PAYMENT AGENT AGREEMENT among OKLAHOMA HEALTH CARE AUTHORITY and HEALTH-CARE PROVIDER GROUP and PROVIDERS WITNESSETH: Based upon the following recitals, the Oklahoma Health Care Authority (OHCA hereafter), ____________________________________ (GROUP hereafter), and the health-care providers (Print Group Name)

listed in Appendix A attached hereto (PROVIDERS hereafter) enter into this Agreement: ARTICLE I. 1.0

The purpose of this Agreement is for OHCA, GROUP, and PROVIDERS to allow and direct payment by OHCA to GROUP as PROVIDERS’ payment agent for Medicaidcompensable services given by PROVIDERS. PROVIDERS desire to submit invoices for services under the Medicaid Program through GROUP. GROUP desires to submit invoices for PROVIDERS’ services under the Medicaid program without the necessity of certifying the contents of a statement before a notary public on each separate invoice.

ARTICLE II. 2.0

2.1

PURPOSE

THE PARTIES

OKLAHOMA HEALTH CARE AUTHORITY (a)

OHCA is the single state agency that the Oklahoma Legislature has designated through 63 Okla. Stat. § 5009(B) to administer Oklahoma’s Medicaid Program. Under Medicaid, the state and federal governments share in the cost of providing health care to certain indigent persons based upon criteria established by the state within the parameters of federal law.

(b)

OHCA has authority to enter into this Agreement pursuant to 63 Okla. Stat. § 5006(A). OHCA’s chief executive officer has authority to execute this Agreement on OHCA’s behalf pursuant to 63 Okla. Stat. § 5008(B).

NAME_________________________________________________________________ (Print Group Name)

(a)

GROUP is composed of individual PROVIDERS who each hold a license as a health-care professional from the appropriate Oklahoma State licensing agency or the appropriate licensing agency in the state where Medicaid services are rendered pursuant to this Agreement.

(b)

PROVIDERS are identified on Appendix A, attached hereto. Each PROVIDER is an individual who has entered into a separate, current Agreement with OHCA for provision of health-care services and has assured compliance with state and federal law.

(c)

In compliance with 42 CFR § 447.10(g), each PROVIDER is one of the following: (i)

Revised 11/2004 Group 2005-2007

an employee of GROUP who is required as a condition of employment to turn over his or her fees to GROUP;

(d)

2.2

(ii)

a health-care professional who has made GROUP his or her agent for the submission of claims on PROVIDER’s behalf for health-care services performed by PROVIDER and to receive payment for such claims on PROVIDER’s behalf; or

(iii)

a health-care professional who has a contract with GROUP, which GROUP is a foundation, plan, or similar organization operating as an organized health-care delivery system, under which contract GROUP submits claims and receives payment for services rendered by PROVIDER.

GROUP has authority to enter into this Agreement pursuant to its organizational documents, bylaws, or properly enacted resolution of its governing authority. The person executing this Agreement for GROUP has authority to execute this Agreement on GROUP’s behalf pursuant to GROUP’s organizational documents, bylaws, or properly enacted resolution of GROUP’s governing authority. Copies of such authorities are attached to this Agreement.

ADDRESSES (a) The parties agree that the mailing addresses for the parties to this Agreement are as follows: FOR OHCA:

FOR GROUP AND PROVIDERS:

Oklahoma Health Care Authority Legal Division Attention: Provider Enrollment P.O. Box 54015 Oklahoma City, Oklahoma 73154

Name of GROUP

(b)

Mailing Address City, State, Zip Code

GROUP shall keep Appendix A current by notifying OHCA in writing of each deletion or addition of a health-care provider to the listed covered by GROUP at least fifteen calendar days prior to such occurrence. In the event of death, sudden illness or infirmity, unexpected license discipline, unexpected resignation, or similar event, GROUP shall notify OHCA by telephone (either orally or by facsimile) immediately and follow up in writing within three calendar days. Each PROVIDER, likewise, shall notify OHCA of changes in his or her GROUP status in the manner set out in this paragraph. GROUP and PROVIDER notification may be made in the same communication.

ARTICLE III. TERM 3.0

TERM OF THE CONTRACT This Agreement shall be effective upon completion when; (1) it is executed by Provider, (2) it is received at the Oklahoma City offices of OHCA, and (3) all necessary documentation has been received and verified by OHCA. The terms of this Agreement shall expire at 12:00 midnight, December 31, 2007.

3.1

ASSIGNMENT GROUP and PROVIDERS shall not assign or transfer any rights or obligations under this Agreement without OHCA’s prior written consent.

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ARTICLE IV. SCOPE OF WORK 4.0

GENERAL PROVISIONS. (a)

Each PROVIDER names GROUP as his or her payment agent for purposes of the Medicaid Program and directs OHCA to make payments for his or her services in the Medicaid Program to GROUP.

(b)

GROUP and PROVIDERS agree to comply with all applicable Medicaid statues, regulations, policies, and properly promulgated rules of OHCA.

(c)

GROUP and PROVIDERS agree that the state has an obligation under 42 U.S.C. §1396a(25)(A) to ascertain the legal liability of third parties who are liable for the health care expenses of recipients under the care of PROVIDERS. Because of this obligation, GROUP and PROVIDERS agree to assist OHCA, or its authorized agents, in determining the liability of third parties.

(d)

GROUP and PROVIDERS shall maintain all applicable licenses. GROUP and PROVIDERS shall ensure that PROVIDERS provide services to eligible Medicaid recipients pursuant to professional standards during the term of this contract. Should any PROVIDER’s license to practice a health-care profession be modified, suspended, revoked, or in any other way impaired, GROUP and the affected PROVIDER shall notify OHCA, within thirty days of such action. In the event a PROVIDER’s license is modified, GROUP will ensure that PROVIDER abides, and PROVIDER shall abide, by the terms of the modified license. In the event of suspension, revocation, or other action making it unlawful for any PROVIDER to practice his or her health-care profession, this Agreement shall terminate immediately as to that PROVIDER. A violation of this paragraph, at the time of execution or during any part of the term of this contract, shall render the contract immediately void.

(e)

Provision of health-care services for purposes of this Agreement shall be limited to those services within the scope of the Oklahoma Medicaid State Plan reflected by properly promulgated rules. To the extent that services within the practice of PROVIDERS’ health-care profession are not compensable services under the Oklahoma State Medicaid Program, the services may be provided but shall not be compensated by OHCA.

(f)

GROUP shall maintain a clinical record system.

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(i)

The system shall be maintained in accordance with written policies and procedures, which shall be produced to OHCA’s on-site reviewers upon request.

(ii)

GROUP shall designate a professional staff member to be responsible for maintaining the records and for ensuring they are completely and accurately documented, readily accessible, and systematically organized.

(iii)

Each patient’s record shall include, as applicable and in addition to other items set forth herein, identification and social data, evidence of consent forms, pertinent medical history, assessment of patient’s health status and health-care needs, brief summary of presenting episode and disposition, instructions to patient, report of physical examination, diagnostic and laboratory test results, consultative findings, all PROVIDER’s and physician’s orders, reports of treatments and medications, other pertinent information necessary to monitor the patient, and signatures of PROVIDER, physician, and other health-care professionals involved in patient’s care.

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4.1

4.2

(g)

GROUP’s clinical services shall be under the medical supervision of a physician duly licensed by the Oklahoma State Board of Medical Licensure and Supervision, the Oklahoma Board of Osteopathic Examiners, or the appropriate licensing body of the state where the GROUP’s facility is located. GROUP shall state in writing its organizational policies, responsibilities, and lines of authority, including responsibilities of physicians, physician assistants, and nurse practitioners.

(h)

GROUP shall render services in an appropriate physical location, which shall include barrier-free access, adequate space for provision of direct services, proper exit signs, and a safe environment for patients.

(i)

GROUP shall train staff in handling emergencies to ensure patient safety.

(j)

GROUP shall have a written preventive maintenance program to ensure all essential mechanical, electrical, and patient-care equipment is maintained in a safe operating condition.

PAYMENT (a)

OHCA shall pay GROUP for PROVIDERS’ services within the scope of OHCA’s programs on a published statewide rate based on the Medicare-established rates.

(b)

GROUP and PROVIDERS agree and understand that payment cannot be made by OHCA to vendors providing services under federally assisted programs unless services are provided without discrimination on the grounds of race, color, religion, sex, national origin or handicap.

(c)

GROUP and PROVIDERS agree to accept payment by direct deposit and by accepting such payment certify that the services submitted for payment were provided.

(d)

Pursuant to 42 CFR § 447.15, payments made by OHCA shall be considered payment in full for all covered services provided to a Medicaid recipient. GROUP and PROVIDERS shall not bill a Medicaid recipient for such service and shall not be relieved of this provision by electing not to bill OHCA for the service. This provision shall not apply to co-payments allowed by OHCA.

(e)

Satisfaction of all claims will be from federal and state funds. Any false claims, statements, or documents, or any concealment of a material fact may be prosecuted under applicable federal or state laws.

(f)

GROUP and PROVIDERS certify that the services for which payment is billed on behalf of PROVIDER were medically indicated for the health of the patient and were rendered by PROVIDER.

BILLING PROCEDURES (a)

Prior to submitting claims to OHCA via a billing service, GROUP agrees that written authorization for that service to bill for GROUP shall be on file with OHCA’s claims payment agent. Prior to the year 2003, such agent will be Unisys. After January 1, 2003, the agent will be EDS.

(b)

GROUP agrees all claims shall be submitted to OHCA in a format acceptable to OHCA.

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(c)

If GROUP enters into a billing service Agreement, GROUP shall be responsible for the accuracy and integrity of all claims submitted on GROUP’s behalf by the billing service.

(d)

GROUP shall not pay any percentage fees for collection services or use the billing service or any other entity as a factor, as defined by 42 CFR § 447.10.

(e)

GROUP guarantees that PROVIDERS shall not submit claims for payment of any service subject to this Agreement. GROUP shall hold OHCA harmless for any payment made to any PROVIDER included in this Agreement who separately bills OHCA.

(f)

GROUP shall release any lien securing payment for any Medicaid-compensable service. This provision shall not affect GROUP’s ability to file a lien for noncovered service or OHCA-permitted co-payment.

(g)

GROUP and PROVIDERS are responsible for determining a patient’s appropriate eligibility by contacting OHCA Recipient Eligibility Verification System (REVS).

ARTICLE V. LAWS APPLICABLE 5.0

The parties to this Agreement acknowledge and expect that over the term of this Agreement laws may change. Specifically, the parties acknowledge and expect (i) federal Medicaid statutes and regulations, (ii) state Medicaid statutes and rules, (iii) state statutes and rules governing practice of health-care professions, and (iv) any other laws cited in this contract may change. The parties shall be mutually bound by such changes.

5.1

PROVIDER shall comply with and certifies compliance with: (a)

Age Discrimination in Employment Act, 29 U.S.C. § 621 et seq.;

(b)

Rehabilitation Act, 29 U.S.C. § 701 et seq.;

(c)

Drug-Free Workplace Act, 41 U.S.C. § 701 et seq.;

(d)

Title XIX of the Social Security Act (Medicaid), 42 U.S.C. § 1396 et seq.;

(e)

Civil Rights Act, 42 U.S.C. §§ 2000d et seq. and 2000e et seq.;

(f)

Age Discrimination Act, 42 U.S.C. § 6101 et seq.;

(g)

Americans with Disabilities Act, 42 U.S.C. § 12101 et seq.;

(h)

Oklahoma Worker’s Compensation Act, 85 O.S. § 1 et seq.;

(i)

31 U.S.C. § 1352 and 45 C.F.R. § 93.100 et seq., which (1) prohibits the use of federal funds paid under this Agreement to lobby Congress or any federal official to enhance or protect the monies paid under this Agreement and (2) requires disclosures to be made if other monies are used for such lobbying; and;

(j)

Presidential Executive Orders 11141, 11246 and 11375 at 5 U.S.C. § 3501and as supplemented in Department of Labor regulations 41 C.F.R. §§ 741.1-741.84, which together require certain federal contractors and subcontractors to institute affirmative action plans to ensure absence of discrimination for employment because of race, color, religion, sex, or national origin;

(k)

The Federal Privacy Regulations and the Federal Security Regulations as contained in 45 C.F.R. Part 160 et seq. that are applicable to such party as mandated by the Health Insurance and Portability Accounting Act of (HIPPA), Public Law 104-191, 110 Stat. 1936, and HIPAA regulations at 45 C.F.R. § 160.101 et seq.;

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(l)

Vietnam Era Veterans’ Readjustment Assistance Act, Public Law 93-508, 88 Stat. 1578;

(m)

Protective Services for Vulnerable Adults Act, 43A Okla. Stat. § 10-101 et seq.;

5.2

PROVIDER certifies that it complies with 45 C.F.R. §§76.105 and 76.110, Debarment, Suspension and other Responsibility Matters.

5.3

With regard to equipment (as defined by O.M.B. Circular A-87) purchased with monies received from OHCA pursuant to this Agreement, GROUP and PROVIDERS agree to comply with 74 Okla. Stat. §§ 85.44(B) and (C) and 45 C.F.R. §74.34.

5.4

GROUP and PROVIDERS shall comply and certify compliance with 42 USC §§ 1395cc(a)(1), 1395cc(f), and 1396a(w), which require Medicaid providers to provide patients with information about patients’ rights to accept or refuse medical treatment. GROUP and PROVIDERS shall educate staff and Medicaid recipients concerning advance directives. GROUP and PROVIDERS shall include in each patient’s individual medical record documentation as to whether the patient has executed an advance directive. GROUP and PROVIDERS shall not discriminate on the basis of whether an individual has executed an advance directive.

5.5

GROUP and PROVIDERS shall develop and enforce policies and procedures in accordance with laws regarding communicable diseases. These policies and procedures shall include universal precautions, including precautions related to Human Immunodeficiency Virus (HIV) serologically positive patients, which equal or exceed such standards established by the U.S. Occupational Safety and Health Administration.

5.6

The explicit inclusion of some statutory and regulatory duties in this Agreement shall not exclude other statutory or regulatory duties.

5.7

All questions pertaining to validity, interpretation, and administration of this Agreement shall be determined in accordance with the laws of the State of Oklahoma, regardless of where any service is performed or product is provided.

5.8

The venue for legal actions arising from this Agreement shall be in the District Court of Oklahoma County, State of Oklahoma.

ARTICLE VI. AUDIT AND INSPECTION 6.0

GROUP and PROVIDERS shall keep such records as are necessary to disclose fully the extent of service provided to Medicaid recipients and shall furnish records and information regarding any claim for providing such service to OHCA, the Oklahoma Attorney General’s Medicaid Fraud Control Unit (MFCU hereafter), and the U.S. Secretary of Health and Human Services (Secretary hereafter) for six years from the date of provision. GROUP and PROVIDERS shall not destroy or dispose of records, which are under audit, review or investigation when the six-year limitation is met. GROUP and PROVIDERS shall maintain such records until informed in writing by the auditing, reviewing or investigating agency that the audit, review or investigation is complete.

6.1

Authorized representatives of OHCA, MFCU, and the Secretary shall have the right to make physical inspection of GROUP and PROVIDERS’ place of business and to examine records relating to financial statements or claims submitted by GROUP under this Agreement and to audit GROUP and PROVIDERS’ financial records as provided by 42 C.F.R. § 431.107.

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6.2

Pursuant to 74 Okla. Stat. § 85.41, OHCA and the Oklahoma State Auditor and Inspector shall have the right to examine GROUP’s books, records, documents, accounting procedures, practices, or any other items relevant to this Agreement.

6.3

GROUP shall provide OHCA with information concerning GROUP’s ownership in accordance with 42 C.F.R. § 455.100 et. seq. This Agreement shall not be effective until OHCA receives the ownership information requested in the Disclosure of Ownership and Controlling Interest Form which is attached to and made part of this Agreement. Ownership information shall be provided to OHCA at each Agreement renewal and within twenty days of any change in ownership. Ownership information is critical for determining whether a person with an ownership interest has been convicted of a program- crime under Titles V, XVIII, XIX, XX and XXI of the federal Social Security Act, 42 U.S.C. § 301 et seq. GROUP shall also furnish ownership information to OHCA upon request.

6.4

GROUP shall submit, within thirty-five days of a request by OHCA, MFCU, or the Secretary, all documents, as defined by 12 Okla. Stat. § 3234, in its possession, custody, or control concerning (i) the ownership of any subcontractor with whom GROUP has had business transactions totaling more than twenty-five thousand dollars during the twelve months preceding the date of the request, or (ii) any significant business transactions between GROUP and any wholly owned supplier or between GROUP and any subcontractor during the five years preceding the date of the request.

ARTICLE VII. CONFIDENTIALITY 7.0

GROUP and PROVIDERS agree that Medicaid recipient information is confidential pursuant to 42 U.S.C. § 1396a(7), 42 C.F.R. § 431:300-306, and 63 Okla. Stat. § 5018. GROUP and PROVIDERS shall not release the information governed by these Medicaid requirements to any entity or person without proper authorization or OHCA’s permission.

7.1

PROVIDER shall have written policies and procedures governing the use and removal of patient records from PROVIDER’s facility. The patient’s written consent shall be required for release of information not authorized by law, which consent shall not be required for state and federal Medicaid personnel working with records of Medicaid patients.

ARTICLE VIII. TERMINATION 8.0

The parties may terminate this Agreement by three methods. (i) Any party may terminate this Agreement for cause with a thirty-day written notice to the other parties; (ii) any party may terminate this Agreement without cause with a sixty-day written notice to the other parties; or (iii) OHCA may terminate the contract immediately to protect the health and safety of Medicaid recipients, upon evidence of fraud, or pursuant to Paragraph 4.0(e) above.

8.1

If the Oklahoma Legislature or United States Congress ceases funding the Medicaid Program at any time during the term of this Agreement, the Agreement shall terminate immediately upon the effective date of such cessation.

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ARTICLE IX. OTHER PROVISIONS 9.0

The representations made in this memorialization of the Agreement constitute the sole basis of the parties’ contractual relationship. Attachments to this Agreement which are made part of the Agreement are (i) GROUP’s Affidavit, (ii) Disclosure of Ownership and Controlling Interest Form, (iii) Electronic Funds Transfer Authorization, and (iv) Questionnaire. No oral representation by any party relating to services covered by this Agreement shall be binding on any other party. Any amendment to this Agreement shall be in writing and signed by all parties, except those matters addressed in Paragraph 2.2. Address changes shall be in writing but shall not require the signature of the receiving party.

9.1

If any provision of this Agreement is determined to be invalid for any reason, such invalidity shall not affect any other provision, and the invalid provision shall be wholly disregarded.

9.2

Titles and subheadings used in this Agreement are provided solely for the reader’s convenience and shall not be used to interpret any provision of this Agreement.

9.3

As used in this Agreement, the conjunctive references to GROUP and PROVIDERS include the disjunctive.

9.4

OHCA does not create and GROUP and PROVIDERS do not obtain any license by virtue of this Agreement. OHCA does not guarantee GROUP or PROVIDERS will receive any customers, and GROUP and PROVIDERS do not obtain any property right or interest in any Medicaid recipient business by this Agreement.

Group FEIN (Federal Employer Identification Number)

Print Authorized Representative’s Name

Authorized Representative’s Signature

Date

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OKLAHOMA HEALTH CARE AUTHORITY APPENDIX A Health-Care Providers for Whom Group Receives Payment Group Name _________________________________________________________________ Oklahoma Medicaid Group ID ___________________Group FEIN _______________________ (10 digit group ID)

(Federal Employer Identification Number)

By signing this document, each PROVIDER appoints the above-named GROUP as his or her agent for receipt of payment for Medicaid-compensable health-care services and directs the Oklahoma Health Care Authority (OHCA) to make all such payments to GROUP in keeping with the Agreement attached hereto, regardless of any other Agreement PROVIDER has with OHCA. No payments will be made directly to the rendering provider. Each PROVIDER accepts all terms and conditions in the attached Agreement. Effective Date ____________________________________ (Date provider appoints the above group to receive payments)

Provider Name _______________________________________________________________ (Last)

(First)

(Middle)

(Title)

Oklahoma Medicaid Provider ID _____________________ SSN __ __ __ - __ __ - __ __ __ __ (10 digit provider ID)

Provider Signature ____________________________

(Social Security Number)

Date _________________

Effective Date ____________________________________ (Date provider appoints the above group to receive payments)

Provider Name _______________________________________________________________ (Last)

(First)

(Middle)

(Title)

Oklahoma Medicaid Provider ID _____________________ SSN __ __ __ - __ __ - __ __ __ __ (10 digit provider ID)

Provider Signature ____________________________

(Social Security Number)

Date _________________

Effective Date ____________________________________ (Date provider appoints the above group to receive payments)

Provider Name _______________________________________________________________ (Last)

(First)

(Middle)

(Title)

Oklahoma Medicaid Provider ID _____________________ SSN __ __ __ - __ __ - __ __ __ __ (10 digit provider ID)

Provider Signature ____________________________

(Social Security Number)

Date _________________

Effective Date ____________________________________ (Date provider appoints the above group to receive payments)

Provider Name _______________________________________________________________ (Last)

(First)

(Middle)

(Title)

Oklahoma Medicaid Provider ID _____________________ SSN __ __ __ - __ __ - __ __ __ __ (10 digit provider ID)

Provider Signature ____________________________

(Social Security Number)

Date _________________

Effective Date ____________________________________ (Date provider appoints the above group to receive payments)

Provider Name _______________________________________________________________ (Last)

(First)

(Middle)

(Title)

Oklahoma Medicaid Provider ID _____________________ SSN __ __ __ - __ __ - __ __ __ __ (10 digit provider ID)

Provider Signature ____________________________ Appendix A Page _____ of _____

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(Social Security Number)

Date _________________