Issuu on Google+

Provider Check List Completed Provider Fee Schedule Worksheet – MUST BE SIGNED AT BOTTOM (Pgs. 3-4) Read pg. 2 for instructions or if you would like more assistance, go to “Start Here” in members’ area of website and view: Step-by-step Webinar. Choosing Your Fee Schedule

Completed Clinic/Provider Information Forms (Pgs.6,7) Completed and signed CREDENTIALS VERIFICATION AND RELEASE AUTHORIZATION FOR EACH PROVIDER (Pg.8) Completed and signed Provider Enrollment Contract (Pg. 11) Clinic Debit/Credit Card Authorization Form For Patient Payments (Pg. 12) Copy of existing clinic fee schedule (May be printed from software program. All information kept strictly confidential as required by contract)

Copy of Malpractice Declaration page for Each Provider Copy of Premises Liability Declaration page (May be faxed or mailed by insurance agent. One for each clinic if multiple locations)

Fax the above documents to 1-888-685-2220 Or mail to:

P.O. Box 5307 Brandon, MS 39047

1-888-719-9990 www.chirohealthusa.com

Once completed documents are received and approved, we will execute the contract and return the signature page for your files along with your initial supply of patient brochures and enrollment forms. We look forward to working with you and your clinic!

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Contracted Fee Schedule Options ChiroHealthUSA allows you to select the fee schedule that best serves your practice and patient’s needs. Please keep in mind these are for NON-COVERED SERVICES, SERVICES WHEN BENEFITS ARE EXHAUSTED, UNISURED OR UNDERINSURED PATIENTS, PATIENTS WITH HEALTH SAVINGS ACCOUNTS OR SIMILAR ACCOUNTS, OR WHEN YOU ARE NOT “IN-NETWORK” WITH A PARTICULAR PLAN OR A PATIENT CHOOSES TO OPT-OUT OF FILING IF PERMITTED BY THEIR PLAN AND YOUR PROVIDER AGREEMENTS. A contracted fee schedule allows you and your staff to help set your patient’s mind at ease by being able to answer some of the most frequent questions patients have such as; “How much is the first visit” and “How much is a regular visit?” You can now advise patients they will receive a discount off your normal fees, and if you choose, you can offer a “maximum fee” for their 1st visit and routine office visits. You simply indicate the actual services (CPT codes) along with your normal clinic fees on any receipts/statements for patients along with a ChiroHealthUSA CONTRACTURAL DISCOUNT to reflect the lower total fee. Or, if you prefer, you may enter the ChiroHealthUSA fee schedule in your software program as you would any other fee schedule. Examples will be provided at the end of this packet in Attachment A. YOUR FEE SCHEDULE OPTIONS: All providers must indicate the percentage off normal clinic charges for ChiroHealthUSA enrollees. A minimum of 5% is required on professional services to comply with various state laws. ChiroHealthUSA also allows you to offer a percent reduction with maximum charges depending on services rendered for new and existing patients. This choice provides you maximum flexibility in setting your ChiroHealthUSA Fee Schedule. For example, for new patients, a clinic may choose a maximum fee of $125.00, but you are free to set your fees. Regardless of what your clinic UCR fees may be, you agree to “reduce” the fee to the amount selected for all new patients in ChiroHealthUSA. Experience has shown, most doctors, patients and staff prefer the ability to quote a set rate for the patient’s first visit, regardless of what is needed or performed in the way of treatment. This frees you and your staff from “negotiating” on whether exams, x-rays or other diagnostics are needed, which areas to adjust, or whether 1 therapy or 2 therapies or other treatments are needed or wanted by the patient. Again, you set your fee. If you offer services we do not list, such as decompression, you may list these at the bottom of section. Patients with partial coverage only or NON-covered services can also be given discounts. As a ChiroHealthUSA provider, you now have the ability to offer a percent discount off these services OR you may simply choose to charge a flat fee per service for these non-covered services. This would include Medicare, FEP Blue and similar plans. Use the Provider Fee Schedule Worksheet on the next page and enter the charges and or discounts you wish to offer in your clinic. ALL providers in your clinic must adhere to the charges and or discounts indicated on this Worksheet. If you need help in completing this Worksheet, log on to our website and go to “Start Here” for a webinar that will walk you through the form step-by-step. YOU MUST SIGN THE BOTTOM OF THE WORKSHEET!

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Provider Fee Schedule Worksheet If you currently offer cash or time of service discounts, you may consider keeping your discounts in the same range when setting your ChiroHealthUSA fee schedule. Using ChiroHealthUSA will allow you to continue offering discounts within a legal network model.

Section 1 REQUIRED – Fee Schedule Under the terms of this agreement, all providers must offer a minimum of a 5% discount on professional services. You may choose to offer discounts that are more significant to patients. While we do not dictate the discounts you offer, many discount medical plans offer discounts in the range of 10% to 30% and even up to 50% on some services. Below, you will enter the percent discounts you wish to offer; for example 20%. Most providers additionally choose to set a “capped” or maximum fee for new patient visits and/or routine office visits; for example, you may charge a $125.00 maximum for an all-inclusive first visit and/or $45 for an all-inclusive routine visit. These options are not required. If you choose to do so, enter your selections below.

For All Member Patients Members of ChiroHealthUSA will be offered a 5% _____ discount off professional services. 10% _____ discount off professional services. 20% _____ discount off professional services. 30% _____ discount off professional services. Other:____ discount off professional services.

Section 2 OPTIONAL – Fee Schedule A. New Patient Services On Same Day Limited to Maximum Fee of: ____ $ 75.00 for all non-covered services. ____ $ 125.00 for all non-covered services. ____ $ 150.00 for all non-covered services. ____ $ 175.00 for all non-covered services. ____ Other: $ _________ B. Routine Office Visits: (defined as CMT & therapy) Limited to a maximum fee of: _____$35.00 for all non-covered services. _____ $45.00 for all non-covered services. _____ $55.00 for all non-covered services. _____ $75.00 for all non-covered services.. _____ $Other: ______ for all non-covered services.

C. For Medicare or other partially insured patients and when services other than a routine office visit as noted in “2B” are rendered, you may select a flat fee per CPT code for their non-covered services.

If you would like to set certain discounted fees per code, fill in this section. $____ for CMT codes (989x series) $____ per modality (970xx series) $____ per procedure (971xxseries) $____ per service (975xx series) $____ per service (977xx series) $____ per EM code (9921x series) $____ per film (720xx series) $____ per other service, please list (Use additional pages if needed)

Section 3 OPTIONAL – Materials, Supplies, Orthotics, Nutritional The percentage discount you selected above was for professional services only. If you choose to offer discounts on supplies and materials, please enter the percent discount here. _____% off on durable medical goods. (TENS, Equipment, Rehab Materials etc.) _____% off stock orthotics, pillows, supports, soft goods etc. _____% off CUSTOM orthotics supports soft goods etc. _____% off Nutritional supplements or products

Section 4 OPTIONAL – Exclusions (Use separate page if necessary) Providers who utilize specialty services: decompression, acupuncture, laser etc. are encouraged to extend discounts but may exclude these services listed below, if any (include CPT code & Description). __________________________________________________________________________________________________ __________________________________________________________________________________________________ Provider Contract v03.20.10

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Section 5 OPTIONAL – Family Plan Addendum The first member of a family should be extended the discounts selected in Section 1(above). For additional family members, you may offer the discounts selected in Section 1or you may choose to offer more substantial discounts noted below. You may also choose to offer a “capped” or maximum, per visit fee for each subsequent family member. If you do not wish to set a capped or maximum fee, please leave the “maximum fee” line blank.

Family Members Discounts are: First Visit 1st member discounts are as noted above in Section 1/Section 2 2nd or Subsequent Patient Family Member ____% discount, or a maximum fee of $_________ for all non-covered services on their first visit. 3rd or Subsequent Patient Family Member ____% discount, or a maximum fee of $_________ for all non-covered services on their first visit.

Routine Office Visits 1st member discounts are as noted above in Section 1/Section 2 2nd or Subsequent Patient Family Member ____% discount, or a maximum fee of $_________ for all non-covered services on their first visit. 3rd or Subsequent Patient Family Member ____% discount, or a maximum fee of $_________ for all non-covered services on their first visit.

ROUTINE OFFICE VISIT STIPULATION To receive family plan discounts on routine office visits family members must be seen: _____ On the Same Day _____ In the Same Week

____ No stipulations _____ Other stipulations: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

___________________________________________________________________________ Provider or Clinic Owner Signature Required Date___________

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Based on your choices above, we will supply you with a laminated “fee schedule� that will allow your staff to review the discounts offered in your clinic. Below is a sample.

As a member of ChiroHealthUSA, DR. B. J. PALMER offers a 25% discount off all clinic professional services with the following capped fees:

New Patient or Established Patient with new complaint requiring consult, examination with or without x-rays

25% reduction of normal clinic fees with a maximum fee of $135

Routine Follow Up Visits 25% reduction of normal clinic fees with a maximum fee of $45

For Patients With Partial Coverage Only: (such as Medicare or FEPBlue)

$35 per CMT code (989xx series) $10 per modality (970xx series) $15 per procedure (971xx series) $20 per service (975xx series) $25 per film (720xx series)

Materials and Supplies 10% off on durable medical goods 10% off stock orthotics, pillows, (TENS, Eqpt, Rehab Materials, etc.) supports, soft goods, etc. 10% off CUSTOM orthotics, supports soft goods, etc.

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Clinic Information Provider Name:______________________________________ Degree:_____ Date Licensed:__________ State(s) License #: _________________________ Tax ID # _____________________________ Malpractice Carrier: ________________________ Premise Liability Carrier: ________________________ Clinic Name: _______________________________________________________________ Clinic Address: _____________________________________________________________ City: _________________________________ State:_____ Zip:________________ Phone:____________________________ Fax:_______________________________ Clinic Website: _____________________________________________________ Drs Email: _________________________________________________________ Staff/Clinic Contact Name: _________________________________________________ Clinic Contact Email: __________________________________________________ Average # of New Patients per Month if Separate from Primary Location: ____________ (This number is used to determine the initial number of Patient Enrollment Forms you will need.)

How Did You Hear About ChiroHealthUSA? __________________________________________________

IMPORTANT! ChiroHealthUSA is committed to supporting YOUR state association and we are a Platinum Sponsor for the Congress of Chiropractic State Associations. We pledge over 5% of our gross revenues to the states and the Congress from each membership card in every state. Please indicate the state association you are a member of and/or support so we can track the pledges that go to help YOUR state and the profession. State Association Supported: FLORIDA CHIROPRACTIC ASSOCIATION Please fax or mail signed agreements along with proof of malpractice for each provider and premise liability coverage for each location to:

P.O. Box 5307 Brandon, MS 39047

Phone: 1-888-719-9990 PROVIDER_CONTRACT_Florida_2.14.10

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FAX: 1-888-685-2220 www.chirohealthusa.com

Additional Providers or Clinic(s) Information Complete ONE form for each additional provider and/or location

Provider Name:________________________________ Degree:_____ Date Licensed:_________ State(s) License #: ________________________________________________________________ Tax ID #: ______________________________ Malpractice Carrier: _____________________________________________ Premise Liability Carrier:__________________________________________ Clinic Name: _______________________________________________________________ Clinic Address: _____________________________________________________________ City: ____________________________________________

State:_____ Zip:______

Phone:____________________________ Fax:____________________

*Copy and attach additional sheets if needed for multiple clinics and/or providers.

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CREDENTIALS VERIFICATION AND RELEASE AUTHORIZATION (Must be completed by each provider) I, the undersigned applicant, represent and warrant to ChiroHealthUSA that the information contained in this application is true and accurate to the best of my knowledge and belief. I understand that any significant omission or misstatement in this application may be grounds for denial or revocation of participation status. In making application to be a contracted provider with ChiroHealthUSA, I hereby acknowledge that I agree to be bound by the terms of agreement outlined in the Provider Enrollment Contract. I hereby authorize ChiroHealthUSA and its representatives to access any and all information regarding my general and professional liability insurance records, past and present, including the insurance term, amounts, and claims activity. I further name ChiroHealthUSA as a CERTIFICATE HOLDER to my current and future general and professional insurance policies. I hereby release from liability all representatives of ChiroHealthUSA for their acts performed in good faith and without intentional fraud in connection with evaluating my application and credentials. I hereby release from liability any and all individuals and organizations that provide information to ChiroHealthUSA in good faith and without intentional fraud concerning my qualifications for participation. I understand that this application form and all information relating to my application will form a part of my Provider Enrollment Contract. Signature_______________________________________________ Date: ________________________ Print Name: ____________________________________________

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Provider Enrollment Contract A completed, signed contract must be returned to ChiroHealthUSA to enroll as a Provider. 1. Upon receipt of your provider enrollment Contract and documentation of adequate malpractice and liability coverage, you will become eligible to participate as a Contracted provider in ChiroHealthUSA and will be bound by the terms of the provider Contract. 2. Provider agrees to maintain malpractice and premise liability coverage throughout the term of this Contract and to name ChiroHealthUSA as a certificate holder to my current and future general and professional insurance policies. Any changes in coverage must be reported to ChiroHealthUSA within 48 hours. Loss of coverage for any reason may result in removal from the network. 3. The terms of the Contract shall be for a period of 1 year and shall automatically renew for consecutive one-year periods (“Renewal Period”) unless otherwise terminated in writing by either party within thirty (30) days prior to the end of the initial term or Renewal Period. 4. You have the right to choose to “opt-out” of the network or any future programs with or without cause upon 30 days written notice. 5. This Contract and selected fee schedules only apply to patients who choose to purchase an annual membership in ChiroHealthUSA and their covered legal dependents. 6. This program is made available ONLY to individual patients and their dependent family members and may not be assigned, sold or transferred under any circumstances. 7. Fees paid by ChiroHealthUSA members are based on a Contract with fee options selected by each provider. These fees are NOT a time of service discount and do not require payment at the time of service. Fees may be collected in accordance with your normal clinic office policy. 8. Enrollees or their dependants may be required to show proof of membership if requested by your office. Providers are authorized to enroll patients in the program at the point of sale or service. Providers will be issued coded patient membership enrollment forms and agree to be responsible for mailing and/or faxing membership registrations to ChiroHealthUSA within 48 hours of enrollment. 9. In order to minimize the risk of identity theft or fraud by transmitting credit card and banking information by fax or mail, patients should make payment of the $39.00 enrollment fee directly to the clinics. Clinics shall maintain a credit or debit card on file with ChiroHealthUSA which will be debited as enrollment cards are received. If a credit/debit card is not on file, a bank draft authorization may be required. 10. ChiroHealthUSA reserves the right to charge the provider for enrollment forms that are unaccounted for unless there is documented loss due to fire, vandalism or other acts out of the control of the provider. Should provider elect to resign from ChiroHealthUSA, un-issued enrollment forms and fees must be returned within 48 hours of resignation. ChiroHealthUSA may seek compensation of no more than the cost of the minimal enrollment membership form, not to exceed $39.00. Providers who fail to submit payments as required may be removed from the network upon 30 days notice. Providers will also be responsible for any and all legal costs incurred by ChiroHealthUSA in the attempt to recover patient payments that have been misappropriated by the provider. 11. Providers agree not to discriminate in any manner prohibited by law against ChiroHealthUSA members and specifically in regards to availability of appointments.

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12. Providers must maintain patient records and documentation standards as required by their respective licensure boards and/or malpractice carriers. Providers must utilize commonly recognized ICD and CPT coding for those patients that may submit receipts for Health Savings Accounts or other third party reimbursement. 13. Providers may enter their ChiroHealthUSA fees in to their software program as they would any other payer profile. Or, you may itemize charges according to procedures performed and utilize a line item reduction to adjust the fees according to the fee schedule selected as outlined in Attachment A, “Staff Instructions and Examples”. Fee schedule adjustments should be identified as ChiroHealthUSA Network Reduction, or a variation thereof. If a provider has a complaint filed against them for failing to honor the ChiroHealthUSA discounts, an appropriate investigation will be made into the complaint. If it is determined that the provider has not honored the contracted discounts the provider will be responsible for refunding any and all overpayments that may have been made by ChiroHealthUSA enrollees within 30 days of such notification from ChiroHealthUSA or in accordance with state law. Failure to do so may result in termination or legal action. 14. Unless prohibited by your participating provider contract, this Contract MAY be used in conjunction with other health insurance plans, including Medicare and others federally insured, but only for NON-COVERED services. Providers must honor the terms of their contracts with managed care organization or other entities and may not use ChiroHealthUSA for services covered under those contracts. Provider may not require patients insured under a network based health plan, for which you are a participating provider, to use ChiroHealthUSA as a means to reduce costs for those services which are covered but may be subject to a deductible or other out-of-pocket costs. Providers may request a review of their provider Contracts at no charge to determine any prohibitions that may exist. Providers will allow a minimum of 30 days for review and an opinion of any participating provider documents by ChiroHealthUSA’s legal counsel. Fax requests to 1-888-685-2220. 15. ChiroHealthUSA’s web site will list the name(s) of any known provider networks that may preclude specific patient groups or providers participation in this Contract. 16. In the event there is a third party (other than those set forth herein) liable for a patient’s care, the patient may elect to have the responsible party billed at the provider’s UCR rates, OR they may pay the negotiated rate and be reimbursed by the third party payer. Patients will be provided with a copy of charges and payments reflecting the amounts the patient has been billed and paid. In the case of Workers Compensation, these are state and/or federally mandated benefits and the prevailing state/federal fee schedules apply since the patient is not responsible for payment of medical treatment related to on the job injuries. 17. The filing of a third party liability claim and/or Workers’ Compensation claim does not suspend or extend the 1-year membership for the patient and/or their family members that may be receiving services. 18. Providers agree that their name and clinic contact information may be made available on our website or other marketing materials. Clinics with multiple providers or locations must have this Contract signed by the clinic owner and it will be considered binding upon clinic associates and/or partners either employed by or practicing in the clinic(s) listed on this Contract. 19. Provider’s agreed upon fee schedules will remain confidential and will NOT be published, distributed or utilized by ChiroHealthUSA for any purpose other than to verify a member patient’s request for discount verification. 20. Provider may change UCR fee schedules at any time but filed ChiroHealthUSA discounts may only be changed at the time of ChiroHealthUSA provider enrollment contract renewal. Provider agrees to honor any filed ChiroHealthUSA discounts in effect at the time the provider enrolls a patient as a member of ChiroHealthUSA for that patient’s full membership year regardless of whether Provider’s enrollment contract has renewed with different filed discounts or Provider has terminated participation with ChiroHealthUSA during the term of that patient’s membership year. The provisions of this section shall survive the termination of this agreement. 21. Patients who choose to discontinue care for any reason, other than for the provider’s failure to honor the agreed upon fee schedule, shall not be entitled to any refund of their membership fee unless required by state law. If ChiroHealthUSA determines that a provider is not in compliance with the agreed upon fee schedule, ChiroHealthUSA may elect to deselect the provider and may refund the patient’s membership fees in full. PROVIDER_CONTRACT_Florida_2.14.10

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22. ChiroHealthUSA may deny, suspend, or terminate membership of any provider by a majority vote of the ChiroHealthUSA Board for violations of this Contract, including but not limited to: a. Criminal or civil violations. b. Violations of state licensure board rules and regulations. Provider must notify ChiroHealthUSA of any restrictions or encumbrances placed on their license to provide services to patients. c. Substantiated complaints by members in regard to honoring the Contract. d. Loss of malpractice and/or premise liability coverage. 23. Provider must notify ChiroHealthUSA of: a) restrictions or encumbrances placed on Provider’s license to provide services to patients, b) criminal conviction, c) complaints by members in regard to honoring the ChiroHealthUSA fees, d) on loss of malpractice and/or premises liability coverage. Notice shall be given in writing to ChiroHealthUSA within five (5) working days of Provider’s knowledge of the same. 24. In the event any clause of this Contract shall be held invalid, illegal, or unenforceable in any respect, such invalidity, illegality, or unenforceability shall not affect any other provision herein, and this Contract will be construed as if such illegal, invalid, or unenforceable provisions had never been contained herein. 25. This Contract constitutes the entire Contract with respect to its subject matter, and supersedes all prior and contemporaneous promises, understandings, and Contracts related to its subject matter. No provision of this Contract may be amended, altered, or waived except in writing referring expressly to this Contract entered into by both Parties. 26. ChiroHealthUSA may from time to time, upon advanced written notice, modify this Contract. Upon such modification and notification, the provider will have the right to terminate the Contract in accordance with the terms of the Contract. 27. This Contract shall be governed and construed in accordance with the laws of the State of Mississippi. Any action to enforce the terms of this Contract shall be brought exclusively in the courts of the State of Mississippi. 28. All notices, offers, demands, requests, consents, objections and communications required or authorized under this Contract will be given by first class certified or registered mail, return receipt requested, or by a nationally recognized overnight courier, postage prepaid, to be effective when properly sent and received, refused or returned undelivered to the addresses noted below.

ChiroHealthUSA

PROVIDER: _________________________________________

P.O. Box 5307 Brandon, MS 39047

Address:_________________________________________ __________________________________________ Fax: _____________________________________________

, MS 39047

SIGNATURE REQUIRED FROM EACH PROVIDER UNLESS CLINIC OWNER HOLDS POWER OF ATTORNEY 

Please Date & Sign Date:_____________________________________

 Provider Signature:________________________________________________________________  Provider Signature:__________________________ Provider Signature:_____________________________  Provider Signature:__________________________ Provider Signature:_____________________________ (copy page if additional doctors are affiliated with clinic)

ChiroHealthUSA By: ________________________________________________________ President or Officer of ChiroHealthUSA PROVIDER_CONTRACT_Florida_2.14.10

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CLINIC DEBIT/CREDIT CARD AUTHORIZATION FORM THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND USED ONLY FOR PROCESSING OF PATIENT ENROLLMENT FORMS SUBMITTED BY CLINIC

NAME ON CARD: _________________________________________________ VISA _____

MC _____

AMEX _____ DISC _____

CARD NO.: ______________________________________________ EXP. DATE ______________________ SEC. CODE _____________ BILLING ADDRESS:

__________________________________________ __________________________________________

A receipt for charges to your debit card will be emailed. The receipts will reflect the enrollment form numbers for which the charges apply. Please provide an email address in order to receive confirmation for each transaction. RECEIPT EMAIL ADDRESS: _________________________________________________

SIGNATURE: _____________________________________________________

Please Mark:

DEBIT CLINIC On the patient enrollment forms and fax enrollment form to 1-888-685-2220

P.O. Box 5307 Brandon, MS 39047

Phone: 1-888-719-9990 FAX: 1-888-685-2220 www.chirohealthusa.com PROVIDER_CONTRACT_Florida_2.14.10

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“Attachment A” Staff Instructions and Examples Remember, if your clinic participates in ANY managed care plan, you must first abide by THOSE agreements for covered services. You are free to use OUR agreements for non-covered services, when benefits are exhausted, or for any patient paying out of pocket that is enrolled in ChiroHealthUSA, or if a patient chooses to opt-out of filing their insurance if permitted by their plan and your provider agreements. Please keep in mind, that patients covered under OTHER NETWORK agreements are entitled to the fees outlined in the network agreement ONLY as long as there are benefits available. AFTER benefits have been exhausted or limits reached, the patient is responsible for payment at the provider’s prevailing usual, customary and reasonable rate. You should notify patients BEFORE their benefits are exhausted and advise them of availability of ChiroHealthUSA to help them control their health care costs. Otherwise, once benefits are exhausted, the patient SHOULD be charged the clinic’s UCR fees, not the discounted fees through their health plan network. This should be discussed with your clinic owner and your policy followed. When the patient again becomes eligible for benefits, such as on the first of the year or their calendar year, or upon receiving new insurance, only then do their health plan network fees apply. Under the terms of the contract with ChiroHealthUSA, you are required to: 1) Bill out your normal fee schedule and reflect a ChiroHealthUSA Contractual Discount “adjustment” to equal the fees your provider has agreed to accept. For some clinics, this will be a simple percentage off the normal clinic fees, as selected by your doctor. For others, it will be a “maximum” or one set fee per CPT category. You will enter the normal CPT codes with the dollar amounts charged by your clinic and make a “ChiroHealthUSA Contractual Discount” entry (or similar language) in the patient’s account, reflecting the reduction. This allows your patients to be given a receipt showing your NORMAL charges and the Contractual Discount received. If they choose to seek reimbursement from their Health Savings Account, or other plans such as Cafeteria Plans, they will ONLY be credited or compensated for the amount they actually paid if permitted by their plan. OR 2. If you prefer to have your ChiroHealthUSA fees post to your software, you may enter the ChiroHealthUSA fee schedule as a payer profile, as you would any other fee schedule. If they choose to seek reimbursement from their Health Savings Account, or other plans such as Cafeteria Plans, they will ONLY be credited or compensated for the amount they actually paid if permitted by their plan.

Please remember that if the fee charged for a CMT code is less than your regions’ Medicare allowable fee for the same level of CMT, you MAY have to offer the lower fee to ALL Medicare beneficiaries. Medicare rules do not permit you to charge Medicare “substantially in excess” of what you charge other payers. “Substantially in excess” has NOT been defined by CMS or the Office of Inspector General and will be determined on a case by case basis. If you have ANY questions about how to calculate patient fees or other implementation issues, simply call our corporate offices at 1-888-719-9990 and we will be glad to assist you. PROVIDER_CONTRACT_Florida_2.14.10

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EXAMPLES The simplest way to apply your ChiroHealthUSA fee schedule would be to set up the fees in your software as a payer profile, like any other contracted fee schedule. By doing so, your staff can enter the services rendered and not have to make line item reductions at the time of entry. If you prefer to show your normal fees with the line item reductions, you may do so. In either case, the patient’s receipt would show what services were received and the amounts they paid. The key to applying the fee schedule is the concept of WHICHEVER IS LESS. We agree to a _____% discount OR a maximum of $________, WHICHEVER IS LESS. For these examples, the clinic has decided on a 20% discount off normal fees, or a maximum of $150.00 for new patients, and routine office visit maximum of $45.00, WHICHEVER IS LESS. New Patients If the initial fee is ABOVE the Maximum Agreed Service E/M Consult & Exam CMT Code Intersegmental Traction Stim Heat Xray (Minimum 4 view)

CPT 99202 98941 97012 97032 97010 72050

Total ChiroHealthUSA Network Discount ChiroHealthUSA Patient Charge

Clinic Fee $73 $45 $22 $20 $12 $95 $267 -$117

Enter the charges based on your normal clinic fees. If the clinic agreed to a MAXIMUM fee of $150 for the new patient visit, including all services, you reduce the fee by whatever amount is needed to reach the $150. You can see that the $150.00 IS LESS than taking a 20% discount. Since the contract read: WHICHEVER IS LESS, the patient receives the lesser fee. The $117.00 discount is equal to a 44% discount. (117 divided by 267= .438 or 44%) *You can see that the patient actually saves the enrollment fee on the first visit.

$150

If the clinic initial fee is BELOW the Maximum Agreed. Service CPT Clinic Fee E/M Consult & Exam 99201 $45 CMT Code 98940 $40 Stim 97032 $20 Heat 97010 $12 Total $117 ChiroHealthUSA Network 20% -$23.40

If the new patient requires a minimal workup and treatment and the total normal clinic fee is BELOW $150, simply make the % reduction agreed to by the clinic.

Discount

ChiroHealthUSA Patient Charge

$93.60

Routine Office Visit Service CMT Code Stim Heat Total

CPT 98940 97032 97010

ChiroHealthUSA Network Discount ChiroHealthUSA Patient Charge

PROVIDER_CONTRACT_Florida_2.14.10

Clinic Fee $40 $20 $12 $72 -$27

In this example, the agreed maximum fee is $45. The total charges are $72. $72 minus the maximum fee of $45.00 is a $27 ChiroHealthUSA Contractual reduction. If the patient only received a 98940, manipulation of 1-2 regions with a normal clinic fee of $40.00, and NO therapy and a 20% discount had been agreed to, and then the fee would be $40.00 – 20% = $32.00

$45

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Routine Office Visit –Patient with CMT coverage only and a flat fee per therapy. In this example, collect the co-pay required on the CMT ($6.25) and Service CPT Clinic Fee collect the per therapy fee. For this example, the provider selected CMT Code COVERED BY INS. 98940 $6.25 co-pay $5.00 / therapy. Stim 97032 $5 Heat 97010 $5 Total $16.25 ChiroHealthUSA Patient Charge $16.25

Routine Office Visit –Patient with CMT coverage only and a 20% discount on therapy. In this example, collect the co-pay required on the CMT ($6.25) and Service CPT Clinic Fee collect the charged fee with the agreed upon % reduction. CMT Code COVERED BY INS. 98940 $6.25 copay Stim 97032 $20 Heat 97010 $12 Total $38.25 ChiroHealthUSA Network 20% Discount off therapy @ $32.00 = $6.40

-$6.40

ChiroHealthUSA Patient Charge

$34.25

Routine Office Visit – Patient has NO CMT coverage or CMT coverage exhausted. Clinic has agreed to a maximum fee of $30.00 for any CMT code, as long as it is at or above your Medicare allowable, and to a flat fee of $15 for one or more non CMT code services. Service CMT Code NOT covered Stim Heat Total Patient Insurance Co-Payment ChiroHealthUSA CMT

Total Patient Payment

CPT 98940 97032 97010

Clinic Fee $45 $20 $12 $77 $15 $30 $45

In this example, the $15 co-pay covers all services with the exception of the CMT. The patient will be responsible for the $15 co-pay as well as the ChiroHealthUSA fee for the CMT, $30, which makes the total patient charge $45.

If you have any questions regarding implementing the fee schedule or the program, please call us at 1-888-719-9990. We will be happy to assist you. Or, feel free to email questions to info@chirohealthusa.com.

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CHUSA FL Provider Agreement as of 3.28.10