Document 1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 1 of 13 D I L IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF MISSISSIPPI MAY -4 2O17 NORTHERN DIVISION syLL=0,==c----1— BLUE CROSS & BLUE SHIELD OF MISSISSIPPI, A MUTUAL INSURANCE COMPANY PLAINTIFF CIVIL ACTION NO. VS. 7CA/3—_-, L) SHARKEY-ISSAQUENA COMMUNITY HOSPITAL; SUN CLINICAL LABORATORY, LLC; MISSION TOXICOLOGY MANAGEMENT COMPANY, L.L.C.; MISSION TOXICOLOGY, L.L.C.; MISSION TOXICOLOGY II, LLC; AND DEFENDANTS JOHN DOES 1-19 COMPLAINT (JURY TRIAL Plaintiff Blue Cross & Blue Shield of DEMANDED) Mississippi, A Mutual Insurance Company ("Blue Cross"), files this Complaint against Sharkey-Issaquena Community Hospital ("SICH" Sun Clinical "Hospital"), Mission Laboratory, LLC, Toxicology, L.L.C., shows the Court as Mission Mission or the Toxicology Management Company, L.L.C., Toxicology II, LLC, and John Does 1-10, and respectfully follows: PARTIES Plaintiff Blue Cross is Mississippi with its 2. principal place Defendant be served with process a mutual insurance company of business in Flowood, the president or clerk of the Supervisors. 02641668 Page 1 of 13 under the laws of Mississippi. Sharkey-Issaquena Community Hospital on organized is a county hospital Sharkey County, Mississippi, that can Board of Case 3:17-cv-00338-DPJ-FKB can Laboratory, LLC ("SCL") is Sun Clinical 3. Filed 05/04/17 Document 1 be served with process its on a Texas limited registered agent Michael L. Murphy 2 of 13 Page liability at 7373 company that Broadway Ste. 507, San Antonio, Texas 78209. Mission 4. limited company that liability Jr. at 1018 Solitude can be served with process on L.L.C. its ("MTMC") is a Texas registered agent Jesse Saucedo liability company that Cove, San Antonio, Texas 78260. Mission 5. can Toxicology Management Company, Toxicology, be served with process on its L.L.C. ("MT-I") is registered agent a Texas limited Jesse Saucedo Jr. at 1018 Solitude Cove, San Antonio, Texas 78260. Mission 6. can Toxicology II, be served with process on its LLC ("MT-II") registered agent is a Texas limited liability company that Jesse Saucedo Jr. at 1018 Solitude Cove, San Antonio, Texas 78260. John Doe Defendants 1-10 7. Cross is currently unable to John Doe Defendants are in a course for payment for ordered by privileges a unknown entities and/or individuals whom Blue identify despite diligent affiliates, subsidiaries, with SCL, MTMC, MT-I and MT-II engaged are owners, (collectively the Upon information and belief, investors, and/or contracting parties "Non-Hospital Defendants") laboratory services purportedly performed at and by the Hospital licensed at the the who have of conduct with the Non-Hospital Defendants to submit claims to Blue Cross physician Hospital or other licensed health and which were not Page 2 of 13 which were not professional who has appropriate staff performed Mississippi. 02641668 efforts. at the Hospital in Rolling Fork, Filed 05/04/17 Document 1 Case 3:17-cv-00338-DPJ-FKB Page 3 of 13 JURISDICTION AND VENUE and personal jurisdiction This Court has 8. personal jurisdiction business in over is proper because Defendants operate, conduct, engage in and carry on Mississippi. Personal jurisdiction is also proper before this Court because Defendants engage in substantial and not isolated activities within This Court has 9. Constitution, laws, Blue Cross asserts claims in this case Act of 1974 ("ERISA"), administering 29 U.S.C. plans, and 1001 et. seq., owe as action pursuant to 28 U.S.C. treaties of the United States. Specifically, Retirement Income Employee Blue Cross acted as an ERISA Security fiduciary in by the labs for beneficiaries under certain fully-insured as the claims administrator, seeks to to it in the future and seeks Blue Cross, submitting misrepresented claims Blue Cross does not or that arise under the certain claims submitted ERISA benefits Mississippi. matter jurisdiction over this subject 1331 because it arises under the from non-resident Defendants in this action, a enjoin Defendants declaratory judgment that Defendants payments for such claims submitted in the past, but for which Blue Cross has denied payment. 10. U.S.C. This Court has 1367 because the state and federal claims that 11. common Blue Cross' law claims Venue is proper in the Southern District of giving rise to the 1391(b)(2), remaining alleged claims pursuant to 28 herein are so related to the and 18 U.S.C. Mississippi pursuant 1965(a) because a to health plans and members can be Page 3 of 13 29 U.S.C. substantial part of the claims in this action occurred in the Southern District of Specifically, many of Blue Cross' 02641668 over they form part of the same case or controversy. 1132(e)(2), 28 U.S.C. events jurisdiction Mississippi. found within this district. Filed 05/04/17 Document 1 Case 3:17-cv-00338-DPJ-FKB Page 4 of 13 FACTUAL BACKGROUND Blue Cross entered into 12. the Hospital terms, the services on or Hospital are about is to ordered January 1, by licensed a at "Hospital Service(s)" Subscribers and other Participating Hospital Agreement (the "Contract") Exhibit 1995. physician or [the] Hospital." as As stated and are at and by the Hospital who has Hospital 14. the professional ¶3.1. who has The Contract supplies provided by [the Hospital] to organization or do not include services acute when such performed by hospital." an 2.12. See id. at above, beginning in February, 2017 through the present, claims were being submitted to Blue Cross for payment for laboratory services purportedly performed professional at the Medically Necessary other licensed health "those services and patients [and] are with Contract, among other Pursuant to the See Exhibit 1, Contract at facility not itself licensed by the state as a general 13. 1.1 provide "Hospital Services which appropriate staff privileges defines a in which were not appropriate ordered by a licensed staff privileges at the physician Hospital or other licensed health and which were not performed Rolling Fork, Mississippi ("Misrepresented Claims"). The has breached the Contract Hospital Mispresented Claims. The Misrepresented by submitting Claims to Blue Cross for paid by Blue Cross on payment behalf of its Members, Members of other Blue Cross and/or Blue Shield Plans and Members of the Federal Employee Plan are in excess in excess of $33, 800, 000. been submitted but not of $9, 800, 000. Misrepresented Claims were filed with total charges Mispresented Claims with total charges in excess of $24, 000, 000 have paid. and procedures, contains confidential and proprietary business information of Blue Cross. Pursuant to Uniform Local Rule 79, Blue Cross will file a motion to file the Contract under seal, and thus a copy of the Contract is not attached to the Complaint filed in the public Court record. Blue Cross will serve a copy of the Contract upon the Hospital, as it is a party to the Contract, and will serve a copy of the Contract on other Defendants upon the entry of an appropriate Confidentiality and Protective Order. 1The Contract, with its incorporated exhibits, policies 02641668 Page 4 of 13 Upon information and belief, 15. more entities and/or individuals through submit claims to Blue Cross for payment laboratory services the though information and belief, the an employee and were the Hospital which it is entered into Page 5 of 13 contract with a allowing these entities one or and/or individuals to using the Hospital's name and billing information even performed not Hospital attempted space at Filed 05/04/17 Document 1 Case 3:17-cv-00338-DPJ-FKB one or more at or by the Upon further Hospital. to obscure its breach of the Contract by "leasing" of these entities' facilities in further breach of the Contract. The Contract 16. allowed provides for a Percentage of Charge reimbursement rate, Blue Cross because of the small rural nature of the by at this rate with the Hospital as a hospital, and not as a certainly not to allow third parties to take advantage Upon information and belief, 17. of the third party entities for this reimbursement for laboratory services ordered to be Blue Cross's initial Toxicology, 2145 NW Toxicology or of the Hospital were the non-Hospital patients; and, being "reimbursed" by Misrepresented Claims reflect performed by the Hospital named laboratories and not Military Hwy #102, one or more submitted to the providers in Rolling Fork, laboratory were CLIA example, 45D2027576 and Mission 45D2071649. The who ordered the tests 5 of 13 For submitted to Sun Clinical on Laboratory logos but with the Hospital's Page submissions for by the Hospital. San Antonio, TX CLIA Mississippi address and with a Texas phone number. 02641668 is Surgical Hospital, Houston, TX, Sun Clinical for Blue Cross contracted Percentage of Charge rate. investigation revealed laboratory services Hermann Drive results services not performed by Laboratory, laboratory laboratory was "arrangement." Upon information and belief, 18. the Hospital. which resulting forms with Mission CLIA number and 19. A CLIA number is representation a certified under the Clinical Laboratory The certification issued to the performed was in the 20. services The as has been 263a. 42 U.S.C. 25D0317776—is for laboratory work laboratory work related to the examples above, Misrepresented upon information and Claims belief, the Necessity in accordance with procedures incorporated into the Contract, not meet Medical they did specimens to policies not drawn in and Mississippi and/or Blue Shield Plan in the State in which the the particular laboratory required by the Contract. Moreover, pursuant claims submitted for 6 of 13 Rolling Fork. reimbursable because benefit plan terms, 21. in Page Improvement Amendments of 1988, With respect to the claim were not that the Hospital—CLIA Hospital laboratory. performed in the Hospital not Filed 05/04/17 Document 1 Case 3:17-cv-00338-DPJ-FKB specimen are to be submitted to the Blue Cross is drawn. A significant percentage of Misrepresented Claims were improperly filed directly with Blue Cross. BREACH OF CONTRACT (Against the Hospital) COUNT 1 prior paragraphs are incorporated as 22. All 23. Under the contract between the provide "Hospital licensed Services which physician or are if stated herein. Hospital and Medically Necessary other licensed health professional Blue Cross, the when such services who has appropriate Hospital are staff ordered is to by privileges a at [the] Hospital." See Exhibit 1, Contract at 113.1. 24. The Hospital's actions constitute a breach of the Contract which resulted from the filing of Mispresented Claims. 25. As a direct, proximate and foreseeable result of said breaches, Blue Cross has suffered, and will continue to suffer, actual damages in other relief that the Court deems just and proper. 02641668 Page 6 of 13 an amount to be proven at trial and such Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Document 1 7 of 13 Page INJUNCTIVE RELIEF UNDER ERISA 4 502(0(3) (Against All Defendants) COUNT 2 26. All 27. Blue Cross acts prior paragraphs are incorporated as as a claims fiduciary if stated herein. on under 29 U.S.C. behalf of certain §1132(a)(3)(A) to fully-insured bring ERISA- civil action in governed plans and thus has federal court to enjoin any act or practice which violates the terms of an ERISA-governed plan. standing, Blue Cross seeks to 28. services where the lab does not services that are enjoin Defendants from submitting claims Medically Necessary pursuant to the Contract and not to Blue Cross for intend to collect members' payment responsibilities. Blue Cross seeks to 29. enjoin Defendants from submitting claims a to Blue Cross for Blue Cross's benefit plans incorporated therein. Blue Cross seeks to 30. services requested or caused to be investments in the lab that Defendants that seeks to All 33. Each by paid by Blue 02641668 individuals or to Blue Cross entities with direct or for indirect regarding of conduct utilized the coverage of services by performed by by John Doe Defendants. DECLARATORY RELIEF UNDER ERISA (Against All Defendants) 502(a)(3) prior paragraphs are incorporated as if stated herein. 32. submitted submitting claims injunctive relief because the pattern mislead Blue Cross entities controlled and directed COUNT 3 requested by from performs the services. Blue Cross seeks 31. enjoin Defendants or on Cross allegation in this Count is directed to behalf of Defendants prior to Misrepresented Claims the date of this ("Pended Misrepresented Claims") Page 7 of 13 that have been Complaint and which have not Case 3:17-cv-00338-DPJ-FKB Blue Cross acts 34. governed plans and thus has in federal court to obtain the a as a claims standing, Filed 05/04/17 Document 1 fiduciary on Page behalf certain ERISA- fully-insured §1132(a)(3)(B)(ii) under 29 U.S.C. 8 of 13 bring to declaratory judgment decreeing the rights, duties, and a civil action obligations of parties under the relevant ERISA plans. Blue Cross seeks 35. there is coverage for Pended no Defendants for services that there is Misrepresented not were Blue Cross seeks 36. terms Claims submitted to it of its ERISA by and/or on plans, behalf of actually requested by the listed provider. declaratory judgment that, under the a coverage for Pended no declaratory judgment that, under the a Misrepresented terms Claims submitted to it by of its ERISA and/or on plans, behalf of Defendants. Blue Cross seeks 37. no a declaration that, under the terms of its ERISA coverage for services contained in the Pended and/or on behalf of Defendants for services that were COUNT 4 Misrepresented not plans, there is Claims submitted to it by medically necessary. FRAUD (Against the Non-Hospital Defendants and John Doe Defendants) more All 39. Upon information and belief, the Hospital entered into agreements with of the prior paragraphs are incorporated as Non-Hospital Defendants and John individuals to submit name and Hospital billing who has Hospital 02641668 in Misrepresented Claims information and which professional at the if stated herein. 38. were even appropriate Doe Defendants to allow such entities and/or to Blue Cross for payment using the Hospital's though the laboratory services not ordered by a one or licensed staff privileges at the Rolling Fork, Mississippi. Page 8 of 13 physician Hospital, were or not performed by the other licensed health and which were not performed The submission of the 40. Hospital, ordered by staff privileges at the Claims reflect Hospital representations a licensed physician or were 9 of 13 Page material and false a was Services other licensed health performed by professional with the appropriate Hospital, and performed at the Hospital in Rolling Fork, Mississippi. false or were John and Non-Hospital Defendants The 41. Misrepresented to Blue Cross that such claims representation Filed 05/04/17 Document 1 Case 3:17-cv-00338-DPJ-FKB Doe and submitted such ignorant of their truth, such knew Defendants Misrepresented Claims with the intent that Blue Cross pay such claims. Blue Cross did not know 42. have or reason Misrepresented Claims and rightfully and justifiably relied on to know of the of the falsity being submitted in the such claims Hospital's name with the Hospital's CLIA number as being proper claims entitled to payment. 43. As a result of the actions of the Non-Hospital Defendants and John Doe Defendants, Blue Cross has suffered actual and consequential damages. Accordingly, the Non-Hospital Defendants and John 44. Blue Cross for compensatory and Doe Defendants punitive damages, costs, attorneys' fees, are liable to and such other relief the Court deems just and proper. CIVIL CONSPIRACY (Against the Non-Hospital Defendants and John Doe Defendants) COUNT 5 prior paragraphs are incorporated as if stated herein. 45. All 46. Upon information and belief, Defendants agreed and conspired on Blue Cross services under the Hospital's commit a fraud fraudulently misrepresented physician 02641668 or as the to engage in by submitting name and Non-Hospital a course of conduct, jointly and severally, claims to Blue Cross for payment for using the Hospital's billing having been performed other licensed health Defendants and John Doe professional Page at the who has 9 of 13 Hospital, appropriate laboratory number which ordered staff by to a were licensed privileges at the Document 1 Case 3:17-cv-00338-DPJ-FKB Hospital, and performed at the Hospital in Blue Cross been Accordingly, jointly and the damaged not 10 of 13 for compensatory and entitled. result of the as a between Defendants. conspiracy Johil Doe Defendants Non-Hospital Defendants and severally, Page Rolling Fork, Mississippi, for the purpose of receiving payments from Blue Cross to which they were 47. Filed 05/04/17 punitive damages, costs, are liable to Blue Cross, attorneys' fees, and such other relief the Court deems just and proper. COUNT 6 NEGLIGENT MISREPRESENTATION (Against the Non-Hospital Defendants and John Doe Defendants) prior paragraphs are incorporated as 48. All 49. Additionally and upon information and alternatively, Defendants and John Doe Defendants submitted payment using the Hospital's were not performed by the Hospital licensed health not 50. representation in to Misrepresented billing information and which were appropriate even not ordered staff privileges at the Blue Cross that such claims reflect Hospital staff privileges at the The licensed physician or other licensed health Hospital, and performed at the Hospital Non-Hospital Defendants degree of diligence and care the laboratory services by a licensed physician or other Claims a Claims to Blue Cross for though Misrepresented by belief, the Non-Hospital Hospital, and which were Rolling Fork, Mississippi. The submission of the ordered 51. and who has professional performed at the Hospital Hospital, name if stated herein. in was material and false a Services performed by professional with the appropriate Rolling Fork, Mississippi. and John Doe Defendants failed to exercise the expected of such entities and/or individuals in the submission of medical claims for payment. 52. Blue Cross reasonable reliance 02641668 on reasonably the relied on the misrepresentation Misrepresented Claims submitted by Page 10 of 13 and and/or paid certain claims on in behalf of the Non- Hospital Filed 05/04/17 Document 1 Case 3:17-cv-00338-DPJ-FKB Defendants and/or John Doe Defendants in the Hospital's 11 of 13 Page name with the Hospital's CLIA number. Blue Cross has suffered actual and 53. its reasonable reliance upon the 54. Misrepresented Claims. the Accordingly, consequential damages as a proximate result of Non-Hospital Blue Cross for compensatory and Defendants and John Doe Defendants punitive damages, are liable to costs, attorneys' fees, and such other relief the Court deems just and proper. UNJUST ENRICHMENT (Against the Non-Hospital Defendants and John Doe Defendants) COUNT 7 prior paragraphs are incorporated as 55. All 56. Additionally Defendants are not a submission of the and to a party alternatively, network the should be are not By virtue of the payment of the John Doe Defendants have received entitled, and which in good conscience and justice repaid to Blue Cross. 57. required they with Blue Cross. to Blue Cross and Blue Cross's Non-Hospital Defendants and money from Blue Cross to which and John Doe Non-Hospital Defendants provider agreement Misrepresented Claims Misrepresented Claims, the if stated herein. Accordingly, the Non-Hospital Defendants to pay to Blue Cross all monies received as a and John Doe Defendants should be result of the filing of the Misrepresented Claims with Blue Cross. REQUEST FOR RELIEF 58. interests and Blue Cross, acting on its own behalf to vindicate its obligations, requests that judgment be entered own against following: a. 02641668 An award of both actual and consequential damages; Page 11 of 13 personal the and contractual Hospital for the Case 3:17-cv-00338-DPJ-FKB Document 1 Filed 05/04/17 b. Prejudgment and post-judgment interest; c. Costs of court; d. Such other and further relief at law or in equity Page 12 of 13 to which Blue Cross may be justly entitled. 59. interests and Blue Cross, acting on its behalf to vindicate its own obligations, requests that judgment be and John Doe Defendants for the personal and contractual against the Non-Hospital Defendants following: An award of both actual and a. entered own b. An award of punitive and consequential damages; exemplary damages; attorneys' fees; c. Reasonable and necessary d. Prejudgment and post-judgment interest; e. Costs of court; f. Such other and further relief at law or in equity to which Blue Cross may be justly entitled. 60. administered Blue Cross, by as on and/or final trial hereof, Blue Cross have judgment against on behalf of ERISA following: Declaratory and injunctive relief as requested herein; b. Reasonable and necessary 02641668 plans provided fiduciary Blue Cross, requests that Defendants for the a. acting attorneys' fees under ERISA. Page 12 of 13 Case 3:17-cv-00338-DPJ-FKB Dated: "4, May, Document 1 Filed 05/04/17 Page 13 of 13 2017. Respectfully Submitted, BLUE CROSS & BLUE SHIELD OF MISSISSIPPI, A MUTUAL INSURANCE COMPANY By: One ofrnIs Attorneys Of Counsel: BRUNINI, GRANTHANI, GROWER & HEWES, James A. McCullough II (MSB No. 10175) PLLC imccullough@brunini.com (MSB No. 102243) Karen E. Howell khowellbrunini.com Post Office Drawer 119 Jackson, Mississippi 39205 The Pinnacle Building Capitol Street, Suite Jackson, Mississippi 39201 Telephone: (601) 948-3101 Telecopier: (601) 960-6902 190 East 02641668 100 Page 13 of 13 Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 1 of 47 1 PARTICIZATING HOSPITAL AGREEMENT is made and entered This Participating Hospital Agreement of Mississippi, Inc., into by and between Blue Cross & Blue Shield hospital, medical, and surgical service a Mississippi nonprofit referred ih=rainafter to As "PLAN"), and )47.9coot. (hegi711114141:1=1 tC;IW7iiiii;1[17am. I. i6-a Mississippi nonprofit hospital, medical, the service corporation., duly licensed by of Mississippi. Insurance of the State PLAN 1.1 and RECITALS surgical Commissioner of of HOSPITAL is duly licensed by the State Department 1.2 acute Health of the State of Mississippi to provide general services.inpatient and outpatient hospital of the mutual covenants NOW, .THEREFORE, in consideration is by and between PLAN it agreed contained, and agreements herein and HOSPITAL as follows: 1 EXHIBIT 12.93pd Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB II. 2 of 47 Page DEFINITIONS Participating "Agreement" means this written attachments hereto. Hospital Agreement, Including any 2.1 2.2 obligated to Contract/Certificate Agreement. Hospital the means "Benefits" Subscriber to pay be would PLAN of a Subscriber in the absence of this .amount under. for Covered Services terms made "Billed Charges" Means the total charges 2.3 Subscriber. to for all services and supplies provided by portion of that "Copayment" "Coinsurance, 2.4 amount, for as a percentage or dollar expressed Services, Covered a Subscriber under which Subscriber is financially responsible means Contract/Certificate. of act the and among between liability determining and paying benefits in various health care benefit programs Subscribers are when accordance with established guidelines care benefit's health one for benefits under more than 2.5 "Coordination Benefits" of means primary/secondary/tertiary eligible program. "Covered Noncovered Charges. 2.6 Charges" means Billed Charges "Covered Services" means those medically for which Benefits are health care services and supplies under a Subscriber Contract/Certificate. 2.7 minus necessary specified of Covered amount "Deductible(s)" means a specific be incurred by must that in dollars, Services, u0ally expressed to assume Subscriber to Subscriber before Plan is obligated Covered or part of the remaining financial responsibility for all Services under a Subscriber Contract/Certificate. 20 medical a sufficient condition could of immediate medical attention severity that the absence a Subscriber's health in reasonably result in permanently placing to body functions; causing serious "Emergency" means manifesting itself by 2.9 sudden onset of a acute symptoms of impairment jeopardy; causing and permanent dysfunction of serious any body organ or part; or causing other serious medical consequences. 2 12.93pd Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 the Page 3 of 47 use of any "Investigative Services" means device, or supply treatment, procedure, facility, equipment, drug, boards and/or licensing agencies not yet recognized by certifying for as standard medical practice 2.10 peer review criteria treated. PLAN makes the treatment of the condition being for Investigative Services. or published no payment activity the program means Audit" that relate to this HOSPITAL of records audit by PLAN to 2.11 "Hospital developed Agreement. services those and "Hospital Service(s)" means and other patients. subscribers supplies provided by HOSPITAL.io by an services performed include a Hospital Services do not as state the itself licensed by organization or facility not general acute hospital. 2.12 card issued to the 2.13 "Identification Card" means the to receive entitled as Subscriber identifying the Subscriber for services Contract/Certificate benefits under a Subscriber for such providers to use in rendered by health care providers and to the Subscriber by such rendered to PLAN those services reporting providers. (or services Necessary" "Medically 2.14 -"Medical hospital, physician, services provided by identify or treat a provider that are required toPLAN determines are Subscriber'sillness or injury and which based on the covered under a Subscriber Contract/Certificate TO be in (a) through (d). criteria lieted immediately below be: must the services determined by PLAN to be Medically Necessary, a means those Necessity") or other covered (a) of treatment Consistent with the Subscriber's the symptoms condition, or diagnosis ailment, disease, and or injury; and appropriate (b) practice; 1 or regard to standards of good medical and not (c) his with her for the convenience of the Subscriber, HOSPITAL, or other provider; and solely physician, supply or level of service (d) the most appropriate When applfed to the Subscriber. which can safely be provided to for the it further means that service6 of an inpatient, care the that require condition or Subscriber's services medical cannot be symptoms safely provided to the Subscriber as an outpatient. makes ino Necessary. .Plan payment for services 3 which are not Medically 12.93pd Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 4 of 47 :1 2.15 "Noncovered Noncovered Services. 4 Charges" means HOSPITAL charges 'for "Noncovered Services" means all health care or 2:16 and other services supplies provided to Subscribers other than Covered Services. Noncovered Services include, but are not limited to, the following: (a) Television, guest cots and guest meals, personal grooming items, and the like, and for other services and supplies for specifically excluded by a Subscriber 'Contract/Certificate and custodial care, cosmetic procedures, conditions, preexisting the like; and (b) for a service covered by the Subscriber in excess of the allowance specified in the Charges Contract/Certificate Subscriber.Contract/Certificate. 2.17 "Participating Hospital" means a hospital which is licensed by the State Department of Health to provide general acute to inpatient and outpatient hospital services and which is a party A Participating Hospital Agreement with PLAN. 210 "Payment Amount" means the amount payable under this PLAN to HOSPITAL for services to Subscriber, minus any Agreement .whether said applicable Deductible, .Co-insurance and Copayment Benefits. than less or than, amount is equal to, greater 2.19 "Payment Program" means the program developed by PLAN to pay HOSPITAL-for services rendered to Subscribers as more made a part of this fully set out in Attachments A and B hereto and from time to are as thereto Agreement, together with amendments time adopted. their 2.20 enrolled "Subscriber(s)" means employees or individuals and eligible dependents covered under a Subscriber Contract/Certificate benefits as defined Certificate. 2.21 who are entitled to in and pursuant to a "Subscriber contract/certificate issued receive health care Subscriber1Contract/ Contract/Certificate" administered or by means PLAN, any its subsidiaries and affiliates, or another Blue Cross and Blue Shield Plan with which PLAN has a participating or reciprocal agreement, as defined in entitling Sdbscribers to receive health care benefits Contract/Certificate. and pursuant to a Subscriber 2.22 "Usual Charge" means the fee most commonly charged HOsPITAL for Hospital Services provided to all HOSPITAL by the patients. 4 12.93pd Case 3:17-cv-00338-DPJ-FKB PLAN to review and provided, or to be developed by are Covered Services Certificate. III. means determine whether Page 5 of 47 the the Hospital program provided, are Medically Necessary and the applicable Subscriber Contract/ HOSPITAL SERVICES AND RESPONSIBILITIES as provide to Subscribers, insofar are which Services permit, Hospital HOSPITAL shall 3.1 of facilities under Filed 05/04/17 Management" "Utilization 2;23 Services Document 1-1 HOSPITAL when such services'are ordered by a licensed who has aPpropriate physician or other licensed health professional staff privileges at HOSPITAL. Medically Necessary All services provided by HOSPITAL to other patients shall be provided to shall be available to Subscribers and are provided to Subscribersin the same manner ao those services Services of The Hospital quality all other patients at HOSPITAL. the quality of to least at be equal shall provided to Subscribers to other patients at HOSPITAL. services 3, 2 provided the with HOSPITAL PLAN to cooperate agrees and to Utilization Management process without charge by HOSPITAL, to rights of review such from subject abide by decisions resulting appeal as provided in Article VII(Appeals). 3.3 HOSPITAL agrees to permit PLAN to conduct Hospital deemed mutually permit such other activities as are for 'services HOSPITAL to ensure correct payment on-site reasonable conduct PLAN may rendered to a Subscriber. hours'. HOSPITAL business HOSPITAL'S regular scheduled audits during access to relevant Subscriber agrees to provide, wlthout charge, to complete the on-site audit. and/or financial records necessary 3.4 Audits and to necessary •to 3'.5 patient cer4, Commission other on To satisfy recognized minimum standards in providing the Joint HOSPITAL shall be either (a) accredited by or Accreditation of Healthcare Organization (JCAHO) applibable nationally recognized accreditation body, or (b) Health care program for certified and Quality, Standards Financing Administration, DiviEtiOn of Health or accreditation to decision deny After a as applicable. the have right, shall PLAN to HOSPITAL, certification herein, to terminate other the Medicare through the provision'contained notwithstanding any this Agreement upon giving HOSPITAL thirty (30) days' prior written notice of such intent to terminate. 5 12.93pd Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 6 of 47 HOSPITAL If a Subscriber who is an inpatient at 3.6 or Supplier, receives services or supplies from another hospital services or supplies HOSPITAL is responsible for paying for such of Section 5.5. and for billing PLAN therefor under the terms to PLAN during Upon request, HOSPITAL shall furnish records and medical relevant of HOSPITAL, hours regular business each Subscriber, bills covering treatment of Any itemized 3.7 law relating to such Subscriber having waived any provision of to benefits and entitlement enrollment of condition disclosure as a One copy of such records shall be provided to In the event PLAN requires additional copies PLAN wIthout, charge. HOSPITAL may charge PLAN its usual, customary of the same records, HOSPITAL and PLAN agree to keep recordi. such for copying charge be prepared and/or maintained to confidential all recorderrequired unauthorized disclosure of the and to prevent this as a by Subscriber. Agreement such records. IV. 4.1 PLAN SERVICES AND RESPONSIBILITIES PLAN Agreement directly due under this agrees to make its payments to to HOSPITAL for Covered Services provided each Subscriber. PLAN 4.2 accordance with the PLAN 4:3 be made payments to HOSPITAL shall B. Payment Program as set out. in Attachment HOSPITAL' the status of a as HOSPITAL and identify informational materials to Subscribers. agrees Hospital" "Participating Participating Hospital on in to grant to Benefits to which a Subscriber is otherwise Subscriber entitled are limited to those set out in the applicable are Services time Hospital Contract/Certificate in effect at the for misrepresentany be not responsible performed and PLAN shall made to HOSPITAL by ation of the Subscriber Contract/Certificate 4-04 PLAN Subscriber. review maintain to professional 4.5. PLAN agrees to committees and consultants composed of practicing physicians Medical Necessity to-make and unusualcases of conduct reviews determinations. 4.6 appropriate and Subscribers of agrees to notify HOSPITAL Deductibles, Coof Noncovered Services, amounts insurance and the PLAN Copayments that are the financial respon4bility of Subscriber. 6 12.93pd Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 7 of 47 PLAN shall provide reports to HOSPITAL containing to the operation of this data determined by PLAN to be relevant 4.7 Agreement. and in directly to HOSPITAL for Amount calculated in accordance the Payment of Sdbscriber behalf Policies and with the terms of Plan's Participating Hospital A Attachments forth in Procedures and the Payment Program, as set and B, for services rendered by HOSPITAL to Subscriber. 5.1 full of PLAN shall pay HOSPITAL shall accept Payment Amount 5.2 PLAN'S financial responsibility for all supplies provided to as payment in services and Subscriber. Subscriber for any applicable and for those Noncovered Deductible, Co-insurance.and Copayment responsibility. financial has which Subscriber for Services amount in excess of not bill the Subscriber for any HOSPITAL 5.3 HOSPITAL may bill may the Payment Amount. 5.4 physician may It is request recognized that Subscriber or Subscriber's not covered by Subscriber shall have services of HOSPITAL that are Subscriber Contract/Certificate. for those financial responsibility for Noncovered Services, except Necessary not Medically Noncovered Services determined to be either the However, under provisions of this Agreement. that advance in in writing where HOSPITAL notifies Subscriber not is which named Noncovered Service, payment for the specifically if provided, shall, Medically Necessary or which is Investigative and not PLAN'S, HOSPITAL be Subscriber's financial responsibility are Usual Charges for such services if they may bill Subscriber its or Investigative provided to Subscriber. Subscriber or upon expiration of under the applicable Subscriber days of service provided for theHOSPITAL shall promptly furnish to Subscriber Contract/Certificate, and procedures in policies accordance with PLAN's in PLAN or forms claim standardized on A appropriate Attachment for 'made all charges electronically an itemized statement of all to Subscriber, together with and provided supplies services was which information additional and any claim form required data when or the Subscriber at the time of admission 5.5 provided services Upon discharge of a to were rendered. 7 12.93pd Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 8 of 47 .1 amounts PLAN shall be 5.6 due LPLAN because of permitted payments to made recover from HOSPITAL in error, inaccurate Management Medical Necessity and other Utilization or recovery required determinations, Investigative determinations, of Benefits, of Coordination or because under a Hospital Audit, Plan shall determinations. workers' compensation, or subrogation from future payments to be made have the right to offset, deducting of the payments, to amounts due Plan upon notice to Hospital service and relevant offset, the name of the Subscriber, Hospital, amounts dates. for amounts due PLAN shall make payments to HOSPITAL in error. made or underpayments HOSPITAL because of omissions discovered by PLAN as soon made as be of Payment for such errors shall HOSPITAL of written notice given by or within thirty (30) days PLAN's.error. 5.7 V/. 6.11 UTILIZATION MANAGEMENK -PLAN shall engage in, and HOSPITAL shall cooperate designed to avoid unnecessary in, Utilizaelon Management programs while ensuring the delivery of Services or unduly costly Hospital HOSPITAL is required for Subscribers. quality health care services Continued Stay Preadmission Certification/Certification, as Case Management guidelines Review, Outpatient Certificationland Procedures, and Policies described in Plan's Participating Hospital to follow Attachment A hereto. 6.2 Utilization Management shall include not but be 1 limited to: Continued Preadmission Certification/Certification, Certification and Case Management. Outpatient Review, Stay (a) conduct Medical Medical Necessity Review. PLAN may to be provided or provided Necessity reviews of Hospital Services the applicable Subscriber Subscribers where required by to of the place or (b) Contract/Certificate as to the appropriateness or outpatient); intensity setting of treatment (inpatient and reporting services; readmission frequencies; assignment procedures and secondary); diagnosis o.i.; diagnoses (principal medical coding the appropriate used in assigning other criteiia reviews and the like. Such Medical Necessity payment, either before determinations may be conducted made payment (c) for Services. charged or after of of and for and PLAN has to HOSP/TAL. Investigative Services. shall not make payment for New and and PLAN shall not be any Investigative 12.93pd Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 9 of 47 Inpatient stays-at (d) Organ Transplant Services. of kidney, end other .liver, heart, HOSPITAL involving transplants transplants are tissue and certain solid organ transplants Subscriber certain and exclusions of limitations Contracts/Certificates subject obtain prior must HOSPITAL the Subscriber Contracts/Certificates. written to the PLAN from PLAN shall not make approval Otherwise, under Subscribers to available such transplant services. services. such payment for for PLAN conduct reviews for, may (e) Noncovered Services. Noncovered Services regarding, determinations make and payment cosmetic conditions, including, but not limited to, pre-existing like. procedures, Custodial care, and the for not charge PLAN or Subscriber determined by PLAN to be either not Medically HOSPITAL shall 6.3 Hospital Services PLAN nor Subscriber shall Necessary or Investigative, and.neither as otherwise provided be obligated to pay for such services, except this of 5.4 Agreement. in paragraph Service Where PLAN alone has determined a Hospital or Necessary, not Medically Service, a Noncovered be to such to appeal the have right shall Investigative, HOSPITAL Article VII of determination in accordance with provisions 6.4 (Appeals). Yal.:—AREEKLA and confer in good PLAN and HOSPITAL agree to meet that may arise under to resolve any problems or questions 7.1 faith this Agreement. 7.2 question is not event any problem or as provided in appeal resolved, either party may set out in Hospital Policies and Procedures .In the satisfactorily Plan's Participating Attachment A hereto. and binding on The appeal decision shall be final 7.3 have no effect, relevance, or both PLAN and HOSPITAL, but shall a Participating Hospital other bearing on any decision involving than HOSPITAL. VIII. TERM AND TERMINATION shall When executed by both parties, this Agreement in effect continue shall and date effective become effective on the 8.1 until terminated. 9 12.93pd Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 10 of 47 with or Either party may terminate this Agreement, of at least thirty notice written without cause, by giving prior be made provided termination shallcontained (30) days to the other party, month. Nothing effective on the last day of a calendar limit either party's lawful in this Agreement shall be construed to of this Agreement. remedies in the event of a material breach 8.2 terminate upon Agreement shall automatically to license operate, or the suspension or revocation of HOSPITAL'S of such date the with effective a change of ownership of HOSPITAL, suspension, revocation, or change. 8.3 This terminated, HOSPITAL In the event this Agreement is 8:4 the terms of this under Services shall continue to provide Hospital HOSPITAL is inpatient on the a who Agreement to each Subscriber and Plan is discharged, Subscriber such date of termination until in HOSPITAL to shall make payment for such services directly at the time of effect in accordance with the Payment Program Subscriber's admission. IX. GENERAL PROVISIONS entities. PLAN and HOSPITAL are independent legal 9.1 to create be deemed or construed be Nothing in this Agreement shall and agent, or or and principal employee a relationship of employer relationship other thin that of partnership, joint venture, or any each other solely to carry out with contracting independent parties the provisions Agreement. of this breach of any provision of this a Waiver of of the a waiver of any other breach Agreement shall not be deemed same or different provision. 9.4 given pursuant to the be in writing and terms and provisions of this Agreement requested, postage return receipt shall be sent by certified mail, Box 1043, Jackson,, Office .Post at PLAN to prepaid, 39215-1043, and to Hospqmi at s-4, tay 9.3 Any notices required to be shall Mt:tZppi effeCiiveliime-date indicated on the return receipt. 9.4 Neither respective employees or PLAN nor agents HOSPITAL shall be nor liable any for of any their act or omission of the other party. initiate In the event that either PLAN or HOSPITAL of this the enforce to provisions any action, suit, or proceedings fees. and attorney costs own its bear shall each 9.5 Agreement, party 10 12.93pd Case 3:17-cv-00338-DPJ-FKB 9.6 This contains the entire rights granted and prior agreements, Document 1-1 Filed 05/04/17 Page attachments, Agreement, together with its relating to the agreement between the parties the parties. Any assumed by the obligations or representations, -negotiations, promises, of this matter the subject either oral or written, relating to set forth not expressly Agreement and its attachmentsare of no force or effect. attachments Agreement arid its Agreement replaces and supersedes between HOSPITAL and participating hospital agreements 9.7 11 of 47 This in this all prior PLAN. and enforced in This Agreement shall be construed 9.8 of Missiesippl. accordance with the laws of the State time during the This Agreement maybe amended at any 9.9 authorized of consent duly written term of the agreement by mutual to the Attachment A changes Any representatives of the parties. be B Payment Program shall Policies and Procedures or Attachment before days (30) least thirty at made known to HOSPITAL in writing must be become effective. Said changes proposed changes are to mutually agreed upon prior the to implementation. of th'es rights, .No assignment of this Agreement, of part of this or any obligations of this Agreement, Any attempted or PLAN. 9.10 duties, or by HOSPITAL to PLAN. Agreement shall be. made this of provision shall be void as assignment Jn violation expressly acknowledges its HOSPITAL hereby 9.11 constitutes a contract between understanding that this agreement is an independent corporation that PLAN HOSPITAL and PLAN, Blue Shield and Blue independent Association, an to use the Blue PLAN Shield Plans, (the "Association") permitting and Mark in the State of Mississippi, Cross and Blue Shield Service Association. the of the agent as that PLAN is not contracting entered and agrees that it has not acknowledges further HOSPITAL by any person other into this agreement based upon representations or organization other than than PLAN and that no person, entity, for any of or liable to HOSPITAL PLAN shall be held accountable this agreement. This created under PLAN's obligations to HOSPITAL whatsoever on obligations any additional paragraph shall not create created wider other the part of PLAN other than those obligations provisions of this agreement. operating under with association of a license the Blue Cross Blue 11 and Cross 12.93pd Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 12 of 47 a 12 IN WITNESS WHEREOF, PLAN and HOSPITAL, acting through duly authorized officers, have executed this Agreement in duplIcate on the date(s) indicated-below for an effective date of a_At.itt.lk t 19q5 their BLUE CROSS & BLUE SHIELD OF MISSISSIPPI, INC. Date: 141 etVos By: Title: (PLAN) Authorized 0 SAAeltel TSs 4G1 keg (00.1v4T2 I e H.,11 zr (HOSPITAL) Date: Bys tAlikd 0.4104.4:4(N-J Title: 12 12.93pd Case 3:17-cv-00338-DPJ-FKB Item.Index Item PC: Document Agreement Date: 8/5/2003 PC: Document Description: Agreement Tex Number: 640650533 000020129 Provider Number: Filed 05/04/17 Page 13 of 47 13 document PC: Type Document 1-1 Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 14 of 47 PARTICIPATING HOSPITAL PERCENT OF CHARGE PROGRAM Policies and Procedures Manual Effective January 1, 2017 t.76v- Blue Cron & Blue Shield of MississOpi, A Mutual tuurance Company. is an independent licensee of the Blue Cross and B1-ye Shield Associadon Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 15 of 47 Percent of Charge Policies and Procedures Manual ATTACHMENT A POLICIES AND PROCEDURES TABLE OF CONTENTS PAGE SECTION 1. Introduction 1 2. Definitions 2 3. Percent of Charge 4. 5. Program 9 3.1 Payment Processing Rules 3.2 Special Payment Provisions 14 3.3 Monitoring 15 3.4 Updates and Revisions 15 Administrative Policies and Procedures 4.1 Submission of Claims 18 4.2 Appeals Procedures 21 4.3 Information Requirements 22 4.4 Utilization 23 4.5 Quality Management 23 4.6 Services Furnished Under Arrangement 25 4.7 Electronic information 4.8 Minimum Data Management Exchange and Communication Security Standards 27 28 References Appendix A Utilization Management Program Appendix B 26 Minimum Data Security Standards Bitie Ooss & &us She'd of &Ewa=f A Haw marinas Camay, is an Odscendeni kensee ofY',.0 Nt.e Cross and VIA3 Shkaki ASSOdattr Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 16 of 47 Percent of Charge Policies and Procedures Manual INTRODUCTION Section 1 PARTICIPATING NETWORK HOSPITAL Note: The words, Network Hospitals Participating and Network, are those hospitals with Blue Cross & Blue Shield of are used interchangeably. which have entered into a Participating Hospital Agreement Mississippi. The Network Hospital is recognized in Blue Cross & Blue Shield of Mississippi's products and services as being a Network Provider. Blue Cross and Blue Shield Subscribers have benefit incentives in their Subscriber Contracts/Certificates to choose Network Hospitals over Non-Network Hospitals. For Network Hospitals, the Subscriber's Benefits are paid directly to the Network Hospital, while payments are made to the Subscriber for services rendered in NonNetwork Hospitals. Network Hospitals accept the Blue Cross & Blue Shield of Mississippi payment as full compensation with the exception of Deductible, Co-insurance/Co-payment and Non-Covered Services which are the Subscriber's responsibility. Page Flue Crns & Slue Shield ssiA MutuaGnsaunce Compsny. LS 8/7 1 ihdependerat licensee of the Blue CAMS and Bfue Shield Associadon 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 17 of 47 Percent of Charge Policies and Procedures Manual DEFINITIONS Section 2 BCBSMS Blue Cross & Blue Shield of Mississippi, a Mutual Insurance Company. Benefits The amount BCBSMS would be obligated to Subscriber to pay under the terms of a Participating Subscriber Contract/Certificate for Covered Services in the absence of the Hospital Agreement Deductible and and its Percent of Charge Payment program, and exclusive of applicable Co-insurance/Co-payment amounts. Billed Charges Total charges made by the Network Hospital for all services and supplies provided to the Subscriber. Case Rate A specific reimbursement rate established for certain hospital Diagnostic Related Groups (DRGs). Center of Excellence A Network Excellence Clinical Hospital that designation in certain illnesses and/or treatments. specializes is based on Center of particular criteria established by BCBSMS. Component Billing The practice of billing the clinical a professional fee as laboratory tests performed in an an add-on professional service to some or all of inpatient or outpatient hospital setting. Co-insurance, Co-payment The portion of Covered Services, expressed amount as a percentage (Co-insurance) or dollar (Co-payment), for which the Subscriber is financially responsible under a Subscriber Contract/Certificate. Page 2 Blue Crass .4 Slue Shied of Vfissssipro. 4 Utrhod (rtsrgence Compery is an indn_,oendent itensee v'ttv 3hie Cross end am Striod Associsocn 11/16 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Document 1-1 Page 18 of 47 Percent of Charge Policies and Procedures Manual Covered Charges Charges minus Non-Covered Charges. Billed Covered Services Those Medically Necessary health care services and supplies for which Benefits are specified under a Subscriber Contract/Certificate. Deductible(s) A specific amount of Covered Services, a Subscriber before BCBSMS is all or usually expressed in dollars, that must be incurred by obligated to Subscriber to assume financial responsibility for part of the remaining Covered Services under a Subscriber Contract/Certificate. Hospital Acquired Conditions (HACs) Those conditions that are acquired are during hospitalization (i.e. not present on admission) and reasonably preventable by following evidence-based guidelines. A listing of HACs is as follows: 1. Object Left in During Surgery 2. Air Embolism 3. Blood 4. Pressure Ulcers 6. Catheter-Associated Urinary Tract Infections 6. Vascular Catheter-Associated Infections 7. Manifestations of Poor 8. 9. Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft Surgical Site Infection Following Certain Orthopedic Procedures 10. Surgical Site Infection Following Bariatric Surgery for Obesity 11. Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) Deep Vein Thrombosis and Pulmonary Embolism Foilowing Certain Orthopedic 12. Incompatibility Glycemic Control Procedures 13. Hospital Acquired Injuries Injury, 14. Burns and Other Fractures, Dislocations, Intracranial Injury, Crushing Unspecified Effects of External Causes Latrogenic Pneumothorax with Venous Catheterization Page 3 ale Cress & Slue Shield of Wass^ssippi. A MUILIal insurance Cormany, is an independent licensee piths. Blue Cross and Blue Shield Association 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB 19 of 47 Page Percent of Charge Policies and Procedures Manual In addition to the specific HACs listed above, BCBSMS may review all claims and associated medical records to quality of care rendered the assess to Subscribers for the purpose of identifying Hospital Quality-of-Care Conditions. Certain conditions that occur in a hospital setting are deemed to be HACs or by BCBSMS Hospital Quality-of-Care Conditions and the Network Hospital shall not be reimbursed by BCBSMS for any charges to relating or resulting from HACs Conditions. BCBSMS shall take into account the HAC when pricing or or Hospital Quality-of-Care Hospital Quality-of-Care Condition In the event it is determined that circumstances the claim. acquired during hospitalization resulted or conditions in substantive clinical changes to the detriment of the Subscriber's health status, BCBSMS will consider the claim to be based HAC related claim and a Rule 2: Percent of Covered Charge Payment will reimburse the Network Hospital Formula Involving HACs Hospital Quality-of-Care Conditions located within Attachment A. or on Hospital Service(s) supplies provided by Network Hospital to Subscribers Those services and Hospital Services licensed by the do not include services general state as a acute and other patients. performed by an organization or facility not itself hospital Medically Necessary Services, treatments, procedures, equipment, drugs, devices, items or supplies provided by a Network Hospital, physician, Subscriber's illness, are covered under a. a or other provider Subscriber Contract/Certificate based condition, illness or injury; b. appropriate with regard c. not solely for or are required to identify or or diagnosis on the and to standards of good medical provider; criteria: and treatment of the Subscriber's practice; and the convenience of the Subscriber, his other following or her physician, Network and 11/16 Page 4 aia C;oss & 3k.e S, treat a injury or Nervous/Mental Conditions, and which BCBSMS determines Consistent with the symptoms Hospital, that of A."&-issppi. A Aguituei!rszzanal Ccapary t n .:Vependerd atersee Ie Ste C....'erss and Ste Shkted Asscciadcn Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 20 of 47 Percent of Charge Policies and Procedures Manual appropriate supply the most d. Subscriber. When safely provided NOTE:BCBSMS makes devices, items or no level of which can safely be provided it further means that services outpatient. payment for services, treatments, procedures, equipment, drugs, are not Medically Necessary, bill the Subscriber for any services rendered within The fact that the Network a and Network Hospital may not Network Hospital determined to be not Hospital, physician or other provider has prescribed, ordered, recommended or approved a service or supply does not, in itself, it to symptoms or condition require that the services cannot to the Subscriber as an supplies which Medically Necessary. care applied to the care of an inpatient, for the Subscriber's medical be or make Medically Necessary. Mississippi Specialty Care Hospital A Network Hospital that Services and meets criteria established by the BCBSMS related to Specialty designated as such by BCBSMS myBlueProvkier The to secure BCBSMS designated website available solely for the usage by Network Hospitals provide information regarding BCBSMS policies and procedures, patient information, reference tools and information, such Non-Covered as guides and various tools to electronic medical records, promote the electronic exchange of appeals, etc. Charges Network Hospital charges for Non-Covered Services. Non-Covered Services All health care or other services and supplies provided to Subscribers other than Covered Services for which benefits are not available under the Subscriber Contract/Certificate. NonCovered Services include, but are not limited to: Television, guest cots and guest meals, personal grooming items, and the like, and for other services and supplies specifically excluded by a Subscriber Page 5 Blue Cr= & Slue Sllie,d r Vississtri 4 Muivei Insurwce Con-loam, ri ricteuendene licensee 3, the ale Cross and Blue Shield Associaton 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 21 of 47 Percent of Charge Policies and Procedures Manual Contract/Certificate for preexisting conditions, cosmetic procedures, custodial care, and the like; and Network Hospital A hospital which inpatient and Agreement by the State Department of outpatient hospital services and which is Health to party to a provide general acute Participating Hospital with BCBSMS. Present On Admission Diagnosis is licensed is (POA) present develop during at the time the order for inpatient admission occurs. Conditions that outpatient encounter, including emergency department, observation an outpatient surgery, are considered present on or admission. Quality Management The program BCBSMS to designed by services for Subscribers in an ensure the provision efficient, cost-effective of manner high quality healthcare which is consistent with nationally recognized standards of medical practice. Quality-of-Care Condition Those conditions, outside of defined HACs, that on during hospitalization (i.e. not present admission) and are reasonably preventable by following nationally recognized standards of medicil practice, including circumstances or conditions acquired during hospitalization that resulted in substantive clinical Serious occur changes to the detriment of the Subscriber's health Reportable Events (SREs) Medical errors injury or death that should to the Performed Surgery 2. Surgery Performed 3 Wrong Surgical 4. Leaving a never happen in the Network patient. Examples of these SREs 1. 5. on on the Wrong Body Part the Wrong Patient Procedure Performed Foreign Object Injury Occurring in on a Hospital are as and can cause & Slue Patient Patient a Due to Lapse Wssiwicrt. A Mutual frrstirwce arssarry, is serious following: or Error in the Network Hospital Page 6 3§.:e status. so licependert 'Icsinseis 71` the eke Cross and Blue shoe 4sscciatbn 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 22 of 47 Percent of Charge Policies and Procedures Manual Specialty Service Treatment and care related to the following services: Hip Replacement Inpatient or Outpatient Services 1. Total Knee and/or Total 2. Spine Surgery Discectomy, spinal fusion and spinal decompression procedures Inpatient or Outpatient Services Cardiac Care 3. Inpatient Service, non-emergent cardiac care, (including outpatient percutaneous surgery 4. Other (including coronary Specialty Services as coronary interventions) cardiac catheterization and inpatient cardiac artery bypass graft surgery) defined by the Company. Specially Service Area A geographical service area as defined by BCBSMS Subscriber Employees or individuals and their enrolled eligible dependents covered under a Subscriber Contract/Certificate who are entitled to receive health care Benefits as defined in and pursuant to a Subscriber Contract/Certificate. Subscriber Contract/Certificate Any Contract/Certificate issued or administered by BCBSMS, its subsidiaries and affiliates, or another Blue Cross and Blue Shield Plans with which BCBSMS has a Network or reciprocal agreement, entitling Subscribers to receive health care Benefits as defined in and pursuant to a Subscriber Contract/Certificate. Utilization Management The program developed by BCBSMS and delegated determine whether the Network to the Network Hospital services provided, or to be Hospital to review and provided, are Medically Necessary and are Covered Services under the applicable Subscriber Contract/Certificate. BCBSMS has delegated the following Utilization Management responsibilities to Network Hospitals: Page Six opss &Nue Shieki cfMssiv, A 7 mutual Insurance Company is an independent licensee ofthe Ske Cross and ale Shield Assecttico 11/16 Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 23 of 47 Percent of Charge Policies and Procedures Manual Eligibility and Benefits; 1. Verification of 2. Submission of Electronic Inpatient and Outpatient Patient Data; 3. Precertification/Certification; 4. Continued Stay Review; 5. Discharge Planning; 6. Case 7. Outpatient Services; Details Management; and regarding this program may be accessed via Appendix A Utilization Management Program. Page 8 B.te Ouss 3, Blue SI•delid Adssissmi.4 Ittard Ilstrxce Conpany. w independent tensee cf the Bite Cross and Blue SNefd Assoctalion 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 24 of 47 Percent of Charge Policies and Procedures Manual PERCENT OF CHARGE PROGRAM Section 3 3.1 INPATIENT PAYMENT PROCESSING RULES As indicated in the BCBSMS's Participating Hospital Agreement, the Payment Amount Deductible, and as payment Co-insurance/Co-payment to Deductible and Only amounts related the Percent of Covered Charge in full, Network Hospital except for any Non-Covered Co-insurance/Co-payment on Covered The Deductible, Co-insurance Charges, Charges, must be deducted from Amount to determine the amount of BCBS MS's by Subscriber Contract/Certificate. accept amounts. The amount and basis for calculation of the Deductible, Co-insurance and calculated based shall or the or payment. Co-payment vary Co-payment negotiated amount, which may be is based on a percent of Covered Charges. BCBSMS pays the Network Covered Charge Discount Percentage Negotiated Hospital generally as follows: Amount Deductible Co-insurance/Co-payment Payment Amount The Network Hospital collects Non-Covered Charges, Deductible payment from the patient. The Network Hospital the Negotiated and Co-insurance/Co- does not collect any amount in excess of Amount. Page Blue Cr= & Blue She'd &Miss:est& a tedg..s/ insuw, ce Corrpany, is an 9 independentlicensee &Os RUB Cross and Blue Striae ASSOCiaoLY; 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB 25 of 47 Page Percent of Charge Policies and Procedures Manual Following is a summary of the Percent of Charge PERCENT OF CHARGE AMOUNT INPATIENT STAY RULE payment processing rules: Negotiated Amount (Covered Charges percentage) Coin/Copay/Ded Percent of Covered Charge Payment Amount x Discount Negotiated Amount (Covered Charges for days prior to or Hospital Quality-of-Care Condition x Discount Percentage) Percent of Covered HAC Charge Payment Amount Involving HACs or Quality-of-Care Conditions Case Rate Amount (All-inclusive rate and is lesser of Case Rate or Payment Amount) Case Rate In the event of HACs not being POA but listed as a at secondary diagnosis discharge, involving HACs or Hospital Quality-of- BCBSMS will pay a reduced payment on those claims Care Conditions, and the member will be held harmless for any amounts in excess of the allowed amount. The following three pages detail the formulas for calculating the Percent of Covered Charge Payment Amount and the reduced payment for claims involving HACs or Hospital Quality-ofCare Conditions. Immediately following the rule example is a sample vouchered Provider Remittance Statement that reflects Certain conditions that occur in a corresponding field definitions. hospital setting are deemed by BCBSMS Hospital Quality-of-Care Conditions, and the Network Hospital shall BCBSMS for any charges relating to or from HACs resulting Conditions. BCBSMS shall take into account the HAC or when or to be HACs not be reimbursed or by Hospital Quality-of-Care Hospital Quality-of-Care Condition In the event it is determined that circumstances or conditions pricing the claim. acquired during hospitalization resulted in substantive clinical changes to the detriment of the Subscribers health status, BCBSMS will consider the claim to be will reimburse the Network Hospital based Amount There Involving HACs are should or happen in the Network Page Blue Cross & Ste SntiNd IndiSSisSippi. Atituai ;ASI,E117C0 awrzeny. 45 and Charge Payment Conditions located wtthin Attachment A. by BCBSMS to Hospital HAC related claim and Rule 2: Percent of Covered Hospital Quality-of-Care also certain events deemed never on a be SREs which are medical can cause serious injury or errors that death to the 10 ;ndepencer-ht tkansee Ie Due C:css am' Slue Shield Assacegich 11/16 Case 3:17-cv-00338-DPJ-FKB Document 1-1 Filed 05/04/17 Page 26 of 47 Percent of Charge Policies and Procedures Manual patient. Under no circumstances will there be reimbursement for these SREs, and the Subscriber and BCBSMS will be held harmless for any charges relating to these SREs. RULE 1: PERCENT OF COVERED CHARGE PAYMENT AMOUNT FORMULA The payment amount is based upon the Negotiated Amount (H) minus amounts for Co- insurance/Copay/Deductible (F). FORMULA: PAYMENT [NEGOTIATED AMOUNT (CO/DED)] OR I F G EXAMPLE #1 EXAMPLE #2 4 1 A COV DAYS B TOTAL CHARGES C NON-COV CHARGES 100.00 200.00 D COVERED CHARGES 900.00 $4, 800.00 E DISCOUNT PERCENTAGE F NEGOTIATED AMOUNT G CO/DED H I $1, 000.00 .20 $5, 000.00 .20 720.00 $3, 840.00 72.00 150.00 BENEFIT AMOUNT 648.00 $3, 890.00 PAYMENT AMOUNT 648.00 $3, 890.00 Page Blue Cfoss & Blue Shield al kfississippl, 4 11 /Vulva, insurerce Company is an independent licemee thhe Blue Ovss end Blue StiledAssociato 11/16 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Document 1-1 Page 27 of 47 Percent of Charge Policies and Procedures Manual RULE 2: PERCENT OF COVERED CHARGE PAYMENT FORMULA INVOLVING HACs HOSPITAL QUALITY-OF-CARE CONDITION If any of the HACs listed in this manual was not present payment will on any identified or admission but was listed be based upon the total covered day prior to documentation of the HAC record. These charges will be or Negotiated Hospital Quality-of-Care Condition secondary diagnosis at discharge, then the charges (D) incurred by the member up to the Hospital Quality-of-Care Condition multiplied by your Discount Percentage (E) Negotiated Amount (F), and the member will the as a or in the medical and will be the be held harmless for any amounts in excess of Amount. FORMULA: PAYMENT [NEGOTIATED AMOUNT (COIDED)] OR I F G EXAMPLE 3 A COV DAYS B TOTAL CHARGES C NON-COV CHARGES 800.00 COVERED CHARGES $1, 200.00 $2, 000.00 .20 E DISCOUNT PERCENTAGE F NEGOTIATED AMOUNT G CO/DED H BENEFIT AMOUNT 864.00 PAYMENT AMOUNT 864.00 960.00 96.00 Page Ste Ovss Slue Shiek dUsgssippi. A Mutual !twat= Carzeny. r's n 12 ixispendent licensee cfthe :Slue Cross ed9kie Shiekl.4ssocialion 11/16 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 28 of 47 Percent of Charge Policies and Procedures Manual RULE 3: CASE RATE If the DRG Code is identified as (A) of the Case minimum Rate a (G) Case Rate DRG, the or insurance/Copayment/ Deductible (F) Percent of payment Charge is based upon the Amount (H) ERG CODE B COV DAYS C DISCHARGE STATUS D TOTAL CHARGES E NON-COV CHARGES $0.00 F COINS/COPAY/DED $0.00 G CASE RATE H PERCENT OF CHARGE PAYMENT $2, 000.00 I PAYMENT $2, 000.00 applicable DRG 795 DRG 775 DRG 766 DRG 743 3 01 $10, 000.00 $4,000.00* and does not reflect the actual rates Case Rates that fall under this calculation applicable are as to this follows: Normal Newborn: $1, 095 Normal Vaginal Delivery: $3, 481 Normal C-Section: $5, 092 Normal Hysterectomy: $7, 459 Page Ste Ova & ale SNee (PERCENT xxx A DRGs and Co- amounts. MINIMUM OF: [(CASE RATE) OR CASE RATE PAYMENT FORMULA: OF CHARGE AMOUNT)] (COINSURANCEICOPAY/DEDUCTIBLE) OR MINIMUM OF: [(H) OR (G)] F This example is hypothetical agreement. minus wssisppi. A WARM :restrance Carotin y. w 13 Trdeperxien1 licensee dthe Elue Goss and Blue Shbld Asscdaton 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB 29 of 47 Page Percent of Charge Policies and Procedures Manual 3.2 SPECIAL PAYMENT PROVISIONS Billing for Pre-Admission Testing within 48 hours prior All outpatient, to admission as an outpatient pre-admission testing/services provided included in the Percent of Covered are Charge Payment for the inpatient stay and must be billed to BCBSMS as part of the inpatient claim. This and provision applies only to outpatient services performed at the same (or related) related to the facility where the patient Outpatient Services BCBSMS pays for outpatient services based Network The Percent of Physicians on the provisions of the Attachment B. Hospital's Payment Program Provider Based inpatient hospital stay subsequently admitted. is Charge reimbursement includes all Network Hospital medical directorships, and all activities associated with them including, but not limited to, the selection of instruments, quality of results of tests and quality control activities, responsibility for the results of the section(s), surveys, and accreditation activities, and other quality control processes. Network Hospitals will assure that the practice of clinical component billing (by pathologists or medical directors) will All utilized provider-based physicians by not occur. the Network Hospital must be BCBSMS network providers. Network Hospitals are responsible for all provider-based physician services rendered and will ensure that all services are performed by BCBSMS provided by a non-network physician/provider within will ensure that the Subscriber is not billed If a Network a network Network providers. If a service is Hospital, the Network Hospital by any non-network providers. Hospital changes its arrangements with provider-based physicians to provide for separate billing where combined billing had been used, the Network Hospital must notify BCBSMS so an appropriate adjustment and addendum to the contract can be made. Payment the professional allowance with a payment hold harmless for for these services will be based on the Subscriber. This does not apply to professional services Services related to operative monitoring related to operative monitoring. should be included in the Network Hospital inpatient claim. Page Blue Cross & atre Shiekt klississippt 4 /Antal insuPrice Company is w^, 14 rdeperrdem•Itensee 0/the Blue acms and Bfue si*e Association 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 30 of 47 Percent of Charge Policies and Procedures Manual BCBSMS will review re-admissions and, Re-admissions BCBSMS, conduct quality of care within Section 4.5 same reviews deemed necessary behalf of BCBSMS Subscribers Quality Management. BCBSMS as by referenced will also review re-admissions for the diagnosis or condition for Medical Necessity. Network Hospitals will be required to share clinical information regarding re-admissions, including treatment plans, discharge plans, of re-admission assessments and Network or on as Hospitals condition is may be clinical a subject to a explanation as reduction in payment, to why re-admissions risk occur. dependent upon if the diagnosis directly related to the initial admission. Additionally, re-admissions within forty- eight (48) hours based upon complications of a previous discharge are to be considered part of the inpatient stay for the previous discharge and combined into one claim for that previous inpatient stay. SRE Under no circumstances will there be reimbursement for SREs subsequent procedures, and the Subscriber will be held or any related, harmless for any charges relating to these SREs. 3.3 MONITORING Auditing procedures: BCBSMS site or or BCBSMS's designated representative may conduct on- off-site audits at the sole discretion of BCBSMS during the Network business hours. These audits may consist of verification of medical coding ICD-10 accuracy, abstract verification, claims verification, and Claims filed using lCD-10 procedure codes variances in reimbursement, and adjustments charge Hospital's regular necessity of services, audits. will be monitored for abnormal may be made to ensure appropriate reimbursement for services. 3.4 UPDATES AND REVISIONS PERCENT OF CHARGE The Discount Percentage is reviewed annually using the following methodology: Page avss S M.0 Sherd cf,tdssir..40. A MuLai .'nsuarce Company ;s is 15 IndepertterVitersee d'17e Blue Doss and atA9 Shield Assodakn 11/16 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Document 1-1 Page 31 of 47 Percent of Charge Policies and Procedures Manual 1. BCBSMS will conduct a review of the Network Hospital specific charges for the most recent twelve months. 2. BCBSMS will analyze the Network Hospital specific information in relation to its peers. 3. BCBSMS will notify the Network Hospital of the updated Discount Percentage by September 1 of any year, to be effective the following October 1, unless the renewal period is otherwise stated. In such instances, the notification timeframe the renewal 4. period will remain the Updated Discount Percentages of any given year, and are in advance of same. are effective for the October 1 renewal period or after not considered in effect until both BCBSMS and the Network Hospital have executed the Attachment B and the new rates have been loaded into the reimbursement system by BCBSMS. Only claims with date of the executed Attachment B will be effective date is service no priced dates of service at the earlier than October 1 of any on or after the updated rates, provided the given year. Claims with dates of prior to the date of the executed Attachment B will not be priced at the updated rates, meaning BCBSMS will not process retro-reimbursement adjustments. Case provisions, Rates and other reimbursement effective October 1 of the renewal as outlined within Attachment A, period. Should the renewal period are be otherwise stated, all statements above will be applied accordingly. Percent of Charge Payment Application the Discount Percentage and other provisions BCBSMS will use admission the basis for payment. APC as in effect at the time of patient Outpatient Methodology BCBSMS will Outpatient systematically implement Code Editor (OCE) software the most current version of the CMS as Integrated it becomes available from CMS. There will also be quarterly revisions to the BCBSMS APC program based on Medicare's quarterly APC Integrated OCE updates. Page Ble Cross & Blue Shietd of Mississippi. A MALT! !nsurarat Comoarly, z 16 .irdependerVicensee a/the Blue Crass we Blue Sliield Associelien 11/16 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Document 1-1 Page 32 of 47 Percent of Charge Policies and Procedures Manual Reimbursement Methodology BCBSMS shall implement its updated reimbursement methodology program when the Network Hospital's current reimbursement methodology program is obsolete and no longer maintained by BCBSMS. The Network Hospital will be notified in writing via certified letter at least thirty (30) days in advance of the implementation, the Network implementation date, ouliining no upcoming change. Hospital must its rationale for Should the Network respond in Hospital oppose this wilting via certified letter, before the continuing to operate under an obsolete program longer maintained by BCBSMS. Page 3va, :foss 1 &Le Shield of lvas...tssop; A Mutual ;noStrence CCrnpeny. :s n 11/16 17 rniependent licensee of:he Ske Oass and 31a3 Shithi Asscciaticn Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 33 of 47 Percent of Charge Policies and Procedures Manual ADMINISTRATIVE POLICIES AND PROCEDURES Section 4 4.1 SUBMISSION OF CLAIMS Network Hospitals must submit claims for services provided to BCBS MS Subscribers using the Electronic Submission of Claims (ESC) system. Reference should be made to the UBO4 specific instructions on claims preparation. Manual for for providing all information necessary to for 1. The Network Hospital is responsible adjudicate the claim. Following are some key rules billing: Include on inpatient billings any charges for Network hospital services obtained from (related or unrelated) while an inpatient at the Network Hospital. A patient cannot be considered an inpatient and an outpatient at the same time. A another organization patient cannot be considered Professional an inpatient and components of these services services under professional provider a outpatient an may be billed number with a at the same time. separately for covered separate hold harmless addendum, subject to section 3.2. For any Durable Medical Equipment devices used within the hospital setfing and then discharged home with the Subscriber, these charges are to be included on the hospital claim. 2. All claims must indicate if work-related services so, the 3. In are related to number of illnesses are involved, if the when available. inpatient days of care day of admission, but not the day of discharge. fractional part of a 4. or accident, and if the Subscriber has other coverage and, if identity of the other carrier or Plan computing the the an injuries provided to a Subscriber, count No charge will be allowed for a day. BCBSMS will inform the Network Hospital of services not included as Covered Services under the various Subscriber Contracts/Certificates. BCBSMS will also identify the amounts for these services that the Network the Subscriber. However, the Network Hospital Hospital can bill directly to must include all such charges on the claim submitted. Page 18 Elba Cross & Baia Shield of lierssissigpi. 4 Marta Mscrance Company a an 'Pecendent licensee cl are alua Doss and Eke Skald Asation 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB 34 of 47 Page Percent of Charge Policies and Procedures Manual Appeal of Audits Reviews The Network Network Hospital may appeal a determination made an The Audit Review. Hospital must notify BCBSMS, as directed by BCBSMS, within thirty (30) days of the This notification and any added information the payment/adjustment on the appealed claim. Network during Hospital provides will be reviewed by BCBSMS. Appeal of Reimbursement Calculations Hospital may appeal The Network the pricing of Remittance Statement is incorrect based upon the Hospital The Network located on myBlueProvider, appeal will be 4.3 must reviewed notify BCBSMS within one a payment claim if it feels the appropriate rates and related time via the online submission of year of the process date of the by Provider Appeals and on the period. appeals process disputed claim. This its decision shall be final. INFORMATION REQUIREMENTS Information deemed necessary in the sole discretion of BCBSMS to carry out the terms of the Participating Hospital Agreement shall be provided by the Network Hospital at no charge to BCBSMS, BCBSMS's designated representative or its Subscribers. Likewise, BCBSMS shall furnish any such information at records are no charge to the Network the Network Hospital may required, Hospital. If additional copies of charge BCBSMS reasonable copying charges. BCBSMS requires the Network Hospital designated by BCBSMS, including 1. Financial statements, patient ledgers 2. to provide information in a format and method but not limited to: ledgers, billings, itemized statements, price lists, invoices, and other financial records of the Network Hospital. Medical records and medical record abstract information. When Network Hospital shall make available complete medical records abstracts in a format and method which BCBSMS personnel can or requested, medical record utilize. Page 22 Blue Crass Sax Slusid ofAdssissgsa A Muwaf ins•-xance Ccrnpany. the is an ixiesendent licensee cjhecf.,e Cnass end eke Shield Assxidion 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 35 of 47 Percent of Charge Policies and Procedures Manual 5. The Network a Hospital cannot require any subscriber (before or after the rendering of service) to pay any amount in excess of any deductible, co-insurance/co-payment and non-covered amounts. The Network Hospital shall look only to BCBSMS for payment of covered charges except for the deductible, co-insurance/co-payment and non-covered amounts. The Network Hospital cannot bill the Subscriber for covered charges 6. in excess of the Per Diem Payment Amount. Hospital The Network cannot bill Subscribers for services which BCBSMS has Medically Necessary, determined to be not the Subscriber In advance in writing that services will be the Subscriber's signed by the Generic patient. written authorization or not as a specific, non-medically responsibility. This necessary notification must be specific all-encompassing notifications without advanced by BCBSMS will requirement mentioned above. BCBSMS Hospital has notified unless the Network not be deemed to meet the specific notification In addition, the Network covered service any service which the Network Hospital cannot bill Hospital knows to be Medically Necessary. 7. The Network Hospital may not submit interim 8. The Network Hospital must submit 9. Hospital is required to file a POA indicator on all primary and secondary diagnosis codes submitted on all inpatient Network Hospital claims. Claims billings. separate billings for mothers and newborns. The Network submitted without a POA Indicator will be Specifications Manual Reporting (or indicator. are Refer to the UB-04 Data and the ICD-9-CM Official Guidelines for most current Below rejected. guidelines) to facilitate the Coding and assignment the five values that BCBSMS will accept as of the POA valid POA indicators. A. 1 Exempt from POA Reporting B. Y Yes, present at the time of inpatient admission C. N No, not present at the time of inpatient admission D. U Insufficient documentation to determine if present on admission Page 19 B/w? Owe I Blue Shield oiMisstssippr, 4 Wild Insurance Cuireeny, is en irdepertfeul licensee oflhe Blue Goss and Blue Shield Associalion 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 36 of 47 Percent of Charge Policies and Procedures Manual 10. Clinically unable W E. to determine if present on admission Claims for services related to SREs shall not be submitted to BCBSMS. If attempting to submit, BCBSMS will not accept these claims, and they will be returned to the provider. The Subscriber will also be held harmless for any charges related to the SREs. 11. Hospital should make every effort to file an Network corrected claim should allowable amount only corrected claim, Network months after 12. amount. Hospital If the Network a change in Hospital needs to refile a must submit corrected claim within twelve payment of original claim. Only one corrected claim will be the (12) accepted. Any hospital-owned ambulance services provided wili be considered part of the hospital and considered network. All medical necesstty and hold harmless guidelines will be considered 13. be submitted when there will be payment or accurate and complete claim. A applicable to these services. The Network Hospital will file claims electronically as soon as possible and will not withhold submission of claims for any reason other than the lack of an accurate and complete claim. All claims are subject to the timely filing requirements of the Subscriber's contract. 14. The Network Hospital is responsible for submitting admissions data on all BCBSMS Subscribers via the Electronic Census Data Transfer (ECDT) process Coordination ECDT portal on myBlueProvider. Failure the eCare Coordination or portal to transmit the will result in a or the eCare required ten data via percent (10%) reimbursement penalty for claims not submitted via ECDT or the eCare Coordination portal. 15. Claims with benefit reviewed also as review, records to payments equal to, or greater than, $50, 000 will be automatically part of the BCBSMS Quality of Care review process. BCBSMS may as deemed necessary by BCBSMS, any claims and associated medical assess the quality of care rendered to Subscribers. 11/16 Page 20 .9tue Crws 3 eye Shied 4dississipei, A Minced 4150,3PC8 COMDEry,IVepelldeni itEKISSe of the eue Crass end abe Shieb Asscdaticn Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 37 of 47 Percent of Charge Policies and Procedures Manual 16. Hospital shall The Network BCBSMS or not bill nor the Subscriber for any services malfunction. This includes any resulting otherwise be billed separately from manufacturers' device malfunctions implants, 17. resulting a manufacturer's device hospital-based provider services that may the Network are Hospital. of such Examples defibrillators, neurostimulators, stents, Setting is applied, Hospital claims will ensure it may be necessary for the to submit the ICD Procedure Codes that match the outpatient ICD Procedure Codes on outpatient procedures performed. The submission of the 18. from etc. At times when the Lowest Cost Network to seek reimbursement from etther attempt accurate reimbursement is provided. In the event BCBSMS becomes insolvent or ceases operations, Covered Services to Members will continue BCBSMS on through the period for which a premium has been behalf of the Member or until the Member's discharge from an paid to inpatient stay, whichever is greater. Covered Services to Members during an inpatient stay at the Network Hospital on the date of insolvency or other cessation of operations will inpatient stay continue until the Member's 4.2 is no longer medically necessary. APPEAL PROCEDURES A Network Hospital may electronically submit an appeal for the following items with regard to the Percent of Charge program: Management decisions 1. Utilization 2. Medical Necessity decisions 3. Audit Reviews 4. Reimbursement Calculations Appeal of Utilization The Network Necessity Management/Medical Necessity Decisions Hospital decisions may using Management Program", request the an appeal of Utilization Management and Medical procedures outlined in the "Appendix A which is part of this manual. Page Blue C-css & Blue Shfa'd Utilization 1.1.4ississioc4 .4 Mutual frsura•lcs cerneary. is w 21 illiependent iicersee cf ft Rue Crass vxl Rue Shield Associabbn 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 38 of 47 Percent of Charge Policies and Procedures Manual 3 Questionnaire, Room Rate Form, and Listing of Physicians with Admitting Privileges Form, which are part of Network the Hospital renewal package mailed out each year. 4. A listing of new being performed services at the Network in advance of Hospital will notify BCBSMS sixty (60) days services. Failure on the part of the Network Hospital. The Network beginning Hospital to notify BCBSMS of any new services within the proper tirneframe will result in denial of any such with a new services hold harmless to the Subscriber. Certain Specialty Services may only Mississippi Specialty Care/Center members. This list of these the new be covered at of Excellence Specialty Services is a Network Hospital with a designation for certain BCBSMS subject to change by BCBSMS. Since Specialty Services may only be covered at Network Hospitals with one of these designations, the Network Hospital must notify BCBSMS if it is planning to begin performing any of these services. 5. Charge increases implemented by Network Hospital. to report anticipated charge increase(s) Network The Network Hospital is required to BCBSMS by June 1 of each year. If Hospital does implement a charge increase(s) during the term ofthe current Attachment B payment program, Network Hospital will provide sixty (60) days notice in advance to BCBSMS. 4.4 UTILIZATION MANAGEMENT The Network Hospital is Management Program required as to referenced in Appendix A. Failure to comply with the Utilization Management Program may result 4.5 implement, monitor and comply with the Utilization in a reimbursement penalty. QUALITY MANAGEMENT BCBSMS shall engage in, and the Network Hospital shall cooperate in, Quality Management/ Improvement programs designed to the ensure provision of high quality health care services for Subscribers. Page 23 Slue Cross & F-Pae Stiev +Assissippi. VOLT:I frnverce Cor-rany. ;ncieperKlen: acerisee of !he Blue Cross 6,711 Blue Shiee Assocation 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB 39 of 47 Page Percent of Charge Policies and Procedures Manual Quality Management/Improvement shall include but (a) not be limited to: Quality Care Review. BCBSMS may conduct quality of care reviews of the Network Hospital Services provided to Subscribers related to potential quality of care concerns; focused quality of care studies; generic quality indicators; subscriber complaints/grievances; and an annual, random sampling review of inpatient records. BCBSMS may also coordinate conference calls with Network Management, review Risk Management, of questionable quality Chief Medical Officer care or other Hospital Quality applicable staff to events to determine if an event is a HAC or Quality-of-Care Condition. Additionally, external, independent physician reviewers may be utilized to render an opinion regarding quality of care when the Network Hospital appeals the HAC or BCBSMS may also review, Quality-of-Care Condition determination. associated medical records to (b) by BCBSMS, any claims and quality of care rendered to Subscribers. deemed necessary as assess the Development/Implementation of quality improvement plans. the Network Hospital to develop/implement quality improvement activities based on the identification and confirmation of quality of Quality of Care Benchmarks. certain and/or service issues. Hospital will be responsible for providing quality requirements for continued network participation. BCBSMS will minimum of six (6) at least a Clinical Data. provision of notice for sixty (60) day months for Network (c) The Network care quality metrics, supporting clinical documentation and relevant data to meet minimum provide BCBSMS may request Hospitals to comply requirements and with a quality requirements. BCBSMS may request the Network Hospital's cooperation with inpatient and outpatient clinical data related to BCBSMS's Disease Management and/or Quality Management initiatives. (d) Transparency. BCBSMS may ratings make available for certain hospital services to ensure episode of care costs and BCBSMS Subscribers are Page 24 .S.k.e Cross & dlue Shield Nftsstsippi 4 MutuaPrsaarce Ccmpany is 3n ildapendent ficansee of the Nue Cross aro' Vero Shefd Association quality provided 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 40 of 47 Percent of Charge Policies and Procedures Manual with to make informed decisions on their health care appropriate information services. (e) Certain services will only be approved for coverage and/or benefits based Hospital lesser benefit at the Network the Network on provided at a Hospital's best practices, certifications, specialty care and/or Center of Excellence designation. 4.6 SERVICES FURNISHED UNDER ARRANGEMENT 1. Hospital may furnish The Network or discretion to have furnished services with outside suppliers or or may be deemed supplies service providers. to by BCBSMS Member under a arrangement supplies/services Such in its sole include the and provision of facilities, professional services rendered by physicians supplies/services provided by professional providers outside of Provider-Based Physicians. Under any and all circumstances, the Network Hospital will assure that be rendered by network providers, reimbursed based upon BCBSMS's allowed amounts and be subject to BCBSMS's medical necessity these supplies/services shall The Network requirements and Benefits. Hospital may supplies/services as a part of the Network Hospital ensure The Network The Network Hospital Hospital is required is to contract with a Medically Necessary. Network Ambulance Provider. to utilize a Network Ambulance Provider for required emergent and non-emergent ambulance services, which services Medical If Necessity review. a are subject to a non-Network Ambulance Provider is used for emergent ambulance transfer services, the Network attempt to use a Network Ambulance Provider and air or Hospital will the member will be held harmless for any amounts in excess of the allowed amount and shall not be billed for any services deemed not 2. also include these claim. The Network its Hospital must document its unavailability for the emergent ground ambulance transfer. The Network Hospital will emergent Network prior authorization the Network ensure prior authorization is obtained for any Air Ambulance Provider air is not or ground non- ambulance transfer. If obtained, BCBSMS will deny services. In such situations, Hospital and the Network Ambulance Provider will ensure that the Subscriber will not be billed and will hold the Subscriber harmless for any charges attributable to these services. Page 25 Blue CA-:ss Slue S:aeld Nfisse., .*0 .1011,11,13l fnstrance Company. s an nciaperVenVicersee ..-Phe Blue O•uss anc' Blue Shied Assoc:Ialion 11/16 Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB Page 41 of 47 Percent of Charge Policies and Procedures Manual Any Network Hospital-owned ambulance services provided will be considered part of Hospital and considered the Network hold harmless 4.7 network. All Medical guidelines will be considered applicable Necessity and patient to these services ELECTRONIC INFORMATION EXCHANGE AND COMMUNICATION The Network electronic electronic Hospital agrees means to participate and utilize BCBSMSweb-based for the electronic exchange exchange of information of information is requirement a as or other required by BCBSMS. This tools to be considered for network participation. Examples of electronic information exchange requirements include, limited to, the (a) (b) but are not following: Electronic submission of medical records; Electronic Inpatient and Outpatient Admissions Data submissions via electronic data transfer or the eCare Coordination (c) Electronic submission of claims; (d) Electronic (e) Electronic submission of appeals; (f) E-Prescribing medications; (9) Usage of myBlueProvider; portal myBlueProvider; on receipt of claims payments via Automated Clearinghouse (ACH); 1. eCare Coordination 2. Verification of patient eligibility and benefits; Policy search functions; 3. Medical 4. Verification of claims status; 5. Retrieval of electronic remittance advices; 6. Responses 7. Usage of Contact 8. Usage of reference tools for policies and other 9. Usage to myNotifications Requests: Blue for inquiries; operational guidelines, and procedures manuals, including coding and of informational articles relevant to the operations of the Network Hospitals. 11/16 Page 26 Cross & Beie Shield ofA4iwisaftp, A A4A14 Irsorarce Corxerly s ar)ilg.le,cerxfer.t!icensee a'the Blue Crass rd9ue S11dMsccr Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Document 1-1 Page 42 of 47 Percent of Charge Policies and Procedures Manual 4.8 MINIMUM DATA SECURITY STANDARDS On an annual recurring basis, Network Hospital will furnish BCBSMS an attestation of its compliance with BCBSMS Minimum Data Security Standards, defined in Appendix B, for the security of Personal Health Information (PHI) and Personal Identifiable Information (PII). If compliance cannot be met, Network Hospital mitigating controls expected will document and submit to BCBSMS the and corrective actions to become compliant for each standard. The date of compliance for each standard must be included in the submitted documentation. Page Blue :D'oss Me Shisio c1MLspci.A Mullis, !num= Company, is &I 11/16 27 indeperdant ricessee ofthe Eike Doss 11 Blue SNehl Association Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 43 of 47 Percent of Charge Policies and Procedures Manual REFERENCES Section 5 Appendix A Utilization Management Program Appendix B Minimum Data Security Standards Page VIM CI= & 31ue $hied 0I Aississippi 4 Mutua !nstrance Cancany, e an 11/16 28 independent licensee !he Sue Otss snd Flue ShieldAssociation Document 1-1 Case 3:17-cv-00338-DPJ-FKB Filed 05/04/17 Page 44 of 47 9A A5 rOt* 'Poe occot,,, b ATTACHMENT B PAYMENT PROGRAM Hospital Reimbursement: Percent of Charge Sharkey-Issaquena Community Hospital Rolling Fork, Mississippi Participating Hospital: October 1, 2005 Effective Date: Inpatient Reimbursement: 15% (fifteen percent) discount from covered charges. Outpatient APG Outpatient Reimbursement: Rate $262 Reimbursement will be based on the APG Payment Processing defined in the APG Payment Program Manual. Outpatient Rules as including, but not limited to, regular Federal Employee national accounts, Cross Blue underwritten, excluding self-funded and Card program, Program, Out of Area Blue of Medicare but exclusive the State of Mississippi Employee Group, All lines Lines of Business: supplementary coverages. Special Provisions: 1. hospital 2. been HOSPITAL has for the Federal Outpatient designated as a PPO (Preferred Care) Employee Program. related services the to APOs with no established weight for the APG Outpatient Payment Program will be reimbursed at 3. a 15% (fifteen percent) discount from covered charges. HOSPITAL shall provide HCPCS codes on all outpatient UB-92 claims submitted for payment. 4. HOSPITAL recognizes that all Cross & Blue Shield of mean Blue Cross Company, & Mississippi, Blue Shield of licensed in the State of reference Inc., to the name Blue in Agreement is amended Mississippi, Mississippi as A Mutual a for to /nsurance profit mutual insurance company. 5. PLAN and HOSPITAL agree to keep confidential in accordance with State and Federal law all records required by this Agreement. Filed 05/04/17 Document 1-1 Case 3:17-cv-00338-DPJ-FKB PLAN and HOSPITAL agree that the 6. this Agreement are to be amended to Page 45 of 47 termination provisions of provide at least 60 days notice of termination. the In 7. B Attachment Agreement event of conflict between Program Payment Attachment A Policies and Procedures or Diem Payment Program, the this Hospital the Per regarding this Attachment B of provisions of provisions Participating the and the shall prevail. further This agreement 8. secondary other to coverage Contract/Certificate specifies an applies to applicable the and claims where PLAN is Subscriber Allowable Charge for coordination of benefits. HOSPITAL 9. initiating for responsible is pre- certification/certification of hospital inpatient admissions and the outpatient procedures in accordance with provisions of Utilization Management the where program Subscriber requires pre-certification/certification of inpatient admissions and/or outpatient procedures. HOSPITAL agrees Contract/Certificate not to bill the any Subscriber Subscriber and to hold the Subscriber harmless for Contract/Certificate pre-certification penalties for and admissions inpatient outpatient procedures not pre- certified/certified. 10. HOSPITAL shall submit claims and any necessary to process such claims services are not PLAN, were PLAN or year from date or be entitled to payment from Subscriber for services associated with such claims. HOSPITAL agrees to submit all claims for services Subscribers Submission of Claims 12. one Claims and any requested information that and HOSPITAL shall not bill 11. later than submitted within this time period shall not be honored by either PLAN to rendered. no requested information in (ESC) accordance with the PLAN's provided Electronic system. HOSPITAL agrees to provide monthly credit balance reports Document 14 Case 3:17-cv-00338-DPJ-FKB in electronic format to PLAN 13. Services rendered Filed 05/04/17 by Hospital based physicians and/or will be reimbursed providers professional allowance schedule and medical any services that that these ensure are providers 46 of 47 by the 15th of the following month. contracting HOSPITAL agrees to Page based PLAN's upon necessity requirements. that Sdbscriber receives hold harmless for determined not to be Medically Necessary and do not the balance-bill patient for the difference between the total charges and PLAN's allowed amounts. IN WITNESS WHEREOF, PLAN and HOSPITAL, acting through their duly authorized officers, have executed this Agreement in duplicate on the date(s) indicated below. SHIELD OF BLUE CROSS & BLUE MISSISSIPPI, A. MUTUAL INSURANCE COMPANY Date: BY: Duly (PLAN) 441?-7144"-i ed Officer SHARKEYSAQ HOSPITAL HOSP Date: BY: Titlei/ A COMMUNITY AL) Case3:17-cv-00338-DPJ-FKB Item Index Item Type PA: Document Document1-1 Filed05/04/17 Page47of47 document PA: BCBS Agreements Date: 10/1/2005 Description: AGREEMENT PA: Document PA: Provider Last RA: Provider First PA: Provider Facility RA: Provider Number: Name: Name: Name: RA: Secondary Provider Number: RA: Tax RA: DTN: RA: NPI: PA: NPI ID: FACILITY: SHARKEY-ISSAQUENA COMMUNITY HOSPITAL 000020129 640650533 JS 44 Filed 05/04/17 Document 1-2 Case 3:17-cv-00338-DPJ-FKB v3 3 q CIVIL COVER SHEET (Rev 08/16) 1 of 1 Page 3g-DPI----6-03 by law, Fxcept The JS 44 civil cover sheet and the information contained herein neither replace nor supplement the 111Mo, and service of pleadins or other papers,as 1974, is required for the use ot the Clerk ot Coun lor the provided by local rules of court. This form, approved by the Judicial Conrerence of the United States in September purpose of initiating the civil docket sheet. (SEC INS1 ltliCT1ONS ON NEXT P.4( lE OF THIS IM.11.) required I. (a) PLAINTIFFS Blue Cross & Blue Shield of as DEFENDANTS Mississippi, A Mutual Insurance Sharkey-Issaquena Community Hospital Company 3OUThRN DlTRTCt (EV L Rankin C of Residence of First Listed Plaintiff (b) County U (IN l'1.11N FIEF 'ASPS) IN I II. BASIS OFJURISDICTION (Place an -.1"ni One AirmuR coo e Only) l'TV Federal Question 1 3 U S. Goveninient Plainti ff (US. liovernmem Nat 0 I Citizen of This Slate Parry) a an "X" in Ow Bre( far Mooing. ond One (lox JUr alintda.rn) DEE PTV lii. CI FIZENSH IP OF PRINCIPAL PARTIES (Place liarOnle) fl.io. Diverge...['ase. Di I ONLY /IA INT11.7, LOCATION OF IN AND CONDEMNATION CASES, USE THE TIl TRACT OF LAND INVOLVED. MAY -4 20# (C) Attorneys (hem Nwne, Addresy. will Telephone Ananber) James A. McCullough, II, Brunini Grantham Grower & Post Office Drawer 119, Jackson, Mississippi 39205; Sharkey Co., Mississippi f R sidence of First Listed Defendant DEE' 0 incorporated 1 or Principal Place X 1 X4 0 5 0 5 0 0 0 6 of Business In This Stale D 2 X U S Government findicoie 1 in:enxhip ry Pam, ;a (Mae,. un "X" in One X or P•RSONAL INJURY 110 Insurance 0 310 Airplane & Enforcement I] 315 zi 152 I ofJudgmem Liability Recovery of Del:tithed Student Loans 0 310 Marine (Fucludes Veterans) D 345 Marine Product O 153 Recovery orOverpayment El 440 Other Civil Rights 0 441 Voting O 210 Land Condemnation D 220 Emeclosure O 0 D 0 230 Rent Lease & 340 Tarts to Ejectment 3 442 1 443 Land Liability Real Propentl, 245 Toil Product 290 All Other 0 530 General X I Original Proceeding 11 2 (Ale (fox Removed from State Court Act FEDERAL TAN SUITS 0 870 Taxes (U.S. Plaintiff or Plaintiff to CI VIII. RELATED CASE(S) IF ANY 0 899 Administrative Procedure ActiReVICW or Appeal of Defendant) Agency Decision State Statutes IMMIGRATION 0 462 Naturalization Application n 46> I Allot i mmigv;ition Aitions I 1 3 Renumded from 1 4 Reinstated Appellate Court Reopened or 0 5 Transferred from Another District (veeil.j.) filine (Do nor citelurkglienunal et. seq.; von are StaturCS tin lox 0 6 0 8 Multidistrict Multidistrict Litntation Transfer Litigation Direct File divervUr.) of cause, enjoin Defendants from submitting misrepresented claims; declaratory judgment CHECK 1E 'FIBS IS A CLASS ACTION UNDER RULE 23, F.R Cy P re DEMAND S JURY DLNIAND: (Nce laS)t'Ilt'lltlli.q: DOCKET NUMBER siGN...au. W ATTORNEY DI: RECORD 05/04/2017 FOR OFFICE USE ONLY RUCH vr AMOUNT APPLYING IFP 414tLfl9C1( past claims CHECK YES only if demanded in eompluinL JUDGE DATE Constitutionality of D 950 Other: 3 540 Mandamus k Other 0 550 Civil Rights D 555 l'rison Condition El 560 Ciyil Detainee Conditions of Confinement 29USC Brief REQUESTED IN Act i3 896 Arbitration n 871 IRS—Third Party 26 USC 760 Vacate 28 USC 1367 1001 USC 1331; ACTION. description COMPLAINT: Securities/Commodities/ Exchange 0 890 Other Statutory Actions 0 850 Omit) 28 VII, Corrupt Organizations 0 480 Consumer Credit 0 490 CableSat Ty Litigation Set:Wily 13anking 0 150 Commerce 0 460 Deportation 0 470 Racketeer Influenced and 0 891 Agricultural Acts 0 893 Environmental Matters 1 595 Freedom uf Information D 791 Emm ployee Retireent, illcollIC 1 535 Death Penah Co, e the U.S Civil Statutc, under which VI, CAUSE OF Act 0 720 Labor/Management ReIntions ri 740 Railway Labor Ael 0 751 Family and Medical Sentence Other 0 448 Education in to 0 430 Banks and Copyrights SOC1 A L SECU Ian' 0 S6I 111A1139510 0 502 Blae's Lung ()23) 0 863 DI WC/D1WW (405(5)) 0 1161 SS1D Title XVI 0 565 RSI (405(5)) LABOR 0 716 Fair Labor Staii, buds Reapportionment D 410 Antitrust D 840 Trademark 0 -163 Alien Detainee lotions 3729(a)) 0 830 Patent Leave Act D 790 Other Labor Corpus: Accommodations 0 145 Amer. %Disabilities -X" I labeas D 510 Employment an Property Damage Liability Product Employment Housing/ 0 446 Amer. w:Disabilines V. ORIGIN (Place 0 820 PRISONER PETITIONS CIVIL RIGHTS REAL PROPERTY 0 376 Qui Tain131 USC 28 USC 157 PROPERTY RICIITS Property Damage 0 362 Personal Injury Medical Malpracke 0 375 False Claims Act 0 422 Appeal 28 USC 158 0 123 Withdrawal 71 400 State Product Liability 0 368 Asbestos Personal Injury Product 3 385 Injury 0 625 Drug Related Seizure of Property 21 LISC 881 0 690 Other IALLtIES BANkRUI EC 't FORFEITURE/PENA LTY 0 367 [lentils Care Pharmaceutical Personal Injury Liability 0 350 Mom Vehicle 0 355 Motor Velnele Product Liability 0 360 Other Personal O 190 Other Contract O 105 Contract Product Liability O 196 Ftanchise Liability PERSONAL PROPERTY 0 370 011ier Fraud 0 371 Truth in Lending I 380 Other Personal Liabilit±, or Veteran's Benelits O 160 Stockholders' Suits PERSONAL. INJURY D 305 Personal Injray Product 0 320 Assault. Lthel & Slander El 330 Federal Employers' Foreign Nation 3 0 3 arc I. 011111iN Click here for! Airplane Prodno Liability O 151 Medicare AO Subject Era Only., TORTS O 120 Maille O 130 Miller Act O 140 Negotiable Inshument O 150 Recovery of Overpayment Incorporated and Principal Place 2 of Business In Another State 01.-1,-.11 CONTRAC I q hew Ith Citizen IV. N.ATU RE 0 F. SU IT 13 2 Citizen of Another Slate Diversny .1 Defendant JUDGE MAO. JUDGE X Yes 1 No