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2021-074B
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Last modified
6/22/2021 12:13:29 PM
Creation date
6/11/2021 3:23:37 PM
Metadata
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Template:
Official Documents
Official Document Type
Agreement
Approved Date
05/11/2021
Control Number
2021-074B
Agenda Item Number
12.D.1.
Entity Name
Employer Direct Healthcare, LLC
Subject
Surgeryplus Services Agreement
Addition of SurgeryPlus Benefit as Optional Benefit
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DocuSign Envelope ID: 29EAB906-1936-4BAB-83BE-97C974F00293 <br />(the "Report Date"), EDH will calculate and provide Sponsor with a tabulation of: (i) Sponsor's savings during <br />the Term based on: (A) with respect to each Episode of Care during the Term, the difference between the <br />actual Case Rate paid by Sponsor to EDH and the Comparable Case Rate for such Episode of Care; (B) Sponsor's <br />savings attributable to avoided surgical complications of Participants (determined by EDH using the <br />incremental frequency of complications occurring outside of the Network and the increase in procedure cost <br />associated with such complications); and (C) Sponsor's savings attributable to avoided medical procedures <br />(determined by EDH using the cost of procedures which were not performed by a Provider, but were otherwise <br />recommended by a physician outside of the Network) (collectively, the "EDH Savings"); and (ii) the total <br />amount of Network Use Fees paid by Sponsor during the Term pursuant to Section 4.3(b) (the "Total Network <br />Use Fee"). <br />(b) Guarantee Payment. If the calculation of EDH Savings described in Section 4.4(a) <br />shows the EDH Savings to be less than two times (2x) the Total Network Use Fee, then EDH shall make payment <br />to Sponsor in an amount equal to the difference between (i) two times (2x) the Total Network Use Fee and (ii) <br />the EDH Savings. Such payment shall be made within thirty (30) days of the Report Date. if the calculation of <br />EDH Savings described in Section 4.4(a) shows the EDH Savings to be in excess of two times (2x) the Total <br />Network Use Fee, Sponsor shall not be entitled to any such payment from EDH. <br />(c) Guarantee Reporting. On an annual basis, EDH shall provide Sponsor with a pro <br />forma calculation of the EDH Savings and Total Network Use Fee for the purpose of tracking and evaluating the <br />progress and performance of EDH under this Agreement. <br />(d) Limitations. If Sponsor: (i) breaches Section 3.4 or Section 3.6 of this Agreement; or <br />(ii) reduces the Plan Incentives without the written consent of EDN, such action shall immediately constitute a <br />full and final waiver by Sponsor of any past, present, or future obligation of EDH arising from this Section 4.4� <br />and EDH shall be fully and finally discharged and released from any such obligations. For the avoidance of <br />doubt, EDH's obligations with respect to this Section 4.4 shall apply to the Term of this Agreement. <br />4.5 Invoicin and Pa ment. During the term of this Agreement, EDH will prepare and submit to <br />Sponsor invoices fully disclosing and itemizing the amounts to be paid by Sponsor pursuant to the terms of this <br />Agreement (each, an "Invoice"). Invoices including amounts related to Claims will be submitted by EDH to <br />Sponsor on a weekly basis, and Invoices including amounts related to EDH Fees will be submitted by EDH to <br />Sponsor on a monthly basis. Invoices including amounts related to Claims shall be paid by Sponsor not more <br />than ten (10) days after Sponsor's receipt of such Invoices, and Invoices including amounts related to EDH Fees <br />shall be paid by Sponsor not more than thirty (30) days after Sponsor's receipt of such Invoices. Sponsor will <br />pay directly to EDH the amounts included in such Invoice via wire transfer or electronic funds transfer. After <br />receiving payment from Sponsor, EDH will pay the appropriate Providers and vendors of Travel Services <br />consistent with the Plan requirements mutually agreed by the Parties in writing. <br />4.6 Cancellation Prior to Medical Procedure. If a Participant, for any reason, is not admitted by <br />a Provider, or if a Participant cancels a scheduled procedure at any time prior to performance of the Episode <br />of Care, Sponsor shall be responsible for the cost of Provider's review of Participant's medical records, the cost <br />of any pre -admission testing or treatment provided by a Provider, any expenses related to Travel Services, <br />consistent with the Plan requirements mutually agreed by the Parties In writing and any other fees, costs, or <br />expenses actually incurred (reduced by the amount of any amount of Participant responsibility received from <br />the Participant). EDN will initiate the refund of any applicable amount of Participant responsibility received <br />from the Participant within fifteen (15) business days of cancellation of the Episode of Care. Any charges to <br />Sponsor pursuant to this Section 4.6 will be listed in an Invoice. <br />4.7 Ur-eent or Emergency Medical Services. If at any time during an Episode of Care, a Provider <br />determines that any Medically Necessary Service must be performed on an urgent or emergency basis to <br />-10- <br />
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