CARRIER AGREEMENTS NOT RENEWED The nonrenewal date is shown in parentheses. Nebraska State Department of Public Welfare: Agreement terminated by mutual consent (5-5-67). The contractor was replaced by Mutual of Omaha. Pilot Life Insurance Company: Agreement terminated by mutual consent (6-30-69). The contractor was replaced by the Prudential Insurance Company of America. John Hancock Mutual Life Insurance Company: Agreement terminated due to inadequate conformance to program requirements (4-5-70). The contractor was replaced by the Prudential Insurance Company of America. Medical Mutual of Cleveland, Inc.: Agreement terminated due to inadequate conformance to program requirements (6–30–71). The contractor was replaced by Nationwide Mutual Insurance Company. REDUCTION IN SERVICE AREAS OF CARRIERS The effective date is shown in parentheses. California Physicians' Service: Jurisdiction for seven counties was transferred to Occidential Life Insurance Co. (12-31-69). The purpose for the change was to bring about a greater balance of workloads between the two Medicare carriers in California and to provide improved service to beneficiaries, physicians, and other suppliers of services. Illinois Medical Service: Jurisdication for four counties was transferred to The Continental Casualty Company (6-30-71). The purpose for the change was to bring about a greater balance of workloads between the two Medicare carriers in Illinois and to provide improved services to the public. Blue Shield of Florida, Inc.: Jurisdiction for two counties was transferred to Group Health, Inc. (6-30-75). The purpose for the change was to ameliorate the effects of a substantial increase in workload and program administration problems which are unique to the State. ATTACHMENT 5 1975 CONTRACTS HOSPITAL INSURANCE BENEFITS FOR THE AGED AND DISABLED (Agreement with Intermediary Pursuant to Sections 1816 and 1842 of the Social Security Act, as Amended) AGREEMENT NO.. AGREEMENT The Secretary of Health, Education, and Welfare and The Blue Cross Association (To carry out the provisions of sections 1816 and 1842 of the Soocial security Act as amended) INTRODUCTION The Secretary of Health, Education, and Welfare, hereinafter referred to as the Secretary and the Blue Cross Association, hereinafter referred to as the Intermediary, pursuant to the authority contained in sections 1816 and 1842 of the Social Security Act, as amended (providing for the use of private organizations to facilitate payments required to be made under Part A and Part B of Title XVIII of the Social Security Act, as amended), hereby agree to the following: I Definitions and Delegations..... II Functions and Duties to be Performed by Intermediary III Functions and Duties to be Performed by the Secretary IV Payment for Covered Services.... V Advance of Funds and Transfer of Funds Through Letter of Credit. VII Compliance with Regulations and General Instructions. Page No. 1 3 4 8 XII Confidential Nature and Limitation of Use of Information and Records 10 10 10 XIV Prior Approval and Prior Notice for Subcontracting and Data Processing 11 XV Subcontracting. 12 XVI Data Processing. 14 XVII Nomination, or Withdrawal of Nomination by a Provider of Services. 14 14 XXV Modification and Termination of Agreement XXVI Termination of Agreement... XXVII Continuance of Functions and Duties Under Prior Agreement 17 17 18 Article I DEFINITIONS AND DELEGATIONS For the purposes of this agreement A. The term "Secretary" means the Secretary of Health, Education, and Welfare or his delegate. B. The term "Act" means the Social Security Act, as amended from time to time. C. The term "provider of services" means an institution, facility, or agency so designated on a list furnished by the Secretary as a participating provider of services. D. The term "nonparticipating provider of services" means an institution, facility, or agency so designated by the Secretary. E. The term "emergency hospital” means an institution which the Secretary has determined to be eligible for payments as authorized by sections 1814 (d) (1), 1814(f), and 1835(b)(1) of the Act. F. The term "eligible individual” means an individual to whom payment may be made pursuant to sections (i) 1814(d)(2), (ii) 1832 (a) (1) for medical and other health services described in 1861(s) (2) (B) and (C), 3 through 9 inclusive when furnished by a nonparticipating provider of services, and (iii) 1835(b) (2) and 1835(c) of the Act. G. The term "covered services" means the items or services for which payment may be made under sections 1812 (a) and 1832(a) of the Act except items or services for which payments may not be made by reason of section 1862 of the Act. H. The term "Plan" means a Blue Cross organization which becomes a subcontractor of the kind referred to in Article II hereof. I. The term "General Instructions" means manuals and written instructions of general application to Carriers or Fiscal Intermediaries issued by the Secretary pursuant to the Act in respect to matters covered by this agreement. J. The term "subcontract" means any contract, agreement, purchase order or lease (including leases of real property) to obtain space, supplies, equipment, or services under this agreement; the term "subcontractor" means any holder of one or more subcontracts. K. The term "Federal Procurement Regulations (FPR),” as used in this agreement, means those Parts of the Federal Procurement Regulations to which reference is made hereinafter, as in effect on the effective date of this agreement. L. Responsibility for the administration of this agreement having been delegated by the Secretary to the Commissioner of Social Security, who has further delegated to the Deputy Commissioner of Social Security and the Director of the Bureau of Health Insurance the authorization to administer matters covered under this agreement, any written statement with respect to matters covered by this agreement by (1) such Commissioner, Deputy Commissioner, or the Director, Bureau of Health Insurance, or (2) the Health Insurance Regional Representative and such other positions as such Commissioner authorizes (but only with respect to matters specifically covered by such authorization) shall have the same force and effect as though issued by the Secretary. With respect to the positions designated in clause (2) of the preceding sentence, the Commissioner of Social Security shall furnish the Intermediary a list of such positions and the matters with respect to which they are authorized to act. Article II FUNCTIONS AND DUTIES TO BE PERFORMED BY INTERMEDIARY A. The Intermediary shall: 1. Make determinations as to whether the services provided an individual are covered services and of the amounts of payments required to be made to each provider of service, to each nonparticipating provider of service, to each emergency hospital and to each eligible individual in accordance with the provisions of the Act, Regulations promulgated pursuant thereto, and General Instructions. 1 76-614 O 76 - 12 2. Receive, disburse and account for funds in making such payments. 3. Make audits of the records of providers of services and of emergency hospitals as provided in Article IX. 4. Assist providers of services in the development of procedures relating to utilization practices and make studies of the effectiveness of such procedures, including the appraisal and evaluation of the results of provider utilization review activity and recommendations for necessary changes in provider utilization practices and procedures; and assist in the application of safeguards against unnecessary utilization of services. 5. Process and pay claims for services found by the Secretary to be emergencies, and for services rendered by hospitals outside of the United States, as authorized by sections 1814(d), 1814(f) and 1835(b) of the Act. 6. With respect to the functions of the Intermediary contained in this agreement, serve as a center for and communicate to providers of services information or instructions of the Secretary, and serve as a channel of communications from such providers of services to the Secretary. 7. Assist any institution, facility, or agency to qualify as a provider of services and to establish and maintain fiscal records for purposes of Title XVIII of the Act. 8. Make such Medicare management studies as may be approved by the Secretary to insure the effective performance of this agreement, except such approval is not required for those activities related to the Intermediary's responsibility for the performance of individual subcontracting plans under this agreement. 9. Participate in or perform statistical and research studies as the Secretary may request or approve. These studies may include, but shall not be limited to, experimentation studies conducted pursuant to section 222 of P.L. 92-603 and section 402 of the Social Security Amendments of 1967, as amended. Notwithstanding these provisions, the Secretary may enter directly into a contract with any Plan for participation in any of the foregoing experimentation studies, in which event, the Secretary will forward to the Intermediary a copy of the protocol of any such experimentation study, and, to the extent that any function or duty of the Intermediary set forth in this Article is inconsistent with the experimentation study, the Secretary shall waive performance of such function or duty by the Intermediary. The allowability of any costs incurred by the Intermediary in the discontinuance of performance of any function or duty waived by the Secretary shall be governed by the provisions of paragraph B of Article XIII applicable to termination costs. 10. Provide that, notwithstanding any provision of this agreement, any Plan may enter into arrangements as approved by the Secretary directly with Professional Standards Review Organizations for purposes of implementation of Title XI of the Act. 11. In pursuance of its primary responsibility under this agreement to receive and review claims from providers of services, nonparticipating providers of services, emergency hospitals and eligible individuals, make provisions for Plans to receive and review such claims and to send such claims forms directly to the Secretary, and to take corrective action with respect to rejected claims forms. 12. Establish and maintain such procedures as the Secretary may approve for considering and resolving any differences which may result when disputes arise from provider dissatisfaction with determinations of provider costs when such disputes concern a claim for less than $10,000. 13. Provide that if a provider of services, pursuant to the provisions of 20 CFR - Subpart R (Section 401.1801 et seq.), requests a hearing before the Provider Reimbursement Review Board, the Plan servicing such provider of services shall prepare and present the Plan's position on the matter to the Board with such assistance, apart from the Intermediary's monitoring duties, incident to the particular case as the Plan may request from the Intermediary. 14. Establish and maintain such procedures as the Secretary may approve for the review and reconsideration of determinations under which payment to an eligible individual or provider of ser |