed through CorVel's PBM. A
pharmacy's status as a mail order pharmacy does not indicate participation in the CorVel
PBM Mail Order Program. Mail Order participation is limited to designated pharmacies
operating within the strict parameters of CorVel's Mail Order Program.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
3
C.CORVEL
(n) "Multi Source Brand" shall mean a Covered Drug specified as a brand name drug
available from more than one manufacturer as determined by CorVel primarily using a
combination of data fields provided to CorVel by Medi-Span (or another nationally
available reporting source that may be selected by CorVel). Multi Source Brand Drugs
are eligible for conversions to Generic Drugs at the Participating Pharmacy.
(o) "Multi Source Generic" shall mean a Covered Drug specified as a multi source generic
drug as determined by CorVel primarily using a combination of data fields provided to
CorVel by Medi-Span (or another nationally available reporting source that may by
selected by CorVel). Generic Drugs in their six month exclusivity period or limited
supply drugs may be excluded from Multi Source Generic Drugs.
(p) "PBM" shall mean Pharmacy Benefits Manager. CorVel performs as the PBM on behalf
of its Customers.
(q) "Presenting Drug" shall mean the drug ordered by the prescriber and presented on a
signed prescription to a Participating Pharmacy and processed through CorVel's PBM.
(r) "Rate application exceptions," per Billing and Payments of Pharmacy Program (below)
sections (d) and (e), apply when either State Fee Schedule AWP Values or Customer's
Negotiated PBM AWP Discount rates are lower than CorVel's Acquisition Price.
CorVel's Acquisition Price reflects CorVel's cost of the Covered Drug plus a processing
and management fee of 10%.
(s) "Single Source Brand" shall mean a Covered Drug specified as a brand name drug
available from only one manufacturer as determined by CorVel primarily using a
combination of data fields provided to CorVel by Medi-Span (or another nationally
available reporting source that may by selected by CorVel). Single Source Brand Drugs
are not eligible for conversions to Generic Drugs.
(t) "Single Source Generic" shall mean a Covered Drug as determined by CorVel that may
not have been purchased by pharmacies at standard Multi Source Generic Drug rates
because of limited manufacturers, limited supply or exclusivity rights. In the
adjudication process, Customer's Brand Drug AWP Discount value may be applied to
Single Source Generic Drugs.
(u) "Specialty Medications" shall mean certain pharmaceuticals, biotech or biological drugs,
that are Covered Drugs used in the management of chronic or genetic disease, including
but not limited to, injectable, infused, or oral medications, or products that otherwise
require special handling. In the adjudication process, Customer's approval is required,
and Customer's Brand Drug AWP Discount value and dispensing fee is applied
irrespective of the Presenting Drug's GCC (Generic Code Conversion) status.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
4
CORVEL
(v) "State Fee Schedule AWP Value" shall exclusively mean the value of a Covered Drug
calculated under an applicable state's posted AWP fee schedule's Brand and Generic
Drug multipliers (AWP value plus/minus the listed percentages) and the state's posted
dispensing fee. For PBM pricing, CorVel does not honor any other values or indices that
may apply under an applicable state's fee schedule.
III. DELIVERY OF SERVICES.
(a) CorVel shall provide its Pharmacy Program's PBM and Network for the benefit of
Customer.
(b) Eligibility, First Fill, Pharmacy Identification (ID) Cards, and Mail Order/Home
Delivery.
Pharmacy ID cards contain the necessary data elements to enable a Participating
Pharmacy provider to electronically process through and transmit claim data to CorVel's
PBM. The electronic transmission that occurs at the point of sale is required for
application of Formulary, Concurrent Drug Utilization Review and contractual pricing.
a. Customer agrees to promptly provide CorVel all information needed to produce
and distribute Pharmacy ID cards to Eligible Claimants. Eligible Claimant
information may include, but is not limited to, claimant name, address, social
security number, cell phone number, home phone number, and email address.
b. Subject to applicable law, Customer shall require Eligible Claimants to use the
Pharmacy ID cards at participating network providers in order to facilitate the
Pharmacy Program. Also, Customer agrees to require the use of pharmacy network
participating providers to Eligible Claimants as appropriate.
c. Distribution of Pharmacy ID cards does not guarantee that Pharmacy ID cards will
be appropriately utilized by Eligible Claimants or Participating Pharmacies;
therefore, Customer understands that claims assigned by Pharmacies to third party
billers or paper bills submitted by the Pharmacies are not adjudicated through the
prospective PBM.
d. CorVel, at its sole expense, agrees to produce and distribute Pharmacy ID cards to
Eligible Claimants upon receipt of all necessary Eligible Claimant information
from Customer. CorVel will also send an introduction letter to the Eligible
Claimant along with the Pharmacy ID card.
e. At the initial stage of injury, a claimant may be issued a temporary Pharmacy ID
(First Fill) card or processing data may be shared with the dispensing pharmacy for
an initial, one (1) time purchase of a pharmaceutical product with a recommended
course of no longer than fourteen (14) days, or such days limit as established by
Customer.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
5
CORVEL
f. CorVel will provide access for Eligible Claimants to the PBM Mail Order
Program. CorVel will work with Customer to establish the parameters of the Mail
Order Program and the process which will be utilized to encourage Eligible
Claimant use of the Mail Order Program.
(c) CorVel's PBM will present and tailor a proprietary Formulary to Customer. Upon
presentation of identification to a Participating Pharmacy, the Formulary will trigger the
Participating Pharmacy's adjudication system to either:
i. Automatically dispense certain medications,
ii. Attain Prior Authorization(PA) approval from CorVel to dispense, or
iii. Deny the medications outright.
In addition to Customer's Formulary, Claimant Level Formularies can be built at the claim
level upon Customer's request.
(d) CorVel's PBM will implement a Concurrent Drug Utilization Review("DUR")program
on behalf of Customer, with permitted program edits as directed by Customer.
Concurrent DUR includes a review of the drug history at the time the prescription is
presented. Absent Customer's directions, DUR shall be performed in accordance with
CorVel's PBM's standard service model.
IV. BILLING AND PAYMENTS OF PHARMACY PROGRAM.
(a) Financial obligations of parties.
(i) Customer shall be financially responsible for all drug charges incurred by
claimants for dispensed medications processed under CorVel's PBM. CorVel
assumes no liability for drug charges with the exceptions noted below in
subsection iii.
(ii) If the CorVel claims professional determines, upon receipt of CorVel's PBM
invoice, that specific formulary and non-formulary drugs should not have
been dispensed, the CorVel claims professional should inform the PBM as
soon as possible.
1. The PBM will request a reversal from the Participating Pharmacy. If
granted, CorVel will reverse the drug charges, however, if the Pharmacy does
not grant the PBM's request, Customer is responsible for payment of the drug
charges; CorVel assumes no liability for drug charges with the exceptions
noted below in subsection iii.
2. Upon CorVel's claims professional request, CorVel's PBM will
include the specific prohibition triggering the request for the reversal in the
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
6
CORVEL
Claimant Level Formulary so that the Claimant Level Formulary will block
subsequent re-fills from processing.
(iii) Within five (5) days of receipt of an invoice, CorVel's claims professional
may dispute charges for drugs that were dispensed in error, triggering
CorVel's PBM to reverse the drug charges, by notifying CorVel for any of
the following reasons:
1. CorVel's PBM and/or the Participating Pharmacy's violation of
Formulary or Utilization Review Parameters set forth in Customer's
DUR program, or in the Claimant Level Formulary; or
2. Duplicate or inadvertent entries or other clerical mistakes on a PBM
invoice.
(b) Invoicing and Payment.
i. On a per Covered Drug basis and directly to the claim file, CorVel will invoice
Customer daily for all drug charges and fees related to the PBM.
ii. CorVel shall invoice and bill pharmacy fees to the specific claims file.
(c) CorVel uses the Medi-Span AWP at pre-settlement levels. To maintain pricing
neutrality CorVel applies the established multiplier to impacted Covered Drugs.
(d) Relative to state pharmacy fee schedules, CorVel will apply the lesser of Customer's
negotiated PBM AWP Discount rate or the applicable State Fee Schedule AWP
Value with one exception: to the extent that the State Fee Schedule AWP Value in
any state is less than CorVel's Acquisition Price, CorVel will apply its Acquisition
Price.
(e) Relative to Customer's negotiated PBM AWP Discount rates, CorVel will apply the
negotiated rates unless the following exceptions apply:
i. CorVel applies CorVel's Acquisition Price on transactions for which
Customer's negotiated PBM AWP Discount rate is lower than CorVel's
Acquisition Price.
ii. Compound Drugs and Specialty Medications are priced per Definition
subsections (d) and (u).
(f) Both parties understand that pricing indices historically used (including under this
Agreement) for determining the financial components of pharmacy billing rates are
outside the control of CorVel and Customer. The parties also understand there are
extra-market industry, legal, governmental and regulatory activities which may lead
to changes relating to, or elimination of, these pricing indices that could alter the
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
7
CORVEL
financial positions and expectations of both parties as intended under this
Agreement.
Both parties agree that, upon entering into this Agreement and thereafter, their
mutual intent has been and is to maintain pricing neutrality as intended and not to
benefit one party to the detriment of the other. Accordingly, to preserve this mutual
intent, if pricing neutrality does change and CorVel undertakes any or all of the
following:
i. Changes the AWP source, or other source if AWP is not applicable, across its
book of business (e.g., from Medi-Span to First Databank); or
ii. Maintains AWP, or other source if AWP is not applicable, as the pricing
index with an appropriate adjustment in the event the AWP, or other,
methodology and/or its calculation is changed, whether by the existing or
alternative sources; or
iii. Transitions the pricing index from AWP, our other source if AWP in not
applicable, to another index or benchmark (e.g., to Wholesale Acquisition
Cost);
Customer's negotiated PBM pricing will be modified as reasonably and equitably necessary
to maintain the pricing intent under this Agreement.
NETWORK SOLUTIONS DESCRIPTION OF SERVICES
Bill Audit,Review and Payment Services
Terms and Conditions
1. DESCRIPTION OF SERVICES
(a) CorVel's proprietary computerized bill review software program enables an application of the
appropriate Fee Schedule or usual and customary value, and further value-added applications
subscribed to by client which includes PPO, Professional Review, Enhanced Bill Review (CERiS),
Onsite, and Check writing Services applied to medical provider bills ("Provider Bills"), hospital
bills("Hospital Bills")and, both together, "Bills").
(b) Fee Schedule or usual and customary services includes:
(i) review of current procedural terminology ("CPT"), revenue code, healthcare common
procedure coding ("HCPCS") and national drug code ("NDC") at the rate is published
and incorporated into the state fee schedule or usual and customary value.
(ii) allowance based on specified conversion factor(s) multiply by referenced value(s)
2. DELIVERY OF SERVICES
(a) Customer's Obligations
(i) During the term of this Agreement, unless agreed to otherwise by the parties in writing,
Customer shall utilize CorVel exclusively(even as to Customer) for audit, review and repricing
services for Bills related to workers' compensation, auto liability and general liability claims. A
breach of the foregoing obligation shall constitute a material breach under this Agreement.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
8
CORVEL
Without limiting any other remedies available under law, a breach of the foregoing obligation
with respect to PPO (as defined in Schedule 7) Provider Bills will result in immediate
termination of all PPO discounts provided by CorVel.
(ii) To facilitate timely processing by CorVel, Customer agrees to deliver to CorVel (A) each
Provider Bill no later than ten (10) days after Customer's receipt thereof, and (B) batches of
Provider Bills on a daily basis or as volume dictates.
(iii)Customer shall process PPO Provider reimbursements within fourteen (14) days from receipt of
the corresponding Bill Review Audit analysis from CorVel.
(b)CorVel's Obligations
(i) CorVel shall provide Bill Review Services described herein to Customer upon receipt of
specific requests from Customer. In the absence of instructions from Customer to the contrary,
which CorVel must approve,Bill Review Services shall be performed as described herein.
(ii) Bill Review Services shall be completed within five (5) business days of CorVel's receipt from
receipt by CorVel of all necessary billing information from Customer ("Complete Billing
Information").
(iii)CorVel will be responsible for monitoring, "flagging" and returning to Customer duplicate
copies of a Bill("Duplicates").
(iv)Any conflicts or complaints from medical providers ("Complaints") concerning Bill Review
Services completed by CorVel initially will be handled directly by CorVel. CorVel will provide
an initial response to a Complaint within one (1) business day following the date on which
CorVel received the Complaint. CorVel will send a written response to the complainant within
five (5) working days that summarizes the nature of the Complaint and the steps CorVel has
taken to resolve it. A copy of this response will be sent to the attention of the designated
Customer representative. Different or more specific parameters of CorVel's authority to
respond to and resolve Complaints hereunder may be agreed to the parties. Further, Customer
shall have the right, but not the obligation, at any time, to interject itself into a Complaint
between CorVel and a medical provider and to resolve the Complaint in a manner acceptable to
Customer at its sole discretion. Notwithstanding the foregoing, Customer shall retain full
responsibility for payment of all benefits and any other expenses or services required to be paid
or provided under applicable policies or state and federal workers' compensation laws.
(v) CorVel agrees to supply Customer, at no additional cost, in the format in which it is then
customarily stored by CorVel, a transmission or tape reflecting the results of the Bill Review
Services provided hereunder. Such data shall be provided as to further allow for the application
of Bill Review fees to the individual claim file, the preparation of insured specific savings
reports and the payment of Bill Review fees.
(c) Savings for the Fee schedule or usual and customary service shall be:
(i) for states having a state mandated Fee Schedule: (A) the medical provider's original bill
amount; less (B) the billed amount resulting from the allowance based on specified conversion
factor(s)multiply by referenced value(s).
(ii) for states not having a state mandated Fee Schedule: (A) the medical provider's original bill
amount; less(B)the bill amount resulting from Usual and customary value.
(d) Scanning Services
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
9
CORVEL
(i) CorVel shall provide Optical Character Recognition ("OCR") Services set forth herein to
Customer on request of Customer. Upon receipt of such request CorVel shall scan all bills and
attached medical notes delivered to CorVel necessary for providing Bill Review services within
seventy-two (72) business hours of CorVel's receipt of such information. Customer shall mark
and date/time stamp the claims as instructed by CorVel.
(ii) Subject to applicable law and obtaining any required authorizations, CorVel also shall provide
OCR Services for such additional claim-related documentation as Customer reasonably
requests, for example, case notes, peer review information and independent medical
examinations.
(iii)All material scanned by CorVel hereunder shall be accessible to Customer on the Internet
pursuant to CorVel's CareMC Agreement with Customer.
Professional Review Services
Terms and Conditions
1. DESCRIPTION OF SERVICES
(a) Professional Review Services. CorVel may provide professional review services to evaluate various
state specific complex rules and verify coding by providers are valid. This can include clinical
review to validate coding is correct for all applicable Provider bills, Ambulatory Surgical Center
bills, and all Hospital Bills(inpatient and outpatient)including:
(i) review and analysis of codes, charges and billing structure for incorrect coding, incorrect
billing, bundling, and up-coding of procedures which effect Fee Schedule values;
(ii) review of bills, records, and documentation by a nurse and/or coder;
(iii)separation of charges not related to the compensable injury;
(iv)review and apply complex state specific rules;
(v) application of utilization review determinations and clinical edits
(vi)diagnostic related group validation (i.e., verification that the diagnostic related group billed is
appropriate for the services rendered); and
(vii) cost shifting of revenue and CPT codes.
2. DELIVERY OF SERVICES
(a) Unless CorVel otherwise notifies Customer, CorVel shall complete Professional Review Services
and return the reviewed Bills to Customer, with any adjustments to identified overcharges, within
ten(10)business days from receipt of Bills.
(b) Savings for the Professional Review Services shall be:
(i) for states having a state mandated Fee Schedule: (A) the bill amount in the Fee Schedule; less
(B)the bill amount resulting from the nurse review services.
(ii) for states not having a state mandated Fee Schedule: (A) the medical provider's original bill
amount; less(B)the bill amount resulting from the nurse review services.
(iii)for states having a state mandated Fee schedule (A) the medical provider's original bill amount;
less(B)the bill amount resulting from complex review services.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
10
CORVEL
(iv)CorVel shall pay bills on behalf of Customer when reviewed by CorVel in a timely manner in
accordance with all state guidelines.
(v) CorVel will identify all bills that are not eligible for Professional Review Services due to: (A)
compensability; (B) a pre-negotiated rate with Customer or other previously established
discount; (C) services that are "review only" due to litigation or other non-payment issues; and
(D)duplicate bills.
(c) If a medical provider questions the adjustment and/or balance bills the patient, and the claim payor
notifies CorVel of such communication, CorVel will provide documentation of its findings. If the
hospital provides corrective or qualifying information sufficient to alter our original adjustments,
CorVel will revise its report, advise the claim payor of the new, corrected adjustment. Only in the
event of a successful appeal of the reduction of the bill by the medical provider shall Customer be
entitled to receive a credit for the portion of the fee previously charged for the amount of the
adjustment successfully appealed.
Enhanced Bill Review Services (CERiS)
(Hospital Bill Itemization Review Services; Negotiation Services; Implant cost Review Service)
Terms and Conditions
1. DESCRIPTION OF SERVICES
(a) Hospital Line Itemization Review Services. CorVel's Enhanced Bill Review Services (CERiS) are
performed on Hospital Bills (inpatient and outpatient) in excess of two thousand five-hundred
dollars ($2,500) and consist of procurement of actual bill itemization, (i) a line-by-line validation
and comparison of the itemization description charges actually billed by a particular hospital to
what CMS billing guidelines allow to be separately billed for in order to disallow inappropriate
charges, and then will compare the valid itemization descriptions to the average itemization
description charges utilized by other hospitals within a pre-designated geographic area, and and (ii)
a review of charges that fall outside of any pre-contracted discounts or fee schedules, and generates
payment recommendations in accordance with the Customer's "Payors Allowable" language. This
service does not itself include negotiation services nor Implant Cost Services.
(b) Negotiation Services. CorVel's Enhanced Bill Review Services (CERiS) can provide negotiation
services with respect to all Hospital Bills (inpatient and outpatient) in excess of two thousand five-
hundred dollars ($2,500). CorVel will contact the provider for agreement of the negotiated rate. A
signed agreement regarding such rates will be maintained by CorVel. CorVel will use its
commercially reasonable efforts to enter into an agreement regarding negotiated rates in accordance
with a mutually agreed upon schedule.
(c) Implant Cost Review Service. CorVel's Enhanced Bill Review Services (CERiS) can include
Implant Cost Review services with respect to the applicability of the Customer's "Payors
Allowable" plan or policy language that specifically addresses implant payments. CorVel will
identify and provide the manufacturers implant cost through its proprietary repository of national
implant invoice data. CorVel then determines the recommended payment in accordance with the
Customer's "Payors Allowable". In the event there is insufficient implant invoice data for the
requested implant, CorVel will notify the Customer and CorVel shall not be responsible for any
costs, fees, damages or penalties for any such inability of CorVel to produce a cost savings per
Customer's request.
2. DELIVERY OF SERVICES
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
11
Cro CORVEL
(d) Unless CorVel otherwise notifies Customer, CorVel shall complete Enhanced Bill Review Services
and return the reviewed Hospital Bills to Customer, together with a written summary of any
adjustments to identified overcharges,within ten(10)business days from receipt of Bills.
(e) Savings for the Enhanced Bill Review Services shall be:
(i) for states having a state mandated Fee Schedule: (A) the bill amount in the Fee Schedule; less
(B)the bill amount resulting from the Enhanced Bill Review Services.
(ii) for states not having a state mandated Fee Schedule: (A) the medical provider's original bill
amount; less(B)the bill amount resulting from the Enhanced Bill Review Services.
(iii)CorVel shall pay bills on behalf of Customer as reviewed by CorVel in a timely manner in
accordance with all state guidelines.
(iv)CorVel will identify all bills that are not eligible for Enhanced Bill Review Services due to: (A)
compensability; (B) a pre-negotiated rate with Customer or other previously established
discount; (C) services that are "review only" due to litigation or other non-payment issues; and
(D)duplicate bills.
(f) If a medical provider questions the adjustment and/or balance bills the patient, and the claim payor
notifies CorVel of such communication, CorVel will provide documentation of its findings. If the
hospital provides corrective or qualifying information sufficient to alter our original adjustments,
CorVel will revise its report, advise the claim payor of the new, corrected adjustment. Only in the
event of a successful appeal of the reduction of the bill by the medical provider shall Customer be
entitled to receive a credit for the portion of the fee previously charged for the amount of the
adjustment successfully appealed.
Preferred Provider Network Access Services (PPO)
Terms and Conditions
I. DESCRIPTION OF SERVICES
(a) CorVel's preferred provider organization is a network of hospitals, physicians and other health care
providers("Participating Providers")that offer services at pre-negotiated rates("PPO Network").
II. DELIVERY OF SERVICES
(a) CorVel shall provide Customer with access to its PPO Network provided it is the exclusive
preferred provider organization utilized by Customer for workers' compensation, auto liability, and
general liability claimants. CorVel may at any time and in its sole discretion add and/or terminate
any provider to or from the PPO Network.
(b) CorVel shall provide, upon Customer request, a listing of PPO Network providers and/or PPO
Network providers may be found by visiting the CorVel website, www.corvel.com. As CorVel
continues to expand its PPO through the development of proprietary networks, Customer will be
notified of their availability in the PPO listing described above and shall be provided access to them,
replacing or supplementing the then-current PPO, if applicable,
(c) Customer agrees that, during the Term of this Agreement and for (12) twelve month period
thereafter, Customer will not contract directly or indirectly with Participating Providers made
known to Customer under this Agreement.
(d) Customer will make reasonable effort to channel all Covered Persons to the Participating
Providers as are allowed under the laws of that service area or state.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
12
CORVEL
(e) Savings for the PPO Network shall be:
(i) for non fee schedule negotiated contracts: (A) the medical provider's original bill
amount; less(B)the bill amount resulting from the contract rate.
(ii) for fee schedule negotiated contracts; (A) the fee schedule amount less (B) the bill
amount resulting from the contract rate.
This document contains confidential and proprietary information of the Parties and may not be disclosed or duplicated without the prior written
consent of the Parties. CorVel 2016
August Georgia Consoidated Government Amendment 2(Renewal Pharmacy and Network Solutions Updates)
11-3-17
13