Preferred Provider Organization has contracts with Preferred Providers (hereinafter “Participating Providers”) to provide medical and related services at pre-negotiated fees to the covered individuals of the FUND. The FUND will have access to those pre-negotiated fees for medical and related services delivered to such employees by Participating Providers in the network. The Preferred Provider Organization represents that it has thoroughly researched and developed the know-how and technology to comply with specific states’ laws to reimburse providers for fees and services as they relate to injuries sustained at work and that it has made provisions and it will obtain necessary updates on medical payments and make necessary changes in payments as outlined in specific sections of fee schedule regulations and usual, customary and reasonable fees in order to perform the services stated herein and agrees to provide the following services: 1) Establishment and maintenance of an adequate network of hospitals, physicians, laboratories and other appropriate facilities, available 24 hours a day, seven days a week. 2) Provide access, to individuals covered under the FUND, to the Preferred Provider Organization network of hospitals, physicians, laboratories, and other appropriate facilities for treatment of work related injuries and health conditions. 3) Perform Health care provider and facility credentialing in compliance with URAC/NCQA standards. 4) Require complete medical documentation of all provider bills. 5) Re-price provider bills by applying the current Preferred Provider Organization discount schedule rates to all billings from Participating Providers for work injury and health condition related medical services provided to individuals covered by the FUND. 6) Furnish FUND or it’s designee with an explanation of benefits (EOB) indicating the approved payment for services rendered. Turnaround time on bill re-pricing and EOB distribution should not exceed five (5) working days. The Preferred Provider Organization shall provide the FUND with quarterly reports showing the re-pricing turnaround time per bill and on average. Any bill for which re-pricing took longer than 10 days shall include an explanation of the circumstances that caused the delay. 7) Attempt to negotiate discount arrangements with out-of-network providers where appropriate. The FUND acknowledges that these discounts may be lost if the FUND does not pay the claim in a timely manner. The Preferred Provider Organization in no way guarantees that a discount can be or will be negotiated. 8) Cooperate with all audits requested or performed by FUND or its designee, at a mutually convenient time. 9) Provide monthly informational savings reports on claims handled in a manner acceptable to the FUND. 10) Meet, as needed, with the FUND or its designee or member authorities to ensure and maintain strong communication and working relationships. 11) The Preferred Provider Organization agrees to cooperate with the FUND or its designee to implement various data and medical bill payment information transfer procedures where necessary in order to ensure the timely and orderly payment of medical bills.
