Contract - Healthstat, Inc. - 7/26/2018 CITY OF ROUND ROCK AGREEMENT FOR
ON SITE MEDICAL CLINIC SERVICES WITH
HEALTHSTAT, INC.
THE STATE OF TEXAS §
CITY OF ROUND ROCK § KNOW ALL BY THESE PRESENTS:
COUNTY OF WILLIAMSON §
COUNTY OF TRAVIS §
THAT THIS AGREEMENT for, and for related goods and services, (referred to herein as
the "Agreement"), is made and entered into on this the26 3-day of the month of July, 2018 by
and between the CITY OF ROUND ROCK, a Texas home-rule municipality, whose offices are
located at 221 East Main Street, Round Rock,Texas 78664-5299 (referred to herein as the"City"),
and HEALTHSTAT, INC., a North Carolina Corporation whose offices are located at 4651
Charlotte Park Dr., Suite 300, Charlotte,NC 28217 (referred to herein as the"Services Provider").
RECITALS:
WHEREAS, Services Provider currently operates the City's medical clinic (the "Clinic")
on City's premises and City desires to purchase goods and services related to the continued
operation of the Clinic, and City desires to procure same from Services Provider; and
WHEREAS, Services Provide desires to continue operating the Clinic pursuant to the terms
set forth herein; and
WHEREAS, the parties desire to enter into this Agreement to set forth in writing their
respective rights, duties, and obligations;
NOW, THEREFORE, WITNESSETH:
That for and in consideration of the mutual promises contained herein and other good and
valuable consideration, the sufficiency and receipt of which are hereby acknowledged, it is
mutually agreed between the parties as follows:
1.01 DEFINITIONS
A. Agreement means the binding legal contract between City and Services Provider
whereby City is obligated to buy specified services and Services Provider is obligated to sell same.
The Agreement includes any exhibits, addenda, and/or amendments thereto.
B. City means the City of Round Rock, Williamson and Travis Counties,Texas.
C. Effective Date means January 1, 2018.
D. Force Majeure means acts of God, strikes, lockouts, or other industrial
disturbances,acts of the public enemy,orders of any kind from the government of the United States
or the State of Texas or any civil or military authority, insurrections, riots, epidemics,
landslides,lightning, earthquakes,fires,hurricanes,storms,floods,restraint of the government and
the people, civil disturbances, explosions, or other causes not reasonably within the control of the
party claiming such inability.
E. Goods and services mean the specified services, supplies,materials, commodities,
or equipment.
2.01 EFFECTIVE DATE, TERM,ALLOWABLE RENEWALS, PRICES FIRM
A. The term of this Agreement shall be effective as of January 1, 2018, and shall
remain in full force and effect unless and until it expires by operation of the initial term indicated
herein, or is terminated or extended as provided herein.
B. The term of this Agreement shall be for twelve (12) months from the effective
date hereof(January 1, 2018) ("initial term"). Upon expiration of the initial term,this Agreement
may be renewed for an additional three (3)months, at the sole discretion of the City but subject to
written consent from Services Provider to the renewal.The City agrees that in the event it desires
to renew the Agreement for an additional three (3) months, it shall provide written notice to
Services Provider at least sixty (60) days prior to the expiration of the initial term. Services
Provider agrees that in the event it desires to terminate the Agreement at the end of the initial term
(i.e. decline the 3-month renewal), it shall provide written notice to City at least sixty (60) days
prior to the expiration of the initial term.
C. Prices shall be firm for the duration of this Agreement and the renewal period for
the Scope of Services defined under Exhibit "A" herein. No separate line item charges shall be
permitted for invoicing purposes,unless agreed upon by the parties. All tenors and conditions shall
remain the same for the renewal period.
3.01 CONTRACT DOCUMENTS AND EXHIBITS
City selected Services Provider to supply the services as outlined in the Scope of Services,
attached as Exhibit "A," and incorporated herein by reference.
The services which are the subject matter of this Agreement are described in Exhibit "A"
and, together with this Agreement, comprise the total Agreement and they are fully a part of this
Agreement as if repeated herein in full.
4.01 SCOPE OF WORK
Services Provider shall satisfactorily provide all services described under the attached
exhibits and herein within the contract term specified in Section 2.01. Services Provider's
undertakings shall be limited to performing services for City and/or advising City concerning those
matters on which Services Provider has been specifically engaged. Services Provider shall perform
its services in accordance with this Agreement, in accordance with the appended exhibits, in
accordance with due care, and in accordance with prevailing industry standards for comparable
services.
5.01 SERVICES
Services Provider shall provide the services set forth in Exhibit "A" and
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herein. City acknowledges that Services Provider is not engaged in the practice of medicine.
5.01.1 Operation of Clinic.
A. Services Provider shall provide licensed and certified Clinician(s)
who are employed by Services Provider, or contract with licensed
physician or physician practices ("Group" or "Groups") to provide
services set forth in Exhibit"A" and herein; to provide professional
services consistent with reasonable and appropriate standards of
care, and who are responsible for supervising the Clinician(s)
operating the Clinic on City's premises as required in accordance
with Texas law. Each Clinician that is employed or contracted by
Services Provider shall be supervised by a physician independently
contracted by Services Provider, as required in accordance with
Texas law. Each Clinician and Group shall remain in good standing
with the licensing authority of the State of Texas. Each Group shall
supervise and oversee each Clinician at the Clinic in accordance
with Texas law. Every Services Provider with a Group shall contain
provisions requiring the Group to comply with all applicable Texas
laws in the provision of professional services with the Clinic.
Services Provider shall further require that each Group carry
malpractice insurance.
B. Any costs associated with renovating the physical space of the
Clinic shall be the City's responsibility.
C. Services Provider shall use commercially reasonable best efforts to
locate and coordinate Clinician to provide hours of service at the
Clinic as mutually agreed upon by the parties.
5.01.2 Intentionally Deleted.
5.01.3 Health Assessment(s).
Health assessments on each participating City employee choosing to have
an assessment shall be completed once every twelve (12) months for the
term of this Agreement. Those employees unable to attend the mass event
may obtain their health assessment within the Clinic. Services Provider shall
be responsible for collecting blood pressure, body weight indexing, and
providing a health survey to be completed by the employees. Services
Provider shall work with the employees to encourage employees to
participate in such health assessment(s). At City's request and for an
additional agreed upon cost between the parties to be paid by City, Services
Provider shall participate in an employee health fair and such other wellness
activities as may be sponsored by City. Personal Health Information
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obtained during each assessment will be collected in accordance with
Service Providers business practices designed to ensure its privacy and
security in accordance with the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA").
5.01.4 Periodic Reports.
Services Provider shall produce the following reports for City and City's
group health plan:
A. Healthy Life Profile — Individual health profiles for assessment
participants shall be compiled and distributed to each participant
only after each health assessment.
B. Health Risk Assessment Overview—Aggregate health risk report(s)
for the entire employee population on an anonymous basis shall be
compiled and distributed to City after each mass health assessment.
C. Clinic Utilization — Monthly clinic utilization reports summarizing
the services furnished on-site at each Clinic in a de-identified
format.
D. Quarterly Report — Provided the City's group health plan, health
insurer, or third-party administrator furnishes historical claims data
in accordance with this Agreement, , Services Provider shall provide
insurance cost claims impact statement four (4) times per twelve
(12) month period. Additionally, Services Provider shall provide
Clinic utilization and activity reports and summary data related to
the Clinic's participants' compliance with the frequency guidelines
recommended for the number of risk factors identified during the
health assessment(s).
E. Non-Compliance Report — Non-compliance reports for employees
with health risk factors and Clinic visit frequency shall be provided
on a quarterly basis in a de-identified format.
F. Business Intelligence Dashboard — City shall have access to the
web-based detailed Clinic utilization tool for self-reporting.
No Protected Health Information about any employee participant shall
be released to the City in any report unless such participant has
provided his or her prior written authorization or unless such
information is released in accordance with HIPAA.
5.01.5 Interventions.
The Clinicians at each Clinic, or, Services Provider's representative shall
contact each health assessment participant which is identified as having two
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(2) or more high healthcare risk factors according to the health assessment
(and each participant with one (1) risk factor if at immediate need levels)
within twelve (12) months of the health assessment. The Clinician at the
Clinic shall be available during regularly scheduled Clinic hours of
operation to consult with and assist in the development of a program for
each health assessment participant contacted in accordance with this
Section.
5.01.6 Appointment of Account Manager.
Services Provider has provided and will continue to provide an account
manager. The account manager shall be available to review and discuss the
activities of and reports generated from the Clinic.
5.01.7 Intentionally Deleted.
5.01.8 Practitioner Selection.
As of the signing of this Agreement, the Clinic is fully staffed. However,
should additional or different staff be needed, Services Provider shall
present a Clinician who is trained and qualified to perform clinical services
required in the Clinic. Services Provider shall offer to introduce the
Clinician candidate to City so City may evaluate the candidate proposed.
City understands that due to the limited availability of Clinician candidates
in some geographic locations, the continued operation of the Clinic may be
delayed if a Clinician candidate is rejected at City's request.
5.01.9 Professional Conduct of Clinician.
A. The professional conduct of Clinician is governed by applicable
Texas law and supervised by Group. Neither Services Provider nor
Employer shall exercise any direction over the method or manner in
which Clinician performs professional services or functions at the
Clinic. Neither Services Provider nor Employer shall intervene in
any manner with the services provided by the Clinician unless
Clinicians' actions are in violation of the regulations and/or rules of
conduct governing employees at City's place of business. It is
understood between the parties that the traditional, customary,usual
and confidential relationship between a health care provider and a
patient exists between the Clinician and employees and all
authorized persons seeking professional services of Clinician.
B. In the event City deems the performance of any Clinician disruptive
to City's place of business, detrimental to the health or safety of
members of City's workforce or any dependent family members, or
is in violation of the regulations and rules of conduct governing
employees of City, City may request that a Clinician be removed
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from the Clinic.When Services Provider is notified of such a request
by City, Services Provider shall notify the Clinician and Group and
Services Provider shall place Clinician on administrative leave
within ten (10) day. If after a review of the requested removal, City
and Services Provider desire that the Clinician be permanently
removed from the Clinic, Services Provider shall immediately
commence actions to recruit another Clinician to provide services at
the Clinic and advise City when a substitute Clinician be placed at
the Clinic. City acknowledges that during the time period in which
Services Provider is recruiting a new Clinician for the Clinic, the
Clinic may not be operational or the hours of availability of the
Clinic may be reduced.
5.01.10 Clinician(s) and Group(s) as Independent Contractors.
Each Clinician providing services at a Clinic is an independent contractor
of City. Each Clinician shall be supervised by Group pursuant to the terms
of a written contract. It is understood and agreed that no Clinician and no
Group shall be deemed to be an employee of City. No Clinician nor any
Group shall be eligible for any City benefits. City shall have no liability for
the compensation due to the Clinician, nor any Group providing direct or
supervisory services at the Clinic. Services Provider shall indemnify City
from and against any and all claims for any compensation or benefits.
5.01.11 Guideline Gap and Predictive Modeling Services.
As long as all data elements described in Section 6 of this Agreement are
supplied, Services Provider shall provide the following services as a part of
the Predictive Modeling and Guidance Gaps Packaging after the Clinic has
been operational for six (6) full months.
A. Services Provider will provide the Patient Profile report to the
Clinician on a monthly basis which includes:
(i) Forecasted Risk Profile
(ii) Impact Scores
(iii) Diagnosis Profile
(iv) Utilization Profile
(v) Risk Contribution Profile
(vi) Guideline Compliance Profile
(vii) Physician Pharmacy Profile—Therapeutic Classes
(viii) Physician Pharmacy Profile—Maintenance Medications
(ix) Physician Pharmacy Profile—Injectibiles
B. Services Provider shall provide the following to City on a
Quarterly basis:
(i) Risk Navigator Clinical Summary
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6.0 ELECTRONIC DATA SHARING
City shall supply the data listed on Exhibit "E" in electronic format compatible with
Services Provider software systems,for its employees who are eligible to take advantage of Service
Provider's services in order to populate the Service Provider's database. This delivery of data shall
be complete thirty(30) days prior to the initial health assessment and monthly thereafter. Services
Provider shall enter into a Business Associate Agreement, as defined in HIPAA, with City and its
health claims processing or insurance vendor. City shall instruct each third-party administrator,
insurance vendor or other party responsible for managing City's Plan claims system to provide
Services Provider all historical claims data, including but not limited to, healthcare claims,
pharmaceutical claims, and medical claims for all employees and described on Exhibit "E".
Services Provider shall use the data provided to establish and track employee utilization trends and
insurance cost impact which shall be provided in the periodic reports generated and supplied to
City. All costs associated with the transfer of data to Services Provider's database, including but
not limited to implementation of software interface, shall be borne by City and shall be mutually
agreed upon between the parties prior to the costs being incurred. All data transmitted pursuant to
this Section must be in electronic non-facsimile format, i.e. CD, floppy disk or direct electronic
interface.
Services Provider shall supply City' claims payer or other similar vendor("Vendor") information
related to each patient's encounter in the Clinic in an 837P "standard" file as the format to transfer
the data to the Vendor. Services Provider and City shall agree to the frequency of regular data
transfers.
7.01 PREMISES AND SUPPORT SERVICES OF EMPLOYER.
7.01.1 Premises.
Employer shall provide Services Provider access to the premises provided
by City as a Clinic during City's normal operating hours. City shall be
responsible for maintaining and securing the safety and safekeeping of the
premises designated as the Clinic and all the equipment therein. City shall
provide heat and air conditioning,janitorial service, telephone, high speed
DSL internet access or similar such service, replace light bulbs as needed
and other materials for the Clinic. City shall maintain the safe and proper
operation of all equipment located within the Clinic.
7.01.2 Clinic Area.
City shall dedicate no less than eighty (80) square feet to be used as the
Clinic.The Clinic shall be in close proximity to toilet facilities,to the extent
reasonably practicable, shall be equipped with a sink. In the event City
desires to offer Clinician services at the Clinic to spouses or dependents of
employees, City shall attempt to provide access to the Clinic from the
exterior of the facility through an administrative or otherwise convenient
public access way.
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7.01.3 Hours of Clinic Operation.
The weekly schedule for the hours of operation of the Clinic will be
mutually agreed upon by City and Services Provider. Changes to the weekly
schedule may be made only with the mutual consent of Services Provider
and City.
7.01.4 Scheduling.
Scheduling will be performed through Services Provider's scheduling
system through either online service, via 800 call number, and or Service
Provider's supplied substitute.
8.01 COSTS
8.01.1 Compensation:
Costs listed on Exhibit"C," shall be the basis of any charges collected by
Services Provider.
8.01.2 Method of Payment:
City agrees to remit payment using Automated Clearing House electronic
funds transfers (ACH) by the twentieth (20th) day of the month the invoice
is received from Services Provider. In the event that payment is not received
by Services Provider on the twentieth (20tH) a late payment penalty in the
amount of one and one-half percent (1 V2 %) per month shall accrue on the
unpaid balance for each month or fraction thereof that payment is late.
9.01 PRIVACY AND SECURITY OF EMPLOYEE HEALTH INFORMATION
Services Provider and City acknowledge and agree that some of the services provided
under this Agreement may involve the sharing of protected health information ("PHI" as defined
under 45 C.F.R. Section 164.501) of City's workforce. Service Provider agrees to maintain the
privacy of such information in accordance with the business associate provisions set forth under
the Privacy Regulations adopted by the United States Department of Health and Human Services
pursuant to HIPAA. In furtherance thereof, Services Provider and City agree to execute the
Business Associate Agreement, attached as Exhibit"D" and incorporated herein by reference.
The parties agree to revise the Business Associate Agreement as necessary in order to
comply with current or subsequent regulations adopted pursuant to HIPAA and as mutually agreed
upon by the parties.
10.01 CONFIDENTIALITY OF INFORMATION
Each party shall keep confidential, and shall not divulge to any other party, all proprietary
and confidential information of the other party including, but not limited to, information relating
to such matters as finance, methods of operation and competition, pricing, marketing plans and
strategies, operation requirements and information concerning personnel,or suppliers,unless such
information: (i) is or becomes generally available to the public other than as a result of disclosure
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by the party, or (ii) is required to be disclosed by law or b a judicial, administrative or regulatory
authority.
The parties acknowledge that City is a local government subject to the Texas Public
Information Act, Chapter 552 of the Government Code.
Upon termination of this Agreement, each party agrees to return to the other all proprietary
infonnation of the other party in their possession including,without limitation, any documentation
evidencing City's or Service Provider's policies and procedures, or, give written assurances of its
destruction.
11.01 NON-APPROPRIATION AND FISCAL FUNDING
This Agreement is a commitment of City's current revenues only. It is understood and
agreed that City shall have the right to terminate this Agreement at the end of any City fiscal year
if the governing body of City does not appropriate funds sufficient to purchase the services as
determined by City's budget for the fiscal year in question. City may effect such termination by
giving Services Provider a written notice of termination at the end of its then current fiscal year.
City shall provide Services Provider with as much advance warning as possible regarding budgeting
concerns.
12.01 TAXES
City is exempt from Federal Excise and State Sales Tax;therefore,tax shall not be included
in Services Provider's charges.
13.01 ORDERS PLACED WITH ALTERNATE SERVICES PROVIDERS
If Services Provider cannot provide the goods as specified, City reserves the right and
option to obtain the products from another supplier or suppliers.
14.01 INSURANCE
Services Provider shall meet all insurance requirements as stated in the attached RFQ,
including all attachments and exhibits thereto, and Services Provider's bid response.
All services provided at the Clinic shall be provided in accordance with Texas law
governing the operation of each Clinic, including, supervision of each Clinician by a Group as
required by the laws of the State of Texas. Each Clinician and Group shall obtain and keep in force
a policy of(a)professional liability(malpractice) insurance with a minimum coverage of
$1,000,000 for each incident and $3,000,000 annually for the aggregate of all claims and (b)
worker's compensation insurance as required by the laws of the State of Texas covering its
Clinician and any other employees or contractors providing services on City's premises pursuant
to this Agreement.
15.01 CITY'S REPRESENTATIVE
City hereby designates the following representative authorized to act in its behalf with
regard to this Agreement:
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Tyler Jarl
Human Resources Department
221 East Main Street
Round Rock, Texas 78664
16.01 RIGHT TO ASSURANCE
Whenever either party to this Agreement, in good faith, has reason to question the other
party's intent to perform hereunder, then demand may be made to the other party for written
assurance of the intent to perform. In the event that no written assurance is given within the
reasonable time specified when demand is made, then and in that event the demanding party may
treat such failure as an anticipatory repudiation of this Agreement.
17.01 DEFAULT
If Services Provider abandons or defaults under this Agreement and is a cause of City
purchasing the specified goods or services elsewhere, Services Provider agrees that it may be
charged the difference in cost, if any, and that it will not be considered in the re-advertisement of
the service and that it may not be considered in future bids for the same type of work unless the
scope of work is significantly changed.
Services Provider shall be declared in default of this Agreement if it does any of the
following:
A. Fails to fully, timely and faithfully perform any of its material obligations
under this Agreement;
B. Fails to provide adequate assurance of performance under the "Right to
Assurance" section herein; or
C. Becomes insolvent or seeks relief under the bankruptcy laws of the United
States.
If either party defaults in the performance of its obligations hereunder, the non-defaulting
party shall provide written notice of default to the defaulting party. The defaulting party shall have
thirty (30) days to cure the breach to the reasonable satisfaction of the nondefaulting party. If the
defaulting party does not cure the breach to the satisfaction of the nondefaulting party, this
Agreement shall automatically terminate.
18.01 TERMINATION
A. City has the right to terminate this Agreement, in whole or in part, for convenience
and without cause, at any time during the initial twelve (12) month term upon sixty
(60) days' written notice to Services Provider.
B. In the event a Clinician resigns, quits or is terminated or otherwise unwilling to
continue at the Clinic location and Services Provider is unable to find a suitable replacement after
employing reasonable commercial efforts,either party may immediately terminate this Agreement.
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C. Services Provider has the right to terminate this Agreement only for cause, that
being in the event of a material and substantial breach by City,or by mutual agreement to terminate
evidenced in writing by and between the parties.
D. In the event City terminates under subsections (A) or (B) of this section, the
following shall apply: Upon City's delivery of the referenced notice to Services Provider, Services
Provider shall discontinue all services in connection with the performance of this Agreement and
shall proceed to cancel promptly all existing orders and contracts insofar as such orders and
contracts are chargeable to this Agreement.Within thirty(3 0)days after such notice of termination,
Services Provider shall submit a statement showing in detail the goods and/or services
satisfactorily perfonned under this Agreement to the date of termination. City shall then pay
Services Provider that portion of the charges, if undisputed. The parties agree that Services
Provider is not entitled to compensation for services it would have performed under the remaining
term of the Agreement except as provided herein.
19.01 INDEMNIFICATION
Services Provider shall defend (at the option of City), indemnify, and hold City, its
successors, assigns, officers, employees and elected officials harmless from and against all suits,
actions, legal proceedings, claims, demands, damages, costs, expenses, attorney's fees, and any
and all other costs or fees arising out of, or incident to, concerning or resulting from the fault of
Services Provider, or Services Provider's agents, employees or subcontractors, in the performance
of Services Provider's obligations under this Agreement, no matter how, or to whom, such loss
may occur.
City agrees to indemnify, and hold Services Provider harmless from and against any and
all suits, actions, legal proceedings, claims, demands, damages, costs, expenses, attorney's fees,
and any and all other costs or fees arising out of, or incident to, concerning or resulting from the
fault of City, or City's agents, employees or subcontractors, in the performance of City's
obligations under this Agreement,no matter how,or to whom,such loss may occur.Nothing herein
shall be deemed to limit the rights of City or Services Provider (including, but not limited to the
right to seek contribution) against any third party who may be liable for an indemnified claim.
Services Provider shall require any Clinician or Group contracted to provide services to
City's employees to enter into a written agreement, satisfactory to City,to indemnify and hold City
harmless City, City's agents, employees or subcontractors, from and against any suits, claims,
liabilities, losses, or expenses including without limitation reasonable attorneys' fees, arising or
resulting from the negligent performance of professional services or acts and omissions of the
Clinician or Group.
20.01 COMPLIANCE WITH LAWS, CHARTER AND ORDINANCES
A. Services Provider,its agents, employees and subcontractors shall use best efforts to
comply with all applicable federal and state laws,the Charter and Ordinances of the City of Round
Rock, as amended, and with all applicable rules and regulations promulgated by local, state and
national boards,bureaus and agencies.
B. In accordance with Chapter 2270, Texas Government Code, a governmental entity
may not enter into a contract with a company for goods or services unless the contract contains
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written verification from the company that it: (1) does not boycott Israel; and (2) will not boycott
Israel and will not boycott Israel during the tenn of this contract. The signatory executing this
Agreement on behalf of Services Provider verifies Services Provider does not boycott Israel and
will not boycott Israel during the term of this Agreement.
21.01 ASSIGNMENT AND DELEGATION
The parties each hereby bind themselves,their successors,assigns and legal representatives
to each other with respect to the terms of this Agreement. Neither party shall assign, sublet or
transfer any interest in this Agreement without prior written authorization of the other party.
22.01 NOTICES
All notices and other communications in connection with this Agreement shall be in writing
and shall be considered given as follows:
1. When delivered personally to the recipient's address as stated in this Agreement;
or
2. Three (3) days after being deposited in the United States mail, with postage
prepaid to the recipient's address as stated in this Agreement.
Notice to Services Provider:
Healthstat, Inc.
4651 Charlotte Park Dr., Suite 300
Charlotte,NC 28217
Notice to City:
Laurie Hadley, City Manager Stephan L. Sheets, City Attorney
221 East Main Street AND TO: 309 East Main Street
Round Rock, TX 78664 Round Rock, TX 78664
Nothing contained herein shall be construed to restrict the transmission of routine
communications between representatives of City and Services Provider.
23.01 APPLICABLE LAW; ENFORCEMENT AND VENUE
This Agreement shall be enforceable in Round Rock,Texas,and if legal action is necessary
by either party with respect to the enforcement of any or all of the terms or conditions herein,
exclusive venue for same shall lie in Williamson County,Texas.This Agreement shall be governed
by and construed in accordance with the laws and court decisions of the State of Texas.
24.01 EXCLUSIVE AGREEMENT
This document, and all appended documents, constitutes the entire Agreement between
Services Provider and City. This Agreement may only be amended or supplemented by mutual
agreement of the parties hereto in writing, duly authorized by action of the City Manager or City
Council.
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25.01 DISPUTE RESOLUTION
City and Services Provider hereby expressly agree that no claims or disputes between the
parties arising out of or relating to this Agreement or a breach thereof shall be decided by any
arbitration proceeding, including without limitation, any proceeding under the Federal Arbitration
Act(9 USC Section 1-14) or any applicable state arbitration statute.
26.01 SEVERABILITY
The invalidity, illegality, or unenforceability of any provision of this Agreement or the
occurrence of any event rendering any portion or provision of this Agreement void shall in no way
affect the validity or enforceability of any other portion or provision of this Agreement. Any void
provision shall be deemed severed from this Agreement, and the balance of this Agreement shall
be construed and enforced as if this Agreement did not contain the particular portion or provision
held to be void.The parties further agree to amend this Agreement to replace any stricken provision
with a valid provision that comes as close as possible to the intent of the stricken provision. The
provisions of this section shall not prevent this entire Agreement from being void should a
provision which is of the essence of this Agreement be determined void.
27.01 MISCELLANEOUS PROVISIONS
Standard of Care. Services Provider represents that it employs trained, experienced and
competent persons to perform all of the services, responsibilities and duties specified herein and
that such services,responsibilities and duties shall be performed in a manner according to generally
accepted industry practices.
Time is of the Essence. Services Provider understands and agrees that time is of the
essence and that any failure of Services Provider to fulfill obligations for each portion of this
Agreement within the agreed timeframes will constitute a material breach of this Agreement.
Services Provider shall be fully responsible for its delays or for failures to use best efforts in
accordance with the terms of this Agreement. Where damage is caused to City due to Services
Provider's failure to perform in these circumstances, City may pursue any remedy available
without waiver of any of City's additional legal rights or remedies.
Force Majeure. Neither City nor Services Provider shall be deemed in violation of this
Agreement if it is prevented from performing any of its obligations hereunder by reasons for which
it is not responsible as defined herein. However, notice of such impediment or delay in
performance must be timely given, and all reasonable efforts undertaken to mitigate its effects.
Multiple Counterparts. This Agreement may be executed in multiple counterparts, any
one of which shall be considered an original of this document; and all of which, when taken
together, shall constitute one and the same instrument.
[Signatures on the following page]
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IN WITNESS WHEREOF, City and Services Provider have executed this Agreement on the
dates indicated.
City of Round Rock,Texas Healthstat, Inc.
By: By: .
Printed Na Printed Name:
Title: Title: w- ,
Date Signed: Date Signed: `
Attest:
By:
Sara L. White, City Clerk
For City,Approved as to Form:
By:_Stephan L. Sheets, City Attorney
LIST OF EXHIBITS:
Exhibit"A": Scope of Services
Exhibit"B": Clinician Clinic
Exhibit"C": Compensation
Exhibit"D": Business Associate Agreement
Exhibit"E": Electronic Data Sharing
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EXHIBIT "A"
SCOPE OF SERVICE
Except as otherwise provided herein, the following services are included in the capitated rate recited in
Exhibit"C":
CLINIC STAFF. Clinic staff at the Clinic defined in Exhibit B shall consist of one (1)forty(40) hour Nurse
Practitioner, one (1) Supervising Physician (not on site), one (1)forty(40) hour Medical Assistant, and one
(1)twenty(20) hour Medical Assistant.
CLINIC SERVICES. The Clinic staff will provide the following services:
• Non-emergent personal health care and wellness, subject to the Nurse Practitioner's authorized
and appropriate scope of practice, and subject further to Services Provider's policies and
procedures governing scope of service
o Scope of Services to be performed in clinic include(but not limited to):
■ Flu and Allergy Shot Administration
■ Urgent Care Services
■ Preventive Care/Physicals
■ Routine lab draws
■ Sports physicals
■ Skin Cancer Screenings
■ Referral Management/Care Coordination
o Wellness Services (provided by Nurse Practitioner) such as:
■ HRA coaching and review of results
■ Wellness-related education materials
■ Quarterly wellness seminars led by the clinic staff
■ Biometric screenings and blood pressure checks in the clinic
■ Provide health condition management programs mutually identified/agreed upon
annually as part of a strategic plan for the clinic.
■ Mammogram referrals and care coordination as needed
• Referrals to specialty and diagnostic care, or as otherwise medically advisable
• RST, Monospot, and rapid glucose CLIA testing
• Clinic Operations
o Prescriptions written by clinic providers shall be generic unless no other option is available
o Referrals to City's Employee Assistance Program (EAP) shall be given if a patient is
prescribed an anti-anxiety or anti-depressant
o Referrals to specialists shall be made by the clinic and associated documents sent to the
specialist within five (5) business days of clinic visit
• Occupational medicine and workers' compensation triage/treatment services shall be provided per
the following:
o Initial triage of any work-related injuries
o Post Offer Physical Examination
o Pre-Employment Drug Testing— Urine based (DOT and non-DOT)
o Department of Transportation ("DOT") Services
o Random, Reasonable Suspicion& Post Accident Drug Testing— Urine based (DOT and
non-DOT)
o Initial, Periodic DOT Physicals & Certifications (*)(**)
o Annual Firefighter Physicals Only
o Annual Police Physicals Only
o Initial, Periodic Criminal Justice Physicals Only
o Respirator Fit Evaluations-administer questions only
o Audiometry and Whisper Test
o Audio Booth Testing-
• Blood Alcohol Testing
o EKG
o Pulmonary Function Testing-
• Vision Testing
15
o Hep-A, Hep-B vaccines
o Minor Injuries
■ Abrasions
■ Burns
■ Contusions
■ Foreign Body Removal (splinters, small subcutaneous punctures)
■ General Medical (medications, splints, braces, etc.)
■ General triage for Musculoskeletal injuries
■ Lacerations
■ Minor Eye conditions (abrasions, Splash Injuries, foreign bodies)
■ Nail Avulsions
■ Puncture Wounds
■ Sprains/Strains
■ Work Restrictions
o Minor injury follow up
■ Bandage/Dressing Change
■ Fit for Duty Evaluation
■ General Medical
■ Suture removal
■ Wound Care
o All other occupational health or worker's compensation matters may be referred out as
medically advisable, subject to employer's workers' compensation rights
o After-hours occupational medicine shall utilize outside vendor as identified by City
o Occupational Medicine electronic tracking is not required
CENTRALIZED SCHEDULING LINE. Services Provider shall provide a toll free centralized scheduling line
for service rendered at the Clinic. The line is available 7am-8pm EST Monday through Thursday, 7am-5pm
EST Friday, and 9am-1 pm EST Saturday.
ANNUAL HEALTH RISK ASSESSMENT INCLUDING BLOOD DRAW, & ANALYSIS. Services Provider
shall provide a mass health risk assessment annually, as mutually agreed to by the parties in writing on an
annual basis. The basic health assessment shall include Services Provider's standard questionnaire,
height/weight and blood pressure collection, and blood analysis including lipid panel and glucose. The blood
will be drawn by venipuncture. Additional blood tests may be included with City approval and cost of such
additional tests will be paid by City in addition to the capitated rate.
CLINICAL&ADMINISTRATIVE SUPPLIES. Services Provider shall order and maintain necessary supplies
and equipment required for the proper operation of the Clinic. City will not be charged extra for items listed
on the attached supplies list. Should the Clinic need any supplies or equipment outside the list, Services
Provider will discuss the necessity of such purchase with City, and upon City's agreement, charge City for
said item. Service Provider will be responsible to maintain appropriate CLIA waivers and medical waste
disposal services at no additional charge to City.
REFERENCE LAB AND PATHOLOGY SERVICES. Clinicians may order labs on the attached list under the
capitated fee, which list may be amended from time to time by mutual agreement of the parties. Services
Provider will be responsible for the costs of labs not on the list or the Clinician may refer out for such labs to
be performed.
MEDICAL RECORDS. City shall pay copying charges of$0.75 per page for Participant medical records as
requested by clinic participants upon termination of this Agreement. This is not included in the capitated fee.
DATA PROCESSING AND PROGRAMMING. All data process and programming necessary to support the
proper function of the Clinic, reporting, and claims transfers are covered under the capitated fee. However,
City shall pay Service Provider a programming fee of $150 per hour for Ad Hoc reporting, data integration,
and/or testing not specifically covered under this Agreement. City and Services Provider will agree to the
number of programming hours in writing before any programming services begin. Up to 10 free hours shall
be provided annually(unused hours do not roll over). In addition, Services Provider will charge$200 for each
data exchange from Services Provider's system to City's healthcare plan or other designated recipient based
on the frequency agreed to in writing by Service Provider and City, but there will be no charge for demographic
file submissions required of City hereunder or$0 claims adjudication from Services Provider to City's TPA.
16
SUPPLIES INCLUDED IN CAPITATED FEE
Description Unit Qty
Accu-check comfort Curve Control Solution BX 1
Acetamin susp 4oz/bt 1
Advil Childrens Suspension 4oz/bt 1
Air-Lift Stool Black Ea EA 1
Albuterol Inhalation Sol 3mL 0.083%25/Bx BX 1
Alcohol Isopropyl 70% 16oz/Bt EA 2
Alcohol Prep Pads 200/Bx BX 2
Allergy Syringe w/Needle 1cc 27gx1/2" 100/Bx BX 2
Alumafoam finger splints stock EA 1
APAP Chewables not avail in LID 30/bt 1
Arm Sling Deluxe Large Ea EA 1
Arm Sling Deluxe Medium Ea EA 1
Arm Sling Deluxe Small Ea EA 1
Arromatic Ammonia Ampules(10/box) BX 1
Aspirin Tablets 325mg 250x2bx not coated Bx 1
Bandage Scissors EA 1
Bandaid Dots 100/BX BX 3
Band-Aid Sheer Strips 1"x3" 100/Bx BX 3
Benzoin tincture 40/bx 1
Betadine Solution 16oz/Bt BT 1
Betadine Swab Sticks 50/Bx BX 1
Biofreeze Pump 16oz Ea EA 1
Biohazard Protection Kit EA 2
Biopsy Punch Disposable 2mm Ea EA 3
Biopsy Punch Disposable 4mm Ea EA 3
Biopsy Punch Disposable 6mm Ea EA 3
BP Cuff-Sphygmomanometer Cuff/Bladder Latex Safe Thigh Ea EA 1
BP Cuff-Sphygmomanometer Latex Safe Large,Adult Ea EA 1
BP Cuff-Sphygmomanometer Latex Safe Regular,Adult Ea EA 1
Cauteries-Cordless Surgical Ea EA 2
Chair Blood Drawing w/Flip Arm Ea(6060-P Clinton Industries) EA 1
Cloth Surgical Tape 1"x10yd 12/Bx BX 3
Cold/Hot Pack Reusable(5)/pack PK 5
Conforming Stretch Gauze N/S 3" 12/Bg BG 2
Conforming Stretch Gauze Ster 3" 12/Bg BG 2
Cotton Balis Medium 500/Bg BG 2
Cotton Tipped Applicator Sterile 6" 100Pks/2 BX 2
CPR Microshield EA 2
Curity Gauze Sterile 2s 8ply 4"x4"50/Bx box 1
Diagnostic Set Hard Case 3.5v Ea EA 1
Diamode Anti-Diarreha Caplets(100x1 pks) BX 1
Diphendydromine SDV 50mg/ml VIAL 1
Discide Disinfectant Spray BX 2
Drape Exam Sheet 2-Ply White 40x48 100/Ca CA 2
Dual Glove Box Holder Regular Ea EA 1
Ear Basin Ea EA 4
Ear Curette Disposable White 50/Bx BX 2
17
Elastic Bandages Latex Free 4x4.5Yds 10/Bx BX 3
Elbow W/Floam Universal Surround EA EA 2
Emesis Basin 500cc Rose EA EA 2
Epinephrine 1:100 5/pk EA 2
Ethyl Chloride spray 4/bx 1
Exam Table uph 204 soft black EA 3
Eye Chart Kindergarten 11 x22" Ea EA 1
Eye Chart Plastic Snellen Ea EA 1
eye cover for eye testing EA 1
Eye Pad Oval Sterile 50/Bx BX 2
Eye Wash Irrigating 4oz/Bt BT 2
Eye Wash Unit EA 1
Fenestrated Drapes Sterile 50/Ctn BX 2
BioGlo Fluorescein Strips 1 mg 100bx BX 1
Fluoro-Dot Cobalt Blue Light Ea EA 1
Futuro Deluxe Ankle Stabilizer One Size Ea EA 1
GBG AloeGel Instant Hand Sanitizer 18OZ EA EA 3
Gelfoam 6x2/pk 1
Generic-Ceftriaxone 1 gm 10/bx 1
Generic-Ketorolac inj 30mg Ea 1
Glucometer Accu-Chek Advantage Kit Ea EA 1
Glucometer AccuChek Comfort Curve Test Strips 50/Bx BX 1
Glucose Tablets Orange 6/Bx box 1
Gooseneck Exam Lamp Dlx EA EA 1
Gown Exam 3-Ply White 30x42 50/Ca CA 2
Hydrogen Peroxide 16oz/Bt EA 1
Hydroxyzine Inj MDV, 50mg/mL 10 mL bottle Ea 1
I-Prin Ibuprofen Tabs 200mg 100x2/box bx 1
Instrument Basin w/cover Ea 1
Insufflator bulb for Welch Allyn otoscope Ea 1
Iodoform Pk Strip Sterl'/x5yd 1/Bt BT 1
Kelly Forceps Ea 1
Kenalog-40 Inj 40mg/mL 10m1/VI VIAL 1
Kleenspec Disp Otosc Specula 2.75mm 850/Bg BG 1
Kleenspec Disp Otosc Specula 4.25mm 850/Bg BG 1
Kleenspec Specula Dispenser 524 Series Ea EA 1
Knee Sleeves EA 3
Laceration Tray w/Web NH Ea EA 5
Lancets,Soft-Clik for Accu-Chek glucometer, 100/BX BX 1
Latex Gloves Medium, Powder Free 100/Bx BX 2
Lidocaine HCL Inj Non-Return 1%50ml/VI VL 3
Lidocaine w/Epi FTV Non-Ret 1%50m1/VI VIAL 1
Life-O-Gen portable oxygen EA 1
Lube Jelly 5GM foil Surgical 144bx BX 1
Marcaine No Epi FlipTop MDV.25%50m1/VI VIAL 1
Mayo Instrument Stand Chrome Single Post Ea EA 1
Medikoff Cough Drops(600/bx) BX 1
MediRip bandage 3" 12/bx 1
Minor Laceration Tray w/Instr Ea EA 4
18
Description Unit Qty
N95 Particulate Respirator Masks 20/bx 1
Nail splitter 6"straight Ea 1
Nebulizer(Micro Mist)Delivery Sets, Small Volume EA 20
Nebulizer(Pulmo-Aide)Ea EA 1
Needle Disposable 18gx1-1/2" 100/Bx BX 1
Needle Disposable 21 gx1-1/2" 100/Bx BX 1
Needle Disposable 25gx1" 100/Bx BX 1
Needle Disposable 27gx1/2" 100/Bx BX 1
Neosporin Ointment 1 oz/Tb TUBE 2
Nitroquick Sublingual Tablets 0.4mg 100/Bt BT 1
One Step HCG Cassette Test Kit 25/Bx BX 1
One Step Strep A Dipstick Test Kit 25/Bx BX 1
Paper Tape(1 inch) BX 1
Peak Flow Meter Ea EA 1
Peak Flow Meter Mouthpiece Disp 710/50 Adult 100/Bx BX 1
Phenergan, MDV, 25mg/mL 25/bx 1
Physician Scale(Health O Meter) EA 1
Pillow Disposable 20x26 Ea EA 2
Pillowcase White 21"x30" 100/Ca CA 2
Pink Pepto Bismuth Tablets(2 boxes of 30) BOX 3
Plastic Medicine Cups box 2
Poster—Dangers of Smoking EA 1
Poster—Ear, Nose,&Throat EA 1
Poster-Heart EA 1
Poster—Keys to Healthy Eating EA 1
Poster—Understanding Allergies EA 1
Poster—Understanding Asthma EA 1
Poster—Understanding Diabetes EA 1
Poster—Understanding the Common Cold EA 1
Procedure Masks(patient and/or staff 50/bx 1
Reflex Hammer,Taylor Hammerchrom 7'/2" Ea EA 1
Refrigerator/Freezer Thermometer EA 2
Replacement Bulb for exam light EA 3
Safety Glasses w/Side Shields, Clear EA 1
Sani-Cloth Plus Large 6"X6.75 160/Pk PK 2
Scalpels Disposable Sterile#11 10/Bx BX 1
Silver Nitrate Applicators 100/vl 1
Silver Sulfadiazine Cream 1%50gm/Jr JR 1
Small paper bags(pt. urine transport) PACK 1
Sodium Chloride 0.9% Irrig 1000mL/Ea EA EA 2
Speculum Vag Disposable SM 10/bx BX 1
Speculum Vag Disposable MED 10/bx BX 1
Speculum Vag Disposable LRG 10/bx BX 1
Sphygmomanometer Standatd Blue Child Ea EA 1
Spill Kit EA 3
Sponge Non-Sterile 2"x2"4ply 200/Pk PK 3
Sponge Sterile 2"x2"2's 50/Pk PK 3
Sponge,TruGauze Non Sterile 2"x2"4ply 200/Pk PK 3
Stadiometer Wall Mounted Ea EA 1
19
staple removers(disposable) EA 2
Steristrips 50/bx 1
Stethoscope(Littmann Lightweight II, Black) EA 1
Sundry Jr Plas W/cvr Labeled(5 Jars) EA 1
Surgeon Glove Size 7 50Pr/Bx box 1
Surgical Tape, Durapore 1"x10yds 12/Bx BX 2
Surgilube(KY Jelly) 144/box BX 1
Surround Ankle w/Air 10"Right EA EA 2
Surround Ankle W/Air 10"LEFT EA EA 2
Suture Nylon 5-0 DSM13 5-0 12/Bx BX 1
Suture Removal Kit w/Scissors 4/Pack PACK 5
Syringes Luer Lok Disp 10cc/ml 100/Bx BX 1
Syringes Luer Lok Disp 20cc 25/Bx BX 1
Syringes Luer Lok Disp 5cc 100/Bx BX 1
Syringes w/Needle LL Disp 3cc 23gx1" 100/Bx BX 1
System Illuminator Vaginal Ea EA 1
Table Exam 204 Base Only EA 1
Table Paper Smooth White 18"x225' 12RI/Ca CASE 1
Tape Measure 72"Long Ea EA 1
Test Tube Rack 48-16mm Ea EA 1
Tetanus,diptheria tox Adsorbed,Adult, 10 doses SDV 1
Tetracaine Ophthalmic Solution 0.5% 15ml/Bt BT 1
Thermometer Covers Sheath Digital BX 1
Thermometer Digital Welch Allyn EA 1
Tongue Depressors Blades N/S Senior#10 100/Bx BX 2
Towelettes w/BZK Bx BX 1
Tuberculin PPD(Mantoux) 10 doses MDV 1
Tylenol 500mg UD 50x2/box Bx 1
UltraSense PF Nitrile Glove Large 100/Bx BX 1
UltraSense PF Nitrile Glove Medium 100/Bx BX 1
UltraSense PF Nitrile Glove Small 100/Bx BX 1
Underpads 200/ca 1
Underpad 23x36 50/Bx BX 1
Unna Boot 4"width Ea 1
Uri spec 11-Way 100/13t BT 1
Vaginal Specula Disposable Medium 25/Bx BX 1
Vaginal Specula Disposable Small 25//Bx BX 1
Verruca-Freeze 175 mL kit EA 1
Washbasin Ea 1
Wavicide Gal/ea 1
Wavicide Indicator Strips 50/bt 1
Welch Allyn Audioscope 1 1
Wrist Brace Elastic Black X-Large Ea EA 1
Wrist Brace Elastic Large Ea EA 1
Wrist Brace Elastic Medium Ea EA 1
Wrist Brace Elastic Small Ea EA 1
20
LABS INCLUDED IN CAPITATED FEE
CPT Code Test Description CPT Code Test Description
82570,84156 24 HR TOTAL URINE PROTEIN 8,669,586,696 HSV 1/2 Herpeselect
86900,86901 ABO GRP AND RH TYPE 87275,87276 INFLUENZA A,B DFA
82040 ALBUMIN 83525 INSULIN
84075 ALKALINE PHOSPHATASE 83540,83550 IRON,TOTAL,&IBC%,SAT
84460 ALT 83540 IRON,TOTAL
82150 AMYLASE 83615 LDH
86038 ANA W/RFX 83690 LIPASE
84450 AST 80061 LIPID PANEL
80048 BASIC METAB PNL 80061 LIPID Panel w/Reflex DLDL
82248 BILIRUBIN,DIRECT 80178 LITHIUM
82247 BILIRUBIN,TOTAL 83002 LUTEINIZING HORMONE
84520 BUN 86618 LYME AB-WB CONFIRM
86304 CA125 83735 MAGNESIUM
82310 CALCIUM 82043 Microalbumin,urine without Cr
80156 CARBAMAZEPINE,TOTAL 82043,82570 Microalbumin,urine w/Cr
82374 CARBON DIOXIDE 83887 Nicotine and Metabloite,blood
86141 CARDIO CRP 80185 PHENYTOIN
85027 CBC 84100 PHOSPHOROUS
85025 CBC(DIFF/PLT) 84132 POTASSIUM
82378 CEA 84703 PREGNANCY TEST-SERUM/QUALITATIVE
PREGNANCY TEST-
87110 Chlamydia&GC Culture w/reflex 84702 SERUM/QUANITIATIVE
82435 CHLORIDE 84144 PROGESTERONE
82465 CHOLESTEROL,TOTAL 84146 PROLACTIN
82550 CK,TOTAL 84155 PROTEIN,TOTAL
80053 COMP METAB PNL CMP 85610 PROTHROMBIN TIME WITH INR
84681 C-PEPTIDE 84153 PSA
82565 CREATININE W/EGFR 82310,83970 PTH,INTACT&CALCIUM
86140 CRP 85730 PTT,ACTIVATED
87491,87591 CT/NG DNA,SDA,w/Thin Prep 85045 RETICULOCYTE COUNT
87491,87591 CT/NG SDA 86431 RHEUMATOID FACTOR
87070 CULTURE,AEROBIC BACTERIAL 86592 RPR MONITOR W/REFL
CYCLIC CITRULINATED PEPTIDE AB
86200 IGG 86592 RPR(DX)REFLFTA
82627 DHEA-SULFATE 86762 RUBELLA IGG AB
21
CPT Code Test Description CPT Code Test Description
80162 Digoxin Level 85652 Sed Rate
83721 Direct LDL 84295 Sodium
80051 Electrolyte Panel 84480 T3 Total
82670 ESTRADIOL 84479 T3 Uptake
82728 Ferritin 84481 T3 Free
82746 Folic Acid 84439 T4,free
83001 FSH 84436 T4,TOTAL
87070 GENITAL CULTURE 84403 TESTOSTERONE,TOTAL
82977 GGT 84402,84403 TESTOSTERONE,FREE&TOTAL
82947 GLUCOSE 88142 THINPREP PAP W/OUT REFLEX
87081 88142,87491,87591,
GROUP A STREP CULTURE 87661 THINPREP W/REFLEX HPV
THINPREP W/COMP.ASSIST/REFLEX
87081 GROUP B STREP CULTURE 88175 HPV
86677 H.Pylori IGA,Ab 87070 THROAT CULTURE(BACK-UP)
86677 H.Pylori IGg,Ab Qua] 86800 THYROGLOBULIN AB
86677 H.Pylori IGM,Ab 86376 THYROID PEROXID AB
86677 H.Pylori IGG,Quant 84478 TRIGLYCERIDES
83718 HDL-CHOLESTEROL 84443 TSH
85014 HEMATOCRIT 84443 TSH W/REFLEX T-4,FREE
85018 HEMOGLOBIN 81001 UA COMPLETE(dip and micropscopic)
83036 HEMOGLOBIN A1C 81001 UA COMPLETE(REFLEX TO CULTURE)
86705 HEP B CORE IGM AB 81003 UA,DIPSTICK(reflex to microscopic)
86317 HEP B SURFACE AB ON 81005 URIC ACID
86706 HEP B SURFACE ANITBODY 81003 URINALYSIS,MACROSCOPIC
87340 HEP B SURFACE ANTIGEN 87086 URINE CULTURE(ROUNTINE)
86803 HEP C ANTIBODY 80164 VALPROIC ACID
80076 HEPATIC FUNCTION PANEL 8370184478 VAP Cholesterol Test
86709 HEPATITIS A,TOTAL 82306 VIT D 250H LC/MS/MS
86704 HEPATITIS B CORE ANTIBODY 82607 VITAMIN B12
80074 HEPATITIS PANEL ACUTE 82607,82746 VIT B12/FOLATE,SERUM
86308 HETEROPHILE,MONO SCREEN 82652 VITAMIN D,1,25 DIHYDROXY
86701 HIV 82652 VITAMIN D,1,25
87624 87070 87075,87205 WOUND CULTURE,A&A W/GRAM
HPV,DNA,AMP PROBE STAIN
22
EXHIBIT "B"
CLINICIAN CLINIC
Clinic(s) shall be opened at the location(s) and for the number of operating hours at each location as
described in the table below.
Clinic Name City, State Number of Hours of Clinic
Operation Per Week
The City of Round Rock Round Rock, TX 40 hours per week
If the clinic is normally scheduled on the following holidays, please know that it will be
closed: New Years, Good Friday, Memorial Day, July 4t", Labor Day, Thanksgiving Day,
and Christmas.
The clinic will be closed the following
in any given 52-week period: 2 Weeks for Vacation
1 Week for Continuing Education
*Healthstat can provide coverage for additional absences occasioned by clinic staff for an agreed
upon "fill-in" rate.
*Each four(4) hours of clinic time requires thirty(30) minutes of administrative time for each
diagnosing and treating staff member. The administrative time is included in the above table.
17
EXHIBIT "C"
SERVICE COST
(COSTS ON THE FOLLOWING PAGE)
18
City of Round Rock, TX - Healthstat 2018 Fee
Monthly Annually
Current Service/Staffing Offering
1/1/2018-12/31/2018 $59,729.35 $716,752.20
Effective 1/1/2019-3/31/2019 $67,025.00 $804,300.00
Assumptions:
1. Pricing is flat rate and independent of participants The total annual fees will be invoiced 1/12 each
month.
2. Consult Exhibit A regarding what is included in the capitated rate and the rates for items falling outside
the covered Scope of Services.
healtl-stat
EXHIBIT "D"
FORM OF BUSINESS ASSOCIATE AGREEMENT
This Agreement is made effective January 1, 2018 (the "Effective Date") between
City of Round Rock group health plan ("Covered Entity"), and Healthstat, Inc. ("Business
Associate"). The parties referenced above may be referred to individually as "Party" and collectively
as"Parties."
WITNESSETH
WHEREAS, the Parties wish to enter into or have entered into an agreement whereby Business Associate
will provide certain healthcare services to Covered Entity("Services Agreement");
WHEREAS, pursuant to such Services Agreement, Business Associate may be considered a "business
associate" of Covered Entity as defined in the Health Insurance Portability and Accountability Act of 1996
("H I PAX);
WHEREAS, Business Associate may have access to Protected Health Information and Electronic Protected
Health Information (each as defined below) in fulfilling its responsibilities and obligations under such
Services Agreement;
WHEREAS, HIPAA establishes certain obligations for a covered entity under regulations known as the
Privacy Rules ("Privacy Rules") and the Security Rules ("Security Rules") when a business associate has
access to Protected Health Information and Electronic Protected Health Information of the Covered Entity;
WHEREAS, Title XII of Division A and Title IV of Division B, called the "Health Information Technology for
Economic and Clinical Health("HITECH")of the American Recovery and Reinvestment Act of 2009"expand
on the mandates of the Privacy Rules and the Security Rules (all references herein to the Privacy Rules
and the Security Rules are deemed to include all amendments to such rule contained in HITECH and any
accompanying regulations, and any other subsequently adopted amendments or regulations); and
WHEREAS, the Parties wish to enter into this Agreement in order to comply with HIPAA's Privacy Rules
and Security Rules.
AGREEMENT
THEREFORE, in consideration of the Parties' continuing obligations under the Services Agreement, and
compliance with HIPAA's Privacy Rules and Security Rules, and for other good and valuable consideration,
the receipt and sufficiency of which is hereby acknowledged, the Parties agree to the provisions of this
Agreement in order to address the requirements of the HIPAA Privacy and Security Rules and to protect
the interests of the Parties.
DEFINITIONS
Except as otherwise defined herein, any and all capitalized terms in this Agreement shall have the
definitions set forth in the HIPAA Privacy and Security Rules (collectively, the "Rules"). In the event of an
inconsistency between the provisions of this Agreement and mandatory provisions of the Rules, as
amended, the applicable provisions of the Rules shall control. Where provisions of this Agreement are
different than those mandated in the Rules, but are nonetheless permitted by the Rules, the provisions of
this Agreement shall control.
The term "Protected Health Information" shall be referred to in this Agreement as "PHI" and means
individually identifiable health information including, without limitation, all information, data, documentation
and materials, including without limitation, demographic, medical and financial information, that relates to
the past, present or future physical or mental health or condition of an individual; the provision of health
19
care to an individual; or the past, present or future payment for the provision of health care to an individual;
and that identifies the individual or with respect to which there is a reasonable basis to believe the
information may be used to identify the individual."Electronic Protected Health Information"shall be referred
to in this Agreement as "EPHI" and means PHI that is transmitted by or maintained in electronic media.
Business Associate acknowledges and agrees that all PHI and EPHI that is created or received by Covered
Entity and maintained, disclosed, transmitted or otherwise made available in any form, including paper
record, oral communication, audio recording, and electronic media by Covered Entity or its operating units
to Business Associate or is created, received, maintained or transmitted by Business Associate on Covered
Entity's behalf is the property of the Covered Entity and shall be subject to this Agreement. Notwithstanding
the above, Covered Entity acknowledges and agrees that certain services provided under the Services
Agreement involve the delivery of health care services, in which capacity Business Associate is a separate
"covered entity." Therefore, the terms of this Agreement apply only when Business Associate is acting in
its role as a"business associate"to Covered Entity. When Business Associate is acting in its role as health
care provider and not a "business associate" to Covered Entity, the terms of this Agreement do not apply
and Business Associate shall be the owners of all such PHI and EPHI.
PERMITTED USES OF PHI AND EPHI BY BUSINESS ASSOCIATE
Business Associate is only authorized to use or disclose PHI and EPHI as set forth in this Agreement. All
other uses or disclosures of PHI and EPHI are prohibited. Business Associate agrees to use or disclose
PHI or EPHI solely:
(1) For fulfilling its obligations as set forth in the Services Agreement, or any other agreement
evidencing the business relationship between the Covered Entity and the Business Associate,
provided that such use or disclosure would not violate the Privacy Rule if done by the Covered
Entity.
(2) As required by applicable law, rule or regulation.
(3) As otherwise expressly permitted under this Agreement or the Services Agreement.
(4) If necessary for the proper management and administration of Business Associate or to carry out
the legal responsibilities of Business Associate; provided that, as to any such disclosure, the
following requirements are met:
(a) the disclosure is required by law; or
(b) Business Associate obtains reasonable written assurances from the person to whom the
information is disclosed that(1)it will remain confidential and used or further disclosed only
as required by law or for the purpose for which it was disclosed to the person, and
(2)the person notifies Business Associate of any instances in which the confidentiality of
the information has been breached.
(5) For data aggregation services, if to be provided by Business Associate for the health care
operations of Covered Entity pursuant to any agreements between the Parties evidencing their
business relationship. For purposes of this Agreement, data aggregation services means the
combining of PHI or EPHI by Business Associate with the PHI or EPHI received by Business
Associate in its capacity as a business associate of another covered entity, to permit data analyses
that relate to the health care operations of the respective covered entities.
(6) In a manner consistent with Covered Entity's minimum necessary policies and procedures.
Business Associate will request, use and disclose (including to its workforce, contractors,
subcontractors, or agents)the minimum PHI necessary to perform or fulfill its function or to comply
with its duties under the Services Agreement.
Business Associate acknowledges and agrees that any use or disclosure of PHI by Business Associate
not expressly permitted under the Services Agreement or this Agreement is prohibited.
20
DUTIES OF THE BUSINESS ASSOCIATE
The Business Associate represents and agrees to perform the following duties:
(1) Not use or disclose PHI other than as permitted or required by this Agreement or as required by
law.
(2) Implement and enforce appropriate safeguards to detect and to prevent the use or disclosure of
PHI and EPHI other than as permitted in this Agreement. This shall include, but not be limited to,
taking reasonable steps to ensure that its employees' and agents' actions or omissions do not
cause Business Associate to breach the terms of this Agreement. With specific regard to EPHI,
Business Associate shall implement administrative, physical and technical safeguards that
reasonably and appropriately protect the confidentiality, integrity and availability of the EPHI that it
creates, receives, maintains or transmits on behalf of the Covered Entity. Business Associate shall
de-identify all PHI and EPHI as directed by HIPAA prior to taking it off-site, to the extent Business
Associate does not require such PHI and EPHI to perform its functions, activities or services on
behalf of Covered Entity. Business Associate will comply, pursuant to HITECH and its
implementing regulations,with all applicable requirements of the Security Rule contained in 45 CFR
§§164.308, 164.310, 164.312 and 164.316 at such time as the requirements are applicable to
Business Associate.
(3) Ensure that its agents, including subcontractors, to whom it provides PHI and EPHI agree in writing
to the same restrictions and conditions that apply to Business Associate under this Agreement and
agree to implement reasonable and appropriate safeguards to protect such PHI and EPHI.
(4) Allow the Secretary of Health and Human Services ("Secretary") and the Covered Entity the right
to audit Business Associate's internal records and practices related to the use and disclosure of
PHI and EPHI to ensure Covered Entity is in compliance with HIPAA. Business Associate shall fully
cooperate with the Secretary in this audit. Business Associate shall also provide Covered Entity
with a full copy of the information made available under this provision.
(5) Make PHI and EPHI available to the Covered Entity in response to an individual's request for
access to PHI as required by 45 CFR § 164.524.
(6) Make PHI and EPHI available as directed by the Covered Entity for amendment and incorporate
any amendments as directed by the Covered Entity and as required by 45 CFR §164.526.
(7) Document such disclosures of PHI and EPHI and information related to such disclosures as would
be required to respond to a request by an individual for an accounting of disclosures of PHI under
45 CFR § 164.528 of HIPAA.
(8) (a)Advise Covered Entity if any use or disclosure of PHI or EPHI by Business Associate,
its employees, agents or subcontractors did not comply with the terms of this Agreement.
(b) Report to Covered Entity any"Security Incident" of which it becomes aware, as such term
is defined in the security regulations of the HIPAA Privacy and Security Rule. Provided, the
Parties agree that this Section constitutes notice by Business Associate to Covered Entity
of the ongoing existence and occurrence of attempted but Unsuccessful Security Incidents
(as defined below)for which no other additional notice to Covered Entity shall be required.
"Unsuccessful Security Incidents" shall include pings and other broadcast attacks on
Business Associate's firewall, port scans, unsuccessful log-on attempts, denials of service
attacks that do not result in a server being taken offline, and any combination of the above,
so long as no such incident results in any of the following: (i) unauthorized access, Use,
Disclosure, modification, or destruction of PHI; (ii) modifications to Business Associate's
security policies or procedures; (iii) modifications to Business Associate's safeguarding
measures; (iv) interference with Business Associate's operations; or (v) interference with
Business Associate's information system.
(c) Following the discovery of a Breach of Unsecured PHI, as such terms are defined in the
security regulations of the HIPAA Privacy and Security Rule, notify Covered Entity of such
Breach in accordance with 45 CFR §164.410. A Breach shall be treated as discovered by
21
Business Associate as of the first day on which such Breach is known to Business
Associate. Business Associate will provide such notification to Covered Entity without
unreasonable delay and in no event later than sixty(60) calendar days after the discovery
of the Breach. Such notification will contain the elements required in 45 CFR
§164.410.
(d) The parties will work together to conduct a risk assessment and determine if there is a
Breach requiring notification under 45 CFR § 164.404. If notification is required, the
parties will cooperate in issuing any required notices and will comply with the notification
requirements under 45 CFR§ 164.410. Business Associate will notify Covered Entity prior
to making any notification of breaches relating to Covered Entity's PHI.
These duties are in addition to any duties that Business Associate may have directly under
HIPAA for breach notification.
(9) Mitigate, to the extent practicable, any harmful effect that is known to Business Associate of an
improper or unauthorized use or disclosure of PHI or EPHI, provided that, Business Associate shall
notify Covered Entity of its mitigation efforts.
(10) To the extent Business Associate is to carry out one or more of the Covered Entity's obligation(s)
under Subpart E of 45 CRF Part 164, comply with the requirements of Subpart E that apply to the
Covered Entity in the performance of such obligation(s).
(11) Make its policies, procedures, and documentation available to the Secretary of the U.S. Department
of Health and Human Services, and, at Covered Entity's request, to the Covered Entity, for
purposes of the Secretary determining compliance with the HIPAA Privacy and Security Rules.
Business Associate will not directly or indirectly receive remuneration in exchange for any PHI, subject to
the exceptions contained in the HITECH Act, without a valid authorization from the applicable individual.
Business Associate will not engage in any communication which might be deemed to be"marketing" under
the HITECH Act.
TERM AND TERMINATION
(1) Term. The term of this Agreement shall be effective as of the Effective Date, and shall terminate
upon the termination of the Services Agreement or no the date Covered Entity terminates this
Agreement for cause as authorized in Subsection 2(b) below, whichever is sooner.
(2) Termination rights. Upon Covered Entity's knowledge of a material breach of this Agreement by
Business Associate, notwithstanding anything in this Agreement or the Services Agreement to the
contrary, Covered Entity shall have the right to either:
(a) Provide an opportunity for Business Associate to cure the breach or end the violation and
terminate this Agreement and the Services Agreement if Business Associate does not cure
the breach or end the violation within the time specified by the Covered Entity;or
(b) Immediately terminate this Agreement and the Services Agreement.
RETURN OR DESTRUCTION OF PHI AND EPHI
Upon termination of this Agreement, the Services Agreement or upon request of Covered Entity, whichever
occurs first, Business Associate will, if feasible, return or destroy all PHI and EPHI received from or created
by Business Associate on behalf of Covered Entity. Business Associate shall return to Covered Entity or
destroy all PHI and EPHI in any form and retain no copies.
If return or destruction of the PHI and EPHI is not feasible, then Business Associate shall:
(1) Retain only that PHI and EPHI which is necessary for Business Associate to continue its proper
management and administration or to carry out its legal responsibilities;
(2) Return to Covered Entity [or, if agreed to by Covered Entity, destroy] the remaining PHI and EPHI
22
that Business Associate still maintains in any form;
(3) Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with respect
to EPHI to prevent use or disclosure of the PHI, other than as provided for in this subsection, for
as long as Business Associate retains the PHI;
(4) Not use or disclose the PHI retained by Business Associate other than for the purposes for which
such PHI was retained and subject to the same conditions which applied prior to termination; and
(5) Return to Covered Entity[or, if agreed to by Covered Entity, destroy] the PHI retained by Business
Associate when it is no longer needed by Business Associate for its proper management and
administration or to carry out its legal responsibilities.
MISCELLANEOUS
(1) Restriction of Rights. Except as expressly stated herein or in HIPAA, the Parties do not intend to
create any rights in any third parties.
(2) Survival. The obligations of Business Associate under this Agreement shall survive the expiration,
termination or cancellation of this Agreement, the Services Agreement and/or the business
relationship of the parties, and shall continue to bind Business Associate, its agents, employees,
contractors, successors and assigns as set forth herein.
(3) Entire Agreement; Amendment. This Agreement supersedes all agreements previously made
between the parties relating to its subject matter, including but not limited to any previously
executed business associate agreements. There are no other understandings or agreements
between them.This Agreement may be amended or modified only in a writing signed by the Parties.
Notwithstanding the foregoing, the Parties agree that this Agreement shall amend automatically to
comply with any changes in the regulations and legislation governing HIPAA and to comply with
any other relevant state or federal law, and shall incorporate all such changes without the need for
a writing signed by the Parties.
(4) Non-assignment. No party may assign its respective rights and obligations under this Agreement
without the prior written consent of the other party.
(5) Relationship. None of the provisions of this Agreement are intended to create, nor will they be
deemed to create, any relationship between the Parties other than that of independent parties
contracting with each other solely for the purposes of effecting the provisions of this Agreement
and any other agreements between the Parties evidencing their business relationship.
(6) Waiver. No change, waiver or discharge of any liability or obligation hereunder on any one or more
occasions shall be deemed a waiver of performance of any continuing or other obligation, or shall
prohibit enforcement of any obligation, on any other occasion.
(7) Controlling Terms. The Parties agree that, in the event that any documentation of the agreement
pursuant to which Business Associate provides services to Covered Entity contains provisions
relating to the use or disclosure of PHI and EPHI that are more restrictive than the provisions of
this Agreement, the provisions of the more restrictive documentation will control. Otherwise, the
terms of this Agreement shall control.
(8) Minimum Standards.This Agreement is intended to establish the minimum requirements regarding
Business Associate's use, protection and disclosure of PHI and EPHI.
(9) Severability. In the event that any provision of this Agreement is held by a court of competent
jurisdiction to be invalid or unenforceable, the remainder of the provisions of this Agreement will
remain in full force and effect. In addition, in the event a party believes in good faith that any
provision of this Agreement fails to comply with the then-current requirements of HIPAA, such party
shall notify the other party in writing. For a period of up to thirty(30)days, the parties shall address
such concern in good faith and amend the terms of this Agreement if necessary to bring it into
compliance with HIPAA. If, after such thirty (30) day period, the Agreement fails to comply with
HIPAA, then either party has the right to terminate upon written notice to the otherparty.
23
(10) Governing Law. To the extent not pre-empted by federal law, this Agreement will be governed by
the laws of the State of Texas.
[Signatures on the following page.]
24
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the day and year
written above.
COVERED ENTITY:
CITY OF ROUND ROCK, GROUP
HEALTH PL N
By:
Name: 14/M&A(A
Title: YVIGtV (/7,�
BUSINESS ASSOCIATE:
HEALTHSTAT, INC.
� E
By:
Name: till'a1cf- M/
Title:
25
EXHIBIT "E"
Electronic Data Shariina
Following are the elements the employer is required to provide to Healthstat as described in this
Agreement.
Ae�raphic Data File Requirements
Below are the general guidelines for creating two separate files for all eligible employees and for
all eligible dependents in the program. A dependent file is not necessary if dependents are not
eligible for the program.
1. Create a tab-delimited text file or an Excel workbook file with the fields in the indicated order.
Please use the column header names exactly as specified.
2. Populate all required fields, even if the value is the same for all records—e.g.
"CompanyName," "PlantName," or"PlantLocation."
3. For optional fields that will not be populated, include the empty column(s)with the column
header(s).
4. Please format data fields as indicated, using only alphanumeric characters, numbers, or
numbers plus the special characters listed in the Field Format specified. For example, do not
use parentheses in the "Hphone" and "Wphone" columns. Do not use hyphens in the"DOB,"
"HireDate," and "TermDate" columns.
5. Send complete files monthly through your secured email site or Ftp/SFTP connection.
Healthstat would be happy to set you up an account on our SFTP server. If this is your
preference please send an email request to data(a-)-Healthstatinc.com.
File naming conventions and field definitions follow.
I. Employee File:
Description Comment Requirement Field Format
CompanyName Company Name Required Alphanumeric
Max Size: 50 characters
LastName Employee Last Name Required Alpha Characters, do not include suffix
Max Size: 50 characters
FirstName Employee First Name Required Alpha Characters
Max Size: 50 characters
MiddleName Employee Middle Name or Optional Alpha Characters
Initial Max Size: 50 characters
Alphanumeric
Suffix Employee Name Suffix Optional Max Size: 10 characters
(ex: Jr, Sr, II, III, 2nd)
Alphanumeric(numbers and hyphens
SSN Employee Social Security Required only)
Number Max Size: 15 characters
ex: 123-45-6789
Alphanumeric(numbers and slashes only)
DOB Employee Date of Birth Required Max Size: 10 Characters
m m/dd/ ex: 01/21/1956
Gender Employee Gender Required M or F
Max Size: 1 character
Alpha from list: Active, Cobra, Layoff,
PositionStatus Current Employee Status Required Leave, NoClinic, Other, Retired,
Temporary, Terminated Only
26
Description Comment Requirement Field Format
Max Size: 15 characters
Address1 Employee Home Address Required Alphanumeric
Line 1 Max Size: 50 characters
Address2 Employee Home Address Optional Alphanumeric
Line 2 Max Size: 50 characters
City Employee City Required Alphanumeric
Max Size: 50 characters
State Employee State Required Alphanumeric
Max Size: 2 characters
Alphanumeric(numbers and hyphen only,
Zip Employee Zip Code Required 5 or 9 digit zip codes)
Max Size: 10 characters
ex: 12345 or 12345-6789
Alphanumeric(numbers, '-`, `x' if
Hphone Employee Home Telephone Required extension)
Number Max Size: 50 characters
ex: 123-456-7890 x1234)
Alphanumeric (numbers, '-', `x' if
Wphone Employee Work Telephone Optional extension)
Number Max Size: 50 characters
ex: 123-456-7890 x1234
PlantName Plant Number or Name of Required Alphanumeric
Employee's Work Location Max Size: 50 characters
PlantLocation City of Employee's Required Alphanumeric
Plant/Work Location Max Size: 50 characters
Alphanumeric(numbers &slashes only)
HireDate Employee Date of Hire Required Max Size: 10 Characters
(mm/dd/ ex: 01/21/1956)
Required Alphanumeric(numbers &slashes only)
Term Date Date of Employee (if Position Max Size: 10 Characters
Termination Status = (mm/dd/yyyy ex: 01/21/1956)
Terminated
Employee's unique Optional* Alphanumeric
Custom erMemberlD insurance identifier# if (*if=SSN) Max Size: 15 characters
other than SSN #
Employee's unique Optional Alphanumeric
Custom erEmployeelD identifier#within the Max Size: 15 characters
company
InsPlanElection Code Insurance Plan Election Optional Alphanumeric
MaxSize: 10
HomeWorker Remote Employee Indicator Optional Alpha Y or N
Max Size: 1
Wellness Enrolled in Wellness Optional Alphanumberic
Program Max size: 25
II. Dependent File:
Description Comment Requirement Field Format
CompanyName Company Name Required Alphanumeric
Max Size: 50 characters
Alpha Characters, do not include
LastName Dependent Last Name Required suffix
Max Size: 50 characters
FirstName Dependent First Name Required Alpha Characters
Max Size: 50 characters
27
Description Comment Requirement Field Format
MiddleName Dependent Middle Name or Optional Alpha Characters
Initial Max Size: 50 characters
Alphanumeric
Suffix Dependent Name Suffix Optional Max Size: 10 charaters
(ex: Jr, Sr, Il, III, 2nd)
Alphanumeric(numbers and hyphens
SSN Dependent Social Security Required only)
Number Max Size: 15 characters
ex: 123-45-6789
Alphanumeric(numbers and slashes
DOB Dependent Date of Birth Required only)
Max Size: 10 Characters
m m/dd/ ex: 01/21/1956)
Gender Dependent Gender Required M or F
Max Size: 1 character
Alphanumeric
RelationCode Relationship To Employee Required Max Size: 10 characters
S ouse, Child, or Other)
Alphanumeric(numbers and hyphens
RespPartySSN Employee's Social Security Required only)
Number Max Size: 15 characters
ex: 123-45-6789)
Optional
RespPartyEmployee Employee's unique (unless Alphanumeric
ID EmployeelD EmployeelD is Max Size: 15 characters
key identifier
Optional
RespPartyMemberlD Employee's unique (unless Alphanumeric
MemberlD MemberlD is Max Size: 15 characters
key identifier)
Dependent Home Address Optional if Alphanumeric
Address1 Line 1 same as Max Size: 50 characters
employee
Address2 Dependent Home Address Optional Alphanumeric
Line 2 Max Size: 50 characters
Optional if Alphanumeric
City Dependent City same as Max Size: 50 characters
employee
Optional if Alphanumeric
State Dependent State same as Max Size: 2 characters
employee
Optional if Alphanumeric (numbers and hyphen
Zip Dependent Zip Code same as only, 5 or 9 digit zip codes)
employee Max Size: 10 characters
(ex: 12345 or 12345-6789)
Optional if Alphanumeric(numbers, '-', `x' if
Hphone Dependent Home same as extension)
Telephone Number employee Max Size: 50 characters
ex: 123-456-7890 x1234
Alphanumeric(numbers, '-', `x' if
Wphone Dependent Work Optional extension)
Telephone Number Max Size: 50 characters
(ex: 123-456-7890 x1234)
Dependent's unique Optional* Alphanumeric
Custom erMemberlD insurance identifier# if (*if= SSN) Max Size: 15 characters
other than SSN#
Claims Data File Reauired Elements
28
Claims data files should be fixed-length text files. Headers are not allowed. If delimited files are used
instead, a column header record is required. Please send documentation of your file layout and any
definitions/descriptions/formulas. Data should be in HIPAA-compliant format wherever possible.
I. Medical and Pharmacy Claims File:
Healthstat Medical Claims Fields Requested
Please include your file layout and any definitions/descriptions.
Data should be in HIPAA-compliant format wherever possible.
Description Comment Requirement
Group Number Required
Subgroup Number Optional
Claim Number Required
Line number for claim lines that belong to the same claim
Service Sequence number number Required
Paid Date MM/DD/YYYY- Critical Required
Beginning Date of Service Admit Date MM/DD/YYYY Required
Ending Date of Service Discharge Date MM/DD/YYYY Required
Process Date MM/DD/YYYY Optional
Claim Begin Date MM/DD/YYYY Optional
Claim End Date MM/DD/YYYY Optional
Patient's SSN Other term for Patient is Claimant Required
Patient's Last Name Required
Patient's First Name Required
Patient's Middle Name Optional
Patient's Gender Required
Patient's Date of Birth MM/DD/YYYY Required
Patient's City Optional
Patient's State Optional
Patient's Zip Code Optional
Patient Relationship to Policy Employee, Spouse, or Dependent Required
Holder
Code to identify uniquely each member on the policy.
Dependent Suffix Sometimes called Dependent Number or Person Code. Required
A typical code would be "01"for the policy holder, "02"
for the spouse, and "03"and higher for children.
This must be the identifier included in the Healthstat
demographic file for matching claims data to the policy
holder. This ID may be the SSN, but it may be the
Policy Holder Number Required
insurance carrier's internal member ID or the company's
employee ID. Other terms for Policy Holder are
Subscriber, Insured, and Employee.
Policy Holder's SSN Required in addition to Policy Holder Number Required
Policy Holder's Last Name Required
Policy Holder's First Name Required
Policy Holder's Gender Required
Policy Holder's Date of Birth MM/DD/YYYY Required
Policy Holder's Zip Code Optional
I-Inpatient; O-Outpatient; P-Professional (physician-
In/Out Flag related) Optional
29
Place of Service Code *Please provide a separate list of place of service codes Required*
and descriptions if description is not included in file.
*Please provide a separate list of service type codes and
descriptions if description is not included in file. These
are high-level descriptions of the service such as
Service Type Code HEMODIALYSIS, SURGERY, MATERNITY, Optional
ANESTHESIA, X-RAY(DIAGNOSTIC), AND MEDICAL
CARE (INPATIENT & OUTPATIENT). Details are
provided in the CPT4 procedure codes.
Procedure Code CPT4 Procedure Code _ Required
Procedure Modifier Standard CPT4 Modifier Optional
UB92 Revenue Code UB92 FL42 Optional
Primary Diagnosis Code ICD9 Diagnosis Codes Required
Medical and Pharmacy Claims File continued. . .
Secondary Diagnosis Code Optional
Tertiary Diagnosis Code Optional
Quaternary Diagnosis Code Optional
DRG (Diagnosis Related
Group) Optional
Standard ICD9 Procedure Code (different from CPT4
ICD9 Procedure Code Codes) Optional
UB92 Bill Type UB92 FL4 (e.g. 111, 121, 131) Optional
Amount Requested Amount Requested by the pharmacy Optional
Amount Allowed Amount Allowed under the plan Required
Paid Amount Amount paid by the plan Required
Claim Type Drug, Dental, Vision, or Medical Required
The unique number used by the carrier to identify each
Provider Number(Rendering provider. This may be an internal identifier or a national
Provider) identifier. *At least one of the following four national IDs Required
is also required. If it is not included in this file, then a
cross-reference file must also be provided.
Provider NPI NPI number for provider Required*
Provider UPIN Unique Physician Identification Number Required*
Provider DEA Number Required*
Provider Tax ID Number Required*
These are high-level descriptions of the specialty such
as OPTOMETRIST, DENTAL GROUP, MD, PHYSICAL
THERAPIST, HOSPICE NURSE, and URGENT
Provider Type CARE/CLINIC/GROUP. Optional
*Please provide a separate list of provider specialty
Provider Specialty Code codes and descriptions if description is not included in Required
file.
Provider First Name * Please send if available Optional*
Provider Last Name * Please send if available Optional*
Provider Suffix Optional
Provider Address 1 Optional
Provider Address 2 Optional
Provider City Optional
Provider State Optional
Provider Zip Code Optional
Additional Data Fields Requested for Rx Claims
Pharmacy Number Optional
30
National Drug Code NDC Required
Drug Name Required
Ordering Physician DEA number of prescribing physician Optional
Drug Quantity Required
Generic Indicator Required
Days Supply, Required
II. Medical Claims File Only:
Healthstat Medical Claims Fields Requested
Please include your file layout and any definitions/descriptions.
Data should be in HIPAA-compliant format wherever possible.
Description Comment Requirement
Group Number Required
Subgroup Number Optional
Claim Number Required
Line number for claim lines that belong to the same claim
Service Sequence number number Required
Paid Date MM/DD/YYYY-Critical Required
Beginning Date of Service Admit Date MM/DD/YYYY Required
Ending Date of Service Discharge Date MM/DD/YYYY Required
Process Date MM/DD/YYYY Optional
Claim Begin Date MM/DD/YYYY Optional
Claim End Date MM/DD/YYYY Optional
Patient's SSN Other term for Patient is Claimant Required
Patient's Last Name Required
Patient's First Name Required
Patient's Middle Name Optional
Patient's Gender Required
Patient's Date of Birth MM/DD/YYYY Required
Patient's City Optional
Patient's State Optional
Patient's Zip Code Optional
Patient Relationship to Policy Employee,Spouse, or Dependent Required
Holder
Code to identify uniquely each member on the policy.
Dependent Suffix Sometimes called Dependent Number or Person Code.A Required
typical code would be"01"for the policy holder, "02"for the
spouse, and "03"and higher for children.
This must be the identifier included in the Healthstat
demographic file for matching claims data to the policy
Policy Holder Number holder.This ID may be the SSN, but it may be the insurance Required
carrier's internal member ID or the company's employee ID.
Other terms for Policy Holder are Subscriber, Insured,and
Employee.
Policy Holder's SSN Required in addition to Policy Holder Number Required
Policy Holder's Last Name Required
Policy Holder's First Name Required
Policy Holder's Gender Required
Policy Holder's Date of Birth MM/DD/YYYY Required
Policy Holder's Zip Code Optional
31
In/Out Flag I-Inpatient; 0-Outpatient; P-Professional (physician-related) Optional
Place of Service Code *Please provide a separate list of place of service codes Required*
and descriptions if description is not included in file.
*Please provide a separate list of service type codes and
descriptions if description is not included in file.These are
high-level descriptions of the service such as
Service Type Code HEMODIALYSIS,SURGERY, MATERNITY,ANESTHESIA,X-RAY Optional
(DIAGNOSTIC),AND MEDICAL CARE (INPATIENT&
OUTPATIENT). Details are provided in the CPT4 procedure
codes.
Procedure Code CPT4 Procedure Code Required
Procedure Modifier Standard CPT4 Modifier Optional
UB92 Revenue Code UB92 FL42 Optional
Primary Diagnosis Code ICD9 Diagnosis Codes Required
Medical Claims File Only continued. . .
Secondary Diagnosis Code Optional
Tertiary Diagnosis Code Optional
Quaternary Diagnosis Code Optional
DRG (Diagnosis Related
Group) Optional
Standard ICD9 Procedure Code (different from CPT4
ICD9 Procedure Code Codes) Optional
UB92 Bill Type UB92 FL4 (e.g. 111, 121, 131) Optional
Amount Requested Amount Requested by the pharmacy Optional
Amount Allowed Amount Allowed under the plan Required
Paid Amount Amount paid by the plan Required
Claim Type Drug, Dental, Vision, or Medical Required
The unique number used by the carrier to identify each
Provider Number(Rendering provider. This may be an internal identifier or a national
Provider) identifier. *At least one of the following four national IDs Required
is also required. If it is not included in this file, then a
cross-reference file must also be provided.
Provider NPI NPI number for provider Required*
Provider UPIN Unique Physician Identification Number Required*
Provider DEA Number Required*
Provider Tax ID Number Required*
These are high-level descriptions of the specialty such
as OPTOMETRIST, DENTAL GROUP, MD, PHYSICAL
THERAPIST, HOSPICE NURSE, and URGENT
Provider Type CARE/CLINIC/GROUP. Optional
*Please provide a separate list of provider specialty
Provider Specialty Code codes and descriptions if description is not included in Required
file.
Provider First Name *Please send if available Optional*
Provider Last Name * Please send if available Optional*
Provider Suffix Optional
Provider Address 1 Optional
Provider Address 2 Optional
Provider City Optional
Provider State Optional
Provider Zip Code Optional
32
III. Pharmacy Claims File Only:
Healthstat Rx Claims Fields Requested
Please include your file layout and any definitions/descriptions.
Data should be in HIPAA-compliant format wherever possible.
Description Comment Requirement
Group Number Required
Subgroup Number Optional
Rx Claim Number Required
Line number for claim lines that belong to the same claim
Prescription Sequence number- required if used Required
Paid Date MM/DD/YYYY-Critical Required
Date of service/Date
Prescription Filled MM/DD/YYYY Required
Process Date MM/DD/YYYY Optional
Patient's SSN Required
Patient's Last Name Required
Patient's First Name Required
Patient's Middle Name Optional
Patient's Gender Required
Patient's Date of Birth MM/DD/YYYY Required
Patient's City Optional
Patient's State Optional
Patient's Zip Code Optional
Patient Relationship to Policy Employee, Spouse, or Dependent Required
Holder
Code to identify uniquely each member on the policy.
Dependent Suffix Sometimes called Dependent Number or Person Code. A Required
typical code would be "01"for the policy holder, "02"for the
spouse, and "03" and higher for children.
This must be the identifier included in the Healthstat
demographic file for matching claims data to the policy holder.
Policy Holder Number This ID may be the SSN, but it may be the insurance carrier's Required
internal member ID or the company's employee ID. Other
terms for Policy Holder are Subscriber, Insured, Employee.
Policy Holder's SSN Required in addition to Policy Holder Number Required
Policy Holder's Last Name Required
Policy Holder's First Name Required
Policy Holder's Gender Required
Policy Holder's Date of Birth MM/DD/YYYY Required
Policy Holder's Zip Code Optional
Pharmacy Number Optional
National Drug Code NDC Required
Drug Name Required
Ordering Physician !, DEA number of prescribing physician Optional
Drug Quantity Required
Generic Indicator Required
Days Supply Required
Amount Requested Amount requested by the pharmacy Optional
33
Amount Allowed Amount allowed under the plan Required
Paid Amount Amount paid by the plan Required
Primary Diagnosis Code ICD9 Diagnosis Codes Optional
*Claims data cannot be processed unless the demographic data files and any claims files contain the
same unique identifier for each covered member, including dependents.
When Healthstat submits claims for reporting purposes:
In the event the Claims Payor for Employer(TPA or Insurance Carrier) does not use the same
unique identifier as Employer to identify each plan member, the Claims Payor must provide a
cross reference file which connects each plan member on the Employer demographic file. This
may be at an additional cost to Employer.
34
CERTIFICATE OF INTERESTED PARTIES FORM 1295
10f1
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business.
Healthstat, Inc.
2018-381935
Charlotte, NC United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 07/19/2018
being filed.
City of Round Rock Date Acknowledged:
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
Healthstat Renewal
Onsite Clinic
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Party.
X
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of 20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711
CERTIFICATE OF INTERESTED PARTIES
FORM 1295
1 of 1
Complete Nos.1-4 and 6 if there are interested parties. OFFICE USE ONLY
Complete Nos.1,2,3,5,and 6 if there are no interested parties. CERTIFICATION OF FILING
1 Name of business entity filing form,and the city,state and country of the business entity's place Certificate Number:
of business. 2018-381935
Healthstat, Inc.
Charlotte, NC United States Date Filed:
2 Name of governmental entity or state agency that is a party to the contract for which the form is 07/19/2018
being filed.
City of Round Rock Date Acknowledged:
07/25/2018
3 Provide the identification number used by the governmental entity or state agency to track or identify the contract,and provide a
description of the services,goods,or other property to be provided under the contract.
Healthstat Renewal
Onsite Clinic
4 Nature of interest
Name of Interested Party City,State,Country(place of business) (check applicable)
Controlling Intermediary
5 Check only if there is NO Interested Party. ❑
X
6 UNSWORN DECLARATION
My name is and my date of birth is
My address is
(street) (city) (state) (zip code) (country)
I declare under penalty of perjury that the foregoing is true and correct.
Executed in County, State of on the day of ,20
(month) (year)
Signature of authorized agent of contracting business entity
(Declarant)
Forms provided by Texas Ethics Commission www.ethics.state.tx.us Version V1.0.6711