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«SOLO PROVIDER RECORD ID INFORMATION FORM PACKET The Solo Provider Record ID Information Form Packet should be completed by any of the following:  ...»

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The Solo Provider Record ID Information Form Packet should be completed by any of the following:

 A provider who will not be employing another professional provider

 A provider who will be using his/her social security number (SSN) for tax purposes

 A provider whose Federal Tax Identification Number (TIN) is legally in the provider’s name

 A provider who is not incorporated The attached packet contains all of the forms that are required to be completed to assign a Blue Cross and Blue Shield of Texas (BCBSTX) internal Solo Provider Record ID. Please fully complete all applicable information in its entirety and forward the completed packet along with a copy of the provider’s State License and completed W-9 to BCBSTX Provider Administration by fax (preferred method) or by mail. The fax number and mailing address are indicated below.

Provider of Service Information – Please indicate only one specialty which represents the majority A.

of the provider’s practice on the Provider Record ID Application Form on page 2. Residents should note that a Provider Record ID will not be assigned, nor can reimbursement be made for their services in an approved residency program.

B. Billing Information – Social Security Number, Federal Tax Identification Number. W-9 Form must be completed in its entirety; the name that will appear on any reimbursement or Form 1099 will be the party to which payment is made. We will only make provider payments to the individual that rendered the service(s) and supplied a Tax Identification Number belonging to the named individual. If an individual provider wishes to be paid directly, the provider must qualify to receive an internal Solo (Individual) Provider Record ID which will be established in the name that matches the TAX Identification Number supplied. If you are applying for an internal Solo Provider Record ID, please complete the Provider Record ID Application Form on page 2 and the W-9 Form on page 3.

C. Individual PARPLAN contract is attached at the back of this packet if you are interested in joining.

In the event there are changes to your information, i.e., TIN, NPI and/or any other contact information or address change, please notify us as soon as possible so that we may correct your records. Any such change that is not reported could affect our ability to make accurate payment to you. These changes or any Provider Record ID questions should be directed to the Provider Administration department indicated below.

After BCBSTX has processed your information and has established your Solo Provider Record ID, the Provider Administration department will notify your office by mail.

IMPORTANT – Please Note: Your assigned BCBSTX internal Solo Provider Record ID does NOT mean that you are a participating provider. Until you are contracted and credentialed and have an effective date with Blue Choice PPOSM, HMO Blue TexasSM, Blue Advantage HMOSM, Blue Cross Medicare Advantage (PPO)SM and/or Medicaid (STAR) and CHIP, your claims will be processed as out-of-network as applicable.

To become a BCBSTX participating provider, you will need to be contracted and credentialed with Blue Choice PPO, HMO Blue Texas, Blue Advantage HMO, Blue Cross Medicare Advantage (PPO) and Medicaid (STAR) and CHIP. Please visit the BCBSTX Provider website at bcbstx.com/provider, click on the Network Participation tab and go to “How to Join BCBSTX Provider Networks” for contracting information and CAQH credentialing information.

We look forward to assisting you in the future.

Blue Cross and Blue Shield of Texas Attn: Provider Administration P.O. Box 650267 Dallas, TX 75265-0267 Phone: 972-996-9610 Fax: 972-996-8445 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

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To the best of my knowledge, the information supplied on this document is accurate and complete.

Upon submission of this application, provider hereby releases this information to Blue Cross and Blue Shield of Texas for the purpose of establishing a BCBSTX Solo Provider Record ID.

Please complete all information above.

This form will be returned if incomplete.

Attach copies of: State License (required) & W-9 (required)Return completed forms to:

Blue Cross and Blue Shield of Texas Attn: Provider Administration P.O. Box 650267 Dallas, TX 75265-0267 Phone: 972-996-9610 Fax: 972-996-8445

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Page 3 of 6 Page 4 of 6 Page 5 of 6 Page 6 of 6


ParPlan is a program open to physicians and other practitioners (providers) who have contracted with Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an independent licensee of the Blue Cross and Blue Shield Association (hereafter referred to as “BCBSTX”) with a common objective - to offer convenient, cost effective medical services to our company's subscribers.

Advantages of ParPlan There are many advantages for providers and subscribers, as well as for employers providing coverage through BCBSTX.

ParPlan was developed in response to employers' concerns about health care costs. ParPlan makes those costs more predictable and makes payment more convenient for their employees.

As a ParPlan provider, you are assured:

 BCBSTX will compensate you for claims you file for Covered Benefits;

 the reimbursement for professional services will be fee-for-service; and  of being included in a directory of ParPlan providers that could offer the potential of an expanded patient base.

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This Contract is made and entered into by and between Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an independent licensee of the Blue Cross and Blue Shield Association (hereinafter referred to as “BCBSTX”), and, duly licensed by the State of Texas (hereinafter referred to as “ParPlan Provider”).

In consideration of the promises and the obligations and agreements herein contained, it is mutually agreed as follows:

Article 1. Definitions A.

“Allowable Amount” means the maximum allowable amount determined by BCBSTX to be payable for a particular service or procedure based on the provisions of the Subscriber contracts / certificates and the BCBSTX payment methodology in effect on the date of service.

B. “Covered Benefits" means those medical, dental or other health care services specified in Subscriber contracts / certificates as being allowable benefits under the contracts / certificates and which are within the scope of the license of the ParPlan Provider.

C. “Hospital Acquired Conditions (HAC) means serious preventable medical events which have been identified by the Centers for Medicare Services (CMS) that should never occur in a hospital and as may be more fully described in the Provider Manual.

D. “Maximum Allowance” means the lesser of ParPlan Providers actual charge for a Covered Benefit or the Allowable Amount as defined in this Contract.

D. “Serious Reportable Events” means, as defined by the National Quality forum (NQF), adverse events that are serious, but largely preventable, and of concern to both the public and health care providers and as may be more fully described in the Provider Manual.

E. “Subscriber” means any person with whom or for whose benefit BCBSTX, a Blue Cross or Blue Shield Plan in another state, a subsidiary of a Blue Cross or Blue Shield Plan in another state or a BCBSTX or Health Care Service Corporation (“HCSC”) affiliate has entered into any agreement to provide or administer Covered Benefits. The phrase “provide or administer” includes an insured arrangement or a self-funded arrangement. The term “affiliate” includes, but is not limited to, any licensed entity in which BCBSTX or HCSC has an ownership interest.

Article 2. Obligations of BCBSTX A.

Encourage Subscribers through education, informational activities and benefit designs as contained in Subscriber contracts / certificates to utilize the services of ParPlan Provider and to provide ParPlan Provider’s name to Subscribers.

B. Directly pay ParPlan Provider up to the Maximum Allowance under a Subscriber’s specific contract / certificate and as described in Attachment A. ParPlan Provider shall be entitled to direct payment, except when benefits are for a non-assigned claim or the claim indicates payment should be made to the Subscriber.

C. Review on a continuing basis the BCBSTX payment methodology and advise ParPlan Provider of any significant changes in advance of their implementation.

D. Utilize peer review committees, BCBSTX’S medical director or other personnel to recommend Allowable Amounts for unlisted procedures, to consider reasonable payment for unusual or selected cases, and to consider the medical necessity of services.

E. Hold in strict confidence ParPlan Provider’s charges, and under no circumstance disclose such charges to any person or entity with which BCBSTX does not have a participating or reciprocal agreement entitling Subscribers to receive payment for provider services without written consent of ParPlan Provider unless legally compelled to do so, or for the purposes of peer review.

Page 2 of 7 PAR1014 F. Provide BCBSTX’S Subscribers with identification cards, and notify ParPlan Provider and Subscribers of generally applicable deductible, copayment and coinsurance amounts and noncovered benefits that are the financial responsibility of Subscriber.

Article 3. Obligations of PARPLAN PROVIDER A.

Allow BCBSTX to use the name of ParPlan Provider for the purposes of informing Subscribers or prospective Subscribers of the identity of ParPlan Provider, and otherwise to carry out the terms of this Contract.

B. Accept as full compensation for Covered Benefits BCBSTX’S determination of Allowable Amount, or if less, ParPlan Provider’s actual charge, and agree not to bill Subscribers for any amounts in excess of the Maximum Allowance or the amount other patients are charged for the same or similar service. This provision applies to all Subscriber contracts / certificates underwritten and/or administered by BCBSTX or a BCBSTX or HCSC affiliate including those which coordinate benefits with governmental programs, commercial health insurers, self-insurers, third-party payers or other similar entities. This provision also applies to payments made on behalf of Subscribers by other Blue Cross and Blue Shield Plans when these payments meet or exceed the benefits which would be provided by BCBSTX. In the event that BCBSTX determines a proposed service is not a Covered Service, ParPlan Provider must inform the Subscriber in writing in advance of the service being rendered that the service is a non-Covered Service and bill the Subscriber for the service rendered. The Subscriber must acknowledge this disclosure in writing and agree to accept the stated service as a non-Covered Service billable directly to the Subscriber. Such acknowledgement shall state the Subscriber accepts payment responsibility of the non-covered Service. In the event the Subscriber’s benefits are exhausted, ParPlan Provider may continue to provide treatment to the Subscriber if the Subscriber agrees in writing to pay for those services; provided, however, that ParPlan Provider may not charge the Subscriber more than the amount allowed as described in Attachment A. In addition, ParPlan Provider who is responsible in whole or in part for a Serious Reportable Event or HAC agrees that in no event shall ParPlan Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Subscriber for any identified Serious Reportable Event or HAC C. Cooperate with BCBSTX in utilization review activities and participate with BCBSTX in pre-admission certification, concurrent review, discharge planning and other BCBSTX sponsored utilization review, quality assurance, preprocedural review and cost containment initiatives.

D. BCBSTX shall determine medical necessity of all ParPlan Provider services through the advice of BCBSTX'S review committees, medical director or other personnel. Such medical necessity determinations shall include the appropriateness of the place of treatment, the length of stay when the inpatient setting is indicated and the appropriateness of all services provided and/or ordered regardless of the setting.

E. Permit BCBSTX the right to deduct the amount overpaid from any future payments. Such deduction shall be made and/or permitted regardless of the cause of such erroneous payment, including services obtained from ParPlan Provider through fraudulent or unauthorized means.

F. BCBSTX may conduct reasonable audits during ParPlan Provider's regular business hours at ParPlan Provider' office to identify duplicate or erroneous payments made by BCBSTX. These audits may consist of, but shall not necessarily be limited to, verification of services reported to BCBSTX and review of relevant medical and billing records related to such services. ParPlan Provider agrees to provide and furnish, without charge, copies of relevant Subscriber medical and billing records.

G. Cooperate with BCBSTX in resolving Subscriber complaints and inquiries concerning payment of Covered Benefits.

H. Abide by the rules, regulations and procedures of BCBSTX pertaining to Contract and payment issues as may be published and distributed from time to time in policy statements, newsletters and other communications to ParPlan Provider.

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