EX-10.22 7 ex10_22.txt EXHIBIT 10.22 MANAGED CARE ALLIANCE AGREEMENT CONTENTS PARTIES 2 PURPOSE 2 I. DEFINITIONS 2 II. PARTIES OBLIGATIONS 6 A. SERVICES 6 B. COMPENSATION AND BILLING 12 C. RECORDS 16 D. PARTICIPANT GRIEVANCE 17 E. INSURANCE AND LIABILITY 17 F. INSPECTIONS 18 G. REPRESENTATIONS 18 H. CONFIDENTIALITY/DAMAGING COMMUNICATIONS 20 I. MARKETING EFFORTS 21 J. REPORTING /DATA ACCESS 20 K. BEST RATE GUARANTEE 22 L. PERFORMANCE GUARANTEES 22 III. MISCELLANEOUS OBLIGATIONS 24 A. INDEPENDENT CONTRACTOR RELATIONSHIP 24 B. TERM OF AGREEMENT 24 C. TERMINATION 25 D. RIGHTS AND OBLIGATIONS UPON TERMINATION 28 E. ASSIGNMENT AND DELEGATION OF DUTIES 29 F. USE OF NAME 29 G. INTERPRETATION 29 H. AMENDMENT 29 I. PROGRAM ATTACHMENTS 30 J. ENTIRE CONTRACT 30 K. NOTICE 30 L. ENFORCEABILITY AND WAIVER 30 M. DISPUTE RESOLUTION 31 N. NON-SOLICITATION 29 MANAGED CARE ALLIANCE AGREEMENT PARTIES This Agreement is by and between CIGNA HEALTH CORPORATION, FOR AND ON BEHALF OF ITS CIGNA AFFILIATES (INDIVIDUALLY AND COLLECTIVELY, "CIGNA") and Gentiva CareCentrix, Inc. ("MCA") and is entered into as of the Effective Date. PURPOSE CIGNA contracts directly or indirectly with Payors, employers, individuals, insurers, sponsors and others to provide, insure, arrange for or administer the provision of health care services; CIGNA contracts with physicians, hospitals and other health care practitioners and entities to provide, arrange for or administer, at predetermined rates, the delivery of such health care services; MCA contracts with health care providers to arrange for their provision of health care services to enrollees in managed health care programs; and CIGNA and MCA both desire for MCA's participating health care providers to become Participating Providers under this Agreement and to make available Covered Services to Participants on the terms and conditions set forth herein. In consideration of the mutual promises herein, the parties agree as follows: I. DEFINITIONS Defined terms are set forth herein and in the Program Attachments. CIGNA AFFILIATE means any direct or indirect subsidiary of CIGNA Corporation, as designated by CIGNA. COINSURANCE means a payment that a Participant is required to make to a Participating Provider for Covered Services under a Service Agreement, which is calculated as a percentage of the contracted reimbursement rate of such services, or, if reimbursement is on a basis other than a fee-for-service amount, as a percentage of a CIGNA determined fee schedule or as a CIGNA determined percentage of actual billed charges. COMPLETE ORDER means all information and physician orders, to the extent applicable, reasonably required by MCA and/or any applicable Represented Provider in order to provide or arrange for Covered Home Care Services. MCA shall have received a Complete Order if MCA has received the information delineated in EXHIBIT III. 2 COPAYMENT OR DEDUCTIBLE means a payment that a Participant is required to make to a Participating Provider under a Service Agreement, which is calculated as a fixed dollar payment. COVERED HOME CARE SERVICES means the Medically Necessary Home Health Services, Home Infusion Therapy Services and Home Medical Equipment/Durable Medical Equipment provided to a Participant in accordance with a Service Agreement. It also includes the following services with respect to Participants receiving Covered Home Care services: (a) training and education; (b) family orientation; (c) family/caregiver training, if required; (d) instructional literature; and (e) oxygen patient assessments, if required. COVERED SERVICES means those health care services/supplies provided to a Participant in accordance with a Service Agreement. The term Covered Services includes Covered Home Care Services. EMERGENCY means a condition for which Emergency Services are required. EMERGENCY SERVICES are as defined in each applicable Service Agreement. HOME CARE SERVICES means those Home Health Services, Home Infusion Therapy Services, Home Medical Equipment, as defined below, appropriately and safely (see Exhibit IX Safe Home Care Admission Criteria) provided in a Home Setting (except that Home Infusion Therapy Services includes the administration of the first dose of home infusion therapies in a controlled medical setting for the purpose of managing potential acute anaphylactic reactions, and Home Medical Equipment includes medical equipment used in the Home Setting, except in preparation for hospital discharge), subject to the conditions and limitations of this Agreement: HOME HEALTH SERVICES means those skilled services and related services and supplies used in conjunction with those skilled services, ordered by a physician for a Participant who is homebound due to a disabling condition, and who requires skilled care, which are safely (see Exhibit IX: Safe Home Care Admission Criteria) and appropriately provided in a Home Setting, including: skilled nursing services rendered by a registered professional nurse, licensed practical nurse or licensed vocational nurse; home health aide services; physical, occupational, speech and respiratory therapy; dietary and nutritional services; medical social services; and family caregiver training and education. Home Health Services does not mean hospice services. HOME INFUSION THERAPY SERVICES means intravenously administered, subcutaneously administered or self-injected drugs and medications prescribed by a physician for a Participant (including all services and supplies necessary for such administrations), which are 3 administered in the Home Setting. Home Infusion Therapy Services includes the administration of the first dose of home infusion therapies in a controlled medical setting for the purpose of managing potential acute anaphylactic reactions. Home Infusion Therapy Services do not include those medications which are provided under a Participant's prescription drug benefit program such as oral, rectal, ophthalmic, subdermal, sublingual and topical agents, self-injected medications which are covered under a Participant's prescription drug benefit program (such as anti-diabetic agents and certain subcutaneous medications) and medications not generally considered home infusion therapy (such as skeletal muscle relaxants, anti-psychotics, anti-convulsants, diagnostic agents, vaccines and hormones (except growth hormone)), fertility agents, and intra-articular steroids. Home Infusion Therapy Services do not include the intra-spinal, intra-articular, or intra-ventricular administration of medications, unless infused via implanted closed delivery system such as a synchromed pump. Home Infusion Therapy Services include blood products, such as whole blood and platelets, home chemotherapy, and insertion of PICC line catheters and management of implantable, programmable infusion devices (i.e. Syncromed pump) only to the extent such products are appropriately and safely (see Exhibit IX: Safe Home Care Admission Criteria) provided in a Home Setting. HOME MEDICAL EQUIPMENT (HME)/DURABLE MEDICAL EQUIPMENT (DME) means equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a Participant in the absence of an illness or injury. It is ordered or prescribed by a physician for a Participant (including all services, training, supplies, maintenance and repairs necessary for use of such equipment) including durable medical equipment, respiratory therapy equipment, and oxygen and is provided in accordance with Exhibit XIII (DME Guidelines Grid). HOME SETTING means the Participant's primary place of residence or the residence where Participant is receiving Home Care Services. MEDICALLY NECESSARY means those Covered Services which under the terms of the applicable Service Agreement are "Medically Necessary". Covered Services must be "Medically Necessary." PARTICIPANT means any individual, or eligible dependent of such individual, whether referred to as "Insured," "Subscriber," "Member," "Participant," "Enrollee," "Dependent" or otherwise, who is eligible to receive Home Care Services pursuant to a Service Agreement. PARTICIPATING HOSPITAL means a hospital that has a direct or indirect contractual agreement with CIGNA with regard to the particular Program under which the Participant is covered and to which a Participating Provider may admit Participants for care and treatment in accordance with Program Requirements. PARTICIPATING PROVIDER means a hospital, a physician or any other health care practitioner or entity that has a direct or indirect contractual 4 arrangement with CIGNA to provide Covered Services with regard to the particular Program under which the Participant is covered and includes, but is not limited to Represented Providers. PAYOR means CIGNA or such other entity which, pursuant to a Service Agreement, funds, administers, offers or insures Covered Services and which has agreed to act as Payor in accordance with this Agreement. PRE-QUALIFIED MATERNITY STAY means a maternity hospital stay of 48 hours for vaginal delivery birth, or 96 hours for caesarean section birth, that does not require prior authorization. PROGRAM means the Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) or other types of health care or administrative services which are provided or arranged by CIGNA or CIGNA Affiliates and which are specifically described in applicable Program Attachments and Program Requirements. It is understood that the Health Maintenance Organization (HMO) Program includes not only benefit plans provided under service agreements by licensed HMOs, but insured or self-funded managed care plans administered by Connecticut General Life Insurance Company and referred to by various names including "FlexCare," "Network," "Network Open Access", and "Network Open Access Plus." PROGRAM REQUIREMENTS means the rules and procedures that establish conditions to be followed by Participating Providers with respect to Programs, copies of which have been provided to MCA. Reference to Program Requirements includes the Summary of Program Requirements distributed by CIGNA. QUALITY MANAGEMENT means the programs established and operated by CIGNA or its designee relating to the quality of Covered Services provided to Participants. REPRESENTED PROVIDER means a home health care, infusion therapy, durable medical equipment, or other like provider: (a) who or which is employed by, associated with or otherwise contracted with MCA; (b) who or which both MCA and CIGNA have agreed may provide services pursuant to this Agreement; (c) who or which has completed an MCA Application (which has been approved by CIGNA and a copy of which is attached in Exhibit I.) and has satisfied applicable credentialing criteria; and (d) who or which has agreed with MCA to be subject to the requirements of this Agreement to the extent applicable to Represented Provider. ROUTINE CARE means services required greater than 4 hours from receipt of Complete Order (see Exhibit III), directed by physician orders with regard to start of care requested date. SERVICE AGREEMENT means those agreements among CIGNA or a CIGNA Affiliate, and an employer, insurer, labor union, trust or other organization or entity, or an individual, that specifies services to be provided to or for the benefit of, or arranged for or reimbursed to, or 5 for the benefit of Participants, the terms and conditions under which those services are to be provided or reimbursed, and is consistent with Program Requirements. STAT CARE means services applied in the homecare setting for existing patients only, where care or professional response is required in less than 2 hours. URGENT CARE means services required, as directed by physician orders, within 4 hours from receipt of a Complete Order (see EXHIBIT III). Services which will be considered urgent for the purposes of this agreement shall include the following; nebulizers, glucometers for newly diagnosed non-hospitalized diabetic, hydration therapy for pregnant members with diagnosis of hyperemesis, hydration therapy for pediatric members, Bili-lights and infusion therapies with less than an every 12 hour dosing schedule. Urgent care services also include same day discharges requiring oxygen and pain management. Urgent care services are not intended to replace appropriate discharge planning when the Participant has been in the facility for greater than 23 hours. Inappropriate utilization of same day and urgent request for same day hospital discharge will be monitored. UTILIZATION MANAGEMENT means the processes to review and determine whether certain health care services provided, or to be provided, to Participants are in accordance with Program Requirements. II. PARTIES OBLIGATIONS A. SERVICES 1. MCA, Represented Providers and CIGNA shall act in accordance with the terms of this Agreement and applicable Program Attachments and Program Requirements. Except as otherwise stated in this Agreement, the rates set forth in this Agreement shall be payment in full for all services provided to Participants pursuant to this Agreement. 2. Subject to the terms and condition of this Agreement, MCA shall: (a) Arrange for the provision of Home Care Services to Participants; (b) Require Represented Providers to accept, treat, and otherwise render Covered Services to Participants in the same manner, in accordance with the same standards, and with the same availability, as offered to other like patients. 6 (c) not close its network to any new Participants unless CIGNA expressly consents to such closure; 3. In no event shall MCA or Represented Providers be required to accept, treat, arrange for, or otherwise be obligated to render Home Care Services to Participants under this Agreement, even if medically appropriate, if: (a) the provision of such services to Participant would pose risk of bodily harm to the Participant or caregiver personnel of Represented Provider; (b) the provision of such services to Participant would be in violation of MCA's or Represented Provider's applicable license requirements or other applicable laws, and/or MCA policies, including but not limited to admission and discharge policies or discrimination policies; (c) MCA has not received the essential information to process a referral; (d) Participant repeatedly rejects the provision of services by a qualified Represented Provider selected by MCA and/or CIGNA as mutually agreed. MCA and Represented Providers shall not differentiate or discriminate in the treatment of any Participant because of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, health status, handicap or source of payment. 4. MCA shall be bound by, and MCA shall require Represented Providers to be bound by, and comply with, the provisions of applicable state and federal laws, regulations, credentialing and recredentialing requirements of the National Committee for Quality Assurance ("NCQA") or of another appropriate accrediting body designated by CIGNA, and Program Requirements. MCA and its Represented Providers shall maintain all licenses and certifications required in order to perform the obligations set forth herein. MCA shall comply and require Represented Providers to comply with the requirements of, and shall cooperate with, Utilization Management and Quality Management. 5. MCA shall establish and maintain a panel of Represented Providers adequate in size, composition and distribution, as determined by CIGNA, to accommodate the Covered Services required by Participants (the "required Represented Provider panel"). Should CIGNA reasonably determine that the number, composition or distribution of Represented Providers is not 7 adequate, then CIGNA shall notify MCA of the deficiency. MCA shall have sixty (60) days from the date of the notice to contract with sufficient Represented Providers to resolve the deficiency, but if MCA fails to do so, then CIGNA may designate sufficient Participating Providers as Represented Providers until such time as MCA contracts with the necessary Represented Providers and MCA is financially responsible for any such Covered Home Care Services delivered to participants until such time as MCA contracts with the necessary Represented Providers. MCA understands and agrees that, to the extent that Covered Services are rendered under this Agreement to CIGNA's commercial HMO Participants (including "FlexCare", "Gatekeeper", "Open Access" and "Open Access Plus" participants) or to Participants in CIGNA's Medicare and Medicaid Programs, such services shall only be rendered by those Participating Providers in the required Represented Provider panel located within CIGNA's authorized service area. MCA further agrees that it shall secure binding agreements with the required Represented Provider panel three (3) weeks prior to the Effective Date of this Agreement. In the event that MCA has failed to do so, the Effective Date of this Agreement shall be delayed as determined by CIGNA. 6. Upon request, MCA will provide CIGNA with the data elements set forth in Exhibit II for each Represented Provider. MCA further agrees to update CIGNA on any changes to Represented Provider data elements as soon as possible but no less frequently than monthly. MCA will provide CIGNA with thirty (30) days advance notice of all other additions to its panel of Represented Providers. In recognition of CIGNA's need to communicate changes to Participants, MCA shall not make any material changes in the location or hours of operation of its panel of Represented Providers without first providing sixty (60) days advance written notice to CIGNA. In addition, MCA shall provide CIGNA with sixty (60) days advance written notice of the termination of a Represented Provider, or any other circumstance (e.g. death or cessation of operations, loss of licensure, etc.) that results in the Represented Provider ceasing to provide Covered Services to Participants under this Agreement. Notwithstanding the foregoing, in the event that the Represented Provider's participation under this Agreement is terminated for cause and in situations where MCA does not have sixty (60) days advance notice of such termination, MCA shall notify CIGNA in writing of such termination as soon as possible but no later than five (5) days after learning of such termination. 7. MCA shall maintain agreements with each of its Represented Providers, in the form attached hereto as Exhibit I, requiring Represented Providers to comply with all of the terms and conditions of this Agreement to the extent applicable. The 8 form of MCA's standard agreement with Represented Providers and any material amendments thereto comply with applicable law and must be approved in advance by CIGNA. Each of such agreements shall include, among other things, the following: a. a Participant hold harmless provision satisfactory to CIGNA, consistent with applicable law and which provides, among other things, that in no event, including but not limited to nonpayment by MCA, MCA's insolvency or breach of MCA's agreement with the Represented Provider, shall Represented Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against Participant, Payor (if Payor has made payments in accordance with this Agreement) or parties other than MCA for Covered Services provided pursuant to this Agreement; b. if payments for Covered Services rendered hereunder are directed to MCA who, in turn, distributes payments to Represented Providers: i. a provision obligating Represented Providers to notify CIGNA immediately of any payment defaults by MCA relating to services rendered hereunder; and ii. a provision obligating Represented Providers, in the event of such payment default by MCA and at CIGNA's option, to continue rendering Covered Services hereunder so long as payments due Represented Providers for Covered Services rendered after CIGNA's exercise of such option are made directly to Represented Providers by Payor and until a date specified by CIGNA but no later than one hundred twenty (120) days after CIGNA's exercise of such option. Represented Providers shall agree that any such payments during such time period shall be made, at CIGNA's election, either in accordance with the reimbursement terms set forth in Represented Providers' agreements with MCA or in accordance with CIGNA's maximum fee schedule in effect at the time of service. c. a provision or provisions obligating Represented Providers to be available to provide Covered Home Care Services to those patients designated by Gentiva, which during the term of this Agreement would include Participants. d. any other provisions required by applicable law or regulation; and e. a provision wherein the Represented Provider acknowledges and agrees that the Represented Provider's participation agreement with MCA does not contain any financial incentive 9 or make any payment that acts directly or indirectly as an inducement to limit Medically Necessary services. Upon request, MCA shall make available to CIGNA and to any applicable regulatory authority a copy of each of its provider agreements with Represented Providers. 8. For referrals, Represented Providers shall refer Participants to Represented Providers or other Participating Providers except in the case of an Emergency or as otherwise described in applicable Program Requirements or as otherwise required by law. 9. Represented Providers shall be credentialed and recredentialed in accordance with the procedures set forth in Exhibit XII to this Agreement. 10. MCA shall provide trained service personnel to answer questions from CIGNA and to assist CIGNA in responding to complaints from Payors, Participants, and Participating Providers. MCA shall promptly respond to all such inquiries and complaints in accordance with the Joint Complaint Management Process created by MCA and CIGNA, attached in Exhibit XI. 11. CIGNA shall perform administrative, accounting, enrollment, eligibility verification and other functions necessary for the administration and operation of the Programs. CIGNA shall provide MCA with information and data reasonably necessary to carry out the terms and conditions of this Agreement and for operation of the Programs. CIGNA shall establish a system of Participant identification, communicate Program Requirements to MCA or Represented Providers, as applicable, and identify Represented Providers to Payors and Participants. 12. CIGNA shall contract, directly or indirectly, with Payors who agree to pay in accordance with this Agreement for Covered Services rendered by Represented Providers. 13. CIGNA shall, upon specific request by MCA, identify the Payor responsible for payment of Covered Services. 14. Prior to the start date with respect to each of the entities described in Exhibit XIV and any subsequent entities added by amendment: (a) MCA shall obtain CIGNA's approval of MCA's list of participating home care providers (which may include both MCA affiliates and Represented Providers) who will render Covered Home Care Services under this Agreement; (b) MCA shall satisfy CIGNA that it has established a home care services network adequate in size, composition and distribution to accommodate the Covered Home Care Services required by Participants; (c) the parties shall agree upon a plan to ensure appropriate and sensitive transitioning of Participants already receiving Covered Home Care Services such that there is no disruption of care which would be detrimental to such Participants; and (d) the parties 10 shall be satisfied that adequate management systems are in place. CIGNA's financial obligations for payment of Covered Home Care Services rendered hereunder shall not commence with respect to a Service Area until the agreed upon start date for such Service Area. MCA shall not eliminate or change Represented Providers or a MCA location without sixty (60) days' prior written notice to CIGNA, except to the extent MCA is required to do so for cause and, in any such case, MCA shall notify CIGNA of such change as soon as practicable. 15. MCA shall require Represented Providers providing Home Medical Equipment to provide Home Medical Equipment in good working order and condition and ensure that Home Medical Equipment has been properly cleaned and disinfected between uses. MCA shall arrange for at MCA's expense all necessary on-site maintenance and/or repair for Home Medical Equipment (including provision of all necessary parts, mechanisms and devices) in order to maintain the Home Medical Equipment in good condition and working order; provided that such maintenance and/or repair is required as a result of normal wear and tear (as defined by warranty), or a defect in, the Home Medical Equipment. MCA shall require Represented Providers to provide or arrange for twenty-four (24) hour per day, seven (7) day per week maintenance and repair service, provided however, that Represented Provider may elect to pick up the Home Medical Equipment needing maintenance and/or repair and replace it with Home Medical Equipment in operable condition, rather than repair the Home Medical Equipment immediately. 16. MCA shall require Represented Providers to maintain an accurate inventory of solutions, medications, drugs, Home Medical Equipment and ancillary supplies, as applicable, for each Participant, to the extent necessary to provide Covered Home Care Services under this Agreement, and shall make these inventory records available to CIGNA upon request. 17. MCA shall ensure that its facilities and employees, and require that the facilities and employees of its Represented Providers, maintain a neat, clean and professional appearance at all times. 18. MCA will dedicate on a full-time basis (and part-time, as required) the services of appropriate personnel to coordinate the implementation of this Agreement on both local and national levels, and to manage the day-to-day work relationship with CIGNA. MCA will meet with designated CIGNA personnel upon request to review MCA performance, Participant utilization and quality improvement initiatives. 19. MCA will educate CIGNA case managers and CIGNA discharge planners on the capabilities of home care providers. MCA will identify potential home care candidates as early as possible in the hospital stay and prepare for the discharge. CIGNA and MCA acknowledge that none of the activities of their respective 11 personnel described in this section will substitute for the discharge planning obligations imposed on Participating Hospitals by Medicare and/or Medicaid. 20. MCA and CIGNA agree to meet on at least a quarterly basis to assist CIGNA in staying abreast of innovations in home care services (including drug protocols) and to work with CIGNA to see that these services are being appropriately applied to Participants. 21. MCA will dedicate personnel to travel to any Service Area location or to CIGNA Health Corporation's home office on twenty-four hours notice to resolve CIGNA's repeated dissatisfaction with MCA. Said personnel will include at least one officer of MCA, if requested by CIGNA. 22. MCA will provide a mutually agreed upon number of home and community care specialists whose responsibilities will include the items listed in Exhibit VI, (Guidelines for Home & Community Care Specialists). The Home and Community Care Specialists will be located in a CIGNA Health Facilitation Center or other Health Facilitation Satellite location, as mutually agreed, and shall have responsibility for a geographic region, as defined by CIGNA. The Home and Community Care Specialist will be an employee of MCA and the costs for such staffing are included in the rates set forth in the exhibits to the Program Attachments to this Agreement. 23. MCA shall deliver Covered Home Care Services to Participants; Routine, Stat and/or Urgent in accordance with the terms of this Agreement. In those instances where the Covered Home Care Service(s) referred to MCA is to be rendered by a Represented Provider, MCA shall immediately notify the Represented Provider of the referral and, to the extent applicable, the Represented Provider shall immediately attempt to make contact with the referring physician and immediately return phone calls from the referring physician in order to confirm the physician order. 24. Effective January 1, 2004, subject to state regulations, medical appropriateness and availability of personnel, MCA may arrange for physical therapy assistants (PTA) to provide services to Participants. B. COMPENSATION AND BILLING 12 1. For Covered Services provided to or arranged for Participants by MCA and/or Represented Providers consistent with the terms of this Agreement, and for all other obligations hereunder, CIGNA or its designee shall make payments to MCA as set forth in this Section B and in accordance with the applicable Program Attachments. For all fee-for-service charges, CIGNA shall pay MCA within thirty (30) days following receipt of a clean claim submitted by MCA. 2. MCA and Represented Providers shall comply with the following limitations on billing Participants: a. MCA hereby agrees and shall require its Represented Providers to agree that in no event, including, but not limited to non-payment by CIGNA, CIGNA's insolvency or breach of this Agreement, shall MCA or any Represented Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Participants or persons other than CIGNA or MCA for Home Care Services. This provision shall not prohibit collection of (i) any applicable Copayments, Deductibles or Coinsurance; (ii) payments for services provided to a patient who is no longer eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit; or (iii) payments for services provided to Participants that are not Home Care Services. b. MCA further agrees that this provision shall survive the termination of this Agreement regardless of the cause giving rise to such termination and shall be construed to be for the benefit of Participants, and that this provision supersedes any oral or written agreement to the contrary now existing or hereafter entered into between MCA or Represented Providers and the Participant or persons acting on the Participant's behalf. c. Any modification, additions, or deletion to the provisions of this hold harmless clause shall become effective on a date no earlier than fifteen (15) days after the applicable state regulatory agency has received written notice of such proposed change. d. MCA shall not charge, and MCA shall require that its Represented Providers not charge, a Participant for a service which is not Medically Necessary unless, in advance of the provision of such service, the Participant is notified that the service may not be covered and the Participant acknowledges in writing that he or she shall be responsible for payment of charges for such service. 3. MCA or Represented Provider may bill an individual directly for any services provided following the date the individual ceases to be a Participant and for non-covered services delivered to Participants on a fee-for-service basis. Payor has no obligation under this 13 Agreement to pay for services rendered to individuals following the date the individual ceases to be a Participant. MCA may also bill a Participant for any applicable copayments, deductibles, coinsurance, or other ancillary charges. 4. The following provisions apply regarding coordination of benefits: a. CIGNA and MCA agree to cooperate to exchange information relating to coordination of benefits with regard to any Participant for whom MCA's Represented Providers are providing services. b. With respect to those services reimbursed on a capitated basis: 1. Certain claims for services rendered to Participants are claims for which another payor may be primarily responsible under coordination of benefits rules. MCA may pursue and process any such coordination of benefits claims which relate to services provided by MCA's Represented Providers and, in so doing, shall comply with the primary payor's applicable billing rules, including, but not limited to, any of the primary payor's limitations on billing Participants. 2. When Payor is other than primary under applicable coordination of benefits rules, Payor shall not be obligated to pay any amounts in addition to the capitation amounts paid pursuant to this Agreement, and MCA and its Represented Providers agree to reimburse the Participant any CIGNA Copayments, Coinsurance or Deductibles collected from the Participants, that should not have been collected, upon request by CIGNA or the Participant. In the event that MCA or its Represented Providers fail to reimburse such amounts within sixty (60) days of notification by CIGNA that such amounts are due and owing, CIGNA shall have the right to deduct any such amounts from any amounts payable under this Agreement and reimburse the Participant; provided that CIGNA advise MCA in writing of the accounts from which the deduction was taken. 3. When Payor is primary under applicable coordination of benefits rules, MCA shall consider the compensation set forth in this Agreement as payment in full for Covered Services rendered to Participants and shall not seek additional reimbursement from any secondary payors except as required by law. c. With respect to those services reimbursed on a fee-for-service basis: i. Certain claims for services rendered to Participants are claims for which another payor may be primarily responsible under coordination of benefit rules. MCA 14 may pursue and process any such coordination of benefits claims and, in so doing, shall comply with the primary payor's applicable billing rules, including, but not limited to, any of the primary payor's limitations on billing Participants. ii. When Payor is other than primary under applicable coordination of benefits rules, Payor will pay no greater amount than that which, when added to amounts payable to MCA from other sources under the applicable coordination of benefit rules, equals one hundred percent of the MCA's reimbursement for Covered Services pursuant to this Agreement. iii. When Payor is primary under applicable coordination of benefit rules, Payor will pay amounts due pursuant to this Agreement without regard for the obligations of any secondary payors. 5. Upon reasonable notice and during regular business hours, CIGNA or its designee shall have the right to inspect, review and make copies of, at CIGNA's expense, all records maintained by MCA and its Represented Providers with respect to all payments received by MCA and its Represented Providers from all sources for Covered Services rendered to Participants during the term of this Agreement. CIGNA or its designee shall have the right to conduct periodic audits of such records and may audit its own records to determine if amounts have been properly paid under this Agreement. CIGNA shall provide MCA with the results of any such audits and any amounts determined to be due and owing as a result of such audits shall be promptly paid or, at the option of the party to whom such amounts are owed, offset against amounts due and owing by such party hereunder; provided that CIGNA shall notify MCA in writing of the accounts from which any deductions are taken or offsets are made against. This provision shall survive the termination of this Agreement. 6. If MCA or its Represented Providers inappropriately refer a Participant to a non-Participating Provider in a non-Emergency situation, and thereby causes the Participant to become responsible for the charges of the non-Participating Provider, CIGNA or a CIGNA Affiliate may, in its sole discretion, satisfy the obligation of the Participant to the non-Participating Provider. If this occurs, CIGNA may offset the amount paid on behalf of the Participant against the future compensation payable to MCA or its Represented Providers; provided that CIGNA shall notify MCA in writing of the accounts from which any deductions are taken or offsets are made against. 7. MCA and its Represented Providers shall not directly or indirectly bill for or seek to collect from Payor any 15 additional payment for Covered Services beyond the amount required to be paid under this agreement except pursuant to a written request for an appeal or adjustment filed with CIGNA within one hundred eighty (180) days from the date of Payor's payment or explanation of benefits. This provision does not affect any rights MCA might have for reimbursement under any periodic risk sharing settlements described elsewhere in this Agreement. 8. For Home Medical Equipment, MCA agrees to a rental cap at purchase price. Payor shall pay a fee equal to one (1) month's rental charge every six (6) months to compensate for the cost of maintaining the equipment. MCA or Represented Provider, as applicable, shall retain title to the equipment. Notwithstanding the foregoing, oxygen, other respiratory-related equipment and services, and low air-loss beds will not be eligible for rental cap. Payor may continue to rent the equipment until the rental cap is met or purchase the piece of equipment with a maximum of two (2) months rental payments applied to the purchase price. 9. CIGNA shall provide MCA with any applicable limitations on coverage for Covered Home Care Services to Participants under specific Programs. 10. Provider waives any right to interest required to be paid to it under any state law or regulation requiring the payment of claims within a specified period of time it being understood that CIGNA's payment obligations are governed entirely by the terms of this Agreement. C. RECORDS 1. CIGNA, MCA and Represented Providers agree that clinical records of Participants and any other records containing individually identifiable information with respect to Participants shall be regarded as confidential and each shall comply with all applicable federal and state laws and regulations regarding such records. This provision shall survive the termination of this Agreement. 2. MCA or Represented Providers shall maintain and furnish such records and documents as may be required by applicable laws, regulations and CIGNA's Program Requirements. All of such records shall be maintained for the period of time required by applicable law. MCA and Represented Providers shall cooperate with CIGNA to facilitate the information and record exchanges necessary for Quality Management, Utilization Management, peer review, or other programs required for CIGNA's operations. 3. MCA and Represented Providers shall provide CIGNA, its designee and duly authorized third parties, including, but not 16 limited to, applicable governmental regulatory agencies, with reasonable access during regular business hours to specified clinical and medical records related to Covered Services rendered to Participants under this Agreement. Such access shall be provided within the time frames specified by the governmental regulatory authority requesting such access or, if such access is requested by CIGNA only, upon reasonable notice by CIGNA. This provision shall survive the termination of this Agreement. 4. MCA and its Represented Providers shall cooperate in connection with any transfers of Participants' medical records required when Represented Providers cease rendering services to a Participant whether during the term of this Agreement or after termination of this Agreement. MCA and its Represented Providers shall provide copies of such records at no charge. 5. MCA and Represented Providers shall cooperate with CIGNA in the development and maintenance of statistical data, records and procedures in support of Quality Management, Utilization Management and other applicable Program Requirements. 6. MCA and CIGNA shall maintain the confidentiality of all confidential information regarding Participants in accordance with any applicable laws and regulations. MCA shall require Represented Providers to obtain Participant's consent to the disclosure of all records and information necessary to MCA to carry out its utilization management, quality improvement, claims management and payment and other relevant programs and to allow MCA to disclose such information to CIGNA for such purposes. CIGNA agrees to abide by the confidentiality obligations set forth in this Agreement and in the Confidentiality Agreement attached hereto as Exhibit XX and incorporated herein with respect to any private and/or medical record information of Participants disclosed by MCA to CIGNA pursuant to this Agreement. 7. CIGNA agrees to indemnify and hold MCA and Represented Providers harmless for any claim by a Participant for a breach of confidentiality that results from MCA's or Represented Provider's adherence to this Section C and provided that MCA and/or Represented Provider has complied with all the requirements of this Section C and the Business Associates Agreement between MCA and CIGNA. D. PARTICIPANT GRIEVANCE MCA and its Represented Providers shall cooperate with CIGNA in the implementation of its Participant grievance procedure and 17 shall assist CIGNA in taking appropriate corrective action. MCA and its Represented Providers shall comply with all final determinations made by CIGNA pursuant to such grievance procedure. E. INSURANCE AND LIABILITY 1. Throughout the term of this Agreement, MCA shall maintain at MCA's expense general and professional liability coverage in a form and amount acceptable to CIGNA. MCA shall require each Represented Provider to maintain such coverages in a form and amount acceptable to CIGNA. MCA or Represented Providers shall give CIGNA certificates of insurance evidencing the coverages described herein upon request. MCA or Represented Providers shall give CIGNA immediate written notice of cancellation, modification or termination of any such insurances. MCA or Represented Providers shall give CIGNA prompt written notice of any professional liability claims against MCA's or any of its Represented Providers' liability coverage. The Delegated Credentialing Agreement is made part of this agreement in Exhibit XII. 2. MCA shall require that Represented Providers notify MCA immediately, and MCA shall notify CIGNA as soon as it receives notice (i) if there is a material change affecting Represented Provider's or any of Represented Provider's personnel's licensure, accreditation or certification, which would affect the provision of services to Participants under this Agreement or (ii) if a professional, regulatory or legal body (a) serves formal notice that it may take any action due to deficiencies, poor performance or failure to comply with standards, rules or regulations imposed by such professional or regulatory body or (b) initiates an investigation which is material. F. INSPECTIONS Upon reasonable notice and at reasonable hours, CIGNA or its agents may inspect MCA's or Represented Providers' premises and operations to ensure that they are adequate to meet Participants' needs. G. REPRESENTATIONS 1. MCA and each Represented Provider represent and warrant that the information set forth in the CIGNA Application, or MCA Application acceptable to CIGNA, is true and correct to the best of MCA's knowledge. MCA shall promptly notify CIGNA of any changes in the information contained in any Represented Provider's Application within thirty (30) days of such change. 2. MCA represents and warrants that only Participating Providers will be allowed to provide Covered Services under this Agreement, unless otherwise allowed by this agreement. 18 3. MCA will provide evidence of Represented Providers' agreement to abide by the terms of this Agreement upon request. 4. CIGNA makes no representations or guarantees concerning the number of Participants it can or will refer to MCA and its Represented Providers under this Agreement. CIGNA reserves the right to direct business to selected contracted providers in specified geographic areas. See Exhibit XXI for a listing of these areas. 5. CIGNA and MCA acknowledge and agree that: a. this Agreement is a negotiated, armslength transaction in which each party was represented by counsel and has chosen to enter of its own free will; b. Each party fully understands the reimbursement arrangement outlined in this Agreement and believes that it represents a mutually beneficial financial arrangement; and c. neither this Agreement nor any of MCA's participation agreements with its Represented Providers contains any financial incentive or makes any payment that acts directly or indirectly as an inducement to limit Medically Necessary services. 6. CIGNA and MCA acknowledge(s) and agree(s) that: a. Utilization Management decision making for services rendered under this Agreement shall be based only on appropriateness of care and service; b. practitioners or other individuals conducting Utilization Management are not compensated for denials of Covered Services; and c. financial incentives for Utilization Management decision makers do not encourage denials of Covered Services. 7. CIGNA shall cause its affiliate Intracorp to refer to MCA all CIGNA PPO Program Participants referred to or identified by Intracorp to utilize Covered Home Care Services when the utilization review/case management contract applicable to the Participant is between CIGNA and the party with which CIGNA has the Service Agreement. 8. Subject to the exclusions and limitations set forth in Exhibit XXI, and with respect to the HMO, Gatekeeper and PPO Programs only, CIGNA agrees that during the term of this Agreement, it shall not contract with any third party for the provision of Covered Home Care Services which are the subject of this Agreement in those Service Areas for which MCA shall have 19 commenced rendering Covered Home Care Services which are subject to this Agreement and for which all transitioning care has been completed. This provision will not prohibit or restrict CIGNA from contracting with others with regard to services which MCA does not or can not provide or arrange for or for services not included within the scope of this Agreement. 9. CIGNA designates MCA as CIGNA's preferred provider for provision of hemophilia factor products, and agrees to limit Factor providers to Gentiva Health Services and those commercial vendors currently under contract as well as CIGNA Tel-Drug. 10. Effective January 1, 2004, MCA will use all reasonable commercial efforts to arrange for the provision of CPAP and CPAP supplies via direct shipment to the Participant's home. MCA shall provide the appropriate support intervention to include clinic, telephonic or in home support. CIGNA shall establish criteria for appropriate respiratory therapist intervention and assist MCA in enforcing that criteria. 11. Effective January 1, 2004 CIGNA will make all reasonable efforts to advise MCA, in advance, of material health care initiatives, including but not limited to medical management and disease management initiatives, that have the potential to impact the utilization of Home Care Services during the term of the Agreement. MCA agrees to collaborate with CIGNA to maximize the potential of CIGNA initiatives. CIGNA agrees to discuss with MCA and consider the impact of newly developed home care programs that may increase/decrease utilization of Home Care Services activity reflected in the base period used to establish the capitation rate for the impacted period. 12. CIGNA will provide to MCA a quarterly retrospective claims paid report within 120 days following the end of each quarter, to include the HMO, FLEXCARE, PPO and Indemnity populations. MCA will review retrospective claims paid reports provided by CIGNA for the purpose of identifying providers of covered services not subcontracted with MCA. MCA shall use reasonable commercial efforts, as evidenced by contracting results. H. CONFIDENTIALITY/DAMAGING COMMUNICATIONS 1. The parties acknowledge that, as a result of this Agreement, each may have access to certain trade secrets and other confidential and proprietary information of the other. MCA, Represented Providers and CIGNA shall hold such trade secrets and other confidential and proprietary information, including the terms and conditions of this Agreement, in confidence and 20 shall not use or disclose such information, either by publication or otherwise, to any person without the prior written consent of the other party except as may be required by law and except as may be required to fulfill the rights and obligations set forth in this Agreement. With respect to CIGNA, such confidential and proprietary information shall include, without limitation, the Program Attachments, Program Requirements, client lists, and any and all data or information made known to MCA relating to the services rendered to Participants under this Agreement. This provision shall not be construed to prohibit CIGNA from disclosing information to CIGNA Affiliates. In addition, this provision shall not be construed to prohibit CIGNA from disclosing information to the agents or subcontractors of CIGNA or of CIGNA Affiliates or from disclosing the terms and conditions of this Agreement, including reimbursement rates, to existing or potential customers of CIGNA or of CIGNA Affiliates or their representatives, provided that CIGNA is acting in accordance with the terms of the Confidentiality Agreement attached hereto and incorporated herein as Exhibit XX (Confidentiality Agreement). This provision shall survive the termination of this Agreement. 2. Neither CIGNA or MCA shall issue (and MCA will require that its Represented Providers not issue) any disparaging communications which would interfere with or otherwise damage any of the other party's existing or potential contractual relationships. 3. Nothing in subsections 1. or 2. above shall be construed to prohibit: a. communications necessary or appropriate for the delivery of health care services; b. communications to Participants regarding treatment alternatives regardless of the provisions or limitations of the Participant's coverage; c. communications to Participants regarding applicable rights to appeal coverage determinations; d. communications to Participants identifying the type of reimbursement arrangement under which MCA and its Represented Providers are compensated for Covered Services under this Agreement (i.e. fee-for-service, capitation, etc.), excluding any communications with regard to the applicable rates of reimbursement; or e. any other communications expressly protected under applicable state or federal statute or regulation. 21 I. MARKETING EFFORTS MCA agrees to participate in CIGNA's marketing efforts with respect to its various Programs to the extent agreed upon by the parties. J. REPORTING/DATA ACCESS 1. MCA's compensation for the reports, studies, information exchanges and data access delineated in this section and associated exhibits is fully incorporated in the rates and/or fee schedules defined in each Program Attachment and associated exhibits attached hereto. MCA shall receive no additional compensation for the reports, studies, information exchanges and data access. 2. MCA agrees to collect data necessary to complete each report listed in Exhibit VIII. 3. MCA agrees to provide CIGNA with reports, in a form and format mutually agreed upon by both parties, and in accordance with the report timeline set forth in Exhibit VIII attached hereto and incorporated herein. Said reports shall be consolidated reports, incorporating all data from MCA and its Represented Providers. 4. MCA will maintain a quality assurance program (including process improvement initiatives) on Participants on a quarterly basis, and report to CIGNA the results of such initiatives each quarter. CIGNA may conduct home care service satisfaction surveys on Participants, Represented Providers and CIGNA personnel and will supply MCA with the results of any such satisfaction surveys. The format of the quality assurance initiatives shall be mutually developed by the parties. The format of the home care service satisfaction surveys will be developed by CIGNA with input from MCA. 5. MCA agrees to furnish ad hoc reports to CIGNA upon reasonable request by CIGNA to an individual designated by MCA. MCA agrees to provide most simple ad hoc reports requested within 2 to 5 working days. 6. MCA agrees to submit electronic utilization data to CIGNA on Participants as needed. 7. MCA agrees to share with CIGNA all on-line data and all information relating to Participants, including but not limited to, intake, patient status, utilization, outcomes, clinical records, billing and cost information, subject to any applicable confidentiality obligations set forth in this Agreement. 22 8. The parties acknowledge and agree that all of the aggregate data and reports specified in this Agreement relating to Participants and referenced in this Section or elsewhere in this Agreement: a. shall be jointly owned by CIGNA and MCA; b. with respect to such data, information, studies and reports which identify the other party, Participants or parties with whom CIGNA has Service Agreements by name, shall not be used, disclosed or sold by either party (unless such identity shall have been deleted) except as otherwise agreed. This provision shall not apply: (i) to the extent the use or disclosure of such data, information, studies, or reports is required to fulfill obligations hereunder, obligations to Participants and parties with whom CIGNA has Service Agreements or any other obligation imposed by law provided that such disclosure is permitted by the terms of this Agreement or the Confidentiality Agreement (Exhibit XX); or (ii) with respect to usage of such data, information, studies and reports for internal measurement purposes. This provision shall survive the termination of this Agreement and shall not prohibit disclosures by either party to its subsidiaries or affiliates except as otherwise set forth in this Agreement and the Confidentiality Agreement (Exhibit XX). Upon request by CIGNA and free of charge, MCA will provide CIGNA with copies of all materials sold by MCA to third parties containing such data, information, studies and reports. K. BEST RATE GUARANTEE MCA warrants that the rates, terms and benefits granted by MCA as set forth in this Agreement, viewing the package of services hereunder as a whole, are equivalent to, or better than, the rates, terms, benefits being offered by MCA to any company in any area which is contained within or overlaps a CIGNA Service Area which purchases services similar to those provided under this Agreement, viewing the package of such services as a whole. If MCA, during the term of this Agreement, enters into agreements with any other company which provides greater benefits or more favorable terms or rates with respect to like obligations of MCA and like rights of CIGNA, viewing the package of services provided hereunder as a whole, MCA shall notify 23 CIGNA immediately upon consummation of such agreement and at least 30 days prior to the effective date of such agreement. This Agreement shall thereupon be deemed automatically amended to provide the same advantages to CIGNA. This provision shall be enforceable to the extent permitted by applicable law. L. PERFORMANCE GUARANTEES MCA shall perform its obligations under this Agreement in accordance with the standards set forth in Exhibit VII. In the event that MCA fails to achieve a performance standard set forth in Exhibit VII, the amounts due MCA as set forth in the Program Attachments of this Agreement shall be reduced in accordance with the formula set forth in Exhibit VII. III. MISCELLANEOUS OBLIGATIONS A. INDEPENDENT CONTRACTOR RELATIONSHIP 1. This Agreement is not intended to create nor shall be construed to create any relationship between CIGNA and MCA other than that of independent entities contracting for the purpose of effecting provisions of this Agreement. Neither party nor any of their representatives shall be construed to be the agent, employer, employee or representative of the other. 2. Nothing in this Agreement, including MCA and its Represented Providers' participation in the Quality Management and Utilization Management process, shall be construed to interfere with or in any way affect Represented Provider's obligation to exercise independent medical judgement in rendering health care services to Participants. B. TERM OF AGREEMENT This Agreement shall be in full force and effect for a three (3) year period and terminating on December 31, 2006. Notwithstanding the foregoing, CIGNA may terminate this agreement effective December 31, 2005 by providing MCA with no less than ninety (90) days advance written notice of its intention to terminate this Agreement. If CIGNA does not provide such written notice, then the Agreement shall continue in full force and effect. Thereafter, this Agreement shall automatically renew for consecutive one year terms without any further action by either party, unless either party elects not to renew this Agreement by providing at least ninety (90) days advance written notice to the other party, prior to the commencement of the next term. 24 Notwithstanding the expiration or non-renewal of this Agreement pursuant to this Section B., this Agreement shall continue in effect with respect to those Payors covered under Service Agreements in effect as of the end of the term of this Agreement or the notice period, as applicable, but not to exceed twelve months from the effective date of termination or expiration. The parties shall establish capitation rates for year 2005 and 2006 in accordance with the methodology as set forth in Exhibit XXIV. All fee-for-service rates for 2005 and 2006 will be limited to a maximum inflation adjustments, set forth in Exhibit XXIV. MCA will provide to CIGNA the information necessary to establish a capitation rate for 2005 and 2006 no later than November 1st of 2004 and 2005, respectively. In the event that the parties are unable to reach an agreement as to new rates for 2006, either party may terminate this Agreement at any time after December 31, 2005 by giving notice to the other party at least ninety (90) days in advance of the termination specified in such notice. During the notice period (90 days), the 2005 rates shall continue in force for that period. C. TERMINATION 1. FOR CAUSE. This Agreement may not be terminated for cause, except to the extent provided in subsections a. and b. below. All other claims, disputes, controversies, or breaches shall not be cause for termination of this Agreement, but rather shall be resolved through the Dispute Resolution process described in Section III. M. a. MCA may terminate this Agreement for cause: 1. immediately upon written notice to CIGNA if: i. CIGNA ceases to engage in all business activities; ii. CIGNA files a petition for bankruptcy or any other insolvency, rehabilitation, conservation or liquidation proceeding under state or federal law; or iii. Any bankruptcy, insolvency or liquidation proceeding is commenced against CIGNA, which proceeding is (a) not contested by CIGNA or (b) if contested by CIGNA, is not dismissed within sixty (60) days after commencement. 2. upon sixty (60) days advance written notice to CIGNA if: i. CIGNA fails to adhere to any final determination of an arbitrator or, if applicable, the determination of a majority of the arbitrators, within the time frame established by the arbitrator(s), in accordance with 25 the Dispute Resolution procedures pursuant to Section III M; ii. CIGNA fails, without cause, to pay substantially all undisputed amounts due to MCA under this Agreement for more than sixty (60) days after the later of the due date or written notice by MCA. If CIGNA in good faith disputes that monies are due to MCA under this Agreement, then the notice of termination shall not be effective and this Agreement shall remain in effect, subject to sub-subsection i. above; or iii. Any material change or alteration by CIGNA of the Program Requirements is unacceptable to MCA, providing that (a) MCA gives CIGNA notice of rejection of such action within thirty (30) days of receipt by MCA of CIGNA's notice concerning the change or alteration; and (b) CIGNA does not withdraw the change or alteration to the Program Requirements or the parties do not reach an agreement with regard to a mutually acceptable change or alteration to the Program Requirements within thirty (30) days of receipt by CIGNA of MCA's notice of rejection. b. CIGNA may terminate this Agreement for cause: 1. immediately upon written notice to MCA if: i. MCA's license to engage in any business contemplated under this Agreement is revoked, after exhaustion of all appeal rights (so long as MCA is operating while the appeal rights are being exhausted); ii. MCA ceases to engage in all business activities; iii. MCA ceases to be in compliance with applicable federal or state laws, regulations or ordinances, a violation of which would materially impact the ability of MCA to conduct its business, to perform its obligations under this Agreement, to accept reimbursement on the basis described in this Agreement, or to own or control its assets; iv. MCA files a petition for bankruptcy or any other insolvency, rehabilitation, conservation or liquidation proceeding under state or federal law; v. Any bankruptcy, insolvency or liquidation proceeding is commenced against MCA, which proceeding is (a) not contested by MCA or (b) if contested by MCA, is not 26 dismissed within sixty (60) days after commencement; or vi. MCA merges into, becomes a subsidiary or wholly owned affiliate of or is otherwise acquired, in whole or in part, by any other entity. 2. upon sixty (60) days advance written notice to MCA if: i. MCA fails to adhere to any final determination of an arbitrator or, if applicable, the determination of a majority of the arbitrators, within the time frame established by the arbitrator(s), in accordance with the dispute resolution procedures outlined in section III M below; ii. MCA fails to comply with the requirements of Utilization Management and Quality Management; iii. MCA fails to maintain any guarantee of provision of Covered Services as required in this Agreement; iv. MCA fails to correct any deficiency identified by CIGNA in the performance of MCA's responsibilities with respect to any of the functions delegated to MCA under this Agreement within sixty (60) days of notification of such deficiency or, thereafter, fails to maintain compliance with such responsibilities; or v. MCA is in default of its payment obligations to any Represented Provider with respect to services rendered under this Agreement and fails to cure such default within ten (10) days of notification by CIGNA. If CIGNA elects to terminate this Agreement pursuant to this provision, during the time between CIGNA's election to terminate and the effective date of termination, CIGNA may elect to direct any and all payments due MCA hereunder directly to Represented Providers. Such payments shall be made, at CIGNA's election, either in accordance with the reimbursement arrangements set forth in MCA's provider agreements with its Represented Providers or in accordance with CIGNA's maximum fee schedule in effect at the time of service. Payor's payment obligations to MCA hereunder shall be reduced to the extent of such payments. 2. SERVICES UPON TERMINATION. Upon termination of this Agreement, MCA through its Represented Providers shall 27 continue to provide Covered Services for specific conditions for which a Participant was under Represented Provider's care at the time of such termination so long as Participant retains eligibility under a Service Agreement, until the earlier of completion of such services, CIGNA's provision for the assumption of such treatment by another provider, or the expiration of twelve (12) months. MCA shall be compensated for Covered Services provided to any such Participant in accordance with the compensation arrangements under this Agreement until sixty (60) days following termination, and compensation thereafter for continued services authorized by CIGNA shall at the existing fee for service rates. MCA and its Represented Providers have no obligation under this Agreement to provide services to individuals who cease to be Participants. 3. SERVICES AFTER CESSATION OF CIGNA OPERATIONS. In the event of CIGNA's insolvency or other cessation of operations, MCA shall continue to provide Covered Services to Participants through the period for which premium has been paid. MCA shall continue to provide Covered Services to Participants confined in an inpatient facility on the date of insolvency or other cessation of operations until their discharge. MCA further agrees that this Section i) shall survive termination of this Agreement regardless of cause; ii) supersedes any contrary agreement regarding continuation of Covered Services, after cessation of operations; and iii) shall not be modified without the prior written approval of the applicable state or federal governmental authorities. In no event, however, shall MCA be obligated to continue to provide services to Participants under this Agreement for a period of longer than thirty (30) days or as otherwise required by applicable law. 4. AMENDMENT OF MCA AGREEMENTS. If this Agreement is terminated or otherwise expires for any reason other than material breach of its terms by CIGNA, MCA shall cooperate with CIGNA to provide CIGNA with information necessary to communicate with Represented Providers directly regarding CIGNA Participants then receiving Covered Services from Represented Providers. At CIGNA's option, amend MCA's participation agreements with Represented Providers to make CIGNA a party to those agreements for one year beyond the date of termination of this Agreement. CIGNA shall prepare the amendment on behalf of MCA. MCA will cooperate with CIGNA in the implementation of, and in taking any or all action requested by CIGNA to effectuate, said amendments. Notwithstanding the foregoing, MCA shall not be required to amend its participation agreements with Represented Providers as set forth in this section in the event that this Agreement is terminated by MCA due to material breach of its terms by CIGNA. This provision shall survive the termination of this Agreement. 28 5. TERMINATION OF INDIVIDUAL REPRESENTED PROVIDERS. Upon request by CIGNA, MCA shall prohibit a Represented Provider from continuing to provide services to Participants under this Agreement. MCA shall take such action within ninety (90) days of the receipt of CIGNA's request, unless CIGNA requests immediate action by MCA. D. RIGHTS AND OBLIGATIONS UPON TERMINATION Upon termination of this Agreement for any reason, the rights of each party hereunder shall terminate, except as otherwise provided in this Agreement including any Program Attachment to this Agreement. Any such termination, however, shall not release MCA, Represented Providers or CIGNA from obligations under this Agreement prior to the effective date of termination. MCA agrees that for a period of two (2) years following termination of this Agreement by CIGNA, MCA shall not reapply for participation in CIGNA's provider network, unless otherwise agreed by CIGNA. E. ASSIGNMENT AND DELEGATION OF DUTIES Neither CIGNA nor MCA may assign duties, rights or interests under this Agreement unless the other party shall so approve by written consent. It is expressly understood by the parties that CIGNA and MCA may perform its obligations under this Agreement through their affiliates. F. USE OF NAME MCA agrees that CIGNA may include descriptive information relating to MCA and its Represented Providers in literature distributed to existing or potential Participants, Participating Providers and customers of CIGNA or a CIGNA Affiliate. Such information shall include, but not be limited to: Represented Providers' names, office telephone numbers, addresses, specialties, board certifications and hospital affiliations. MCA's use of CIGNA's name or CIGNA Affiliate's name, or any other use of MCA's or its Represented Providers' names by CIGNA shall be upon prior written approval or as the parties may agree. G. INTERPRETATION The validity, enforceability and interpretation of this Agreement shall be governed by any applicable federal law and by the applicable laws of the state in which MCA and its Represented Providers are licensed and have rendered Covered Services. 29 H. AMENDMENT 1. CIGNA may amend this Agreement and Program Attachments by providing prior written notice to MCA. Failure of MCA to object in writing to any such proposed amendment within sixty (60) days following receipt of notice shall constitute MCA's acceptance thereof. Notification to CIGNA of rejection of any proposed amendment means that this Agreement shall remain in force without the proposed amendment. 2. Notwithstanding the foregoing, in the event that state or federal law or regulation, or an arbitration or judicial interpretation of same, should change, alter or modify the present services, levels of payments to CIGNA or MCA, standards of eligibility of Participants, or any operations of CIGNA or MCA, such that the terms, benefits and conditions of this Agreement must be changed accordingly, then upon notice from CIGNA or MCA, the other party shall continue to perform under this Agreement as modified. In this regard, the parties specifically acknowledge the importance of the financial arrangements described herein and, therefore, agree, in the event that the financial arrangements are deemed invalid or unenforceable, the parties shall use best efforts to preserve the underlying economic and financial arrangements to the maximum extent possible. In the event that the parties are unable to reach agreement, then the financial terms shall be set pursuant to the dispute resolution process, giving full effect to the intent of the parties as described in this subsection. 3. Except as provided above, amendments to this Agreement shall be agreed to in advance in writing by CIGNA and MCA. I. PROGRAM ATTACHMENTS The Program Attachments and Exhibits hereto are a part of this Agreement and their terms shall supersede those of other parts of this Agreement in the event of a conflict. J. ENTIRE CONTRACT This Agreement together with all Program Attachments and Exhibits contains all the terms and conditions agreed upon by the parties, and supersedes all other agreements, express or implied, regarding the subject matter. K. NOTICE Any notice required hereunder shall be in writing and shall be sent by United States mail, postage prepaid, to CIGNA and MCA at the addresses set forth below: Al Perry, President and COO 30 3 Huntington Quadrangle 2S Melville, NY 11747 If to CIGNA: CIGNA HealthCare National Contracting 900 Cottage Grove Road, A-136 Hartford, CT 06152 And CIGNA HealthCare Legal Department 900 Cottage Grove Road, W-26 Hartford, CT 06152 L. ENFORCEABILITY AND WAIVER The invalidity and nonenforceability of any term or provision of this Agreement shall in no way affect the validity or enforceability of any other term or provision. The waiver by either party of a breach of any provision of this Agreement shall not operate as or be construed as a waiver of any subsequent breach thereof. M. DISPUTE RESOLUTION 1. Any disputes between the parties arising with respect to the performance or interpretation of the Agreement shall first be resolved in accordance with the dispute resolution procedures outlined in the Program Requirements . 2. In the event that a dispute is not resolved through the aforementioned process, the parties shall attempt in good faith to resolve the dispute promptly by negotiation between designated representatives of the parties who have authority to settle the dispute. If the matter has not been resolved within sixty (60) days of a party's request for negotiation, either party may initiate arbitration by providing written notice to the other party. 3. If a party initiates arbitration as provided above, the proceeding shall be governed by the Rules of the American Arbitration Association then in effect and shall be held in the jurisdiction of MCA's domicile. The parties will jointly appoint a mutually acceptable arbitrator. If the parties are unable to agree upon such an arbitrator within thirty (30) days after a party has given the other party written notice of its desire to submit a dispute for arbitration, then either party may apply to the American Arbitration Association for the appointment of an arbitrator or, if such Association is not then in existence or does not desire to act in the matter, each party shall appoint an arbitrator of its choice. The appointed arbitrators will select a third arbitrator, and the panel of three arbitrators will hear the parties and settle 31 the dispute. Each party shall assume its own costs, but the compensation and expenses of the arbitrator(s) and any administrative fees or costs shall be borne equally by the parties. Arbitration shall be the exclusive remedy for the settlement of disputes arising under this Agreement. The decision of the arbitrator(s) shall be final, conclusive and binding, and no action at law or in equity may be instituted by either party other than to enforce the award of the arbitrator(s). Judgment upon the award rendered by the arbitrator(s) may be entered in any court of competent jurisdiction. N. NON-SOLICITATION During the term of this Agreement and for a period of one (1) year from the date of termination, MCA shall not solicit Participants to enroll in any other insurance or health coverage or alternative delivery system, nor shall CIGNA or MCA actively solicit any employees of the other to be employed by or contracted with the other party in any capacity related to services to be performed under this Agreement during this Agreement, and for a period of one (1) year thereafter without the other party's written consent. [REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK] 32 IN WITNESS WHEREOF, the parties have executed this Agreement effective as of the EFFECTIVE DATE. EFFECTIVE DATE: CIGNA January 1, 2004 By: /s/ William Lamoreaux ---------------------------- Title: Senior Vice President Address: 900 Cottage Grove Road Hartford, CT 06152 Date Signed: 12/12/03 MCA Gentiva Health Services, Inc. Please print or type name By: /s/ Vernon A. Perry ---------------------------- Signature Title: President Address 300 Huntington Quadrangle 2S Melville, NY 11747 Federal Tax Identification Number 11-3454103 Date Signed: 12/8/03 Under penalties of perjury, by executing this Agreement above, MCA hereby certifies that 1) the taxpayer identification number set forth above is the correct taxpayer identification number; and 2) MCA is not subject to backup withholding because it a) is exempt from backup withholding; or b) has not been notified by the Internal Revenue Service (IRS) that it is subject to backup withholding as a result of a failure to report all interest or dividends; or c) the IRS has notified MCA that it is no longer subject to backup withholding. GTKP EXB - 1 GENTIVA CONTRACT EXHIBITS I. REPRESENTED PROVIDER AGREEMENT II. REQUIRED ENCOUNTER DATA ELEMENTS III. INFORMATION REQUIRED FOR A COMPLETE ORDER IV. CLEAN CLAIM DATA REQUIREMENTS V. GENTIVA CARECENTRIX SUBSIDIARIES VI. GUIDELINES FOR HOME & COMMUNITY CARE SPECIALIST VII. PERFORMANCE METRICS VIII. REPORTING TIMELINE IX. SAFE HOME CARE ADMISSION CRITERIA X. REPRESENTED PROVIDER REQUIRED DATA ELEMENTS XI. JOINT COMPLAINT MANAGEMENT PROCESS XII. 2003 STANDARDS FOR DELEGATION OF CREDENTIALING XIII. DME GUIDELINES GRID XIV. PARTICIPATING CIGNA SUBSIDIARIES & AFFILIATES XV. HOME HEALTH CARE BENEFIT CLARIFICATION GUIDELINE XVI. STANDARDS FOR DELEGATION OF CLINICAL SERVICE MANAGEMENT ACTIVITIES XVII. EXCLUSIONS DOCUMENT XVIII. CLINICAL SERVICE MANAGEMENT DELEGATION GRID XIX. MCA REPRESENTED PROVIDER APPLICATION XX. CONFIDENTIALITY AGREEMENT XXI. CIGNA NATIONAL CAPITATION HMO MARKET EXCLUSIONS XXII. STANDARDS FOR DELEGATION OF UTILIZATION MANAGEMENT ACTIVITIES FOR CIGNA HEALTHCARE OF TEXAS, INC. XXIII. MANAGED CARE ALLIANCE AGREEMENT CREDENTIALING PROCESSES XXIV. FUTURE YEARS RATE METHODOLOGY EXHIBIT I REPRESENTED PROVIDER AGREEMENT GENTIVA CARECENTRIX PROVIDER AGREEMENT THIS PROVIDER AGREEMENT is entered into as of this ____ day of _______2003, by and between ________________ located in ________________ ("PROVIDER") and Gentiva CareCentrix, Inc., located in Melville, New York ("GENTIVA"). PROVIDER's federal tax ID number: ________________________________. GENTIVA has entered into agreements with certain managed care entities ("Payors") which may require that health care services be delivered to their respective enrollees; GENTIVA desires to contract with PROVIDER to be available to provide certain of those services, and PROVIDER is willing to provide such services to the managed care patients designated by GENTIVA. NOW THEREFORE, PROVIDER and GENTIVA agree to the following terms and conditions. 1. RESPONSIBILITIES OF PROVIDER. 1.01 GENERAL. PROVIDER shall, to the extent requested by GENTIVA, sell the home care services described on Schedule A hereto (the "Services") to GENTIVA. PROVIDER shall coordinate the provision of Services to patients pursuant to this Agreement with all other providers involved in each such patient's care. GENTIVA is not required to purchase any minimum amount of Services. Upon GENTIVA's request for Services, PROVIDER assumes full responsibility for accepting the patient to home care and for the provision of the Services. 1.02 QUALIFICATIONS. PROVIDER represents and warrants that: (a) All of PROVIDER's employees, agents and representatives hold and shall continue to hold all federal, state and local licenses, registrations, certifications and training required by law, regulation and accreditation standards in order to render the Services pursuant to this Agreement. All RNs, LPNs, Pharmacists, Pharmacy Techs, PTs, OTs, MSWs and other professional and paraprofessional personnel providing the Services on behalf of PROVIDER must be qualified and have demonstrated competency, clinical experience and training in each type of clinical service they will provide. At GENTIVA's request, PROVIDER shall provide to GENTIVA copies of applicable licenses and other evidence of qualifications. (b) PROVIDER is duly licensed to provide the Services and shall furnish to GENTIVA copies of PROVIDER's valid license, certificate and accreditation applicable to the Services and itemized in Schedule A hereto. In lieu of such accreditation, PROVIDER must demonstrate substantial evidence of compliance with current JCAHO, CHAP, CARF OR ACHC accreditation standards. 1.03 PERFORMANCE STANDARDS. PROVIDER shall render the Services with the same standard of care, skill and diligence customarily used by similar providers in the community in which such services are rendered, and shall comply with all of the standards, terms and conditions set forth on Schedule A and all relevant standards, policies and procedures of GENTIVA (including those set forth in the Provider Manual) and PROVIDER. PROVIDER shall ensure that its employees maintain a neat, clean and professional appearance at all times. 1.04 QUALITY MANAGEMENT. PROVIDER shall fully cooperate with GENTIVA in GENTIVA's quality management, utilization review, outcomes monitoring, client satisfaction, complaint/grievance, credentialing and recredentialing programs, including participating in any meetings deemed appropriate by GENTIVA. Nothing in this Agreement shall render GENTIVA responsible for the manner or means by which PROVIDER renders the Services nor shall in any way affect PROVIDER's obligation to exercise independent medical judgment in rendering health care services to patients. 1.05 PERSONNEL CANCELLATION. After Services have been scheduled and confirmed, PROVIDER is responsible for delivery of the Service, and shall, in the event of any personnel cancellation, supply a qualified caregiver replacement of PROVIDER. In the event that PROVIDER cannot service the patient, PROVIDER shall notify GENTIVA immediately of cancellation. 1.06 COMPLIANCE WITH LAWS AND ACCREDITATION BODIES; NOTICE OF CERTAIN ACTIONS. (a) PROVIDER shall comply with all applicable federal, state and local laws, rules and regulations, and if applicable, JCAHO or CHAP (or CARF) (or ACHC) accreditation standards. PROVIDER shall cooperate with GENTIVA in responding to JCAHO or CHAP (or CARF) (or ACHC) inquiries, including without limitation surveys of PROVIDER premises and records by JCAHO or CHAP (or CARF) (or ACHC). (b) PROVIDER shall notify GENTIVA immediately (i) if there is a change affecting PROVIDER's or any PROVIDER's personnel's licensure, accreditation or certification, or (ii) if a professional, regulatory or legal body (x) serves formal notice that it may take any action due to deficiencies, poor performance or failure to comply with standards, rules or regulations imposed by such professional or regulatory body or (y) initiates an investigation which is material. PROVIDER shall give GENTIVA prompt written notice of any claims against PROVIDER's professional liability coverage relating to quality of care issues. (c) To the extent that the rates charged by PROVIDER pursuant to Schedule B hereof represent a discount or reduction in the amount PROVIDER generally charges for the Services, the parties agree to comply at all times with the provisions of 42 C.F.R. Section 1001.952(h), commonly known as the "discount safe harbor." 1.07 INCIDENT REPORTS AND COMPLAINTS. PROVIDER shall inform GENTIVA immediately of any incident or circumstance relating to any Services which adversely affects the health or safety of a Payor's enrollee, and/or of PROVIDER's receipt of any oral or written complaint relating to Services provided hereunder. PROVIDER shall provide copies to GENTIVA of an incident report and such other information related to any such incident and shall fully cooperate with GENTIVA in any investigation of such incident or complaint. 1.08 UNSATISFACTORY PERSONNEL. If GENTIVA reasonably determines that any PROVIDER personnel is unsatisfactory, GENTIVA may require PROVIDER to not use designated personnel, or require personnel to leave a patient's home or other care delivery site, (and in such case shall notify PROVIDER promptly). In any such case, GENTIVA's obligation to compensate PROVIDER shall be limited to the number of hours actually worked or the Services actually provided, and PROVIDER shall not reassign the individual to provide Services under this Agreement without the prior approval of GENTIVA. 1.09 SUBSTITUTION. (a) If any service not listed in Schedule A is required by GENTIVA, PROVIDER shall use reasonable efforts to provide such service and adjust its fees as mutually agreed. (b) PROVIDER shall utilize generic drugs whenever possible and appropriate. 1.10 WARRANTIES. (a) PROVIDER warrants that the Services including any product(s) delivered in connection with the Services, when used in accordance with the directions provided by PROVIDER, are fit for the intended purpose and indications described in the labeling, that all labeling is accurate, legible and can reasonably be expected to be understood by the patient receiving the Services and that all equipment (if any) provided under this Agreement shall be in good working order and condition, and properly cleaned and disinfected between uses. (b) To the extent that PROVIDER provides any equipment hereunder, PROVIDER shall provide or arrange for at PROVIDER's expense all necessary on-site maintenance and/or repair for equipment (including provision of all necessary parts, mechanisms and devices) in order to maintain the equipment in good condition and working order. PROVIDER shall provide or arrange for twenty-four (24) hour per day, seven (7) day per week maintenance and repair service by trained, competent and experienced personnel; provided however, that PROVIDER may elect to pick up the equipment needing maintenance and/or repair and replace it with equipment in operable condition, rather than repair the equipment immediately. PROVIDER shall, upon GENTIVA's request, furnish copies of all applicable inspection reports, manufacturer's operating manuals, instructions and related materials relating to the equipment. 1.11 ACCURATE INFORMATION. PROVIDER represents and warrants that all information (including without limitation information contained in the application materials) which PROVIDER has furnished to GENTIVA to induce GENTIVA to enter into this Agreement with PROVIDER is true and accurate, and that PROVIDER shall promptly notify GENTIVA of any change in the information contained in such materials. 1.12 REPORTS. PROVIDER shall prepare, maintain and deliver to GENTIVA any reports and documentation specified in the Provider Manual or otherwise reasonably requested in writing by GENTIVA including without limitation, pertaining to accurate inventories of solutions, medications, drugs, equipment and ancillary supplies for each patient provided by PROVIDER hereunder, and a listing of all equipment in use by each patient, provided by PROVIDER, including the number of months patients have had the equipment. 1.13 ADDITIONAL PAYOR SOURCES. PROVIDER shall promptly notify GENTIVA when it becomes aware of any additional primary or secondary payor sources for any patient. 1.14 EMPLOYER OBLIGATIONS. PROVIDER shall maintain full responsibility as employer of its personnel for payment of their wages and other compensation, and for any applicable mandatory withholdings and contributions such as federal, state and local income taxes, social security taxes, worker's compensation, unemployment and disability coverages. 2. RESPONSIBILITIES OF GENTIVA. 2.01 GENERAL. For each patient for whom GENTIVA requests Services, GENTIVA shall deliver by facsimile to PROVIDER a written authorization confirming a telephone request for service by next business day, and for services provided in an emergency GENTIVA shall provide authorization by next business day. 2.02 REQUESTS FOR PERSONNEL. GENTIVA shall attempt to request personnel at least 24 hours prior to reporting time and shall provide information regarding reporting time and assignment to PROVIDER at the time of the initial call. 2.03 PAYMENTS. GENTIVA shall compensate PROVIDER as provided in Article 3 below. 3. COMPENSATION. 3.01 INVOICES. PROVIDER shall provide GENTIVA with monthly invoices (on HCFA 1500 or UB92 forms) with an itemization of all Services requested by GENTIVA during the previous month. PROVIDER shall not bill any Payor directly unless PROVIDER shall have obtained GENTIVA's advance written consent in each instance. 3.02 RATES. GENTIVA shall pay to PROVIDER the rates set forth in SCHEDULE B for the Services provided in accordance with this Agreement. These rates are all inclusive and PROVIDER shall receive no additional compensation for reports, information exchanges, or other services contemplated by this Agreement. 3.03 PAYMENT TERMS. GENTIVA shall pay PROVIDER the undisputed invoiced amount under this Agreement within forty five (45) days from GENTIVA's receipt of a properly completed invoice from PROVIDER. 3.04 NON-COVERED SERVICES AND REIMBURSEMENT TO GENTIVA. Notwithstanding the foregoing, GENTIVA shall not be obligated to pay for and PROVIDER shall be required to reimburse to GENTIVA any payment made for any Services (a) that were not (i) requested by GENTIVA (except for any emergency services), or (ii) in accordance with GENTIVA's written authorization, or (iii) in accordance with the physician plan of care; (b) for which a properly completed invoice is not received by GENTIVA within 45 days of the date the Services are rendered; (c) until such time as GENTIVA shall have received from PROVIDER the reports and documentation referred to in Section 1.12; (d) delivered to a patient not enrolled in the Payor health plan at the time Services were delivered; or (e) if the respective Payor was not the primary payor at the time Services were delivered. 3.05 HOLD HARMLESS. (a) PROVIDER agrees that in no event, including but not limited to nonpayment by GENTIVA, insolvency of GENTIVA or breach of this Agreement, shall PROVIDER bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a patient or persons acting on his/their behalf for Services provided hereunder. This provision does not prohibit PROVIDER from collecting fees for non-covered services delivered to patients, subject to subsection (b) below. PROVIDER shall not collect any applicable Co-payment, deductible or coinsurance (determined as a percentage of charges) from patients. (b) When PROVIDER has been notified in advance that a particular service is not medically necessary, PROVIDER shall not charge the patient for such service unless, in advance of the provision of such service, PROVIDER has notified the patient that the service is not covered and the patient acknowledges in writing that he or she shall be responsible for payment of charges for such services. (c) PROVIDER agrees that the provisions of this Section 3.05 shall survive the termination of this Agreement regardless of the reason for termination, and shall be construed for the benefit of the patients, and that this provision supersedes any oral or written agreement to the contrary now existing or hereafter entered into. Any modification to the provisions of this Section shall become effective 15 days after the applicable regulatory authority shall have received written notice of such proposed changes. 4. TERM AND TERMINATION. 4.01 (a) TERM. Upon execution by both parties, this Agreement shall be in effect for one (1) year from the date first written above and thereafter shall automatically renew for subsequent one year terms. (b) TERMINATION. (i) Either party may terminate this Agreement if any warranty, representation or material covenant of the other party contained herein is untrue or is breached during the term hereof, and any such breach is not cured to the satisfaction of the other party within fifteen (15) days after receipt of the written notice from the nonbreaching party; (ii) either party, at its option, may terminate this Agreement at any time upon 90 days written notice to the other party, and (iii) PROVIDER may terminate this Agreement during the first thirty (30) days after the date of this Agreement if PROVIDER objects to the terms and conditions set forth in GENTIVA's Provider Manual. If PROVIDER does not terminate this Agreement during the first thirty (30) day period, then PROVIDER shall have waived its right to terminate this Agreement based on objections to the Provider Manual. 4.02 ORDERLY TERMINATION. Upon termination of this Agreement, PROVIDER shall reasonably cooperate with GENTIVA to ensure that patients are not left without medically necessary care. PROVIDER shall, at GENTIVA's request, continue to provide the Services to any patient receiving the Services at the time of such termination for thirty (30) days thereafter and GENTIVA shall pay PROVIDER in accordance with the rates hereunder. 5. MISCELLANEOUS TERMS. 5.01 INDEMNIFICATION. (a) GENTIVA and PROVIDER ("Indemnitor") shall each defend, indemnify and hold the other party ("Indemnitee") harmless and each of Indemnitee's officers, directors, employees, agents and stockholders (the "Indemnitee Parties"), from and against any and all claims, liabilities, losses, damages, costs or expenses of any kind (including reasonable attorney's fees and disbursements) ("Indemnified Amounts") incurred by the Indemnitee Parties as a result of Indemnitor's performance under this Agreement, but only to the extent that such Indemnified Amounts are caused by the negligence or other wrongful act or omission of Indemnitor. (b) Indemnitee shall notify the Indemnitor in writing of the assertion of any claim, or the commencement of any suit, action or proceeding by any party in respect of which indemnity may be sought under this Agreement within thirty (30) days of such assertion or commencement. Failure to notify the other party shall result in the waiver of indemnity rights with respect to such claim, suit, action or proceeding, but only to the extent that the Indemnitor is prejudiced by such failure. The parties shall cooperate with each other in the defense of any such claim, suit, action or proceeding. 5.02 CORPORATE INTEGRITY COMPLIANCE. PROVIDER represents and warrants that currently, and throughout the term of this Agreement (including any extended term), (I) neither PROVIDER, nor any of its employees or agents who may perform any of the services or obligations under this Agreement ("PROVIDER Individuals"), shall (A) have been convicted of a criminal offense that would trigger exclusion pursuant to 42 USC 1320a-7(a) or (b) unless such entity or individual has been reinstated, or (B) be listed by a Federal agency as currently suspended, debarred, excluded or otherwise ineligible for Federal program participation (including as reflected on the Cumulative Sanctions Report of the United States Health and Human Services Office of the Inspector General's, or the United States General Services Administration's List of Parties Excluded from Federal Procurement and Non-Procurement Programs). Any breach of this representation and warranty shall result in immediate termination of this Agreement with respect to the affected individual or entity, in addition to any other available remedies. 5.03 INSURANCE. (a) Each party shall maintain at its sole expense the following insurances: (i) general liability coverages (including without limitation product liability and contractual liability), in an amount not less than One Million Dollars ($1,000,000) each occurrence and Two Million Dollars ($2,000,000) in the aggregate, for bodily injury and property damage; (ii) professional liability (medical malpractice) coverage in the amount of One Million Dollars ($1,000,000) each occurrence and Three Million Dollars ($3,000,000) in the aggregate (iii) statutory workers' compensation coverage meeting all state and local requirements, including employers' liability coverage in an amount not less than One Million Dollars ($1,000,000) per person; (iv) automobile liability insurance for owned, non-owned and hired automobiles with a minimum combined single limit of One Million Dollars ($1,000,000) for bodily injury and property damage each occurrence and (v) a client fidelity (3rd party) bond in the amount of Fifty Thousand Dollars ( $50,000). All Represented Providers shall at minimum maintain limits in accordance with those required by the state(s) where the Represented Provider is licensed. (b) PROVIDER agrees to ensure that any nurse, pharmacist or other licensed professional who performs an activity pursuant to this Agreement on its behalf and is not an employee of PROVIDER carry the same insurance coverages PROVIDER is required to maintain. This includes but is not limited to (i) malpractice liability insurance in an amount not less than One Million Dollars ($1,000,000) per occurrence and Three Million Dollars ($3,000,000) in the aggregate and (ii) general liability insurance in an amount not less than One Million Dollars ($1,000,000) each occurrence and Two Million Dollars ($2,000,000) in the aggregate, for bodily injury and property damage. (c) The general liability policy shall name Gentiva as an additional insured and be endorsed to cover liability assumed by the PROVIDER under the indemnity provisions of this Agreement. With respect to the workers' compensation policy, PROVIDER shall require the carrier to waive all rights of subrogation against Gentiva. Each party shall give the other immediate notice of any changes in the policy of insurance or self-insurance maintained under this Agreement. Each party shall require any insurer to give the party at least 30 days' advance notice of any cancellation, lapse, termination, or amendment of any policy of insurance. In the event that coverage is of a claims-made variety, each party shall continue to maintain policies of insurance in effect to cover claims that occur during the term of this Agreement for a period of 5 years beyond the term or any renewal term of this Agreement. Failure to maintain such coverage shall be grounds for termination of this Agreement for cause, and the breaching party shall indemnify the other party for any loss incurred as a result of the breaching party's failure to maintain such coverage, which obligation to indemnify shall survive termination of this Agreement. 5.04 ASSIGNMENT/SUBCONTRACTING. Neither party may assign or subcontract its rights or obligations under this Agreement without the prior written consent of the other party which shall not be unreasonably withheld or delayed, provided, however, either party may assign this Agreement to any entity owned by or under common control with such party. The assigning party shall remain fully responsible for compliance with this Agreement. 5.05 ACCESS TO BOOKS AND RECORDS. (a) During the term of this Agreement and for three (3) years following termination of this Agreement, GENTIVA and its duly authorized agents, during regular business hours and upon reasonable notice and demand, shall have access to all information and records related to Services rendered by PROVIDER under this Agreement or to the effectiveness of GENTIVA's utilization management, quality improvement, claims management and payment and other programs. (b) For at least five (5) years after the date of delivery of service, PROVIDER shall maintain and readily make available to government agencies with regulatory authority, medical and administrative records relating to Services, pursuant to applicable law or regulation. 5.06 NON-DISCLOSURE AND CONFIDENTIALITY; NON-SOLICITATION. (a) PROVIDER shall not disclose the terms of this Agreement, including but not limited to any fee schedule, without the prior written consent of GENTIVA. (b) PROVIDER and GENTIVA shall maintain the confidentiality of all confidential information regarding patients in accordance with any applicable laws and regulations. PROVIDER shall provide GENTIVA with all records and information necessary to carry out GENTIVA's utilization management, quality improvement, claims management and payment and other relevant programs (and shall obtain any consents which may be required to allow such disclosure to GENTIVA and to allow GENTIVA to disclose such information to third parties for such purposes). (c) PROVIDER acknowledges that in order to provide the Services hereunder, it may from time to time receive proprietary or confidential information from GENTIVA, including without limitation, patient identification, customer and client identification and lists, accounts, business operating methods, programs, policies, procedures and forms. PROVIDER shall keep such information confidential and (unless otherwise required by law) shall not disclose it to any person except as authorized in writing by GENTIVA. (d) During the term of this Agreement, PROVIDER shall not request, advise, or solicit any client, customer, supplier, or patients serviced by PROVIDER pursuant to this Agreement to curtail, terminate or cancel their relationship with GENTIVA. (e) PROVIDER shall not make any public announcement or press release with respect to its relationship to GENTIVA described in this Agreement or any other matter in connection with this Agreement, without the prior written consent of GENTIVA. (f) The provisions of this Section shall survive the termination of this Agreement. PROVIDER acknowledges that if the provisions of this Section are breached, the damage to GENTIVA shall be irreparable and thereby shall entitle GENTIVA to obtain immediate and permanent injunctive relief restraining PROVIDER from such breach or threatened breach of the provisions hereof, without need to post any bond. PROVIDER further acknowledges that such injunctive relief is in addition to any other legal or equitable remedies GENTIVA may be entitled to under this Agreement. 5.07 PROTECTED HEALTH INFORMATION: Gentiva and Provider agree that all member individually identifiable health-related information ("Protected Health Information") shall be used and disclosed only as permitted by applicable state and federal laws, including without limitation applicable Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated there-under ("HIPAA"). Gentiva and Provider shall also adopt and maintain procedures consistent with applicable law to safeguard the security and confidentiality of Protected Health Information. Provider shall cooperate and assist Payer and/or Gentiva as needed to obtain all necessary or required patient consents in compliance with applicable state and federal law. Except as required to carry out Provider's obligations under this Agreement, Provider shall not disclose, sell or otherwise transfer or provide any Protected Health Information or other Confidential Information on any individually identifiable patient basis to any third party. In no event shall Provider sell any Protected Health Information or other Confidential Information of Payer or Gentiva, whether or not such information is individually identifying. 5.08 USE OF NAME. Neither party may use any trade name or service mark of the other party or any material protected by patents, trademarks or copyrights without the express written permission of the other party, except that either party may list the other party in any relevant directory of services and related marketing materials of such party, or, in GENTIVA's case, of any Payor Directories. 5.09 INDEPENDENT CONTRACTORS. The parties enter into this Agreement as independent contractors, and nothing contained in this Agreement shall be construed to create a partnership, joint venture, agency or employment relationship between the parties or any of their respective officers, directors or employees. 5.10 CORPORATE COMPLIANCE PROGRAM. GENTIVA maintains a voluntary corporate compliance program to detect and prevent illegal and unethical activities. PROVIDER confirms that it has been informed of GENTIVA corporate compliance hotline (1-888-9NOTIFY) for reporting suspected fraud, abuse or other illegal or unethical activities, and will assure that all employees or agents of GENTIVA who may perform any of the services or obligations under this Agreement are informed of the same and instructed to report accordingly. 5.11 OWNERSHIP AND USE OF DATA AND INFORMATION. GENTIVA shall own all data, documents, software programs and other information generated in the performance of this Agreement, including all patient information submitted by PROVIDER pursuant to Section 5.05(b) above. These provisions shall not prohibit PROVIDER from owning data specific to its patients and created by PROVIDER. Subject to the confidentiality obligations under this Agreement and those imposed by law, GENTIVA shall have the right to use any such information in the general course of its business. 5.12 AMENDMENT AND WAIVER. (a) Subject to the provisions of subsection (b) of this Section, no amendment, modification or supplement of this Agreement, and no waiver hereunder shall be valid or binding unless set forth in writing and duly executed by a duly authorized signatory of the party against whom enforcement of the amendment, modification, supplement or waiver is sought. Waiver by either party of an event of default or breach of the provisions of this Agreement shall not constitute a waiver of any other event of default or breach or right, nor of the same event of default or breach or right on a future occasion. (b) GENTIVA may modify any provision of this Agreement upon thirty (30) days prior written notice to PROVIDER. PROVIDER shall be deemed to have accepted GENTIVA's modification if PROVIDER fails to object to such modification, in writing, within the thirty (30) day notice period. In the case of modifications that materially affect the responsibilities or rights of PROVIDER, PROVIDER shall have the right to terminate this Agreement on thirty (30) days prior written notice to GENTIVA delivered within the 30 day notice period referred in the preceding sentence. Amendments required by legislative, regulatory or other legal authority, as reasonably determined by GENTIVA, shall not require the consent of GENTIVA or the PROVIDER and shall be effective immediately upon PROVIDER's receipt of notice of amendment. 5.13 ENTIRE AGREEMENT. This Agreement contains the entire agreement between the parties, supersedes all discussions and writings by and between the parties which may have occurred prior to or contemporaneously with entering into this Agreement and shall be binding upon and inure to the benefit of the parties and their permitted successors and assigns. 5.14 GOVERNING LAW. This Agreement shall be governed by the laws of the State of New York. 5.15 SEVERABILITY. If any provision of this Agreement is held to be invalid or unenforceable under current or future laws, the remainder of the provisions of this Agreement shall remain in full force and effect and shall in no way be affected, impaired or invalidated, as long as the invalid provision is not material to the overall purpose and operation of this Agreement. 5.16 NOTICES. Notices provided hereunder shall be given in writing and sent to the addresses below by hand delivery; facsimile, certified mail, return receipt requested; or nationally recognized overnight courier. Any address or name specified may be changed by a notice given by the addressee to the other party in accordance with this Section. Any notice of demand or other communication shall be deemed given and effective as of the date of receipt. PROVIDER shall notify GENTIVA in writing within seven days after the occurrence of: a. A change of the PROVIDER'S business address or of any Represented PROVIDER'S address, including any relocation or elimination of a location. b. The termination, reduction or cancellation of the insurance coverages required under this Agreement; c. Any material changes in the Providers ownership, to the extent that the ownership or control of the Provider changes by twenty percent (20%) or more; d. Any situation which might materially affect the Group's or a Represented PROVIDER'S ability to carry out the duties under this Agreement or to meet any Credentialing/Re-Credentialing criteria. PROVIDER GENTIVA ___________________________ GENTIVA CARECENTRIX ___________________________ 3 Huntington Quadrangle S2 ___________________________ Melville, NY 11747 ___________________________ Attn.: Provider Relations PHONE #:_____________________ FAX#:________________________ 5.17 HEADINGS. The headings in this Agreement are for convenience only and shall not be considered a part hereof or affect the construction or interpretation of any provisions of this Agreement. 5.18 COUNTERPARTS. This Agreement may be executed simultaneously in two or more counterparts, each of which shall constitute but one and the same instrument. 5.19 SURVIVAL OF OBLIGATIONS. Termination of this Agreement for any cause shall not release either party from any liability which at the time of termination has already accrued to the other party or which thereafter may accrue in respect to any act or omission occurring prior to termination from any obligation which is expressly stated herein to survive termination. 5.20 NON-DISCRIMINATION. Neither PROVIDER or GENTIVA shall discriminate in employment or provision of services with respect to age, race, color, religion, veteran status, sex, national origin, disability, source of payment or any other category protected by law. 5.21 ARBITRATION. Any dispute relating to this Agreement shall be settled by binding arbitration conducted in accordance with the Health Care Arbitration Rules of the NHLA Alternative Dispute Resolution Services. 5.22 MEDICARE PROVISIONS. GENTIVA may request that PROVIDER provide services to enrollees PAYOR's Medicare+Choice plan ("PAYOR PLAN") and PROVIDER recognizes that federal regulations impose certain requirements on all providers, including PROVIDER, rendering services to individuals enrolled in Medicare+Choice plans. Therefore, PROVIDER shall comply with all of the standards, terms and conditions set forth on Schedule C. THEREFORE, the authorized representatives of the parties have executed this Agreement as of the date first written above. PROVIDER: GENTIVA CARECENTRIX: By: By: ---------------------------- ---------------------------- Title: Title: ------------------------- ------------------------- SCHEDULE A TO PROVIDER AGREEMENT HEALTH CARE SERVICES In addition to the terms and conditions identified in previous sections of the Provider Agreement, PROVIDER agrees to the provisions contained in this schedule: A. SERVICES TO BE PROVIDED 1. Home Health Agency [ ] Skilled Nursing [ ] Pediatric Specialty [ ] Therapists [ ] Homemakers/Companions [ ] Rehab Paraprofessional [ ] Medical Social Workers [ ] Home Health Aides/PCW [ ] Live-in [ ] Other ________________ 2. Home Infusion Therapy [ ] Infusion Products [ ] Full Service [ ] Ambulatory Center 3. Hospice Services [ ] Home-based [ ] Facility-based 4. Home Medical Equipment [ ] Standard Equipment [ ] Orthotics and [ ] Medical Supplies Prosthetics [ ] Customized Equipment 5. Respiratory Services [ ] Respiratory Products [ ] Respiratory Therapists 6. Women's Health Services [ ] High Risk OB - Level 1 [ ] Low Risk OB [ ] High Risk OB - Level 2 [ ] Prenatal Education [ ] High Risk OB - Level 3 [ ] HUAM 7. Medical Rehabilitation Services [ ] Physical Therapists [ ] Physical Therapy Assistants [ ] Occupational Therapists [ ] Occupational Therapy [ ] Speech & Language Pathologists Assistants [ ] Outpatient [ ] Rehab Paraprofessionals 8. Quality Assurance/Quality Improvement Program [ ] Proof of Quality Assurance/Quality Improvement Program 9. Other - specify ____________________________________________ B. REQUIRED QUALIFICATIONS Evidence of meeting the following qualifications shall be presented:
YES NO --- -- 1. Valid State Pharmacy license as required. _____ _____ 2. Valid individual pharmacist licenses as required. _____ _____ 3. DEA Registration as required. _____ _____ 4. Sterile area/clean room certifications as required. _____ _____ 5. Valid unrestricted state operating license or certificate as required. _____ _____ 6. Medicare Home Health Agency Certification (may be waived if other credentials are acceptable to GENTIVA). _____ _____ 7. Accreditation by JCAHO, CHAP, ACHC (or CARF for Rehab) (may be waived if other credentials are acceptable to GENTIVA). _____ _____ 8. Medicare/Medicaid Sanctions _____ _____ 9. Adequate Professional and General Liability Insurance _____ _____
C. PERFORMANCE STANDARDS The PROVIDER agrees to adhere to the following standards of performance: 1. Submit changes in the following to the Provider Relations Department in Melville, New York within a timely manner: a. Address(es). b. Telephone number(s). c. Name of key organizational contact(s). d. Name(s) of key local operations contact(s). e. Accreditation status. f. Legal status; i.e., pending or newly active litigation relative to cases, only. g. Licensing status. h. Liability insurance coverage. i. Days/hours of operation. j. Certification status. k. Service/product capabilities. l. Addition/closure of operation/business site. 2. Maintain 24-HOUR ON-CALL COVERAGE 7 DAYS PER WEEK and respond to patient and/or contacts within 30 MINUTES of call after regular business hours and on holidays (unless otherwise specified by contract). 3. Notify the Care Manager IMMEDIATELY if not able to service a referred case. 4. Start care and assessment with in 24 HOURS following acceptance of referral and comply with any other requirements of the individual health plans serviced and individual case needs. 5. Notify the Care Manager IMMEDIATELY if assessment must be delayed. 6. Notify the Care Manager within 2 HOURS of assessment if unable to service the case. 7. Render no services unless so authorized by the referring Care Manager and ordered by the primary physician except in emergencies (see #19.). 8. Notify the Care Manager of additional sources of reimbursement upon their identification. 9. Provide after hours (on call) home visits as appropriate and necessary in situations which cannot be resolved by telephone consultation. 10. Notify the Care Manager of changes in patient/family status WITHIN ONE (1) BUSINESS DAY upon occurrence/identification, including illness, hospitalization, death or other change affecting continued service delivery. 11. Follow/report patient status, progress and projected and actual date of discharge given hospitalization/institutionalization while on service. 12. Respond to all requests for contact from personnel WITHIN ONE (1) BUSINESS DAY. 13. Notify the Care Manager of patient, family, physician, health plan Case Manager complaint(s) upon occurrence and in accordance with the parameters established in the section of the Provider Manual on Complaint Management. 14. Submit/report discharge data to the Care Manager WITHIN ONE (1) BUSINESS DAY of completion of service/product delivery. 15. Routinely submit requests for care reauthorization no later than 24 HOURS prior to completion of authorized care and obtain physician orders for reauthorized services/products. 16. Contact the Care Manager within TWO (2) BUSINESS DAYS providing unauthorized emergency care on a non business day or after business hour. 17. Submit documentation as follows: a. Confirmation of care within 24 HOURS of start of care. b. Physician's orders and other clinical documentation upon confirmation of start of care and reauthorization request. c. Objective reason(s) for reauthorization of care prior to completion of authorized care. d. Discharge summary within 24 HOURS of completing service/product delivery. e. Assessment reports, progress reports, organizational forms, or other organizational documents within 48 HOURS of request by the Care Manager. 18. Report adverse incidents, as defined in Problem Management Section of GENTIVA's Provider Manual, to the Care Manager within 24 hours of occurrence. 19. Respond to grievances/complaints filed against the Provider within 2 BUSINESS DAYS and pursue timely resolution acceptable to GENTIVA staff. 20. SUBMIT NO BILLING TO THE HEALTH PLAN for services/products delivered to patients unless specifically notified to do so by the GENTIVA . 21. Treat all patients, families, physicians, health plan representatives, other providers and personnel with respect, dignity and professionalism. D. ADDITIONAL EVALUATION Provider performance also is evaluated by: 1. Patient, physician and customer satisfaction. 2. Accurate and timely billing. 3. Presence/absence of adverse clinical incidents. 4. Presence/absence of provider-related complaints/grievances from patients, physicians and/or health plan customers. In the event of any conflict between these performance standards and any Payor(s) requirements which are more stringent or restrictive than these performance standards, the Payor(s) requirements shall control and be binding. SCHEDULE B TO PROVIDER AGREEMENT REIMBURSEMENT SCHEDULE (SEE ATTACHED) PROVIDER to check applicable category and attach corresponding fee schedule. B.1 [ ] Home Health Care B.2 [ ] Home Infusion Therapy B.3 [ ] Hospice B.4 [ ] Home Medical Equipment B.5 [ ] Respiratory Services B.6 [ ] Women's Health Services B.7 [ ] Medical Rehabilitation Services B.8 [ ] Other: (Specify)_____________________________ SCHEDULE C TO PROVIDER AGREEMENT MEDICARE+CHOICE PROVISIONS 1. ADDITIONAL PROVISIONS. GENTIVA and PROVIDER agree to the following provisions: A. COMPLIANCE WITH LAWS. PROVIDER shall comply with and is subject to all applicable Medicare program rules and regulations, as implemented and as amended by the Health Care Financing Administration ("HCFA"), including without limitation federal and state regulatory agencies' rights to audit PROVIDER's operations, books, records and other documentation related to PROVIDER's obligations under the Agreement, as well as all other federal and state laws, rules and regulations applicable to individuals and entities receiving federal funds, including without limitation Title VI of the Civil Rights Act of 1964, The Age Discrimination Act of 1975, The Americans With Disabilities Act and The Rehabilitation Act of 1973. PROVIDER shall require that all health care professionals employed by or under contract with PROVIDER to render health services under the Agreement comply with this provision. B. FEDERAL FUNDS. PROVIDER acknowledges that payment from PAYOR PLAN to GENTIVA for services to Medicare+Choice enrollees is derived in whole or in part from federal funds received by PAYOR PLAN from HCFA, and that PROVIDER shall be subject to those laws, rules and regulations applicable to individuals and entities receiving federal funds. C. RECORD MAINTENANCE AND CONFIDENTIALITY. In order to ensure compliance under the Agreement, PROVIDER acknowledges and agrees to retain all contracts, books, documents, papers and other records related to the provision of services to Medicare members and/or as related to PROVIDER's obligations under the Agreement for a period of not less than 6 years. PROVIDER agrees to safeguard the privacy of any information that identifies a particular enrollee, maintain records in a timely and accurate manner, ensure timely access by enrollees to the records at a reasonable time and in a reasonable manner upon written request by the enrollee. D. RIGHT TO INSPECT. PROVIDER agrees to give the United States Department of Health and Human Services, the Comptroller General of the United States, or their designees, the right to audit, evaluate, and inspect books, contracts, medical records, patient care documentation, or other records related to the care of Medicare + Choice patients for a period of no less than six (6) years from the final date of the contract period or the completion of any audit, whichever is later, which period may be extended only in accordance with the terms of 42 CFR 422.502(e)(4). E. DATA COLLECTION/ ACCURATE INFORMATION. With respect to Medicare+Choice patients, PROVIDER acknowledges that PAYOR PLAN is required by HCFA to maintain a health information system that collects, analyzes and integrates all data necessary to compile, evaluate and report certain statistical data related to costs, utilization and quality, and such other matters as HCFA may require from time to time. PROVIDER hereby agrees to submit to GENTIVA or PAYOR PLAN, upon request, all information and/or data necessary for PAYOR PLAN to fulfill these obligations, and within the timeframes specified by GENTIVA or PAYOR PLAN to meet HCFA requirements. PROVIDER hereby represents and warrants that all data including, but not limited to, encounter data and other information submitted to GENTIVA by PROVIDER shall be truthful, reliable, accurate and complete, and upon request by GENTIVA, PROVIDER agrees to certify that such information is truthful, reliable, accurate and complete. PROVIDER further agrees to hold harmless and indemnify GENTIVA and PAYOR for any fines or penalties they may incur due to PROVIDER's submission of inaccurate or incomplete data. F. PATIENT COMMUNICATIONS. The parties acknowledge and agree that nothing contained in the Agreement is intended to interfere with or hinder communications between health care PROVIDER(s) and members regarding patient treatment. PROVIDER(s) will discuss with member their health status and all medical care and treatment options which PROVIDER and/or the member's treating physician deems clinically necessary and appropriate, regardless of any coverage or payment determination(s) made or to be made by PAYOR or GENTIVA. G. MEDICALLY NECESSARY SERVICES. Nothing contained herein is intended by GENTIVA to be a financial incentive or payment that directly or indirectly acts as an inducement for PROVIDER to limit Medically Necessary services. H. NON-DISCRIMINATION. PROVIDER will not discriminate against any enrollee on the basis of any factor related to health status, including without limitation medical condition, including mental and physical illness, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, including conditions arising out of acts of domestic violence, or disability. PROVIDER agrees to observe the provisions of Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975 and the Americans with Disabilities Act. I. COOPERATION. PROVIDER agrees to cooperate with any independent quality review and improvement organization utilized by or under contract with PAYOR PLAN pertaining to the provision of services for Medicare + Choice enrollees. PROVIDER shall comply with applicable GENTIVA and PAYOR policies and, if requested by GENTIVA, shall cooperate in developing and implementing medical policy, quality assurance programs, and medical management programs applied to Medicare + Choice enrollees. J. PARTICIPATION IN MEDICARE. PROVIDER hereby represents that PROVIDER and all employees, subcontractors and/or independent contractors of PROVIDER providing or who will provide services under the Agreement, including without limitation health care, utilization review, medical social work and/or administrative services, each maintains full participation status in the Medicare program and/or is not excluded from participation in the Medicare program. GENTIVA may terminate the Agreement immediately upon PROVIDER'S failure to adhere to the terms of this provision. K. STANDARDS OF CARE. HMO and GENTIVA agree to provide all covered benefits to Medicare + Choice enrollees in a manner consistent with professionally recognized standards of care. L. ADDITIONAL TERMINATION PROVISIONS. Notwithstanding any provision in the Agreement, the following termination provisions shall apply to PROVIDER if rendering services to Medicare+Choice enrollees: (i) GENTIVA may terminate the Agreement immediately upon request of PAYOR due to PROVIDER'S loss or suspension of licensure or certification, or sanction by Medicare. (ii) GENTIVA may terminate the Agreement upon thirty (30) days prior written notice to PROVIDER for PROVIDER'S failure to cooperate and/or comply with any of the provisions of the Agreement (iii) If PROVIDER wishes to terminate the Agreement without cause, it must provide the other party with no less than sixty (60) days prior written notice, given in accordance with the terms of the Notice provision of the Agreement. M. DELEGATION REQUIREMENTS. PROVIDER understands and acknowledges that if any of the PAYOR PLAN'S activities or responsibilities under its contract with HCFA, related to the provision of services to Medicare+Choice enrollees, are delegated to other parties, the following requirements apply to any related entity, contractor, subcontractor, or provider: (i) Written arrangements must specify delegated activities and reporting responsibilities. (ii) Written arrangements must either provide for revocation of the delegation activities and reporting requirements or specify other remedies in instances where HCFA or the PAYOR PLAN determine that such parties have not performed satisfactorily. (iii) Written arrangements must specify that the performance of the parties is monitored by the PAYOR PLAN on an ongoing basis. (iv) Written arrangements must specify that the credentialing process will be reviewed and approved by the M+C organization and the M+C organization must audit the credentialing process on an ongoing basis. (v) All contracts or written arrangements must specify that the related entity, contractor, or subcontractor must comply with all applicable Medicare laws, regulations, and HCFA instructions. N. APPEALS. PROVIDER will adhere to Medicare's appeals procedure for Medicare+Choice enrollees, including the procedures for expedited appeals. PROVIDER shall gather and forward information on enrollee appeals to GENTIVA or PAYOR to the extent required by law or regulation so as to enable PAYOR PLAN to meet the HCFA required timeframes for grievances and appeals. O. COMPLIANCE WITH POLICIES. To the extent that a Medicare + Choice requirement is found in a policy, the Provider Manual or other procedural guide of GENTIVA and/or PAYOR PLAN and is not otherwise specified in the Agreement, PROVIDER will comply with those policies, manuals and procedures with regard to the provision of care to Medicare + Choice enrollees. Written notice of material changes to applicable policies, including the Provider Manual, shall be provided to PROVIDER prior to the effective date of such changes. P. FAILURE TO COMPLY. If GENTIVA denies payment to PROVIDER due to PROVIDER'S failure to comply with any of the provisions of the Agreement, PROVIDER shall not bill the enrollee for the denied amounts. Q. AMENDMENT. GENTIVA may amend this Attachment as needed to comply with applicable state and federal laws, rules and regulations, and shall provide PROVIDER with written notice of such amendment and its effective date. Unless required by such law, rule or regulation, PROVIDER'S signature will not be required to implement such amendment. EXHIBIT II REQUIRED ENCOUNTER DATA ELEMENTS Provider (including Provider's Subcontractors) shall provide CIGNA with the following standard data elements for each service encounter with respect to Covered Home Care Services rendered under this Agreement: o Patient Name, Address, Phone, Date of Birth o Insured's Name, Address, Phone, Date of Birth o Healthplan Identifier o Group Number o Date of Service o Primary and Secondary ICD-9 Codes o CPT-4, HCPCS, or Unique CIGNA Billing Codes o Tax ID # o Charge to CIGNA o Service, Drug, Equipment Description o Unit of Measure o Referring Physician or Other Referral Source Name o Place of Service o Any other data element agreed upon by the parties during the term of this Agreement EXHIBIT III INFORMATION REQUIRED FOR A COMPLETE ORDER o Requested Start of Care (SOC)/Actual Start of Care Date o Last Name, First Name, MI, Phone # o Address where service is to be rendered, including the phone #and zip code o Facility, Facility Discharge Date o Facility Name, Phone # o Date of Birth/Age, Sex, SS#, Marital Status o Ordering Physician (who will follow patient in the community, Office Phone #) o Type of Home Care Personnel o Home Medical Equipment o Infusion Product o All pertinent diagnoses and/or surgical procedures with onset and/or exacerbation dates o Allergies o Specific Orders/Treatment (including frequency, type of dressing, drug, dosage, etc.) Note: subcontractor must contact physician and/or physician's agent directly to validate all orders. o Has client taken ordered drugs(s) before? Y, N, comment o Venous/other access-established? Y, N, if Yes, date placed, type ordered, gauge if applicable (1st dose given?) o Anaphylaxis Order - Y, not applicable (1st dose) o Anaphylaxis medications/dosage/route (1st dose) o Primary Plan, ID# EXHIBIT IV. CLEAN CLAIM SUBMISSION REQUIREMENTS All MCA's must comply with these requirements in order to transmit claims. Below is a list of the minimum data elements required to successfully transmit a claim to CIGNA HealthCare: o Billing provider name, address and tax identification number o Rendering provider name, address and tax identification number o Employee number (9 numeric SSN/ID. If not 9 digits, MUST be zero filled to equal 9 digits) o Employee first and last name o Patient first name o Patient date of birth o Patient account number o Diagnosis code o Procedure/Revenue Code o Anesthesia Minutes/Units o Number of days when dates of service are not equal o Billed Amount (cannot be zeros) o Place of Service/Bill Type o First date of injury for accident claims o Date first consulted to verify pre-existing conditions If the above data elements are not submitted by the provider of service, the Claim Processor must reject the claim back to the MCA for correction and resubmission. EXHIBIT V. GENTIVA CARECENTRIX SUBSIDIARIES o Gentiva Health Services (USA), Inc. o Gentiva Health Services (Certified), Inc. o Gentiva Certified Healthcare Corp. o New York Healthcare Services, Inc. o QC Medi - New York, Inc. o Quality Care-USA, Inc. o Gentiva Services of New York, Inc. EXHIBIT VI. GUIDELINES FOR HOME & COMMUNITY CARE SPECIALIST SUMMARY: Analyzes utilization data, identifying areas for improvement, and provides recommendations to CIGNA Care Center management staff on homecare recovery and treatment. Works with Health Services Director and CIGNA Physician Advisor on the development of action plans to address areas for improvement. Educates and serves as a clinical resource on the safe and appropriate use of home care. Works under moderate supervision. ESSENTIAL DUTIES AND RESPONSIBILITIES: Analyzes utilization data, identifying areas for improvement, and provides recommendations to CIGNA Care Center management staff on homecare recovery and treatment. Works with Health Services Director and CIGNA Physician Advisor on the development of action plans to address areas for improvement. Provides regular reports on progress towards resolution. Educates and serves as a clinical resource on the safe and appropriate use of home care. Provides and/or coordinates training and education for CIGNA staff regarding new services or technology appropriate for the home care setting. Supports communication and promotion of existing and new programs by CIGNA providers through collaborative relationships with Gentiva CareCentrix vendors located in the same geographic community. May facilitate communication between CareCentrix, the vendor of service and patients/clients to remove potential barriers on appropriate discharges. Ensures a coordinated discharge plan for CareCentrix services on complex cases. Supports the CIGNA and Gentiva Provider Relations Teams in ensuring all vendors and providers understand goals related to home health utilization objectives. Participates in ongoing quality assessment/improvement activities as directed. Tracks and trends all issues and complaints in accordance with joint CIGNA and CareCentrix's quality management programs using both an individual and a population-based issue resolution approach. Provides information that enables root cause analysis and preparation of reports. Assists in identifying opportunities for improvement. Participates in discussions with other Regional HUB colleagues to review operational processes and procedures and shares best practices among the HUB sites. Participates in local organizations to keep abreast of current developments in the healthcare market. Participates in special projects and performs related other duties as assigned. QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. EDUCATION AND/OR EXPERIENCE: Current RN license in the state of residence plus a minimum of five years experience in homecare or related industry, with an emphasis in managed care carrier relations. Strong understanding of the concepts of utilization management and ability to provide recommendations to managed care carriers. Thorough knowledge of homecare and related federal and state regulations. Excellent communication, decision, and organization skills and including computer skills required. EXHIBIT VII. PERFORMANCE METRICS 2003 AREAS OF PERFORMANCE ANNUAL STANDARD OF PERFORMANCE MAXIMUM RISK * * Confidential Treatment Requested EXHIBIT VIII REPORTING TIMELINES -------------------------------------------------------------------------------- REPORT CATEGORY EXPECTED DELIVERY DATES -------------------------------------------------------------------------------- Annual Quality Program Evaluation Due Annually in March -------------------------------------------------------------------------------- Quality Program Description Due Annually in March -------------------------------------------------------------------------------- Quality Workplan Due Annually in March -------------------------------------------------------------------------------- Utilization Management Program Description Due Annually in March -------------------------------------------------------------------------------- Utilization Management Workplan Due Annually in March -------------------------------------------------------------------------------- Annual UM Program Evaluation Due Annually in March -------------------------------------------------------------------------------- Start of Care Statistics Ongoing, Due Quarterly, 45 days post end of quarter -------------------------------------------------------------------------------- Telephone Statistics Ongoing, Due Quarterly, 45 days post end of quarter -------------------------------------------------------------------------------- Complaint Statistics Ongoing, Due Quarterly, 45 days post end of quarter -------------------------------------------------------------------------------- Credentialed/Recredentialed Providers Reporting Ongoing, Due Quarterly, 45 days post end of quarter -------------------------------------------------------------------------------- Terminated Providers Ongoing, Due Quarterly, 45 days post end of quarter -------------------------------------------------------------------------------- Patient Satisfaction Report due Annually, by August -------------------------------------------------------------------------------- Referral Source Satisfaction Annual reporting separated from the complaint statistics. -------------------------------------------------------------------------------- Utilization Management Report Ongoing, Due Quarterly, 45 days post end of quarter -------------------------------------------------------------------------------- Missing Information Report Weekly -------------------------------------------------------------------------------- FFS Qtrly PM/PM Reports Ongoing, Due Quarterly, 45 days post end of quarter -------------------------------------------------------------------------------- AR--Aging Report Bi-Weekly -------------------------------------------------------------------------------- Weekly Reports (admit, discharge, auths) Weekly -------------------------------------------------------------------------------- Pended report for non-urgent FFS Weekly authorizations -------------------------------------------------------------------------------- CIGNA Inclusion / Exclusion Grids Monthly -------------------------------------------------------------------------------- CIGNA Capitation Payment Report Monthly -------------------------------------------------------------------------------- CIGNA Leakage Report Quarterly -------------------------------------------------------------------------------- EXHIBIT IX SAFE HOMECARE ADMISSION CRITERIA Acceptance of patients for home care services is to be based on the following criteria, and medical, nursing, psychosocial, and other information provided by the physician responsible for the overall plan of treatment, and other individuals involved in a patients care. Patients will be accepted for care regardless of age, race, color, national origin, religion, sex, disability, being a qualified disabled veteran, being a qualified veteran of the Vietnam era, or any other category protected by law, or decisions regarding advance directives: 1. Adequacy and suitability of personnel and resources to provide service in accordance with the needs of the patient and the physician's Plan of Treatment (if required). Not having adequate or suitable personnel and resources to provide the necessary service(s) does not however relieve MCA from the financial obligation and responsibility to provide such service(s). 2. Attitudes and coping ability of the patient and/ or family towards providing care at home. 3. Reasonable expectation that the patient's overall medical, nursing, rehabilitative, and social needs can be adequately met in his/her place of residence, including a plan to meet any medical emergencies that may arise. 4. Adequate physical facilities in the patient's residence for the safe delivery of service. 5. Availability and willingness of family members or other support services to follow through with the overall plan of care as necessary. The parents or guardians must assume responsibility for the care of a child. 6. Availability and willingness of a primary physician, or authorized professional to provide an overall Plan of Treatment if physician orders are required. 7. Patient resides within the geographic area serviced by this agreement. 8. Staff personal safety is not at risk. 9. The following patients are ineligible for admission to home care services (appropriate referrals to treatment facilities or other community resources will be made): o Patients with a history of intractable violent behavior or homicidal ideation o Patients exhibiting active suicidal behavior or considered a danger to themselves or others o Patients unable to obtain food or shelter o Patients/families persisting in discriminatory job orders EXHIBIT X REPRESENTED PROVIDER REQUIRED DATA ELEMENTS Reports shall be provided to CIGNA on a quarterly basis containing the following Provider Data Elements: o PROVIDER NAME o PROVIDER LOCATION/ADDRESS o CITY, STATE AND ZIP o TELEPHONE NUMBER o SERVICE TYPE INDICATOR (HIT, HME, RESP, THH) o MEDICARE A INDICATOR o MEDICARE B INDICATOR o MEDICARE A PROVIDER NUMBER o STATUS o ORIGINAL CREDENTIALING DATE o DATE RECREDENTIALING COMPLETED o TERMINATION DATE o TERMINATION REASON CODE EXHIBIT XI. JOINT COMPLAINT MANAGEMENT PROCESS COMPLAINT WORKFLOW GENTIVA CARECENTRIX (Definition of Complaint: Any expression of dissatisfaction, oral or written) Shaded areas are steps in process that involve Gentiva [GRAPHIC OF WORKFLOW CHART] * Physician calling on behalf of member or vendor calling with issue that has impacted quality of care or service to member ** Real-time Issue--Any issue relating to coordinating and ensuring appropriate current patient service/care. COMPLAINT WORKFLOW CIGNA HEALTHCARE (Definition of Complaint: Any expression of dissatisfaction, oral or written) Shaded areas are steps in process that involve Gentiva [GRAPHIC OF WORKFLOW CHART] * Physician calling on behalf of member or vendor calling with issue that has impacted quality of care or service to member ** Real-time Issue--Any issue relating to coordinating and ensuring appropriate current patient service/care. EXHIBIT XII. 2003 STANDARDS FOR DELEGATION OF CREDENTIALING ACTIVITIES [Any and all capitalized terms not defined herein shall have the same meaning as in the managed care provider agreement between CIGNA and the delegatee (the "Agreement").] I. GENERAL CONSIDERATIONS A. Delegatee shall be responsible for credentialing and recredentialing all providers permitted to provide Covered Services to Participants under the Agreement (the "Represented Providers"). Delegatee shall not subcontract any of its credentialing and recredentialing responsibilities except with the prior written consent of CIGNA. If delegatee subdelegates credentialing/recredentialing functions to another entity, CIGNA must approve the extent of the subdelegation and review the file oversight conducted by the entity as well as the delegatee's evaluation of the subdelegated organization's credentialing/recredentialing policies and procedures. Any subcontractor approved by CIGNA shall be required to agree in writing to comply with all standards applicable to delegatee with regard to the subcontracted services. B. Delegatee shall maintain a credentialing committee comprised of appropriately qualified persons, including primary care and specialist network providers, who shall be responsible for credentialing all Represented Providers. C. Delegatee's credentialing/recredentialing program shall be in writing. Such program must be reviewed and approved by delegatee's review body and by CIGNA both prior to the delegation hereunder and annually thereafter. Delegatee shall not materially modify its credentialing/recredentialing program without CIGNA's prior written approval which approval shall not be unreasonably withheld. D. Delegatee's credentialing/recredentialing program shall, at a minimum, satisfy the standards of an appropriate accrediting body or set of standards designated by CIGNA (i.e. NCQA, JCAHO, URAC etc.), the requirements established by CIGNA herein and in the Agreement, and any requirements set forth in applicable federal and state laws and regulations. E. Delegatee shall maintain adequate professional liability coverage relating to delegatee's credentialing/recredentialing activities. Such coverage shall be consistent with CIGNA standards for such coverage. F. CIGNA reserves the right to disapprove, terminate, or suspend any of delegatee's Represented Providers from providing Covered Services to Participants if the Represented Provider does not meet the credentialing requirements set forth herein. G. Delegatee shall credential each Represented Provider in accordance with the requirements set forth herein and shall recredential each initially credentialed Represented Provider in accordance with such requirements at least 1) every three years; or 2) as often as is mandated by applicable state or federal law; whichever is more frequent. H. For non-contracted home health care providers that may from time to time provide services in order to meet immediate demands, Delegatee shall establish a process acceptable to CIGNA to ensure that Represented Provider has an unrestricted license, as appropriate for the state in which the Represented Provider practices, has adequate professional and general liability insurance coverage and has an acceptable malpractice claims history as indicated through verifying Medicare/Medicaid sanctions or other appropriate reporting agency or data bank identified by CIGNA. Delegatee shall notify CIGNA if a non-credentialed Represented Provider is used to fulfill a service requirement. If a Represented Provider provides services to more than two different parties within a 60 day period, Delegatee must implement a full credentialing process as outlined below with that Represented Provider. I. Delegatee shall maintain a process acceptable to CIGNA which audits and evaluates delegatee's performance of its credentialing obligations hereunder. Delegatee shall report to CIGNA the results of any such evaluations, including audits by designated third parties, in a format and in time frames acceptable to CIGNA, and shall promptly correct any deficiencies identified. J. CIGNA and applicable governmental regulatory authorities and accrediting bodies shall have the right to audit delegatee's credentialing and recredentialing activities, including delegatee's credentialing and recredentialing files. Delegatee shall cooperate with any such audits. CIGNA's audits shall be conducted at least once a year or as needed. CIGNA will provide delegatee with a written report detailing the findings with respect to any such audits. If such audits reveal any deficiencies, delegatee shall implement policies and/or procedures to address the deficiencies identified in such audit within 60 days of CIGNA's submission of the report detailing such deficiencies. Failure to provide CIGNA with evidence that delegatee has implemented such policies and/or procedures to address any such identified deficiency within the 60 day time period may be cause for revocation of the delegation hereunder or termination of the Agreement. K. If CIGNA determines that delegatee cannot meet its credentialing obligations set forth herein, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in the Agreement shall be adjusted to the extent necessary, and delegatee shall cooperate and provide to CIGNA any information necessary to perform such activities. L. Delegatee shall maintain appropriate records with respect to all credentialing and recredentialing activities hereunder for the duration of the Agreement and six years thereafter. All information relating to delegatee's credentialing and recredentialing activities hereunder shall be confidential, shall not be disclosed to any third parties except as required by applicable law or to fulfill delegatee's obligations hereunder, and shall be maintained in such a manner so that such information shall be protected from discovery and use in judicial or administrative proceedings to the fullest extent possible under applicable law, including, but not limited to, applicable state peer review laws. In the event that delegatee receives a subpoena, civil investigative demand or other similar process requesting disclosure of information relating to its credentialing and recredentialing activities hereunder, delegatee shall immediately notify CIGNA of such subpoena, demand or process so as to afford CIGNA with an adequate opportunity to seek an appropriate protective order should it choose to do so. M. This exhibit and all information provided by CIGNA to delegatee pertaining to CIGNA's delegation of credentialing activities to delegatee is confidential and proprietary information and subject to the protections set forth in the confidentiality provision contained in the Agreement. In the event that delegatee receives a subpoena, civil investigative demand or other similar process requesting disclosure of such confidential and proprietary information, delegatee shall immediately notify CIGNA of such subpoena, demand or process so as to afford CIGNA with an adequate opportunity to seek an appropriate protective order should it choose to do so. N. Delegatee shall indemnify, defend and hold harmless CIGNA and its affiliates from and against any and all liability, fines, penalties, damages and expense, including reasonable defense costs and legal fees, incurred by CIGNA or its affiliates in connection with claims or actions of any nature, governmental examinations, enforcement actions or other administrative proceedings arising from delegatee's failure to perform its obligations under these Standards. II. CREDENTIALING REQUIREMENTS A. Delegatee will ensure that all Represented Providers are in compliance with the delegatee's credentialing requirements, which, at a minimum, shall include those requirements set forth below. In addition, delegatee will meet all timelines for requirements as required by CIGNA. Any exceptions to the credentialing requirements set forth below must be approved by CIGNA prior to the Represented Provider providing Covered Services to CIGNA Participants. Any such requests for exceptions shall only be forwarded to CIGNA for review after delegatee's credentialing committee has completed its review of the provider. Delegatee shall forward to CIGNA all information required by CIGNA in connection with those providers for whom an exception is requested. FACILITY/ANCILLARY PROVIDER CREDENTIALING 1. The Chief Operating Officer, Administrator or other appropriate designated health care facility or ancillary provider representative shall sign the Represented Provider's application for participation which signature must serve to attest to the accuracy and completeness of the credentials, operational, financial and quality information summarized in the application and must serve as a release authorizing external verification of credentials. 2. All Represented Providers shall be licensed without restriction and have all licenses necessary to do business in each state in which they are providing services. 3. All Represented Providers shall maintain appropriate professional and general liability coverage, with minimum limits of liability as acceptable to CIGNA or other, greater, minimum limits that may be required by the state where the Represented Provider is licensed: Professional Liability Coverage Type of Facility Per Occurrence Aggregate ---------------- -------------- ----------- Home Health $1,000,000 $3,000,000 GENERAL LIABILITY COVERAGE Type of Facility Per Occurrence Aggregate ---------------- -------------- ----------- Home Health $1,000,000 $3,000,000 4. All Represented Providers shall have a satisfactory professional liability history. 5. The Joint Commission on Accreditation of Healthcare Organizations ("JCAHO") or the American Osteopathic Association must accredit all hospital Represented Providers. The Commission on Accreditation of Rehabilitation Facilities must accredit rehabilitation facilities. JCAHO, the Community Health Accreditation Program or the Accreditation Commission for Health Care, Inc. must accredit home health agencies. Nursing homes must be accredited by JCAHO. JCAHO or the Accreditation Association for Ambulatory Health Care must accredit ambulatory centers for Ambulatory Health Care. The foregoing accreditations shall not be required in those locations where the attainment of the applicable accreditation is not the community standard. In these instances, on-site assessments meeting CIGNA requirements must be conducted. Delegatee may substitute a CMS (HCFA) review or a State Department of Health review for the site visit if delegatee obtains the CMS/State Department of Health report and the CMS/State Department of Health review meets CIGNA's standards. 6. All Represented Providers must maintain an ongoing quality assurance/quality improvement plan designed to monitor and evaluate the quality and appropriateness of patient/resident care, pursue opportunities to improve patient/resident care, and resolve identified problems. 7. The inclusion of the Represented Provider in CIGNA's provider network must be consistent with CIGNA's business requirements as identified by CIGNA to delegatee. 8. The delegatee's application for participation shall include satisfactory answers to the following questions: Has the Represented Provider ever had or does it currently have: a. Revocations, suspensions or sanctions under the Medicare or Medicaid programs? b. Professional liability insurance cancellation in the past five years? c. General liability insurance cancellation in the past five years? d. State licensing investigations or actions? Any "yes" answers must be accompanied by an explanation. 9. Delegatee will obtain documents as listed below for all Represented Providers as part of their application for participation: a. Current state professional license b. Documentation of current state sanctions, restrictions on licensure, or limitations on scope of practice c. Documentation of sanction activity by either the Medicare or the Medicaid programs in the past 3 years. d. Proof of professional liability and general liability insurance e. The following professional liability information: (1) The number of pending claims (2) The precise facts of each legal action brought against the Represented Provider in the past six years and the resolution of such action (i.e., withdrawn, dismissed, judgment, or settlement), including the amounts of settlements and judgments. f. Proof of accreditation, if applicable B. Delegatee shall require Represented Providers to agree to notify delegatee promptly of any material change in the information on the Represented Provider's application for participation. C. Delegatee shall not credential any provider who: 1) Has been denied participating provider status by CIGNA, or 2) Has had his/her participating provider status terminated by CIGNA for cause 3) Within the last two (2) years, has terminated a CIGNA Healthcare provider contract. Any requests for credentialing from any such provider shall be forwarded to CIGNA and shall not be acted on further by the delegatee. FACILITY/ANCILLARY PROVIDER RECREDENTIALING Delegatee shall recredential every Represented Provider in accordance with the timeframes specified in Section I.G. above employing the same criteria set forth in the facility/ancillary provider credentialing section of this document. V. CONFIDENTIALITY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION To the extent applicable, delegatee shall comply with all federal and state laws and regulations relating to the confidentiality of medical records and other individually identifiable health information, including, but not limited to, the requirements specified below. A. Definitions Applicable to this Confidentiality Section "Confidential Information" shall mean (a) Individually Identifiable Health Information that is (i) transmitted by Electronic Media, (ii) maintained in any medium constituting Electronic Media; or (iii) transmitted or maintained in any other form or medium and (b) any Nonpublic Personal Financial Information, as that term is defined by the NAIC Model Privacy of Consumer Financial and Health Information Regulation (2000) issued pursuant to the Gramm Leach Bliley Act. "Confidential Information" shall not include (i) education records covered by the Family Educational Right and Privacy Act, as amended, 20 U.S.C. Section 1232g and (ii) records described in 20 U.S.C. Section 1232g(a)(4)(B)(iv). "Designated Record Set" shall mean a group of records maintained by or for CIGNA or a CIGNA Affiliate that is (i) the medical records and billing records about individuals maintained by or for CIGNA or a CIGNA Affiliate, (ii) the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (iii) used, in whole or in part, by or for CIGNA or a CIGNA Affiliate to make decisions about individuals. As used herein, the term "Record" means any item, collection, or grouping of information that includes Confidential Information and is maintained, collected, used, or disseminated by or for CIGNA or a CIGNA Affiliate. "Electronic Media" shall mean the mode of electronic transmissions. It includes the Internet, extranet (using Internet technology to link a business with information only accessible to collaborating parties), leased lines, dial-up lines, private networks, and those transmissions that are physically moved from one location to another using magnetic tape, disk, or compact disk media. "Individually Identifiable Health Information" shall mean information that is a subset of health information, including demographic information collected from an individual, and (i) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (ii) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (a) identifies the individual, or (b) with respect to which there is a reasonable basis to believe the information can be used to identify the individual; and (iii) relates to identifiable non-health information including but not limited to an individual's address, phone number and/or Social Security number. "Privacy Standards" shall mean (a) the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder, including the Standard for Privacy of Individually Identifiable Health Information, 45 C.F.R. Parts 160 and 164, (b) the Gramm Leach Bliley Act and any applicable regulations governing privacy and confidentiality promulgated thereunder, and (c) other federal or state laws or regulations governing the use, disclosure, confidentiality, security or privacy of Confidential Information or other personally identifiable information. "Secretary" shall mean the Secretary of the Department of Health and Human Services. B. USE OF CONFIDENTIAL INFORMATION. Delegatee may use Confidential Information to carry out the obligations of delegatee as set forth in the Agreement and these Standards or as required by federal or state law, subject to the provisions of Sections C. through N., below. Delegatee shall ensure that its directors, officers, employees, contractors and agents do not use Confidential Information received from CIGNA or a CIGNA Affiliate in any manner that would constitute a violation of the Privacy Standards if used in a similar manner by CIGNA or a CIGNA Affiliate. Delegatee shall not use Confidential Information for the purpose of creating de-identified information that will be used for any purpose other than to carry out the obligations of delegatee set forth in the Agreement and these Standards or as required by federal or state law. C. DISCLOSURE OF CONFIDENTIAL INFORMATION. Delegatee and its directors, officers, employees, contractors and agents shall not disclose Confidential Information received from CIGNA or a CIGNA Affiliate other than as is necessary to carry out the obligations of delegatee as set forth in the Agreement or these Standards or as required by federal or state law, subject to the provisions of Sections C. through N., below. Confidential Information shall not be disclosed in any manner that would constitute a violation of the Privacy Standards if disclosed in a similar manner by CIGNA or a CIGNA Affiliate. D. SAFEGUARDS AGAINST MISUSE OF INFORMATION. Delegatee agrees that it will implement all appropriate safeguards to prevent the use or disclosure of Confidential Information in any manner other than pursuant to the terms and conditions of the Agreement and these Standards. E. REPORTING OF DISCLOSURES OF CONFIDENTIAL INFORMATION. Delegatee shall, within five (5) days of becoming aware of a loss, a suspected loss, or disclosure of Confidential Information in violation of the Agreement or these Standards by delegatee, its officers, directors, employees, contractors or agents or by a third party to which delegatee disclosed Confidential Information pursuant to Section C. of this Agreement, report any such disclosure to CIGNA's Privacy and Security Officers. This requirement will also apply to any loss, or suspected loss, of Confidential Information. F. AGREEMENTS WITH THIRD PARTIES. Delegatee shall enter into an agreement with any agent, subcontractor or other third party that will have access to Confidential Information that is received from, created or received by delegatee on behalf of CIGNA or a CIGNA Affiliate pursuant to which such third party agrees to be bound by the same restrictions, terms and conditions that apply to delegatee with respect to such Confidential Information as set forth in the Agreement and these Standards. Under such agreement, the third party shall (a) provide reasonable assurances that such Confidential Information will be held confidential as provided in the Agreement and these Standards, (b) provide reasonable assurances that such Confidential Information will be disclosed only as required by federal or state law or for the purposes for which it was disclosed to such third party, and (c) immediately notify delegatee of any breaches of the confidentiality of the Confidential Information, to the extent it has obtained knowledge of such breach. G. ACCESS TO INFORMATION. Within five (5) business days of a request by CIGNA or a CIGNA Affiliate for access to Confidential Information about an individual contained in a Designated Record Set, delegatee shall make available to CIGNA or a CIGNA Affiliate such Confidential Information for so long as such information is maintained in the Designated Record Set. In the event any individual requests access to Confidential Information directly from delegatee, delegatee may not deny access to the Confidential Information requested. Rather, delegatee shall, within two (2) business days, forward such request to CIGNA. H. AVAILABILITY OF CONFIDENTIAL INFORMATION FOR AMENDMENT. Within ten (10) business days of receipt of a request from CIGNA or a CIGNA Affiliate for the amendment of an individual's Confidential Information or a record regarding an individual contained in a Designated Record Set (for so long as the Confidential Information is maintained in the Designated Record Set), delegatee shall provide such information to CIGNA or the CIGNA Affiliate for amendment and incorporate any such amendments in the Confidential Information as required by 45 C.F.R. Section 164.526. In the event that the request for the amendment of Confidential Information is made directly to the delegatee, delegatee may not deny the requested amendment. Rather, delegatee shall, within two (2) business days, forward such request to CIGNA. I. AUDIT. Upon reasonable notice, CIGNA or a CIGNA Affiliate may audit and inspect delegatee's internal practices and the books and records in delegatee's possession for the purpose of assessing delegatee's use and disclosure of Confidential Information received from CIGNA or a CIGNA Affiliate or created by delegatee on behalf of CIGNA or a CIGNA Affiliate. Such books and records shall be made available to CIGNA or a CIGNA Affiliate for its audit or inspection during regular business hours. J. ACCOUNTING OF DISCLOSURES. Within ten business (10) days of notice by CIGNA or a CIGNA Affiliate to delegatee that it has received a request for an accounting of disclosures of Confidential Information regarding an individual during the six (6) years prior to the date on which the accounting was requested, Delegatee shall make available to CIGNA or the CIGNA Affiliate such information as is in delegatee's possession and is required for CIGNA or the CIGNA Affiliate to make the accounting required by 45 C.F.R. Section 164.528. At a minimum, delegatee shall provide CIGNA or the CIGNA Affiliate with the following information: (i) the date of the disclosure, (ii) the name of the entity or person who received the Confidential Information, and if known, the address of such entity or person, (iii) a brief description of the Confidential Information disclosed, and (iv) a brief statement of the purpose of such disclosure that includes an explanation of the basis for such disclosure. In the event the request for an accounting is delivered directly to delegatee, delegatee shall within two (2) business days forward such request to CIGNA. It shall be CIGNA's or the CIGNA Affiliate's responsibility to prepare and deliver any such accounting requested. Delegatee hereby agrees to implement an appropriate recordkeeping process to enable it to comply with the requirements of this Section. K. AVAILABILITY OF BOOKS AND RECORDS. Delegatee hereby agrees to make its internal practices, books and records relating to the use and disclosure of Confidential Information received from, created or received by delegatee on behalf of CIGNA or a CIGNA Affiliate available to the Secretary for purposes of determining CIGNA's or a CIGNA Affiliate's and delegatee's compliance with the Privacy Standards. L. MAINTENANCE AND DESTRUCTION OF RECORDS AFTER TERMINATION. Upon termination of the Agreement and at CIGNA's sole option, delegatee shall be required to either a) return to CIGNA or a CIGNA Affiliate all Confidential Information received from, created or received on behalf of CIGNA or a CIGNA Affiliate in all forms without retaining any copies; or b) maintain all such Confidential Information consistent with the requirements of this Section V. for the period of time such information is required to be maintained by applicable law after which time delegatee shall destroy all such information in all forms maintained and shall not retain any copies of such information, or, if such destruction is not feasible, extend the protections of this Section V. to such information and limit further uses and disclosures to those purposes that make the return or destruction of such information infeasible. M. AUTHORIZATION TO TERMINATE. Delegatee hereby authorizes CIGNA to terminate the Agreement if CIGNA determines that delegatee has violated a material term of this Section V. N. Indemnification Delegatee will defend, indemnify and hold harmless CIGNA and its affiliates and their directors, officers, and employees from any claims, loss, cost (including reasonable attorneys' fees and court costs) or liability resulting from delegatee's breach of this Section V. Delegatee acknowledges receipt of CIGNA's above Standards and, in accordance with the Agreement, will comply with the terms and conditions set forth herein. ---------------------------------- Delegatee's Name By ------------------------------- Its ------------------------------- (insert CIGNA entity on provider agreement with delegatee (i.e. healthplan name or Connecticut General Life Insurance Company)________________ By ------------------------------- Its ------------------------------- EXHIBIT XIII. DME GUIDELINES GRID DURABLE MEDICAL EQUIPMENT (DME) is defined as equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a person in the absence of an illness or injury. DME items have the following characteristics: 1. The equipment is prescribed by a physician; 2. The equipment meets the definition of DME; 3. The equipment is necessary and reasonable for the treatment of a patient's illness or injury. 4. The equipment is manufactured primarily for use in the home environment but is not limited to use in the home. Portable equipment for use outside the home may be covered as an alternative to a stationery unit when the cost of the portable unit is equal to or less than the stationery unit and the member's medical condition supports the need for the equipment periodically outside the home setting. Equipment intended for extended use in the home, but which is appropriately delivered for use and education in an inpatient environment for up to five days will be delivered to the member either in the inpatient environment prior to discharge , or in the member's home prior to an admission. Ventilators will be provided in the inpatient setting for up to two week prior to a member's discharge to home. 5. Institutional equipment requested by CIGNA to be provided by Gentiva in an inpatient facility for use in the facility when the equipment is not part of the discharge plan for use in the member's home, or when the member is not a permanent resident of the facility, is not covered under the member's DME benefit. Initial attempts should be made to have the facility provide the equipment as part of their facility charges. When this cannot be accomplished, Gentiva will contact contracte vendors to obtain the requested equipment for CIGNA on a DISCOUNT FFS basis. If the health plan is not available to issue the FFS authorization (week-ends and after hours) the request will be sent to the health plan and it is expected that a FFS authorization number will be issued by the health plan. It should be noted that Home Medical Equipment vendors do not have all institutional type equipment in stock and there may be a need to special order the equipment HOME: The home is defined as either the member's home; the home of a family member or primary care giver within the national CIGNA/ Gentiva service area. Member's who have been permanently admitted to an inpatient skilled nursing facility or inpatient hospice and who have changed their home address to that of the SNF or hospice will have the SNF or hospice defined as their home. DME covered under cap in the home would be covered under cap in these facilities. PRODUCTS. A listing of the most common items, or group of items, that are or may be perceived as home medical equipment. This listing, while reasonably complete is not intended to quantify the entire spectrum of products that may be considered DME either now or in the future. Installation of equipment that requires attachment to the structure of the home or making home modifications (construction/renovation) is not the responsibility of GENTIVA Care Centrix. COVERAGE CRITERIA. Conditions under which DME coverage is justified. These guidelines are a combination of Medicare guidelines, CIGNA benefit interpretations, and DME industry standards. Equipment noted as "not covered" only refer to coverage under the DME capitation, but may be covered under other benefit plans such as pharmacy, consumable medical supplies, external prosthetic appliances or hospital benefits. EFFORTS SHOULD BE MADE TO PROVIDE "NOT COVERED" ITEMS ON A DISCOUNT FEE FOR SERVICE BASIS TO ASSIST IN MEETING CIGNA AND PATIENT'S NEEDS. ITEMS MAY HAVE SEPARATE COVERAGE GUIDELINES NOTED FOR MEDICARE COVERAGE ISSUES AND ARE IDENTIFIED BY ITALICS. HCPC. Medicare HCFA Common Procedure Coding system. For reference only, note that the existence of a Medicare code does not indicate coverage or reimbursement acceptance. DIAGNOSIS. These are typical diagnosis indicated for each type of DME; this list is a general guideline and is not exhaustive of all potential qualifying diagnosis. SITE OF SERVICE, TRAINING AND SUPPLIES. A listing of common industry practices that are the minimal accepted levels noting how equipment is to be delivered to the patient (or picked up), who is responsible for patient education and how it is accomplished, and which accessories and supplies are included in the DME benefit. Minimum standards will be adjusted on a state by state basis to meet legal and regulatory requirements. Supplies listed as included reflect capitated coverage only, fee for service and Medicare will generally pay additional charges for supplies used with CPAP, BiPAP, ventilators, enteral pumps, suction pumps, and CPM. BRAND SUPPLIED. When completed, it will list typical manufacturers and their model numbers as specific examples of items provided for these product descriptions, but are not considered inclusive of all products that could be offered. If there is an established clinical need for a model number or product other than those listed it will be considered under capitated coverage. RENT/PURCHASE. Used internally at GENTIVA CareCentrix to determine the appropriate time to make the financial decision when it is more cost effective to purchase equipment versus ongoing rental. Patients' diagnosis, prognosis, level of care and equipment maintenance needs will be the key factors. All discount FFS equivalent rental amounts will be applied to the purchase price of any purchased equipment. COVERAGE STATEMENTS FOR GENERAL CATEGORIES. General policies for coverage of items that may fall under multiple benefits are listed beginning on page 39, are unique in their requirements, or are generally excluded from all coverage. Many of these items can be purchased at local drug stores, hardware stores or retail outlets. SITE OF SERVICE DEFINITIONS CATEGORY I (PRODUCT ONLY) - Delivered to patients home by small package delivery service (i.e. UPS or U.S. mail) is an acceptable site of service if: Consumer agrees to small package delivery via telephone or in writing. 1. Meets patients or caregivers requirements for timeliness, same day delivery may incur additional charges; 2. Is a purchase item only; 3. Requires minimal or no assembly; 4. Setup and training can be easily accomplished via written (or video) instruction; 5. Is a supply reorder; and 6. Is easily transported and can sustain shipping and handling. CATEGORY II (PRODUCT AND SERVICE, OUTPATIENT) - Items can be picked up at DME provider or from PCP (consigned from contracted DME provider) location if: 1. It meets the patients or caregivers requirements for timeliness; 2. Requires specialized fitting and measurement that can be best accomplished in a professional environment; 3. May be a stat or rush order; 4. Needs minimal patient or caregiver training (or training completed at physicians office); 5. Requires a written physician order upon pickup; 6. Can easily be transported; 7. Includes all category I items. CATEGORY III (PRODUCT AND SERVICE AT PATIENTS HOME) - Delivered by DME company employee (clinical staff if noted) to patients residence if: 1. Patient or caregiver training required; 2. Clinical assistance required; 3. Is too bulky for easy transport; 4. Is considered a hazardous material; 5. Is a stat or rush order (may apply to all categories) 6. Requires installation and setup; 7. Requires an environmental site inspection; 8. Includes category II items where customer pickup cannot be accomplished; This option may include delivery to physician office or hospital.
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ AMBULATORY EQUIPMENT ------------------------------------------------------------------------------------------------------------------------ o NOTE: o MORE THAN ONE PIECE OF AMBULATORY EQUIPMENT MAY BE APPROPRIATE IF MEMBER IS EXPECTED TO IMPROVE DURING REHABILITATION OR IF THE DIAGNOSIS AND/OR PROGNOSIS INDICATES DETERIORATION IN MEDICAL CONDITION. CANE o Patient has impaired ambulation and E0100 -Joint pain Category I OR there is potential for ambulation. E0105 -Osteoarthritis QUAD CANE o Replacement may be available due to -Osteoporosis patient growth (children) Or change -Rheumatoid arthritis in the medical condition. -Parkinson's disease -Multiple sclerosis (ms) -Congestive heart failure -Cerebral palsy -Intracerebral hemorrhage ------------------------------------------------------------------------------------------------------------------------ CRUTCHES o Patient has impaired ambulation and E0112 -Fracture of: Ankle, knee, Category I there is potential for ambulation. E0114 femur or foot o Replacement may be available due to E0110 -Cerebral palsy patient growth (children) And E0111 -Joint pain change in medical condition. ------------------------------------------------------------------------------------------------------------------------ WALKERS o Patient has impaired ambulation and E0130 -Fracture of: Tibia, fibula, Category I there is potential for ambulation ankle, knee, or foot. and requires additional stability -Rheumatoid arthritis not provided by canes and crutches. -Parkinson's disease o Baskets, trays, and cup holders are -Multiple sclerosis (ms) considered convenience items and -Congestive heart failure are not covered. -Cerebral palsy o Replacement is available for any -Intracerebral hemorrhage covered DME item for growth or -Severe neurological change in medical condition. disorder ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- AMBULATORY EQUIPMENT ------------------------------------------------- CANE Guardian xxxx Purchase only OR Guardian xxxx QUAD CANE ------------------------------------------------- CRUTCHES Guardian xxxx Purchase only Lumex xxxx ------------------------------------------------- WALKERS Guardian xxxx Purchase only Lumex xxxx -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ WALKER o Patient has impaired ambulation and E0143 -Obesity Category I WITH WHEELS there is potential for ambulation. -Muscular dystrophy (MD) o Patient requires additional -Rheumatoid arthritis stability not provided by canes and -Parkinson's disease crutches. -Multiple sclerosis (ms) o Wheeled feature approved if patient -Congestive heart failure lacks the strength to lift the -Cerebral palsy walker. -Intracerebral hemorrhage o Baskets, trays, and cup holders are -Fractures of: tibia, considered convenience items and fibula, ankle, knee or are not covered. foot. o Replacement is available due to patient growth or change in medical condition.. ------------------------------------------------------------------------------------------------------------------------ HEAVY DUTY, Generally not covered, May be covered E0147 -Gross Obesity Category II MULTIPLE only: -Severe neurologic disorders BRAKING o when patient has severe neurologic SYSTEM, WHEEL disorders or; RESISTANCE o restricted use of one hand. WALKER Baskets, trays and cup holders are not covered. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- WALKER Guardian Purchase only WITH WHEELS XXXX Lumex XXXX ------------------------------------------------- HEAVY DUTY, Guardian Purchase only MULTIPLE Lumex BRAKING Winnie walker SYSTEM, WHEEL Etac RESISTANCE Invacare WALKER -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ AMBULATORY EQUIPMENT, CONTINUED ------------------------------------------------------------------------------------------------------------------------ WHITE CANE Not stocked by DME suppliers. Provided by the Association for the Blind. Refer the requestor to the local Association for the Blind. ------------------------------------------------------------------------------------------------------------------------ AMBULATORY Pads, grips and tips are included with A4635 EQUIPMENT the initial provision of equipment. A4636 ACCESSORIES Replacement supplies included for NORMAL A4637 wear & tear. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ COMMODES ------------------------------------------------------------------------------------------------------------------------ COMMODE, Patient must be confined to: E0163 -Obesity Category I STANDARD OR -Muscular dystrophy (MD) THREE IN ONE o one level of their home environment -Rheumatoid arthritis where there is no bathroom on that -Parkinson's disease floor. -Multiple sclerosis (ms) o Unable to ambulate without the -Congestive heart failure assistance of a walker or cane. -Cerebral palsy o Unable to transition from sitting -Intracerebral hemorrhage to standing without stand-by assist -Fractures of: tibia, o Padded commodes are appropriate fibula, ankle, knee or for people with decubiti/ severe foot. emaciation.. -Hemiplegia ------------------------------------------------------------------------------------------------------------------------ COMMODE Drop arm commodes are covered when: E0165 Same as above Category I DROP ARM o Special requirements exist necessitating the feature to be used to facilitate patient transfers or; o if the patient requires extra width. ------------------------------------------------------------------------------------------------------------------------ COMMODE, Not covered, wheeled commode chairs are E0164 Category II WHEELED OR not considered medically necessary. E0166 ALL PURPOSE ------------------------------------------------------------------------------------------------------------------------ SITZ BATH Patient has infection or injury of E0160 Hemorrhoids Category I perineal area. E0161 Pilonidal cyst Post- delivery lacerations ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- AMBULATORY EQUIPMENT, CONTINUED ------------------------------------------------- WHITE CANE ------------------------------------------------- AMBULATORY Purchase only EQUIPMENT ACCESSORIES ------------------------------------------------- ------------------------------------------------- COMMODES ------------------------------------------------- COMMODE, Guardian XXX Purchase only STANDARD OR Lumex XXX THREE IN ONE Invacare XXX Temco XXX ------------------------------------------------- COMMODE Guardian Purchase only DROP ARM Lumex ------------------------------------------------- COMMODE, . WHEELED OR ALL PURPOSE ------------------------------------------------- SITZ BATH Duromed Purchase only Graham Field -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BEDS & ACCESSORIES ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BED Manual beds are no longer provided. See MANUAL, guidelines for semi-electric beds. FIXED HEIGHT WITH SIDE-RAILS AND MATTRESS. ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BED Manual beds are no longer provided. See MANUAL, guidelines for semi-electric beds. VARIABLE HEIGHT WITH SIDE-RAILS AND MATTRESS. ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BED, o Patient requires a hospital bed for E0260 Acute cardio pulmonary Category III SEMI-ELECTRIC use of traction equipment that can conditions, WITH manual only be used with a hospital type Arthritis, height bed. Or, Back disorders, adjustment o Patient requires specific position Neuromuscular or SIDE-RAILS of the body as part of a medical Cerebrovascular disorders AND MATTRESS treatment plan or pain relief for such as MS, MD, CP, CVA at least one month. Or, Fractures o Patient requires immediate and/or Guilliam Barre frequent changes in body position Paralysis o Patient is unable to independently Polio turn or get out of bed without Lower extremity injury. assistance of elevating head of Coma. bed, bed rails or trapeze bar Decubitus ulcers o Patient is unable to toilet Extreme weakness independently ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- HOSPITAL BEDS & ACCESSORIES ------------------------------------------------- HOSPITAL BED MANUAL, FIXED HEIGHT WITH SIDE-RAILS AND MATTRESS. ------------------------------------------------- HOSPITAL BED MANUAL, VARIABLE HEIGHT WITH SIDE-RAILS AND MATTRESS. ------------------------------------------------- HOSPITAL BED, Invacare XXX Same as SEMI-ELECTRIC Joerns XXX above WITH manual Smith Davis height XXX adjustment SIDE-RAILS AND MATTRESS -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BEDS & ACCESSORIES, CONTINUED ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BED, A full electric bed is covered only in E0265 Stroke with hemiplegia Category III FULL ELECTRIC those instances where the member's Paraplegia WITH medical condition requires complete Qaudraplegia SIDE-RAILS care, or extensive skilled services, Guilliam Barre AND and the member is on a regimen of Severe advanced MATTRESS complete bedrest. or is a full lift from neuromuscular disease. bed to chair. ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BED Covered if the patient meets the basic E0305 Same as above Category III SIDE-RAILS, requirements for a hospital bed and E0310 FULL OR condition requires side rails. HALF LENGTH ------------------------------------------------------------------------------------------------------------------------ SIDE-RAILS, Not covered, not primarily medical in HOMESTYLE nature. ------------------------------------------------------------------------------------------------------------------------ OVERBED Not covered, comfort or convenience E0274 TABLE item, not primarily medical in nature. ------------------------------------------------------------------------------------------------------------------------ TRAPEZE o Covered if the requirements for a E0910 Hemiplegia Category III BARS, hospital bed are met and; Lumbago o Patient has a specific condition Osteoporosis (osteoporosis, hemiplegia)and Sciatica confined to bed AND; Senile dementia o patient needs to sit up due to a Spondylosis, lumbosacral respiratory condition OR; o needs to change body position due to medical condition OR; o provide assistance getting in and out of bed. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- HOSPITAL BEDS & ACCESSORIES, CONTINUED ------------------------------------------------- HOSPITAL BED, FULL ELECTRIC WITH SIDE-RAILS AND MATTRESS ------------------------------------------------- HOSPITAL BED Invacare Same as above SIDE-RAILS, Lumex FULL OR Temco HALF LENGTH Smith Davis ------------------------------------------------- SIDE-RAILS, HOMESTYLE ------------------------------------------------- OVERBED TABLE ------------------------------------------------- TRAPEZE Lumex Same as above BARS, Invacare Temco -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ HOSPITAL BEDS & ACCESSORIES, CONTINUED ------------------------------------------------------------------------------------------------------------------------ TRACTION o Covered if patient has orthopedic E0840 Back disorder Category II, training EQUIPMENT impairment requiring traction E0850 Backache, unspecified on equipment setup is equipment, which prevents E0860 Disc, intervertebral done by patient ambulation during its period of disorder service technician. use. (Collars and supports usable E0870 Lumbago Supplies such as during ambulation would E0880 Osteoporosis pelvic belt, head be considered under O&P benefit.) E0900 Sciatica halter, rope, and o Systems such as Pronex, Saunders, Spine, cervical disorder weight bag included. Granberg, and Lossing are not covered unless a standard brand (see column 6) traction has been tried and shown to be ineffective. ------------------------------------------------------------------------------------------------------------------------ FRACTURE o Covered if patient meets E0920 Same as above Category III FRAME requirements for trapeze bar E0930 and /or traction equipment E0946 E0947 E0948 ------------------------------------------------------------------------------------------------------------------------ BED BOARD Not covered, not medical in nature E0273 Category I ------------------------------------------------------------------------------------------------------------------------ BED CRADLE Covered for burn patients or other E0280 Category I medical/surgical situations where contact with bed linens should be limited, such as extensive skin graft ------------------------------------------------------------------------------------------------------------------------ PADS FOR Not covered, a comfort item not SIDERAILS primarily medical in nature. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- HOSPITAL BEDS & ACCESSORIES, CONTINUED ------------------------------------------------- TRACTION Invacare Purchase only EQUIPMENT Duromed Graham field ------------------------------------------------- FRACTURE Invacare Same as FRAME hospital bed ------------------------------------------------- BED BOARD ------------------------------------------------- BED CRADLE Guardian (blanketeze) ------------------------------------------------- PADS FOR SIDERAILS -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ PATIENT LIFTING DEVICES ------------------------------------------------------------------------------------------------------------------------ PATIENT o If transfer between bed and chair E0630 Category III, LIFTS/Hoyer or commode requires the full Acute cardio-pulmonal training and setup on type. assistance of more than one person Alzheimer's disease equipment is done by who routinely lives in the home and Arthritis patient service is responsible for providing care Back disorders technician. Sling or CP, MS, MD, COPD seat for lift is Cerebrovascular accident included. Bathing Chronic brain syndrome accessories and scale Coma, decubitis ulcers are not covered. Diabetes w/complications Emphysema Fractures Guillain barre syndrome Heart, post myocardial infarction Lung disease Myasthenia gravis Paraplegia, quadriplegia Parkinson's disease Polymyositis Spine, cervical injuries ------------------------------------------------------------------------------------------------------------------------ BATHTUB LIFT Not covered, only standard Hoyer E0625 lift is covered..See above. ------------------------------------------------------------------------------------------------------------------------ PATIENT LIFT, Not covered, institutional item not E0635 ELECTRIC suitable for home use. ------------------------------------------------------------------------------------------------------------------------ SEAT LIFT Not covered, not primarily medical in E0627 Osteoarthritis Category III CHAIR nature. Rheumatoid arthritis Muscular dystrophy Central nervous system & degenerative disease ------------------------------------------------------------------------------------------------------------------------ STAIR OR Not covered, convenience item which is PORCH LIFT not primarily medical in nature. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- PATIENT LIFTING DEVICES ------------------------------------------------- PATIENT Guardian Rent initially, LIFTS/Hoyer Lumex if patients' type. Invacare condition is stable and long term (longer than 1 year) then purchase should be considered. ------------------------------------------------- BATHTUB LIFT ------------------------------------------------- PATIENT LIFT, ELECTRIC ------------------------------------------------- SEAT LIFT Pride CHAIR Penox ADI Golden technologies ------------------------------------------------- STAIR OR PORCH LIFT -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ STANDING Prone standers are covered for Cerebral Covered limited to diagnosis TABLE or Palsy, or other advanced neuro-muscular of Cerebral Palsy or other PRONE degenerative disease when requested as advanced neuro-muscular STANDER part of a physical or occupational degenerative disease when therapy program. Or as replacement due requested as part of a to growth or change in condition physical or occupational therapy program or replacement due to growth or change in conditon. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ DECUBITIS CARE EQUIPMENT ------------------------------------------------------------------------------------------------------------------------ FLOTATION o Covered if patient has or is E0196 Category III MATTRESS, highly susceptible to decubitis E0187 Acute cardio-pulmonal GEL AND ulcers and the PCP will be Alzheimer's disease WATER supervising the equipment's use in Arthritis connection with the course of Back disorders treatment; CP, MS, MD, COPD o Bed or chair confinement may Cerebrovascular accident demonstrate the need for equipment. Chronic brain syndrome Coma, decubitis ulcers Diabetes w/complications Emphysema Fractures Guillain barre syndrome Heart, post myocardial infarction Lung disease Myasthenia gravis Paraplegia, quadriplegia Parkinson's disease Polymyositis Spine, cervical injuries ------------------------------------------------------------------------------------------------------------------------ DRY PRESSURE Same as floatation mattress E0184 Same as above Category III MATTRESS ------------------------------------------------------------------------------------------------------------------------ DRY PRESSURE Considered a consumable and comfort item E0199 Category I PAD FOR and is not a covered benefit. . MATTRESS (EGGCRATE) ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- STANDING TABLE or PRONE STANDER ------------------------------------------------- ------------------------------------------------- DECUBITIS CARE EQUIPMENT ------------------------------------------------- FLOTATION Lumex Rent only MATTRESS, Lotus GEL AND Graham field WATER ------------------------------------------------- DRY PRESSURE BG industries Rent only MATTRESS Span America ------------------------------------------------- DRY PRESSURE PAD FOR MATTRESS (EGGCRATE) -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ ALTERNATING Same as flotation mattress. E0180 Same as above Category III PRESSURE PUMP AND PAD ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ DECUBITIS CARE EQUIPMENT, CONTINUED ------------------------------------------------------------------------------------------------------------------------ ALTERNATING Covered if the following criteria are E0277 Same as above Category III PRESSURE met : MATTRESS a) criterion 1,2 & 3 b) criterion 4, or c) criterion 5 & 6 1. Multiple stage II pressure ulcers located on the trunk or pelvis; 2. Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate group I (above items) support surface; 3. The ulcers have worsened or remained the same over the past month; 4. Large or multiple stage III or iv pressure ulcers on the trunk or pelvis; 5. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (within 60 days); 6. Patient has been on a group 2 or 3 support service immediately prior to a recent discharge from hospital or nursing facility (within 30 days). ------------------------------------------------------------------------------------------------------------------------
------------------------------------------------- ALTERNATING Grant Rent only PRESSURE Gaymar PUMP AND PAD Huntleigh Bioclinic ------------------------------------------------- ------------------------------------------------- DECUBITIS CARE EQUIPMENT, CONTINUED ------------------------------------------------- ALTERNATING Huntleigh Rental only PRESSURE Bioclinic MATTRESS KCI -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ DECUBITIS CARE EQUIPMENT, CONTINUED ------------------------------------------------------------------------------------------------------------------------ Roho or Rik Same as above K0413 Same as above Category III MATTRESS ------------------------------------------------------------------------------------------------------------------------ Air Mattress Air mattress overlays are covered only Overlays when the overlay fits the bed the member has in their home, and the cost of the overlay alone, does not exceed the cost of the standard air mattress . ------------------------------------------------------------------------------------------------------------------------ POWERED AIR Same as above E0193 Same as above Category III FLOTATION BED (LOW AIR LOSS) ------------------------------------------------------------------------------------------------------------------------ AIR FLUIDIZED GSA excludes air fluidized beds from the E0194 Same as above Category III BED benefit. Not covered. ------------------------------------------------------------------------------------------------------------------------ HYPERBARIC Not covered as home durable medical CHAMBER equipment. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- DECUBITIS CARE EQUIPMENT, CONTINUED ------------------------------------------------- Roho or Rik Crown Rental only MATTRESS Rik ------------------------------------------------- Air Mattress Overlays ------------------------------------------------- POWERED AIR Huntleigh Rental only FLOTATION Bioclinic BED (LOW AIR & KCI LOSS) ------------------------------------------------- AIR FLUIDIZED KCI Rental only BED ------------------------------------------------- HYPERBARIC CHAMBER -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ WOUND Negative Pressure Wound Therapy VACUUM or Vacuum-Assisted Closure, COVERAGE LIMITED TO THE DEVICES including a FDA-approved pump FOLLOWING DIAGNOSES: (i.e., VAC(R), Kinetic Concepts Inc., San Antonio, TX) and CHRONIC STAGE III OR STAGE supplies, may be covered when IV PRESSURE ULCERS OR, the treating physician's request and supporting documentation CHRONIC DIABETIC NEUROPATHIC establish the following: ULCERS, OR COMPLICATIONS OF A o The ulcer, as described below, SURGICALLY CREATED WOUND demonstrates a lack of improvement* (e.g., DEHISCENCE) OR A despite: TRAUMATIC WOUND 1. Treatment with the following complete wound therapy program: o At least weekly visits with written documentation in the member's medical record of evaluation and care by a licensed medical professional and at least monthly documentation of the wound's measurements; AND o Application of moist topical dressings; AND o Serial sharp, chemical and/or mechanical debridement of necrotic tissue as appropriate; AND o Provision for adequate nutritional status as documented by a serum albumin of > 3.0 g/dl during the month prior to the use of negative pressure wound therapy. AND 1. The member has one of the following: a) CHRONIC STAGE III OR STAGE IV PRESSURE ULCERS; AND o The ulcer has demonstrated a lack of improvement* and remains full thickness despite consistent application of all of the following for at least the last two (2) continuous months prior to initiating vacuum-assisted wound closure: o The member has been appropriately turned and positioned; AND o The member has used an appropriate pressure relief device (e.g., low air loss bed, alternating pressure mattress) for pressure ulcers on the posterior trunk or pelvis; AND o The member's moisture and incontinence have been appropriately maintained. OR a) CHRONIC DIABETIC NEUROPATHIC ULCERS; AND o The ulcer has demonstrated a lack of improvement* despite the consistent application of all of the following for at least the last two (2) continuous months prior to initiating vacuum-assisted wound closure: o The member has been on a comprehensive diabetic management program; AND o The member has had appropriate foot care, including an attempt to reduce pressure on a foot ulcer; AND o The member has been non-weight bearing as appropriate. OR a) CHRONIC VENOUS STASIS ULCERS; AND o The ulcer has demonstrated a lack of improvement* despite the consistent application of all of the following for at least the last two (2) continuous months prior to initiating vacuum-assisted wound closure: o Compression garments/dressings have been consistently applied; AND o Leg elevation and ambulation have been encouraged. *LACK OF IMPROVEMENT IS DEFINED AS A LACK OF PROGRESS IN QUANTITATIVE MEASUREMENTS OF WOUND CHARACTERISTICS INCLUDING WOUND LENGTH, AND WIDTH (SURFACE AREA), AND DEPTH MEASUREMENTS MEASURED IN CENTIMETERS, AND AMOUNT OF EXUDATE (DRAINAGE), SERIALLY OBSERVED AND DOCUMENTED OVER A SPECIFIC TIME INTERVAL. OR o The member has complications of a surgically created wound (e.g., dehiscence) or a traumatic wound (e.g., pre-operative flap or graft) where there is documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other topical wound treatments (e.g., the member has comorbidities that will not allow for healing times achievable with other topical wound treatments). CONTRAINDICATIONS According to the manufacturer, KCI USA Inc., contraindications to V.A.C.(R)use includes any of the following: o The presence in the wound of necrotic tissue with eschar, unless effective debridement has occurred o Untreated osteomyelitis within the vicinity of the wound; o Cancer present in the wound; o The presence of a fistula to an organ or body cavity within the vicinity of the wound. It should be used cautiously in patients with active bleeding, difficult wound hemostasis, and patients who are on anticoagulants. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- WOUND KCI VACUUM DEVICES -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ DIABETIC CARE ------------------------------------------------------------------------------------------------------------------------ GLUCOMETERS The Roche glucometer is the preferred E0607 Diabetes mellitus, also with If training has been Glucometer. Roche dextrosticks are the E0609 ketoacidosis completed by PCP or CIGNA formulary brand. Members who want Vision difficulties hospital staff then to have their dextrosticks covered under Circulatory difficulties category I, otherwise their formulary level of coverage should category II. Initial use Roche glucometers. supplies included with glucometer. Standard device is covered for: Ongoing supplies may o Type I, Type II or Gestational be covered under diabetes; pharmacy benefit. o Special features such as large MEDICARE COVERS TEST read-out or audio are covered for STRIPS AND LANCETS visual impairments. UNDER HME BENEFIT. o Continuous monitoring devices are not covered as they do not replace the need for intermittent glucose monitoring using a standard glucometer. Alternative site or compact glucometers may be provided as an alternative to, not in addition to a standard glucometers at the member or physician request ------------------------------------------------------------------------------------------------------------------------ INJECTORS, May be covered as an alternative to an NEEDLELESS insulin pump in children under age 16 who require three or more insulin injections to maintain a normal blood sugar. ------------------------------------------------------------------------------------------------------------------------ Diabetic NEEDLES, LANCETS, ALCOHOL WIPES, INSULIN supplies. ETC ARE COVERED UNDER THE MEMBER'S PHARMACY PLAN AND NOT SUPPLIED THROUGH GENTIVA. MEDICALLY NECESSARY DIABETIC SHOES MAY BE COVERED UNDER THE MEMBER'S ORTHOTIC COVERAGE. CHECK PLAN LANGUAGE AND REFER TO LOCAL ORTHOTIC VENDOR. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- DIABETIC CARE ------------------------------------------------- GLUCOMETERS Lifescan Purchase only Medisense Boehringer Mannheim ------------------------------------------------- INJECTORS, NEEDLELESS ------------------------------------------------- Diabetic supplies. -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ VACUUM Not covered under DME. ERECTION DEVICES (erectaids) ------------------------------------------------------------------------------------------------------------------------ EXTERNAL Covered if prescribed by a physician E0784 Same as above Category III, AMBULATORY and; delivery should be INFUSION o the patient is injecting insulin coordinated with PUMP FOR three times daily and has PCP to handle INSULIN experienced difficulty training. Supplies in controlling blood sugar levels included. on less than three insulin injections every day.. The member does not need to attempt a fourth injection prior to coverage, ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ CPM ------------------------------------------------------------------------------------------------------------------------ CONTINUOUS Covered: E0935 Total knee replacement Category III, PASSIVE o For patients who have TKR or ACL ACL repair delivery and training MOTION repair and and total duration only performed by patient EXERCISE up to 3 weeks. service technician. (CPM) KNEE o The 3 week limit may be repeated if CPM softgoods a second surgery is required. CPM (fleece) included. is also covered for members requiring joint manipulation after a surgical procedure as a method to prevent further adhesions or repeat surgery. ------------------------------------------------------------------------------------------------------------------------ CPM, HAND, Not Covered WRIST, ANKLE & SHOULDER ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- VACUUM ERECTION DEVICES (erectaids) ------------------------------------------------- EXTERNAL Minimed Purchase AMBULATORY Disetronics only., INFUSION PUMP FOR INSULIN ------------------------------------------------- ------------------------------------------------- CPM ------------------------------------------------- CONTINUOUS Therakinetics Rental only PASSIVE Sutter MOTION Stryker EXERCISE (CPM) KNEE ------------------------------------------------- CPM, HAND, WRIST, ANKLE & SHOULDER -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ COMPRESSION THERAPY ------------------------------------------------------------------------------------------------------------------------ LYMPHEDEMA Covered only for patients with E0650 Lymphedema of extremities Category II, delivery PUMPS, lymphedema postoperative to a generally caused by: and training NON-SEGMENTAL mastectomy, or lymphedema of the Spread of malignant tumors performed by patient (single tube extremities which has been unresponsive Radical surgical procedures service technician. with set to physical therapy and manual Post radiation fibrosis Pneumatic appliance level of compression techniques. Filarlasis (sleeve) included. pressure), COMPRESSION Dual sleeves are covered when a member Post inflammatory thrombosis PUMP requires therapy on both limbs. The goal Milroy's disease of compression therapy is to allow the Congenital lymphedema member to become more active due to Mastectomy decreased edema. The prolonged bedrest required to treat bilateral lymphedema with a single sleeve is considered couterproductive. ------------------------------------------------------------------------------------------------------------------------ LYMPHEDEMA Same as above. Segmental pump has E0651 Same as above Same as above PUMP, multiple outflow ports which lead to SEGMENTAL distinct segments on the appliance which inflates sequentially. ------------------------------------------------------------------------------------------------------------------------ LYMPHEDEMA Covered if above therapy has been tried E0652 Same as above Same as above PUMP, and not successful or patient's lesion SEGMENTAL W/ requires limited pressure to be applied CALIBRATED to a specific area. GRADIENT Pump has a regulator on each outflow PRESSURE port that can deliver a specified pressure to each segment. ------------------------------------------------------------------------------------------------------------------------ COMPRESSION Consumable item, not covered under DME STOCKINGS benefit. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- COMPRESSION THERAPY ------------------------------------------------- LYMPHEDEMA Jobst Rent initially, PUMPS, Kendall if patients' NON-SEGMENTAL condition is (single tube stable and with set long term level of (longer then pressure), 1 year) then COMPRESSION purchase PUMP should be considered. ------------------------------------------------- LYMPHEDEMA Jobst Same as above PUMP, Kendall SEGMENTAL Talley Multicom ------------------------------------------------- LYMPHEDEMA Jobst Same as above PUMP, Kendall SEGMENTAL W/ Talley CALIBRATED Multicom GRADIENT PRESSURE ------------------------------------------------- COMPRESSION STOCKINGS -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ STIMULATORS ------------------------------------------------------------------------------------------------------------------------ DRIONIC Not covered, not primarily medical in DEVICES nature ------------------------------------------------------------------------------------------------------------------------ TRANSCUTANEOUS Standard unit is covered for chronic E0720 Back injury Category II, fitting ELECTRONIC pain. E0730 Sciatica and electrode NERVE Pain in thoracic spine placement to be STIMULATOR Injury to shoulder completed by (TENS) Disc, intervertebral physician or physical disorder therapy department. Osteoporosis, or any other Initial setup of condition resulting in supplies to include chronic pain. lead wires, and one-month supply of electrodes, conductive paste and batteries. Ongoing supplies included. ------------------------------------------------------------------------------------------------------------------------ MUSCLE Covered for patients with following E0745 Diffuse muscle atrophy Same as above STIMULATOR diagnosis. Hip replacement o Standard units (two channel,) must be utilized for a two week period, and proven ineffective prior to the four channel stimulator being covered.. ------------------------------------------------------------------------------------------------------------------------ MUSCLE Not covered, additional features are STIMULATOR, primarily institutional in nature. INTERFERENTIAL PROGRAMMABLE ------------------------------------------------------------------------------------------------------------------------ THERAPEUTIC Not covered, technology not yet proven ELECTRICAL to have significant medical benefit STIMULATION primarily used for pediatric cerebral (TES) palsy. ------------------------------------------------------------------------------------------------------------------------ STIMULATOR, Not covered, technology not yet proven E0755 SALIVARY and alternative therapies exist. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- STIMULATORS ------------------------------------------------- DRIONIC DEVICES ------------------------------------------------- TRANSCUTANEOUS Empi Rent to ELECTRONIC Staodyne purchase NERVE Graham field STIMULATOR (TENS) ------------------------------------------------- MUSCLE Same as above Same as above STIMULATOR ------------------------------------------------- MUSCLE STIMULATOR, INTERFERENTIAL PROGRAMMABLE ------------------------------------------------- THERAPEUTIC ELECTRICAL STIMULATION (TES) ------------------------------------------------- STIMULATOR, SALIVARY -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ HOLTER Holter monitors are diagnostic and not MONITOR covered under DME, they are core medical (ELECTRO- and should not accrue to the members DME CARDIO- max.. Gentiva is not the delivery RECORDER), channel for diagnostic test or diagnostic equipment. ------------------------------------------------------------------------------------------------------------------------ BONE GROWTH o Covered for a long bone fracture E0747 Nonunion of long bone Category III STIMULATOR & that will not be healed in 120 E0748 fractures longer than 120 ULTRASOUND days, days. o Covered for healing of post-operative spinal fusion in Spinal fusion in members who patients AT RISK FOR failure to heal smoke tobacco., due to cigarette/ tobacco abuse. No trial period is required for patients with an identified risk factor. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ ENTERAL ------------------------------------------------------------------------------------------------------------------------ ENTERAL PUMPS B9002 Ulcerative colitis Category III, (food pumps) o Covered under the DME benefit when Gastrointestinal cancer training and setup by a member is dependent upon tube Abnormal loss of weight trained patient feedings for nutritional support. Ischemic bowel disease service technician. o Portable pumps are covered in lieu Nausea/vomiting . SNV required if of stationary pumps if condition Alzheimer's disease training not done in requires continuous feeding and/or Dysphasia facility Ongoing the member is able to leave the CVA supplies and home for prolonged periods such as Short gut syndrome nutritionals may be for physician office visits or Jaw fracture delivered by small medical therapies. package courier. Supplies for gravity feeding are also covered as long as patient meets pump criteria. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- HOLTER MONITOR (ELECTRO- CARDIO- RECORDEr), ------------------------------------------------- BONE GROWTH EBI STIMULATOR & Orthologic ULTRASOUND Bio electron Exogen ------------------------------------------------- ------------------------------------------------- ENTERAL ------------------------------------------------- ENTERAL PUMPS Sherwood Rent initially, (food pumps) medical if patients Ross labs condition is Corpak stable and Mead Johnson long term (longer than 1 year) then purchase should be considered -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ HEAT, LIGHT & COLD THERAPY ------------------------------------------------------------------------------------------------------------------------ DIATHERMY Not covered, institutional use only UNITS ------------------------------------------------------------------------------------------------------------------------ HEAT LAMPS Not covered, not primarily medical in E0200 Category II nature. E0205 ------------------------------------------------------------------------------------------------------------------------ HEATING PADS Not covered, considered a comfort item E0210 not primarily medical in nature. E0215 E0238 ------------------------------------------------------------------------------------------------------------------------ SAD lights Not covered under medical plan. ------------------------------------------------------------------------------------------------------------------------ ULTRAVIOLET Covered for selected patients with E0690 Generalized Refractory Category III, setup PANEL LIGHTS, Refractory psoriasis; psoriasis performed by trained o MD must justify treatment at home service technician. versus alternate sites (e.g. Outpatient department at hospital). Panel lights should be considered, if several discrete body areas can be treated individually. Cabinet style should be reserved for members with extensive involvement > 54% of body surface area. ------------------------------------------------------------------------------------------------------------------------ HYDROCOLLATOR Not covered, not essential to the E0225 UNIT administration of moist heat therapy. E0239 ------------------------------------------------------------------------------------------------------------------------ COLD Not covered, treatment can be THERAPY UNIT accomplished using alternative methods (cryotherapy) (i.e., Ice packs). ------------------------------------------------------------------------------------------------------------------------ PARAFFIN Not covered, not generally considered E0235 BATH effective therapy by the medical UNITS profession. (portable) ------------------------------------------------------------------------------------------------------------------------ WHIRLPOOLS Portable whirlpools are covered in the E1300 Wounds of an extremity home only when required as part of a E1310 requiring home debridement. home physicial therapy program for wound care & debridement of a wound on an extremity. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- HEAT, LIGHT & COLD THERAPY ------------------------------------------------- DIATHERMY UNITS ------------------------------------------------- HEAT LAMPS Brandt Rent only, Graham Field unless under $200. ------------------------------------------------- HEATING PADS ------------------------------------------------- SAD lights ------------------------------------------------- ULTRAVIOLET National Purchase only PANEL LIGHTS, biologic ------------------------------------------------- HYDROCOLLATOR UNIT ------------------------------------------------- COLD THERAPY UNIT (cryotherapy) ------------------------------------------------- PARAFFIN Purchase only BATH UNITS (portable) ------------------------------------------------- WHIRLPOOLS -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIRS ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, o Covered if the member is K0001 Unilateral BK or AK Category II STANDARD functionally disabled and requires amputation assistance beyond the use of a cane Bilateral AK or BK for ambulation. amputation Rheumatoid arthritis Osteoarthritis Paraplegia ALS, MS, CP, MD, CHF Quadriplegia ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Same as above based on ability of K0003 Same as above Category II LIGHTWEIGHT caregiver and/or patient to handle (less than wheelchair in and outside of home in 36 lbs) tranport of patient or chair o ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, K0005 ALS, CP, MD, ms Category II ULTRALIGHT o Quadriplegia (less than o These are generally considered to Paraplegia 30 lbs w/adj. be sport chairs, Customization for Rear axle) sport or athletic activities is not a covered benefit. Ultralight wheelchairs are only covered when the patient's condition has reached a point where they are still able to operate a wheelchair but can only manage propelling an ultra- light weight chair. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- WHEELCHAIRS ------------------------------------------------- WHEELCHAIR, Everest & Rent STANDARD Jennings initially, if Invacare patients Gendron condition is Sunrise Medical stable and Pogon long term Maclaren (longer then Wheelring 1 year) then purchase should be considered ------------------------------------------------- WHEELCHAIR, Same as above Same as above LIGHTWEIGHT (less than 36 lbs) ------------------------------------------------- WHEELCHAIR, Same as above Same as above ULTRALIGHT (less than 30 lbs w/adj. Rear axle) -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIRS ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Same as standard wheelchair AND; K0002 Ms, CHF, MD Category II HEMI o chair is needed to enable the Hemiplegia patient to place feet on the ground Intracerebral hemorrhage for propulsion or short stature Parkinson's disease (5' 4" or less) ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Same as standard wheelchair AND; K0100 Unilateral or bilateral AK Category II AMPUTEE o must have one of the following or BK amputation (or amputee diagnosis adapter) ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Same as standard wheelchair AND; E0958 Category II ONE ARM DRIVE o patient only has use of one hand or (or adapter) arm. ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Same as standard wheelchair, AND; K0006 Same as standard wheelchair Category II HEAVY DUTY o patient must weigh over 250 lbs. Or can not fit into width of standard wheelchair ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Same as above AND; K0007 Same as standard wheelchair Category II EXTRA o patient must weigh over 300 lbs. HEAVY DUTY ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Same as standard wheelchair AND; K0028 Same as standard wheelchair Category II RECLINING o patient must be in wheelchair at BACK least 4 hrs per day AND; o patient must have at least one of the following: quadriplegia, fixed hip angle, trunk or leg casts, extensor tone of trunk muscles; o Patient needs to be in recumbent position two or more times per day AND; o Requires frequent position change. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- WHEELCHAIRS ------------------------------------------------- WHEELCHAIR, Same as above Same as above HEMI ------------------------------------------------- WHEELCHAIR, Same as above Same as above AMPUTEE (or amputee adapter) ------------------------------------------------- WHEELCHAIR, Same as above Same as above ONE ARM DRIVE (or adapter) ------------------------------------------------- WHEELCHAIR, Same as above Same as above HEAVY DUTY ------------------------------------------------- WHEELCHAIR, Same as above Same as above EXTRA HEAVY DUTY ------------------------------------------------- WHEELCHAIR, Same as above Same as above RECLINING BACK -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIRS, CONTINUED ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Covered if ALL the following conditions K0011 ALS, MS, MD, only when the Category II, POWER DRIVE are met: K0012 member's physical condition batteries included. o Meets standard AND; requires this level of a Battery replacement o Patient is unable to operate a wheelchair at the time of limited to once every Wheelchair manually; the request. Power twelve months. o Patient is able to safely operate wheelchairs will not be the controls; covered in "anticipation" of o Patient has severe weakness or possible future (greater other conditions affecting the than three months) need. Upper body due to neuro or muscular Paraplegia condition, usually totally Quadriplegia, non-ambulatory and reasonably independant. o ------------------------------------------------------------------------------------------------------------------------ THREE Three wheeled scooters may be provided E1230 Same as above WHEELED POWER as an alternative to a wheel chair when OPERATED the patient has a condition for which VEHICLE they are confined to bed/chair OR unable (scooter) to endure ambulation more than 20 feet OR has fallen repeatedly within home and functional ability would improve AND; o They are unable to operate WC manually AND; are able to safely operate the controls ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- WHEELCHAIRS, CONTINUED ------------------------------------------------- WHEELCHAIR, Same as above Same as above POWER DRIVE ------------------------------------------------- THREE Pride Same as above WHEELED POWER Orthokinetics OPERATED Amigo VEHICLE Hoveround (scooter) -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIRS, CONTINUED ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR Not covered. W/STANDING FEATURE ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR, Covered when patient meets standard K0009 ALS, ms, MD Category II, fitting, CUSTOM wheelchair criteria AND; K0014 Paraplegia delivery and setup o the features are not readily Quadriplegia performed by rehab available in manufacturers standard technician trained in product offering. seating and o Must be uniquely constructed or positioning. substantially modified for the Nonstandard features specific patient AND; such as special o Assessment or fitting is required. colors or upholstery designs that are not medical in nature are not covered. ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR Covered if patient has or is highly E0962 Paraplegia Category I CUSHION, FOAM susceptible to pressure sores. E0963 Quadriplegia o Foam cushions are not covered E0964 Decubitus ulcer when used for comfort and E0965 Alzheimer's disease convenience. ALS, CVA ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR Same as above E0178 Same as above Category I CUSHION, GEL FLOTATION ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- WHEELCHAIRS, CONTINUED ------------------------------------------------- WHEELCHAIR W/STANDING FEATURE ------------------------------------------------- WHEELCHAIR, Pride Purchase only CUSTOM Invacare Quickie designs Everest & Jennings Hoveround ------------------------------------------------- WHEELCHAIR Bioclinic Purchase only CUSHION, FOAM Mason ------------------------------------------------- WHEELCHAIR Lumex Purchase only CUSHION, GEL Jay medical FLOTATION Lotus Action -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIRS, CONTINUED ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR Same as above E0192 Same as above Category II CUSHION, LOW EQUALIZATION & POSITIONING PAD ------------------------------------------------------------------------------------------------------------------------ WHEELCHAIR ACCESSORIES o Items such as cupholders, backpacks, trays, ashtrays, are convenience items and are not covered. o Items such as elevating legrests, detachable arms, anti-tipping devices, and oxygen tank attachment, are typical of covered items when required for a unique medical condition or functional limitation of the patient. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- WHEELCHAIRS, CONTINUED ------------------------------------------------- WHEELCHAIR Jay medical Purchase only CUSHION, Roho LOW EQUALIZATION & POSITIONING PAD ------------------------------------------------- WHEELCHAIR ACCESSORIES -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ NEWBORN CARE ------------------------------------------------------------------------------------------------------------------------ PHOTOTHERAPY Covered if patient has following E0202 Jaundice Category III, BILILIGHTS diagnosis AND Infant is; delivery and BILIBLANKET o 24-48 hrs old if total bili is equipment training at least 12; performed by patient o 49-72 hours old if total bili is service technician. at least 15; Confirmation of o Over 72 hours old if total bili caregiver ability to is at least 17. receive equipment o Bilirubin greater than 25 is not training by considered to be safe for treatment nonclinincal staff in the home. should be discussed o Two types of equipment exist for with PCP. IF the PCP this therapy; box lights where the has additional infant is placed inside of the unit concerns an RN home (similar in size to an incubator) health visit should or blanket style where the infant also be scheduled. is wrapped with a panel of CPR training, if any, fiberoptic lights. to be done at o The blanket style is more readily hospital prior to available both units provide discharge. Supplies medically efficacious therapy. included in the o Double lights or lights and rental price. blanket are appropriate for infants who are not responsive to therapy with a single modality, or whose bilirubin is begnning to increase rather than decrease. o ------------------------------------------------------------------------------------------------------------------------ BREAST Covered only if the infant will remain Infant has cleft palate or PUMPS hospitalized for more than seven days similar condition inhibiting post discharge of mother; or for the ability to suckle. following infant diagnosis. Battery operated unit is model of choice. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- NEWBORN CARE ------------------------------------------------- PHOTOTHERAPY Ohmeda XXX Rental only BILILIGHTS Fiberoptic BILIBLANKET (wallaby) Physician Eng. Products ------------------------------------------------- BREAST PUMPS -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ INCUBATOR Covered for premature infants less then Category III. Product 4 pounds in body weight. may not be available in all areas. ------------------------------------------------------------------------------------------------------------------------ APNEA MONITOR Covered If one of the following exists: Category III, W/MEMORY = o preterm with pathologic apnea; delivery and setup standard unit. o preterm infant who could be performed by clinical discharged from the hospital but staff. CPR training has immature respiratory control to be done at with feeding; hospital prior to o infant discharged with trach. discharge. Supplies included. Check with PCP for need for RN skilled home health visit. o ;Apnea monitors for infants soley because the parents have previously had a child with SIDS are not covered. Check with state social workers for state coverage of apnea monitors for siblings of children with SIDS. Many states have programs to provide these monitors. Inform Parents and physicians about state and/or community programs to obtain monitors if available. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- INCUBATOR ------------------------------------------------- APNEA MONITOR Corometrics Rental only W/MEMORY = Aequitron standard unit. Healthdyne Edentec -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------------ DIAGNOSTICS ------------------------------------------------------------------------------------------------------------------------------ PNEUMOGRAM Pneumograms are diagnostic and not AND SLEEP covered under DME,, they are core STUDIES medical and should not accrue to the members DME max.. ------------------------------------------------------------------------------------------------------------------------------ OXIMETRY Covered when used as a monitoring and Category III, setup alarm device; Anyone on a ventilator; and training o Not covered under DME benefit premies on active therapy performed by clinical when used as a diagnostic tool for apnea; Infants with staff. o Gentiva will provide "spot broncho-pulmonary dysplasia. checks" for members on chronic O2 Infants, or comatose adults to ascertain the continuing medical with trachs necessity for oxygen in the home members with advanced every 60-90 days. pulmonary disease such as pulmonary hypertension or pulmonary fibrosis who are on an active lung transplant waiting list ------------------------------------------------------------------------------------------------------------------------------ BLOOD Covered only for the following A4660 Pregnancy induced Category I. PRESSURE diagnosis: A4663 hypertension UNIT o Pregnancy induced hypertension A4670 only. Digital or manual units are covered based on member/ physician preference. o Dynamap continuous monitoring equipment is not covered in the home setting. This is institutional equipment. ------------------------------------------------------------------------------------------------------------------------------ BIOFEEDBACK Not a covered benefit. E0746 (electromyography) Incontinence Alarms ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------------- DIAGNOSTICS ------------------------------------------------------- PNEUMOGRAM AND SLEEP STUDIES ------------------------------------------------------- OXIMETRY Nelcor Puritan Bennett ------------------------------------------------------- BLOOD Omron Purchase only. PRESSURE Labtron UNIT ------------------------------------------------------- BIOFEEDBACK (electromyography) Incontinence Alarms -------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ RESPIRATORY ------------------------------------------------------------------------------------------------------------------------ Aerochamber Not covered as DME. May be covered under the member's pharmacy plan. Check pharmacy and Well Aware program. ------------------------------------------------------------------------------------------------------------------------ AIR CLEANER Not covered, environmental control (PURIFIER) equipment, not primarily medical in (electrostatic nature. machines) ------------------------------------------------------------------------------------------------------------------------ DEHUMIDIFIERS Not covered, environmental control unit; (room type) not medical in nature. ------------------------------------------------------------------------------------------------------------------------ VAPORIZERS Not covered, considered a comfort item E0605 not primarily medical in nature. ------------------------------------------------------------------------------------------------------------------------ NEBULIZER Covered if patient's ability to breathe E0570 Pneumonia viral or bacterial Category I, w/compressor is impaired and has difficulties in CHF, COPD, instruction may expectorating sputum or copious Black lung include videotape, secretions. Asthma initial A portable unit may be covered in lieu Chronic bronchitis administration set of a stationary unit. Emphysema included in setup, Asbestosis ongoing supplies included. Medication for nebulizer, MDI's and accessories (i.e. Aerochamber) does not fall under hme benefit. ------------------------------------------------------------------------------------------------------------------------ NEBULIZER, Ultrasonic Nebulizer with compressor is E0575 Same as above Same as above ULTRASONIC appropriate and acceptable medication delivery system. o Covered for delivery of Pentamidine. o Requests for utrasonic nebulizers other than for administration of Pentamadine should be referred to the healthplan medical director if the ordering physician is not satisified with a standard nebulizer as a delivery system. Ultrasonic nebulizers are not covered under the capitated agreement. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- RESPIRATORY ------------------------------------------------- Aerochamber ------------------------------------------------- AIR CLEANER (PURIFIER) (electrostatic machines) ------------------------------------------------- DEHUMIDIFIERS (room type) ------------------------------------------------- VAPORIZERS ------------------------------------------------- NEBULIZER Devilbiss Purchase only w/compressor (pulmoaide) Mada medical Invacare Healthdyne Caire ------------------------------------------------- NEBULIZER, Same as above Purchase only ULTRASONIC -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ PEAK FLOW Not covered as DME. Refer to the E1399 METER healthplan for Well Aware program. ------------------------------------------------------------------------------------------------------------------------ SPIROMETER Not covered under HME, not readily available for use in the home. ------------------------------------------------------------------------------------------------------------------------ COMPRESSOR, Same as nebulizer,AND; E0565 Same as above Same as above AIR o The patient requires higher air pressure (50 psi) to nebulize thicker medications (i.e. Pentamidine) and realize deeper lung penetration. ------------------------------------------------------------------------------------------------------------------------ IPPB Covered if the patients ability to E0550 Same as above Category III breathe is severely impaired. May require a special order as this is not a service traditionally supplied in the home. ------------------------------------------------------------------------------------------------------------------------ SUCTION UNITS Covered for patients with one or more of E0600 Lung cancer Category II, training (aspirators) the following : Tracheostomy and setup done by Gomcos o Difficulty raising or clearing Quadriplegia clinical staff, secretions; Viral or bacterial pneumonia suction canister, o Cancer or surgery of the throat; Emphysema suction tubes and o Dysfunction of the swallowing Bronchiectasis tubing are included. muscles; CF, CP, CHF, Trachea care supplies o Unconscious or in obtunded state; Black lung are not covered. o Tracheostomy. Cancer of the throat o Gomco suction units will be Coma provided at the physician's request. Note this item may be difficult to locate and an alternative may need to be provided while Gentiva locates an available unit. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ SUCTION Portable units are covered in lieu of UNITS, stationery units when the member's PORTABLE condition requires intermittent suction OR AC/DC outside the home; I,e for physician visits of visits for outpatient activities. ------------------------------------------------------------------------------------------------------------------------
------------------------------------------------- PEAK FLOW METER ------------------------------------------------- SPIROMETER ------------------------------------------------- COMPRESSOR, Same as above Rent initially, AIR if patients condition is stable and long term (longer then 1 year) then purchase should be considered ------------------------------------------------- IPPB Puritan Bennett Same as above AP4 or AP5 ------------------------------------------------- SUCTION UNITS Schuco Same as above (aspirators) Devilbiss Gomcos Mada medical ------------------------------------------------- ------------------------------------------------- SUCTION UNITS, PORTABLE OR AC/DC -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ Croup Tent Not covered as home DME. Insititutional in nature. ------------------------------------------------------------------------------------------------------------------------ OXYGEN TENT Covered if patient's ability to breathe E0455 Croup Category III, initial is impaired. setup and instruction performed by clinician. Disposable supplies included ------------------------------------------------------------------------------------------------------------------------ PERCUSSOR Not covered, consider physical therapy E0480 CF, COPD, Category II, training for acute exacerbations. Black lung disease and setup performed Chronic bronchitis by clinical staff. Emphysema Asthma ------------------------------------------------------------------------------------------------------------------------
------------------------------------------------- Croup Tent ------------------------------------------------- OXYGEN TENT Allied Rental only ------------------------------------------------- PERCUSSOR Puritan Bennett Purchase only General physiotherapy Graham field -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ RESPIRATORY, CONTINUED ------------------------------------------------------------------------------------------------------------------------ ThAIRapy Cystic Fibrosis. Vest(TM) ThAIRapy Vests are limited to coverage for members with Cystic Fibrosis requiring chest percussion at least three (3) times a day or more frequently. ------------------------------------------------------------------------------------------------------------------------ POSTURAL Not covered. E0606 DRAINAGE BOARD ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- RESPIRATORY, CONTINUED ------------------------------------------------- ThAIRapy ThAirapy vest Rent initially, Vest(TM) if patients condition is stable and long term (longer then 1 year) then purchase should be considered ------------------------------------------------- POSTURAL DRAINAGE BOARD -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ CPAP Sleep Study results: E0601 Obstructive sleep apnea Category III, An RDI (or AHI) [ ] 15 K0193 (OSA) delivery and setup OR performed by clinical (Any two of the following) staff, initial and RDI of 10-14 supplies (mask, greater than 20 episodes of oxygen headgear, and tubing) desaturation to <85% or any one included. Replacement episode of desaturation <70% supplies included. Type II second degree heart block Specialty masks such or Pause > 3 seconds or ventricular as full face or tachycardia at a rate > 140/bpm silicone are covered with a duration of > 15 seconds. if standard mask or a. Excessive daytime pillows have been sleepiness that has been tried and failed. document through the use of Multiple Sleep Latency Testing OR and Epworth Scale Score > 10. o REQUESTS FOR cpap IN CHILDREN AGE 12 AND UNDER SHOULD BE REFERRED TO THE Healthplan Medical Director for review. If approved cover under cap ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- CPAP Devilbiss Rent for Healthdyne first month, Respironics if patient is Sullivan compliant and is receiving therapeutic benefit then convert to purchase. -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ BIPAP,DPAP & Same as above AND; E0452 Obstructive sleep apnea Same as above self-titrating o Patient did not respond to or was K0194 syndrome CPAP non-tolerant of CPAP. ** If a member failed cpap in a lab and was successful with bipap in a lab and the doctor ordered bipap,, and the member met the AHI requirements then BIPAP will be provided as the initial system. o CPAP failed to stop the regression of the patients' disorder. o BiPAP may be used for diagnosis other then OSA such as ventilatory support, if requested follow coverage guidelines for ventilator. ------------------------------------------------------------------------------------------------------------------------ HUMIDIFIER Covered if patient qualifies for CPAP K0268 FOR CPAP therapy and MD determines humidification is needed. Heated humidifier covered on a rental basis if member is unable to tolerate standard humidifier in the home. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- BIPAP,DPAP & Respironics Same as above self-titrating CPAP ------------------------------------------------- HUMIDIFIER Respironics Same as above FOR CPAP Healthdyne -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ RESPIRATORY, CONTINUED ------------------------------------------------------------------------------------------------------------------------ HELIOX Not covered under the DME benefit, this Swollen vocal cords special mixture of oxygen and helium is considered a drug. May be covered under a pharmacy benefit. ------------------------------------------------------------------------------------------------------------------------ MECHANICAL Covered, if other treatment options have Neuromuscular disease Category III, INSUFFLATION- been tried and failed including: Thoracic restrictive disease delivery and setup EXSUFFLATION o Chest percussion therapy, both Chronic respiratory failure performed by clinical manual and pneumatic; following COPD staff. o suctioning and; o drug therapy. ------------------------------------------------------------------------------------------------------------------------ VENTILATOR & Covered for patients with the following E0450 Neuromuscular disease Category III, NPPV diagnosis: E0453 Thoracic restrictive disease delivery and (NASAL E0460 Chronic respiratory failure setup performed by POSITIVE When negative pressure ventilator is following COPD clinical staff, PRESSURE used chest shell/wrap is included. ventilator circuits VENTILATION) and trachea tubes included in the ongoing rental price, single patient use Ambu bag included. Backup emergency use ventilator included only for ventilator dependent patients. Trachea care kits are not covered. ------------------------------------------------------------------------------------------------------------------------ HUMIDIFIER Covered if patient qualifies for W/ HEATER ventilator therapy or receives oxygen therapy via a trach tube. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- RESPIRATORY, CONTINUED ------------------------------------------------- HELIOX ------------------------------------------------- MECHANICAL INSUFFLATION- EXSUFFLATION ------------------------------------------------- VENTILATOR & Aequitron Requires NPPV Lifecare frequent (NASAL Bear medical maintenance POSITIVE and PRESSURE servicing, VENTILATION) rental only. ------------------------------------------------- HUMIDIFIER Hudson Same as above W/ HEATER Fisher Paykel -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ RESPIRATORY, CONTINUED ------------------------------------------------------------------------------------------------------------------------ OXYGEN E1400 Chronic bronchitis Category III, CONCENTRATOR E1401 Emphysema delivery and E1402 Asthma equipment training An arterial blood gas or oxygen E1403 COPD performed by patient saturation result is required to E1404 Black lung disease service technician. demonstrate the medical necessity of Acute pulmonary heart Emergency backup unit oxygen. disease included in rental On room air the member should have a PO CHF price. Canula, 2 of 55 or less; or an SaO2 of 88% or Lung cancer humidifier and tubing less at rest. Acute cor pulmonale included. Members who desat to a PaO2 of 56-59 or SaO2 of 88% are appropriate for oxygen . Members who have a prescription for oxygen, but who have a blood gas result obtained while on oxygen, should have the results referred for medical review. If the Pa O2 on oxygen corresponds to a Pa O2 of 55 or less or an exercise value of 55- 59 then oxygen is medically appropriate.Standby oxygen will be covered for children or adults who do not meet medical necessity indications for regular oxygen coverage, when medical records show significant desaturation during suctioning or seiziure activity. Children age 10 and under who desat rapidly to 90 or below with any of these activities, should have an oxygen supply for rapid response/ resuscitation. ------------------------------------------------------------------------------------------------------------------------ OXYGEN SYSTEM Same as above E0424 Same as above Category III, GAS (with delivery and regulator equipment training & stand) performed by patient service technician. Canula, humidifier and tubing included. ------------------------------------------------------------------------------------------------------------------------
------------------------------------------------- RESPIRATORY, CONTINUED ------------------------------------------------- OXYGEN Devilbiss Rental only, CONCENTRATOR Healthdyne requires Airsep frequent Invacare maintenance and servicing, ------------------------------------------------- OXYGEN SYSTEM Mada medical Same as above GAS (with Contemporary regulator products & stand) Hudson -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ PORTABLE GAS E0431 Same as above Category III, OXYGEN SYSTEM delivery and (with equipment training regulator performed by patient and cart) service technician. Canula, humidifier and tubing included. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- PORTABLE GAS Mada medical Same as above OXYGEN SYSTEM Contemporary (with products regulator Hudson and cart) -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ RESPIRATORY, CONTINUED ------------------------------------------------------------------------------------------------------------------------ OXYGEN E0439 Same as above Category III, SYSTEM, LIQUID E0434 delivery and (includes base equipment training system and performed by patient portable unit) service technician. Canula, humidifier and tubing included. ------------------------------------------------------------------------------------------------------------------------ PORTABLE GAS THE VENDOR IS EXPECTED TO TEST MEMBER Same as above Category III, OXYGEN SYSTEM, ON A CONSERVATION DEVICE TO ENSURE delivery and Lightweight W/ APPROPRIATE SATURATION LEVEL CAN BE equipment training Conservation REACHED. performed by patient Device service technician. Canula, humidifier and tubing included. ------------------------------------------------------------------------------------------------------------------------ OXYGEN As above. Same as above Category III, CONSERVATION delivery and DEVICE equipment training performed by patient service technician. Canula, humidifier and tubing included. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- RESPIRATORY, CONTINUED ------------------------------------------------- OXYGEN Caire Same as above SYSTEM, LIQUID Puritan Bennett (includes base Invacare system and Penox portable unit) ------------------------------------------------- PORTABLE GAS Chad OXYGEN SYSTEM, therapeutics Lightweight W/ Conservation Device ------------------------------------------------- OXYGEN Penox CONSERVATION Mada medical DEVICE Chad therapeutics -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ MISCELLANEOUS ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------ CONSUMABLE Not covered under the DME benefit, these A codes SUPPLIES are nonreusable for single patient use; urologicals o these may be supplied by Gentiva wound care upon request under a fee for incontinence service arrangement or as part of a ostomy home health visit by a nurse. diabetic o Diabetic strips are covered under pharmacy benefit. o Examples of non- covered consumables include: o Dressing supplies in the absence of a skilled need. o Doughnuts o Bathmats o Incontinence supplies including catheters in the absence of a skilled need. o Eye pads o Pillows o Ostomy supplies * may be covered as a separate benefit. Refer to local or 800 consumable vendor. ------------------------------------------------------------------------------------------------------------------------ Sterile Saline Sterile saline and water in quantities or sterile of >60cc used for irrigation is water for considered a legend item and should be irrigation. obtained through the pharmacy benefit. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- MISCELLANEOUS ------------------------------------------------- ------------------------------------------------- CONSUMABLE SUPPLIES urologicals wound care incontinence ostomy diabetic ------------------------------------------------- Sterile Saline or sterile water for irrigation. -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ ORTHOTICS Not covered under the DME benefit, refer AND to external prosthetic appliance PROSTHETICS benefit. (braces, o A prosthetic item is usually supports, defined as something that replaces collars & a part of the body; splints o an Orthotic is an item that shores up a weakened body part. o Exampes: o custom molded seating for wheelchairs o -Mastectomy bras, o Stump stocks, o heel cups, o girdles, o halos, o insoles, o arch supports, o vests, o rib belts, o gauntlet, o collars, o boots, o elastic wrap, o shoes, o support hose, o slings, o supports, o braces, o trusses, splints ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- ORTHOTICS AND PROSTHETICS (braces, supports, collars & splints -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ MISCELLANEOUS ------------------------------------------------------------------------------------------------------------------------ AIDS TO DAILY Not covered, primarily convenience items LIVING (ADL), not primarily medical in nature. SELF-HELP o This includes items such as; ITEMS. reachers, dressing aids, eating aids, writing utensils, transfer boards, stethoscopes, thermometers, sphygmomanometers (blood pressure cuff or digital monitor), safety belts and personal hygiene items. ------------------------------------------------------------------------------------------------------------------------ EQUIPMENT Repairs are covered to make the E1350 Category II, if REPAIRS equipment serviceable unless caused patient is ambulatory by abuse or improper use of and equipment is equipment. category I or II then o Equipment under manufacturer every effort should warranty may have to be sent to be made for equipment manufacturer for repair or to be brought to replacement. Repair cost limited provider location for to replacement value of equipment. repair. Items such as compressors, tires, upholstery, will be repaired/replaced no more frequently than the expected life of the particular component and is subject to any DME plan maximums. o Adjustments for growth or changes in condition are covered within plan benefit limits, Standard loaner equipment will be provided when a members equipment needs to be sent out for repair; or repair is delayed waiting for parts or service. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- MISCELLANEOUS ------------------------------------------------- AIDS TO DAILY LIVING (ADL), SELF-HELP ITEMS. ------------------------------------------------- EQUIPMENT REPAIRS -------------------------------------------------
------------------------------------------------------------------------------------------------------------------------ SITE OF SERVICE, PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE OF DIAGNOSES TRAINING, SUPPLIES ------------------------------------------------------------------------------------------------------------------------ BATHROOM Not covered, considered comfort or EQUIPMENT; convenience items which are not BATH BENCH primarily medical in nature. TRANSFER Raised toilet seats are covered post BENCH, GRAB total hip or total knee replacement or BARS, TOILET similar surgery/ medical condition where RAILS, a member is physically incapable of RAISED TOILET either lowering themselves or raising SEATS themselves from a standard home toilet. ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------- USUAL BRAND RENT - PRODUCTS SUPPLIED PURCHASE ------------------------------------------------- BATHROOM EQUIPMENT; BATH BENCH TRANSFER BENCH, GRAB BARS, TOILET RAILS, RAISED TOILET SEATS -------------------------------------------------
EXHIBIT XIV. PARTICIPATING CIGNA SUBSIDIARIES AND AFFILIATES Connecticut General Life Insurance Company CIGNA HEALTHCARE MID-ATLANTIC, INC. CIGNA HEALTHCARE OF ARIZONA, INC. CIGNA HEALTHCARE OF CALIFORNIA, INC. CIGNA HEALTHCARE OF COLORADO, INC. CIGNA HEALTHCARE OF CONNECTICUT, INC. CIGNA HEALTHCARE OF DELAWARE, INC. CIGNA HEALTHCARE OF FLORIDA, INC. CIGNA HEALTHCARE OF GEORGIA, INC. CIGNA HEALTHCARE OF ILLINOIS, INC. CIGNA HEALTHCARE OF INDIANA, INC. CIGNA HEALTHCARE OF LOUISIANA, INC. CIGNA HEALTHCARE OF MAINE, INC. CIGNA HEALTHCARE OF MASSACHUSETTS, INC. CIGNA HEALTHCARE OF NEW HAMPSHIRE, INC. CIGNA HEALTHCARE OF NEW JERSEY, INC. CIGNA HEALTHCARE OF NEW YORK, INC. CIGNA HEALTHCARE OF NORTH CAROLINA, INC. CIGNA HEALTHCARE OF OHIO, INC. CIGNA HEALTHCARE OF PENNSYLVANIA, INC. CIGNA HEALTHCARE OF SOUTH CAROLINA, INC. CIGNA HEALTHCARE OF ST. LOUIS, INC. CIGNA HEALTHCARE OF TENNESSEE, INC. CIGNA HEALTHCARE OF TEXAS, INC. CIGNA HEALTHCARE OF UTAH, INC. CIGNA HEALTHCARE OF VIRGINIA, INC. EXHIBIT XV. HOME HEALTH CARE BENEFIT CLARIFICATION GUIDELINES TABLE OF CONTENTS o Benefit Clarification Examples o Medical Interpretation for Chronic and Hourly Cases o Home Health Decision Process HOME HEALTH CARE BENEFIT CLARIFICATION GUIDELINES STANDARD GSA HOME HEALTH SERVICES Home health services when you: o Require skilled care; o Are unable to obtain the required care as an ambulatory outpatient; and o Do not require confinement in a hospital or Other Participating Health Care Facility. Home health services are provided only if the Healthplan Medical Director has determined that the home is a medically appropriate and cost-effective setting. If you are a minor or an adult who is dependent upon others for non-skilled care (e.g., bathing, eating, toileting), home health services will only be provided for you during times when there is a family member or care giver present in the home to meet your non-skilled care needs. Home health services are those skilled health care services that can be provided during intermittent visits of two hours or less by Other Participating Health Professionals. Necessary consumable medical supplies, home infusion therapy, and durable medical equipment administered or used by Other Participating Health Professionals in providing home health services are covered. Home health services do not include services of a person who is a member of your family or your dependent's family or who normally resides in your house or your dependent's house. Physical, occupational, and speech therapy provided in the home are subject to the benefit limitations described under "Short-term Rehabilitative Therapy". END STATE PPO TEMPLATE COVERED EXPENSES HOME HEALTH CARE SERVICES o CHARGES MADE FOR HOME HEALTH CARE SERVICES WHEN YOU: o REQUIRE SKILLED CARE; o ARE UNABLE TO OBTAIN THE REQUIRED CARE AS AN AMBULATORY OUTPATIENT; AND o DO NOT REQUIRE CONFINEMENT IN A HOSPITAL OR OTHER HEALTH CARE FACILITY. HOME HEALTH CARE SERVICES ARE PROVIDED UNDER THE TERMS OF A HOME HEALTH CARE PLAN FOR THE PERSON NAMED IN THAT PLAN. IF YOU ARE A MINOR OR AN ADULT WHO IS DEPENDENT UPON OTHERS FOR NON-SKILLED CARE (E.G. BATHING, EATING, TOILETING), HOME HEALTH CARE SERVICES WILL ONLY BE PROVIDED FOR YOU DURING TIMES WHEN THERE IS A FAMILY MEMBER OR CARE GIVER PRESENT IN THE HOME TO MEET YOUR NON-SKILLED CARE NEEDS. HOME HEALTH CARE SERVICES ARE THOSE SKILLED HEALTH CARE SERVICES THAT CAN BE PROVIDED DURING INTERMITTENT VISITS OF 2 HOURS OR LESS BY OTHER HEALTH CARE PROFESSIONALS. NECESSARY CONSUMABLE MEDICAL SUPPLIES, HOME INFUSION THERAPY, AND DURABLE MEDICAL EQUIPMENT ADMINISTERED OR USED BY OTHER HEALTH CARE PROFESSIONALS IN PROVIDING HOME HEALTH CARE SERVICES ARE COVERED. HOME HEALTH CARE SERVICES DO NOT INCLUDE SERVICES OF A PERSON WHO IS A MEMBER OF YOUR FAMILY OR YOUR DEPENDENT'S FAMILY OR WHO NORMALLY RESIDES IN YOUR HOUSE OR YOUR DEPENDENT'S HOUSE. PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY PROVIDED IN THE HOME ARE SUBJECT TO THE BENEFIT LIMITATIONS DESCRIBED UNDER "SHORT-TERM REHABILITATIVE THERAPY". OTHER HEALTH CARE FACILITIES ARE FACILITIES OTHER THAN A HOSPITAL OR A HOSPICE FACILITY. EXAMPLES OF OTHER HEALTH CARE FACILITIES INCLUDE, BUT ARE NOT LIMITED TO, LICENSED SKILLED NURSING FACILITIES, REHABILITATION HOSPITALS AND SUB-ACUTE FACILITIES. OTHER HEALTH CARE PROFESSIONALS INCLUDE AN INDIVIDUAL, OTHER THAN A PHYSICIAN WHO IS LICENSED OR OTHERWISE AUTHORIZED UNDER THE APPLICABLE STATE LAW TO DELIVER MEDICAL SERVICES. OTHER HEALTH CARE PROFESSIONALS INCLUDE, BUT ARE NOT LIMITED TO PHYSICAL THERAPISTS, HOME HEALTH AIDES AND NURSES. WHAT IS COVERED UNDER THE BENEFIT LANGUAGE? o Skilled services which can be provided through INTERMITTENT two hour visits will be covered. o WOUND CARE o SKILLED ASSESSMENTS o SKILLED INTERMITTENT THERAPIES o SKILLED REHABILITATIVE SERVICES- *REHAB SERVICES IN THE HOME SETTING ARE SUBJECT TO, AND ACCRUE TO THE STR BENEFIT LIMITS o ETC. o Skilled visits of two hours or less necessary to provide intermittent monitoring and/or education or training for supportive family caregivers are covered. o DIABETICS o MEMBERS WITH SELF INJECTABLES o INFANTS REQUIRING BILI-LIGHTS WHERE PARENTAL COMPLIANCE & UNDERSTANDING REQUIRES VALIDATION. o ETC. o Skilled visits of two hours or less by a participating social worker to assist the family with long term planning and access to social services are covered. o Services of home health aides are covered only when the home health aide is used in direct support of a skilled visit. Only skilled visits are covered in the home WHAT IS NOT COVERED UNDER THE BENEFIT LANGUAGE? o Skilled services which are continuous in nature; i.e. airway maintenance, continuous monitoring, are not covered under the new benefit. * WHAT SHOULD CIGNA IN COORDINATION WITH GENTIVA/CARECENTRIX DO WHEN A MEMBER HAS A MEDICAL NEED WHICH SUPPORTS SERVICES BEYOND THE BENEFIT LANGUAGE ? The case manager should discuss the participant's skilled needs, covered services and gaps with the participant or the participant's spouse/parent/guardian. The case manager should work with the family to determine what resources might be available to fill gaps in services. The new case management tools for CHILDREN WITH SPECIAL HEALTH CARE NEEDS or END STAGE MALIGNANCIES offer suggestions on resources available to assist with care for these populations. In addition, potential resources include: o the family as a caregiver o other private insurance coverage o Medicare o Medicaid o Children's Health Services o SSI o Medicaid waiver programs The case manager should assist families with obtaining the necessary forms and information to apply for eligible programs. A consult with a home health social worker should be considered to assist with identification of additional community resources. All plans and activities to assist with alternative coverage should be fully documented in the case management notes. Any gaps in services which remain after a full review of all existing programs MUST be discussed with the Healthplan Medical Director prior to initiating any authorization of services which exceed benefit definitions. DURABLE MEDICAL EQUIPMENT] GSA TEMPLATE [Purchase or rental of durable medical equipment that is ordered or prescribed by a Participating Physician and provided by a vendor approved by the Healthplan. Coverage for repair, replacement or duplicate equipment is not covered except when replacement or revision is necessary due to growth, change in medical condition, or mechanical defect covered by manufacter's warranty . Durable medical equipment is defined as items which are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of illness or injury; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, wheel chairs, ventillators, and dialysis machines. Unless covered in connection with the services described in the "Inpatient Services at Other Participating Health Care Facilities" or "Home Health Services" provisions, the following are SPECIFICALLY EXCLUDED: o Hygienic or self-help items or equipment; o Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment; o Environmental control equipment, such as air purifiers, room humidifiers and electrostatic machines; o Institutional equipment, such as air fluidized beds and diathermy machines; o Elastic stockings and wigs; o Equipment used for the purpose of participation in sports or other recreational activities, including, but not limited to orthotics, braces and splints; o Items, such as auto tilt chairs, paraffin bath units and stationary whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; o Items which under normal use would constitute a fixture to real property, such as ramps, railings, and grab bars.] DURABLE MEDICAL EQUIPMENT PPO TEMPLATE o CHARGES MADE FOR THE PURCHASE OR RENTAL OF DURABLE MEDICAL EQUIPMENT PROVIDED BY A VENDOR APPROVED BY CG. COVERAGE FOR THE REPAIR, REPLACEMENT OR DUPLICATE EQUIPMENT IS NOT COVERED EXCEPT WHEN REPLACEMENT OR REVISION IS NECESSARY DUE TO GROWTH, CHANGE IN MEDICAL CONDITION OR MECHANICAL DEFECT COVERED BY MANUFACTER'S WARRANTY. DURABLE MEDICAL EQUIPMENT IS DEFINED AS ITEMS WHICH ARE DESIGNED FOR AND ABLE TO WITHSTAND REPEATED USE BY MORE THAN ONE PERSON, CUSTOMARILY SERVE A MEDICAL PURPOSE, GENERALLY ARE NOT USEFUL IN THE ABSENCE OF INJURY OR SICKNESS, ARE APPROPRIATE FOR USE IN THE HOME, AND ARE NOT DISPOSABLE. SUCH EQUIPMENT INCLUDES, BUT IS NOT LIMITED TO: CRUTCHES, HOSPITAL BEDS, WHEEL CHAIRS, VENTILLATORS, AND DIALYSIS MACHINES. UNLESS COVERED IN CONNECTION WITH THE SERVICES DESCRIBED IN ANOTHER SECTION OF THIS CERTIFICATE, THE FOLLOWING ARE SPECIFICALLY EXCLUDED: o HYGIENIC OR SELF-HELP ITEMS OR EQUIPMENT; o ITEMS OR EQUIPMENT THAT ARE PRIMARILY USED FOR COMFORT OR CONVENIENCE, SUCH AS BATHTUB CHAIRS, SAFETY GRAB BARS, STAIR GLIDERS OR ELEVATORS, OVER-THE-BED TABLES, SAUNAS OR EXERCISE EQUIPMENT; o ENVIRONMENTAL CONTROL EQUIPMENT, SUCH AS AIR PURIFIERS, ROOM HUMIDIFIERS AND ELECTROSTATIC MACHINES; o INSTITUTIONAL EQUIPMENT, SUCH AS AIR FLUIDIZED BEDS AND DIATHERMY MACHINES; o ELASTIC STOCKINGS AND WIGS; o IN SPORTS OR OTHER RECREATIONAL ACTIVITIES INCLUDING, BUT NOT LIMITED TO, ORTHOTICS, BRACES AND SPLINTS; o ITEMS, SUCH AS AUTO TILT CHAIRS, PARAFFIN BATH UNITS AND WHIRLPOOL BATHS, WHICH ARE NOT GENERALLY ACCEPTED BY THE MEDICAL PROFESSION AS BEING THERAPEUTICALLY EFFECTIVE; o ITEMS WHICH UNDER NORMAL USE WOULD CONSTITUTE A FIXTURE TO REAL PROPERTY, SUCH AS RAMPS, RAILINGS, AND GRAB BARS. COVERAGE IS SUBJECT TO THE MAXIMUM SHOWN IN THE SCHEDULE. Refer to the DME Grid for information on specific pieces of durable medical equipment. WHAT IS THE APPROPRIATE UTILIZATION OF HOME HEALTH AIDES AS A COVERED SERVICE? Home health aides are covered when utilized in support of a skilled service. This would include assisting the skilled professional to turn, position, or mobilize a patient during a skilled visit; i.e. dressing changes, wound assessment, and physical therapy. Hygienic measures or skin care provided during a skilled visit as part of the preparation for assessment or nursing / medical procedures, would be appropriate utilization of a home health aide. However, daily bathing, skin care, or assisting with dressing and activities of daily life would be considered custodial care. Home health aide services not provided in support of a skilled visit are not considered to meet the requirements for benefit coverage and therefore, would not be covered under capitation with Gentiva. Home health aide services for cooking, cleaning, or direct custodial care are not covered benefits under GSA or FlexCare and are not covered under capitation with Gentiva. Home health aides requested for safety issues, or to assist with a patients ability to rest or conserve energy are also not a covered benefit or covered under capitated with Gentiva. WHEN IS A PATIENT CONSIDERED PHYSICALLY ABLE TO ATTEND OUTPATIENT SERVICES? Due to the availability of space, equipment, and regular staff, outpatient services (i.e. rehabilitation therapy, blood draws and certain IM injectables) offer the potential for more efficient delivery of care and a greater level of improvement than may be provided in the home setting. For this reason, outpatient ambulatory services would be the preferred setting for these types of services. Home nursing, or therapy is available for those who are physically unable to attend an outpatient program. The patient must not be able to leave home without significant assistance. Lack of transportation does not qualify for home care. The patient, who poses safety risks due to dizziness, unsteadiness, or muscle wasting from an illness, may be a candidate for home services under the capitated agreement with Gentiva. The primary focus should be to transition patients to outpatient services once they improve should services continue. GSA language specifically states : COVERED EXPENSES HOME HEALTH CARE SERVICES o CHARGES MADE FOR HOME HEALTH CARE SERVICES WHEN YOU: o REQUIRE SKILLED CARE; o ARE UNABLE TO OBTAIN THE REQUIRED CARE AS AN AMBULATORY OUTPATIENT; AND o DO NOT REQUIRE CONFINEMENT IN A HOSPITAL OR OTHER HEALTH CARE FACILITY. While neither the GSA or FlexCare languages mention the term "homebound" related to home health care, the definition is generally interpreted to mean the same as the GSA terminology. However, the Gentiva contract does specifically use this term - (page 5, definition for Home Health Services) "those services, supplies, drugs/medications (limited to topical agents for wound care) and equipment ordered by a physician for a Participant who is home bound due to a disabling condition. Home Infusion Therapy Services and skilled nursing services such as wound care, sterile dressing etc. are covered in the home if provision of these services in the home is the most optimal place of service for the level of care needed. WHEN ARE CONSUMABLES COVERED? There are two situations where consumable supplies are coordinated by Gentiva and covered under capitation: 1. Other than glucose test strips, consumable medical supplies are covered if they are necessary for authorized durable medical equipment to function. Glucose strips are covered under pharmacy, not DME. 2. Consumables are covered when used directly by an authorized skilled home health professional to provide a skilled service, and are used during that visit. In the situation where a family member is educated by the nurse to perform that skilled service between the scheduled skilled visits, the consumables will also now be covered under cap in an effort to ease transition to a willing caregiver. Consumables are not covered under capitation for services, which do not require a skilled level of care. This includes situations where a patient is independent with care (i.e. self-catheterization). CAPITATED CONSUMABLES INCLUDE: Catheters: foley, suction, straight condom catheters Irrigation solution: sterile water, saline Dressing supplies: gauze pads, sterile or unsterile gloves, Vaseline gauze, ABDs, kerlix, steristrips, duoderm, opsite, packing gauze tape, tubing, connectors, trach dressings and trach care kits Betadine wipes Fleet and soap suds enemas Peroxide Syringes for nurses to administer injections (excludes specialty or special order syringes) Lab tubes, vacutainers and needles for lab work KY jelly and NG Tubes Cotton balls and alcohol sponges Band-Aids thermometers sharps containers NOTE: once there is no need for skilled visits, consumables would not be covered under capitation with Gentiva. When are medications, including injectables, covered under capitation? Self injectable subcutaneous and intramuscular medications are intended to be coordinated through the pharmacy benefit and so, are not covered under capitation with Gentiva. Approved Intravenous home infusions are covered under capitation. Gentiva and the healthplan staff will make every effort to successfully support transition of self-injectables to the patient/family within 1-2 teaching visits. The visits required to teach self-injectables are considered part of the home care benefit and covered under capitation with Gentiva. In rare situations where there is resistance by the patient or care giver to learning the skilled service, Gentiva may need to creatively manage the situation with a care plan approach which involves the treating physician, family or CHC Case Manager. Ceredase and Hemophiliac Factor are medications which are specifically mentioned as covered under our home infusion agreement and must be coordinated through Gentiva even though the reimbursement has been defined as fee for service. NON SKILLED SERVICES / CUSTODIAL SERVICES / SELF CARE. TURNING POSITIONING WEIGHING BATHING MAINTAINING A BOWEL PROGRAM OSTOMY CARE** ileostomy ureterostomy colostomy ADMINISTRATION OF ENEMAS** ADMINISTRATION OF SUPPOSITORIES** FEEDING DRESSING ASSISTING WITH ACTIVITIES OF DAILY LIVING AEROSOL THERAPY** ** The patient or family member may perform these services. Home health aides may not perform these services. DURABLE MEDICAL EQUIPMENT - CARE EXPECTED TO BE LIMITED TO TRAINING FOR EXAMPLE: LYMPHEDEMA BOOTS CPAP NEBULIZERS APNEA MONITOR HOME HEALTH DECISION PROCESS WHAT SERVICES ARE BEING REQUESTED? Describe all services being requested. ARE THE SERVICES SKILLED? Yes. Proceed to determination of medical necessity. No. Refer participant to other resources (i.e. community or government programs, self pay options). CAN THE SERVICES BE PROVIDED THROUGH INTERMITTENT VISITS, OR WILL THE SERVICES REQUIRE CONTINUOUS SKILLED NURSING IN THE HOME? The home health benefit only covers intermittent visits. Any request requiring continuous skilled services needs to be approached from a case management , care planning perspective. I.e Assess all resources, other coverage available, family support, finances.. consult a social worker if the member requires referral for additional programs or funding. I,e medicare/ medicaid. Discuss limits of coverage with the member/ family and provider. ARE THE SERVICES MEDICALLY NECESSARY? Evaluate each service. IV therapy for pneumonia- yes Nursing assessment for a patient with pneumonia and ALS - yes Home health aide to stay with patient while family works - no Continuous skilled nursing for 16 hours a day for suctioning a ventilator dependent patient- medically necessary= yes, covered benefit = no. IS THE HOME SETTING THE APPROPRIATE SETTING FOR THIS PATIENT? Is the patient restricted to the home because of physical limitations?--yes Is a mobile patient receiving home therapy verses the more appropriate outpatient facility?--no Are home services being requested over outpatient for convenience?-- no Note: this does not apply to home infusion, which has no restrictions on the patient's mobility. WHAT SERVICES WILL BE PROVIDED, AND FOR HOW LONG? Those services that are skilled, medically necessary, and appropriate for the home setting will be provided. Short-term rehabilitation services are subject to the plan design benefit limitations. Remember the STR benefit maximum applies to all places of service. Inpatient rehab + home rehab + outpatient rehab = maximum. All places of service accrue to one maximum. The member does not have separate benefits for each place of service. All services will be reviewed for continued appropriateness on a regular basis. WHAT SHOULD THE HEALTHPLAN'S GOAL BE IN PROVIDING HOME HEALTH SERVICES? In a managed care environment, our efforts at controlling costs include providing services at the least intensive appropriate level of care. There are many "skilled services" which a family / patient / or caregiver may assume after training by a nursing professional. Our efforts should be aimed in that direction. However, CIGNA and Gentiva recognize that individual patients and families will require different levels of support to achieve the desired outcomes. We cannot force a layperson to assume skilled care. WHAT IF THE PATIENT LIVES ALONE OR HAS NO WILLING CAREGIVER AVAILABLE TO ASSUME RESPONSIBILITY? Patients who are physically incapable of assuming responsibility for their own care in an emergency situation, or who have no willing care giver available on an emergency basis, are not considered appropriate for home health services primarily for safety issues. IS THE CARE, AND THE NEED FOR CARE BEING EVALUATED ON A REGULAR BASIS BY GENTIVA CareCentrix ? The care and the need for care are being evaluated on a regular basis at two to three levels. Home health services are initially received at the Gentiva CareCentrix level. The authorization for the services are then distributed to a local agency. Often, CareCentrix will authorize visits for a limited number of days, as a process to ensure feedback on the progress of the care. The skilled personnel providing the care should continuously evaluate the care. Any patients meeting CIGNA criteria for case management should also be receiving regular evaluations by the CIGNA Case Manager. What questions are being asked when the care/ services are being periodically reevaluated? What is the primary diagnosis driving the service? Are the services skilled? Are the services medically necessary? Is the home the most appropriate location for the services for this individual patient? Is the patient responding to the skilled services? Is there a primary care giver available? WHAT IF THE PATIENT IS NOT RESPONDING TO THE SKILLED SERVICE (I.E. NO IMPROVEMENT, OR WORSENING CONDITION)? 1. The home health agency providing the service is the primary reviewer of progress. In those situations where a patient is showing no progress, or unexpectedly deteriorating, the home health agency / Home Health Nurse, would contact the Primary Care Physician to review the plan of care. 2. The home health agency and the PCP would update the patient care plan. A date for re-evaluation of patient progress would be determined. 3. Based on the patient's condition and progress, the home health agency may continue regular contact with the PCP. 4. In those situations where the home health agency is concerned about the medical appropriateness of the care plan, the home health agency should contact the Care Manager at Gentiva CareCentrix. The Gentiva CareCentrix Care Manager will contact the local CIGNA healthplan Health Services Nurse or Medical Director. 5. The CHC Nurse Reviewer or Medical Director should review the case and discuss the care plan with the PCP. 6. The results of the discussion between CHC medical management and the PCP should be communicated to the Care Manager at Gentiva CareCentrix. 7. In those situations where Gentiva and CIGNA cannot come to agreement, a Homecare Review Panel consisting of both CIGNA and Gentiva corporate staff is available for emergent, urgent, and regular weekly review. 8. If agreement has still not been reached regarding the medical management of the case, the situation should be elevated to the Corporate Medical Directors at CHC and Gentiva for review. EXHIBIT XVI STANDARDS FOR DELEGATION OF CLINICAL SERVICE MANAGEMENT ACTIVITIES FOR GENTIVA CARECENTRIX, INC. /("CIGNA") (the "Standards") [Any and all capitalized terms not defined herein shall have the same meaning as in the managed care provider agreement between CIGNA and Gentiva CareCentrix (MCA) 1. MCA shall be subject to a pre-contract site review and evaluation of its Clinical Service Management Program ("Clinical Service Management Program") for all delegated activities. 2. MCA shall maintain a written Clinical Service Management Program description which includes: A. a description of MCA's 1) policies/procedures to evaluate Medical Necessity, 2) use of nationally recognized and locally approved criteria and information sources; and 3) process to review and approve services; B. a description of MCA's mechanism to periodically update the Clinical Service Management Program description and the Clinical Service Management Program's policies and procedures; C. documented evidence of approval of MCA's Clinical Service Management Program by MCA's appropriate body of governance; D. a description of the roles and functions of MCA's Clinical Service Management Program to include a definition of the roles and responsibilities of MCA's Clinical Service Management Program staff; E. evidence demonstrating an active, current work plan which responds to identified opportunities for improvement and action steps, as well as a process for, and evidence of, an annual evaluation of the Clinical Service Management Program. MCA shall provide annual reports as specified: (i.) Clinical Service management Program Description and Work Plan by March 31st of the current year, (ii.) A written evaluation of MCA's Clinical Service Management Program for the previous year by March 31st of the current year. F. a description of the transition process when benefits end or a Represented Provider's participation in the network terminates. 3. The MCA's Clinical Service Management Program must have been operational for at least the 12-month period preceding the effective date of the delegation, as defined herein. 4. The MCA's Clinical Service Management Program shall at a minimum comply in all respects with the requirements of an appropriate accrediting body designated by CIGNA (i.e. NCQA, JCAHO, etc.), the requirements established by CIGNA herein and in the Agreement and the requirements of applicable federal and state laws and regulations. MCA shall maintain all applicable licensures and certifications required to perform the Clinical Services Management Program activities. MCA shall maintain appropriate records with respect to all Clinical Service Management Program activities for the duration of the Agreement and seven years thereafter. 5. MCA shall maintain professional liability coverage in the amount of 1 million per occurrence and 3 million aggregate, amounts less than these required amounts will be subject to approval by CIGNA. MCA shall not subcontract any of its clinical management responsibilities under its agreement with CIGNA unless otherwise agreed in writing by CIGNA. Any subcontractor approved by CIGNA shall be required to agree in writing to comply with all standards applicable to MCA with regard to the subcontracted services. 6. MCA shall provide CIGNA with a copy of its written Clinical Service Management Program description upon request. Such Clinical Service Management Program description shall be submitted to CIGNA for review and approval prior to the effective date of the contract and annually thereafter and shall not be materially modified without CIGNA's prior written approval. 7. The role of MCA and its Represented Providers is limited to performing certain activities contracted by CIGNA using standards delivered by CIGNA, and which are in compliance with applicable federal and state laws and regulations. MCA hereby agrees to perform those activities identified by an "X" in the MCA column below and understands and acknowledges that its performance of such activities is subject to CIGNA's oversight and monitoring. ---------------------------------------------------------- ACTIVITIES MCA CIGNA ---------------------------------------------------------- Medical Policy Adoption of Criteria X X ---------------------------------------------------------- Precertification - Inpatient Approvals X ---------------------------------------------------------- Precertification - Inpatient Denials X ---------------------------------------------------------- Precertification - Outpatient Approvals X ---------------------------------------------------------- Precertification - Outpatient Denials X ---------------------------------------------------------- Concurrent Review* - Approvals X ---------------------------------------------------------- Concurrent Review* - Denials X ---------------------------------------------------------- Discharge Planning X ---------------------------------------------------------- Retrospective - Inpatient Approvals X ---------------------------------------------------------- Retrospective - Outpatient Approvals X ---------------------------------------------------------- Retrospective - Outpatient Denials X ---------------------------------------------------------- Referral Management - Approvals X ---------------------------------------------------------- Referral Management - Denials X ---------------------------------------------------------- Out-of-Area Management X ---------------------------------------------------------- Case Management* - Approvals X ---------------------------------------------------------- Case Management* - Denials X ---------------------------------------------------------- Disease Management X ---------------------------------------------------------- Denials Benefit Coverage X ---------------------------------------------------------- Appeals - First Level X ---------------------------------------------------------- Member Satisfaction w/ UM X ---------------------------------------------------------- Provider Satisfaction w/ UM X ---------------------------------------------------------- Pharmacy Management X ---------------------------------------------------------- ---------------------------------------------------------- ACTIVITIES MCA CIGNA ---------------------------------------------------------- Member Communication X ---------------------------------------------------------- Monitoring Quality and Timeliness of X X Decisions ---------------------------------------------------------- Inter-rater Reliability X ---------------------------------------------------------- Technology Assessment X ---------------------------------------------------------- * Definitions: CONCURRENT REVIEW- An assessment that determines medical necessity or appropriateness of services as they are being rendered, such as an assessment of the need for continued inpatient care for hospitalized patients. CASE MANAGEMENT- A process for identifying covered persons with specific health care needs in order to facilitate the development and implementation of a plan that efficiently uses health care resources to achieve optimum member outcome. RETROSPECTIVE REVIEW- Assessment of the appropriateness of medical services on a case by case or aggregate basis after the services have been provided. 8. With respect to each request for medical services for which the MCA delivers hereunder, MCA shall apply the clinical service criteria set forth in the Service Agreement applicable to the Participant for whom medical services have been requested. Criteria shall be applied based on the needs of the individual patient. Criteria shall be objective and applied consistently based on the needs of the individual patient. 9. All information relating to MCA's Clinical Service Management Program activities hereunder shall be confidential, shall not be disclosed to any third parties except as required by applicable federal and state law and except as required to fulfill MCA's clinical management responsibilities hereunder, and shall be maintained in such a manner so that such information shall be protected from discovery and use in judicial or administrative proceedings to the fullest extent possible under applicable federal and state law. In the event that MCA receives a subpoena, civil investigative demand or other similar process requesting disclosure of information relating to its Clinical Service Management Program activities hereunder, MCA shall immediately notify CIGNA of such subpoena, demand or process so as to afford CIGNA with an adequate opportunity to seek an appropriate protective order should it choose to do so. 10. This exhibit, all information provided by CIGNA to MCA pertaining to CIGNA's contract with MCA and all data made known to MCA relating to services rendered to Participants under the Agreement is confidential and proprietary information subject to the protections set forth in the confidentiality provision contained in MCA's Agreement with CIGNA. In the event that MCA receives a subpoena, civil investigative demand or other similar process requesting disclosure of such confidential and proprietary information, MCA shall immediately notify CIGNA of such subpoena, demand or process so as to afford CIGNA with an adequate opportunity to seek an appropriate protective order should it choose to do so. 11. MCA shall have a national medical director who provides oversight of the Clinical Service management Program. In states which mandate that the medical director making decisions must be licensed to practice medicine in referenced states, MCA shall access CIGNA HealthCare Medical Directors identified by CIGNA on consultant basis. 12. For non-contracted home health care providers that may from time to time provide services in order to meet immediate demand, MCA shall establish a process acceptable to CIGNA to ensure that Provider has an unrestricted license, as appropriate, in the state which the Provider practices, has adequate professional and general liability insurance coverage and has an acceptable malpractice claims history as indicated through verifying Medicare/Medicaid Sanctions or other appropriate reporting agency or data bank identified by CIGNA. MCA will notify CIGNA if a non-credentialed Provider is used to fulfill a service requirement need. If a Provider provides services to more than two different members within a 60-day period, MCA must implement a full credentialing process for that Provider. 13. All Clinical Service Management Program activities shall be supervised by appropriately qualified professionals including: A. Use of a national medical director who will provide oversight of the Clinical Service Management Program and assist with the development of policies. B. Use of CIGNA board certified specialists to assist in determining Medical Necessity and in preparing documentation to support the decision. 13. Total Clinical Service management Program staff ratios (including nurses) will be maintained to enable MCA to provide a level of service to be compliant with NCQA Standards for delivery, documentation and turn around time. Non-clinical staff shall utilize protocols and criteria approved by the Medical Director and shall not make medical appropriateness/necessity decisions. All decisions of the non-clinical staff shall be supervised by clinical staff. MCA shall maintain appropriate levels of telephone line staffing for the clinical servcie management activities required to be performed hereunder and shall satisfy the following standards: (a) the overall abandonment rate for the pre-certification telephone line shall be 5% or less; (b) the average speed of answer for the pre-certification telephone line shall be less than 30 seconds; (c) telephone prompts shall be clear and user friendly; and (d) a telephone message after hours shall give normal business hours information and after hours instructions. 14. MCA shall maintain a set of mutually agreed upon written clinical service management decision protocols that are based on reasonable available medical evidence, are acceptable to and consistent with CIGNA protocols and indicate that: A. criteria for appropriateness of medical services are clearly documented, communicated to participating physicians, and available to the physician and Participants upon request; B. an appropriate mechanism is present for checking the consistency of application of criteria across physician and non-physician reviewers at least annually and opportunities for improvement are identified and resolved; and C. an appropriate mechanism is present for updating and approving review criteria periodically, actively practicing practitioners are involved in the development and adoption of the criteria and the time of the update is specified in protocol or policy. 15. In connection with all Clinical Service Management Program activities hereunder, MCA shall obtain all necessary information, including pertinent clinical information, and consult with the treating physician, as appropriate, and document such efforts. Urgent home health care services, as defined within the MCA agreement, must be covered where such services are necessary to the prudent care of the patient. 16. The Healthplan retains responsibility for rendering the final coverage determination on all services denied for medical necessity. MCA shall notify CIGNA as expeditiously as possible, but no later than the same business day, of any recommendation for denial of coverage. The notification shall include: A. documentation indicating who recommended denial, why, and any medical information used to render the recommendation; B. documentation that an explanation is provided to the applicable Represented Provider via telephone of the recommended denial. The MCA shall not send any written communication, either via US mail or facsimile, to the requesting provider. 17. CIGNA will notify the MCA, the requesting provider, the PCP, and the Participant via letter which includes all information required by applicable federal and state law. 18. CIGNA will process all requests for appeals, whether expedited or standard. In connection with any such appeal, the MCA shall assist and cooperate with CIGNA and shall promptly provide all documentation reasonably requested by CIGNA to meet all accreditation and regulatory timeframe requirements. A. MCA shall make no denials for experimental/investigative reasons unless such denials have been discussed with and approved by CIGNA. 19. MCA's Clinical Service management Program decisions shall be made in a timely manner. A. MCA's Clinical Service Management Program policies and procedures shall clearly define the maximum time frames for Clinical Service Management Program decisions. All Clinical Service Management Program decisions shall be made within the time frames that allow CIGNA to satisfy all applicable federal and state legal requirements, whichever time frame is earlier (i.e. Department of Labor, Department of Insurance, Department of Corporations, HCFA, etc.). MCA shall implement adequate coverage arrangements to ensure compliance with applicable federal and state legal requirements at all times, including, but not limited to, adequate after hours, weekend and holiday coverage. B. MCA shall implement an appropriate mechanism to monitor and document timeliness of decisions which shall include: (1) Documentation to show urgent requests are responded to within 24 hours, or within the time frame required by applicable federal and state law, if earlier; and (2) Documentation to show routine requests are responded to within one working day, or within the time frame required by applicable federal and state law or regulatory authorities, if earlier (3) The MCA shall monitor and analyze its compliance with timeliness requirements on a quarterly basis and take prompt action to meet or improve adherence to such requirements. 20. Except as otherwise agreed by CIGNA, CIGNA shall retain responsibility for responding to Participant inquiries or complaints. MCA shall notify CIGNA Member Services within 24 hours of any complaint or grievance filed with MCA by or on behalf of any Participant. 21. The MCA shall maintain a system acceptable to CIGNA to track authorizations, to evaluate the MCA's compliance with CIGNA's contract requirements as set forth in Represented Provider Agreement and herein, to monitor providers for inappropriate clinical service and to evaluate Participant satisfaction and provider satisfaction, and other measures of evaluation agreed upon by the parties. MCA shall submit reports to CIGNA, in a format acceptable to CIGNA, on a quarterly basis reflecting the MCA's performance under these measures of evaluation, including an action plan which addresses opportunities for improvement when applicable. 22. CIGNA, its designee and any applicable governmental authorities or accrediting bodies shall have the right to conduct periodic audits of the MCA's Clinical Management service Program activities upon reasonable prior notice, and the MCA shall cooperate with any such audits. In addition, the MCA's performance of its Clinical Service Management Program activities hereunder may be measured by CIGNA at least annually. The MCA shall cooperate with any such audits and shall provide any and all information reasonably requested by CIGNA in connection with such audits. Applicable performance measures include but are not limited to: (a) Participant concerns, complaints and grievances which relate to the UM Process do not exceed .10 per 1000 average eligible members per quarter for individual healthplans and for the CIGNA national rate. A "participant concern" is identified as any oral or written expression of dissatisfaction from a participant or participant's representative such as a physician, guardian or family member. (b) audits of Clinical Service Management Program activities show compliance with CIGNA, and applicable federal, state and accreditation requirements. 23. CIGNA will provide MCA with a written report detailing its findings with respect to any such audits. If such audits reveal any deficiencies, MCA shall correct any deficiencies identified in such audit within 60 days of CIGNA's submission of the report detailing such deficiencies. Failure to correct any identified deficiencies within such 60 day period may be cause for revocation of the delegation set forth herein. 24. MCA shall provide CIGNA with evidence of an appropriate internal control environment acceptable to CIGNA of MCA's Clinical Service Management Program operations on an annual basis. 25. MCA shall prepare and provide such periodic reports or other data as is reasonably requested by CIGNA relating to MCA's Clinical Service Management Program activities in association with Participant's receiving services from Represented Providers. MCA shall participate in Clinical Service Management Program oversight activities (i.e., committee meetings, report submission) to the extent reasonably required by CIGNA and at least quarterly. MCA shall provide CIGNA with any adverse event/sentinel diagnosis information relating to Participants within two business days of MCA's receipt of such information. 26. MCA shall have a process in place to ensure appropriate utilization of services including identifying areas of over utilization and under utilization including: monitoring different types of data, establishing thresholds, conducting quantitative analysis and comparison to thresholds and working with CIGNA to implement actions to address issues that are identified by CIGNA or by the MCA. 27. If CIGNA determines that MCA cannot meet its Clinical Service Management Program obligations, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in the Agreement shall be adjusted to the extent necessary, and MCA shall cooperate and provide to CIGNA any information reasonably required to perform such activities. 28. All referrals shall be to Represented Providers, except where an Emergency requires otherwise or as otherwise required by applicable federal and state law. Except in an urgent/emergent situation, MCA shall require all Represented Providers to obtain authorization from MCA prior to rendering home health services. Or as otherwise required by applicable federal and state law. 29. All electronic data which MCA maintains concerning the detail of all Clinical Service Management Program activities made hereunder shall be made available and submitted to CIGNA using ANSI standard transaction formats or another mutually agreeable format in compliance with applicable state and federal law including, but not limited to, the Health Insurance Portability and Accountability Act (HIPAA) and Administrative Simplification. Such data shall be submitted to CIGNA at least monthly. If a non-ANSI format is agreed upon, MCA shall cooperate with CIGNA in the development of the transmission format, frequency and protocol. 30. MCA shall maintain evidence that MCA distributes a statement to all employees, and Represented Providers involved in Clinical Service Management Program activities, affirming the following: A. Clinical service decision making is based only on appropriateness of care and service. B. The MCA does not compensate practitioners/providers/employees for denials. C. The MCA does not offer incentives to encourage denials. D. The need for special concern about under utilization. MCA shall indemnify, defend and hold harmless CIGNA and its affiliates from and against any and all liability, fines, penalties, damages and expense, including reasonable defense costs and legal fees, incurred by CIGNA in connection with claims or actions of any nature, governmental examinations, enforcement actions or other administrative proceedings, arising from MCA's failure to perform its obligations under these Standards A. Confidentiality MCA shall comply with all applicable federal and state laws and regulations relating to the confidentiality of medical records and other individually identifiable health information, including but not limited to, the requirements specified below. B. Definitions Applicable to this Confidentiality Section "Confidential Information" shall mean (a) Individually Identifiable Health Information that is (i) transmitted by Electronic Media, (ii) maintained in any medium constituting Electronic Media; or (iii) transmitted or maintained in any other form or medium and (b) any Nonpublic Personal Financial Information, as that term is defined by the NAIC Model Privacy of Consumer Financial and Health Information Regulation (2000) issued pursuant to the Gramm Leach Bliley Act. "Confidential Information" shall not include (i) education records covered by the Family Educational Right and Privacy Act, as amended, 20 U.S.C. Section 1232g and (ii) records described in 20 U.S.C. Section 1232g(a)(4)(B)(iv). "Designated Record Set" shall mean a group of records maintained by or for CIGNA or a CIGNA Affiliate that is (i) the medical records and billing records about individuals maintained by or for CIGNA or a CIGNA Affiliate, (ii) the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (iii) used, in whole or in part, by or for CIGNA or a CIGNA Affiliate to make decisions about individuals. As used herein, the term "Record" means any item, collection, or grouping of information that includes Confidential Information and is maintained, collected, used, or disseminated by or for CIGNA or a CIGNA Affiliate. "Electronic Media" shall mean the mode of electronic transmissions. It includes the Internet, extranet (using Internet technology to link a business with information only accessible to collaborating parties), leased lines, dial-up lines, private networks, and those transmissions that are physically moved from one location to another using magnetic tape, disk, or compact disk media. "Individually Identifiable Health Information" shall mean information that is a subset of health information, including demographic information collected from an individual, and (1) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (2) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (a) identifies the individual, or (b) with respect to which there is a reasonable basis to believe the information can be used to identify the individual; and (3) relates to identifiable non-health information including but not limited to an individual's address, phone number and/or Social Security number. "Privacy Standards" shall mean (a) the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder, including the Standard for Privacy of Individually Identifiable Health Information, 45 C.F.R. Parts 160 and 164, (b) the Gramm Leach Bliley Act and any applicable regulations governing privacy and confidentiality promulgated thereunder, and (c) other federal or state laws or regulations governing the use, disclosure, confidentiality, security or privacy of Confidential Information or other personally identifiable information. "Secretary" shall mean the Secretary of the Department of Health and Human Services. C. Use of Confidential Information MCA may use Confidential Information to carry out the obligations of MCA set forth in the Agreement and these Standards or as required by federal or state law, subject to the provisions of Sections C. through N., below. MCA shall ensure that its directors, officers, employees, contractors and agents do not use Confidential Information received from CIGNA or a CIGNA Affiliate in any manner that would constitute a violation of the Privacy Standards if used in a similar manner by CIGNA or a CIGNA Affiliate. MCA shall not use Confidential Information for the purpose of creating de-identified information that will be used for any purpose other than to carry out the obligations of MCA set forth in the Agreement or these Standards or as required by federal or state law. D. Disclosure of Confidential Information MCA and its directors, officers, employees, contractors and agents shall not disclose Confidential Information received from CIGNA or a CIGNA Affiliate other than as is necessary to carry out the obligations of MCA set forth in the Agreement or these Standards or as required by federal or state law, subject to the provisions of Sections C. through N., below. Confidential Information shall not be disclosed in any manner that would constitute a violation of the Privacy Standards if disclosed in a similar manner by CIGNA or a CIGNA Affiliate. E. Safeguards Against Misuse of Information MCA agrees that it will implement all appropriate safeguards to prevent the use or disclosure of Confidential Information in any manner other than pursuant to the terms and conditions of the Agreement and these Standards. F. Reporting of Disclosures of Confidential Information MCA shall, within five (5) days of becoming aware of a loss, a suspected loss, or disclosure of Confidential Information in violation of the Agreement or these Standards by MCA, its officers, directors, employees, contractors or agents or by a third party to which MCA disclosed Confidential Information pursuant to Section C. of this Agreement, report any such disclosure to CIGNA's Privacy and Security Officers. This requirement will also apply to any loss, or suspected loss, of Confidential Information. G. Agreements with Third Parties MCA shall enter into an agreement with any agent, subcontractor or other third party that will have access to Confidential Information that is received from, created or received by MCA on behalf of CIGNA or a CIGNA Affiliate pursuant to which such third party agrees to be bound by the same restrictions, terms and conditions that apply to MCA pursuant to this Agreement with respect to such Confidential Information. Under such agreement, the third party shall (a) provide reasonable assurances that such Confidential Information will be held confidential as provided pursuant to the Agreement and these Standards, (b) provide reasonable assurances that such Confidential Information will be disclosed only as required by federal or state law or for the purposes for which it was disclosed to such third party, and (c) immediately notify MCA of any breaches of the confidentiality of the Confidential Information, to the extent it has obtained knowledge of such breach. H. Access to Information Within five (5) business days of a request by CIGNA or a CIGNA Affiliate for access to Confidential Information about an individual contained in a Designated Record Set, MCA shall make available to CIGNA or the CIGNA Affiliate such Confidential Information for so long as such information is maintained in the Designated Record Set. In the event any individual requests access to Confidential Information directly from MCA, MCA may not deny access to the Confidential Information requested. Rather, MCA shall, within two (2) business days, forward such request to CIGNA. I. Availability of Confidential Information for Amendment Within ten (10) business days of receipt of a request from CIGNA or a CIGNA Affiliate for the amendment of an individual's Confidential Information or a record regarding an individual contained in a Designated Record Set (for so long as the Confidential Information is maintained in the Designated Record Set), MCA shall provide such information to CIGNA or the CIGNA Affiliate for amendment and incorporate any such amendments in the Confidential Information as required by 45 C.F.R. Section 164.526. In the event that the request for the amendment of Confidential Information is made directly to the MCA, MCA may not deny the requested amendment. Rather, MCA shall, within two (2) business days, forward such request to CIGNA. J. Audit Upon reasonable notice, CIGNA or a CIGNA Affiliate may audit and inspect MCA's internal practices and the books and records in MCA's possession for the purpose of assessing MCA's use and disclosure of Confidential Information received from CIGNA or a CIGNA Affiliate or created by MCA on behalf of CIGNA or a CIGNA Affiliate. Such books and records shall be made available to CIGNA or a CIGNA Affiliate for its audit or inspection during regular business hours. K. Accounting of Disclosures Within ten business (10) days of notice by CIGNA or a CIGNA Affiliate to MCA that it has received a request for an accounting of disclosures of Confidential Information regarding an individual during the six (6) years prior to the date on which the accounting was requested, MCA shall make available to CIGNA or the CIGNA Affiliate such information as is in MCA's possession and is required for CIGNA or the CIGNA Affiliate to make the accounting required by 45 C.F.R. Section 164.528. At a minimum, MCA shall provide CIGNA or the CIGNA Affiliate with the following information: (i) the date of the disclosure, (ii) the name of the entity or person who received the Confidential Information, and if known, the address of such entity or person, (iii) a brief description of the Confidential Information disclosed, and (iv) a brief statement of the purpose of such disclosure that includes an explanation of the basis for such disclosure. In the event the request for an accounting is delivered directly to MCA, MCA shall within two (2) business days forward such request to CIGNA. It shall be CIGNA's or the applicable CIGNA Affiliate's responsibility to prepare and deliver any such accounting requested. MCA hereby agrees to implement an appropriate recordkeeping process to enable it to comply with the requirements of this Section. L. Availability of Books and Records MCA hereby agrees to make its internal practices, books and records relating to the use and disclosure of Confidential Information received from, created or received by MCA on behalf of CIGNA or a CIGNA Affiliate available to the Secretary for purposes of determining CIGNA's or CIGNA Affiliate's and MCA's compliance with the Privacy Standards. M. Return of Records Upon termination of the Agreement and at CIGNA's sole option, MCA shall be required to either a) return to CIGNA or a CIGNA Affiliate all Confidential Information received from, created or received on behalf of CIGNA or a CIGNA Affiliate in all forms without retaining any copies; or b) maintain all such Confidential Information consistent with the requirements of this Section 31 for the period of time such information is required to be maintained by applicable law after which time MCA shall destroy all such information in all forms maintained and shall not retain any copies of such information, or if such destruction is not feasible, extend the protections in this Section 31to such information and limit further uses and disclosures to those purposes that make the return or destruction of such information infeasible. N. Authorization to Terminate MCA hereby authorizes CIGNA to terminate the Agreement if CIGNA determines that MCA has violated a material term of this Section 31. O. Indemnification MCA will defend, indemnify and hold harmless CIGNA and its affiliates and their directors, officers, and employees from any claims, loss, cost (including reasonable attorneys' fees and court costs) or liability resulting from MCA's breach of this Section 31. Gentiva CareCentrix acknowledges receipt of CIGNA's above Standards for Delegation and, in accordance with the Agreement, will comply with the terms and conditions set forth herein. -------------------------------------------------------------------------------- Gentiva CareCentrix's Name By ------------------------------- Its ------------------------------- Date ------------------------------ ---------------------------------- CIGNA Entity's Name By ------------------------------- Its ------------------------------- Date ------------------------------ 9. EXHIBIT XVII CONTRACT EXCLUSIONS DOCUMENT
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- DISP DISP ADL 4544 AIDS DAILY LIVING SUPPLIES EA X DISP ADL 4544 AIDS DAILY LIVING SUPPLIES PUR X DISP DIAG 4542 DIAGNOSTIC SUPPLIES EA X DISP DIAG 4542 DIAGNOSTIC SUPPLIES PUR X DISP ONC 4545 L8000, MASTECTOMY SUPPLIES EA X DISP ONC 4545 L8000, MASTECTOMY SUPPLIES PUR X DISP OT/PT 4546 OT/PT SUPPLIES EA X DISP OT/PT 4546 OT/PT SUPPLIES PUR X DISP SKNCARE 4543 SKIN CARE SUPPLIES NOT IN ASSOCIATION WITH HME PUR X DISP URO 4540 INCONTINENCE SUPPLIES PUR X HIT HIT BRM 1087 BIOLOGICAL RESPONSE MODIFIERS THERAPY / INJOT DISP X (Self Injected Only) HIT CERZYME 2424 CEREZYME THERAPY - FULL SERVICE PD X HIT CERZYME 2425 CEREZYME THERAPY - PHARMACY ONLY PD X HIT FACTOR 1085 FACTOR VIII & IX THERAPY DISP X HIT HORM 1093 GROWTH HORMONE THERAPY DISP X HIT REMOD 7725 REMODULIN THERAPY - FULL SERVICE PD X HIT REMOD 7726 REMODULIN THERAPY - PHARMACY ONLY PD X HIT SYNAGIS 7013 SYNAGIS DISPENSING FEE DISP X HME HME BATH* 2575 BATH BENCH WITH BACK (E0245) PUR X X HME BATH* 2867 BATH TUB RAIL (E0241), WALL, L-SHAPE PUR X X HME BATH* 2042 BATH TUB RAIL, FLOOR BASE (E0242) PUR X X HME BATH* 2862 BATH TUB RAIL, WALL, 12" (E0241) PUR X X HME BATH* 2863 BATH TUB RAIL, WALL, 16" (E0241) PUR X X HME BATH* 2864 BATH TUB RAIL, WALL, 18" (E0241) PUR X X HME BATH* 2865 BATH TUB RAIL, WALL, 24" (E0241) PUR X X HME BATH* 2866 BATH TUB RAIL, WALL, 36" (E0241) PUR X X HME BATH* 2043 BATH TUB RAIL, WALL, UNSPECIFIED SIZE PUR X X HME BATH* 2058 BATH TUB STOOL OR BENCH (E0245) PUR X X HME BATH* 2053 SITZ BATH CHAIR PUR X X HME BATH* 2056 TOILET RAIL, EACH (E0243) PUR X HME BATH* 2578 TRANSFER BENCH, NON-PADDED (E0245) PUR X HME BATH* 2577 TRANSFER BENCH, PADDED (E0245) PUR X HME BATH* 2057 TRANSFER TUB RAIL(E0246), ATTACHMENT PUR X HME BED 2063 AIR FLUIDIZED BED (E0194) PUR X HME BED 2067 BED ACCESSORIES: BOARDS OR TABLES, ANY TYPE MO X X HME BED 2067 BED ACCESSORIES: BOARDS OR TABLES, ANY TYPE PUR X X HME BED 2068 BED BOARD (E1399) MO X X HME BED 2068 BED BOARD (E1399) PUR X X HME BED 2069 BED CRADLE, ANY TYPE (E1399) PUR X X HME BED 2563 BED WEDGE (E1399), 12" PUR X X HME BED 2856 BEDROOM EQUIPMENT (E1399), CUSTOM PUR X X HME BED 2082 HOSP BED, INST TYPE, OSCIL, CIRC & STRYKER, WITH MATTRESS MO X HME BED 2097 OVER-BED TABLE (*E0274) PUR X HME BED 2177 PAD, LAMBSWOOL SHEEPSKIN (E0189), ANY SIZE PUR X HME BED 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) PUR X HME ENT 7551 BACK-PACK (E1399), FOR PORTABLE ENTERAL PUMP PUR X HME ENT 7161 FORMULA (B4150) CAT I,SEMI-SYN INTACT PROT/ISOLATE, CS MIN 192 OZ PUR X HME ENT 7162 FORMULA (B4151) CAT I, NATURAL INTACT PROT/ISOLATE, CS MIN 192 OZ PUR X HME ENT 7163 FORMULA (B4152) CAT II, INTACT PROT/ISOLATE, CS MIN 192 OZ PUR X HME ENT 7164 FORMULA (B4153) CAT III, HYDROL PROT AMINO PUR X ACID, CASE MIN 192 OZ HME ENT 7165 FORMULA (B4154) CAT IV, DEFINED SPEC METABOL PUR X NEED,CS MIN 192 OZ HME MISC BABY/ADULT SCALES X HME MISC BATH MATS X HME MISC CENTRIFUGES X HME MISC COMPRESSION STOCKINGS/REID SLEEVES X HME MISC CRAFTMATIC BEDS X HME MISC ENURESIS ALARMS X HME MISC ERGONOMIC OFFICE CHARIS X HME MISC EXERCISE EQUIPMENT X HME MISC GERI CHAIRS X HME MISC HIP CHAIRS X HME MISC HYPERBARIC CHAMBER X HME MISC MAGNETIC THERAPY EQUIPMENT X HME MISC NEEDLELESS INJECTORS X HME MISC POSTURPEDIC MATTRESSES X HME MISC PROTIME TESTER X HME MISC RECTAL DIALATOR X HME MISC ROLL ABOUT CHAIRS X HME MISC SAD LIGHTS X HME MISC SITZ BATHS X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- HME MISC STANDARD MATTRESSES AND PILLOWS X HME MISC ULTRASOUND UNITS X HME MISC VITRECTOMY CHAIRS X HME MISC WHITE CANES X HME OTHER 2568 ADAPTER, AC/DC (A9900) PUR X X HME OTHER 2141 AIR BUBBLE DETECTOR FOR DIALYSIS MO X X HME OTHER 2141 AIR BUBBLE DETECTOR FOR DIALYSIS PUR X X HME OTHER 2144 AUTO INTERMITTENT PERITIONEAL DIALYSIS SYS MO X X HME OTHER 2144 AUTO INTERMITTENT PERITIONEAL DIALYSIS SYS PUR X X HME OTHER 2145 BATH CONDUCTIVITY METER FOR DIALYSIS MO X X HME OTHER 2145 BATH CONDUCTIVITY METER FOR DIALYSIS PUR X X HME OTHER 2552 BATH LIFT (E1399), CUSTOM PUR X X HME OTHER 2147 BLOOD LEAK DETECTOR FOR DIALYSIS MO X X HME OTHER 2147 BLOOD LEAK DETECTOR FOR DIALYSIS PUR X X HME OTHER 2148 BLOOD PUMP FOR DIALYSIS MO X X HME OTHER 2148 BLOOD PUMP FOR DIALYSIS PUR X X HME OTHER 2165 BOTTLE, HOT WATER MO X X HME OTHER 2165 BOTTLE, HOT WATER PUR X X HME OTHER 7168 BREAST PUMP BATTERY PACK (MEDELA) (A9900) PUR X HME OTHER 2581 BREAST PUMP, INSTITUTIONAL (E1399) PUR X HME OTHER 6779 CARDIAC EVENT MONITOR (G0015) MO X X HME OTHER 2140 CHAIR, ADJ FOR ESRD PATIENTS MO X X HME OTHER 2140 CHAIR, ADJ FOR ESRD PATIENTS PUR X X HME OTHER 2560 COLD THERAPY UNIT (E0218) MO X HME OTHER 2560 COLD THERAPY UNIT (E0218) PD X HME OTHER 2560 COLD THERAPY UNIT (E0218) PUR X HME OTHER 2593 COLD THERAPY UNIT, PAD (E1399) PUR X HME OTHER 2149 COMPACT (PORT) TRAVEL HEMODIALYZER SYS MO X X HME OTHER 2149 COMPACT (PORT) TRAVEL HEMODIALYZER SYS PUR X X HME OTHER 2150 CYCLER DIALYSIS MACH FOR PERITONEAL DIALYSIS MO X X HME OTHER 2150 CYCLER DIALYSIS MACH FOR PERITONEAL DIALYSIS PUR X X HME OTHER 2151 DEIONIZER WATER PURIFICATION SYS MO X X HME OTHER 2151 DEIONIZER WATER PURIFICATION SYS PUR X X HME OTHER 2152 DELIVERY AND/OR INSTALL CHARGES FOR RENAL MO X X DIALYSIS EQUIP HME OTHER 2152 DELIVERY AND/OR INSTALL CHARGES FOR RENAL PUR X X DIALYSIS EQUIP HME OTHER 2153 DIALYSIS EQUIP, UNSPEC, BY REPORT MO X X HME OTHER 2153 DIALYSIS EQUIP, UNSPEC, BY REPORT PUR X X HME OTHER 2104 DYNAMIC ADJ ELBOW EXTENSION/FLEXION DEVICE MO X HME OTHER 2104 DYNAMIC ADJ ELBOW EXTENSION/FLEXION DEVICE PUR X HME OTHER 2129 DYNAMIC ADJ EXTENSION/FLEXION DEVICE, SOFT PUR X INTERFACE MATERIAL HME OTHER 2106 DYNAMIC ADJ KNEE EXTENSION/FLEXION DEVICE MO X HME OTHER 2106 DYNAMIC ADJ KNEE EXTENSION/FLEXION DEVICE PUR X HME OTHER 2108 DYNAMIC ADJ WRIST EXTENSION/FLEXION DEVICE MO X HME OTHER 2108 DYNAMIC ADJ WRIST EXTENSION/FLEXION DEVICE PUR X HME OTHER 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK MO X X DEVICE HME OTHER 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK PUR X X DEVICE HME OTHER 2110 HARNESS (E0945), EXTREMITY BELT PUR X X HME OTHER 2223 HEAT COLD WATER (*E0237) CIRCULATING PAD W/PUMP PUR X X HME OTHER 2186 HEAT UNIT (E0249), WATER CIRCULATING PAD PUR X X HME OTHER 2155 HEATING PAD (E0215), ELECTRIC, MOIST PUR X X HME OTHER 2179 HEATING PAD (E0238), MOIST, NON-ELECTRIC PUR X X HME OTHER 2156 HEATING PAD, STANDARD (E0210) PUR X X HME OTHER 2161 HEEL OR ELBOW PROTECTOR, EACH MO X X HME OTHER 2161 HEEL OR ELBOW PROTECTOR, EACH PUR X X HME OTHER 2162 HEMODIALYSIS MACH MO X X HME OTHER 2162 HEMODIALYSIS MACH PUR X X HME OTHER 6780 HOLTER MONITOR (G0004) MO X X HME OTHER 2166 HYDROCOLLATOR UNIT, INCLUDING PADS MO X X HME OTHER 2166 HYDROCOLLATOR UNIT, INCLUDING PADS PUR X X HME OTHER 2167 HYDROCOLLATOR UNIT, PORT MO X X HME OTHER 2167 HYDROCOLLATOR UNIT, PORT PUR X X HME OTHER 2168 ICE CAP OR COLLAR MO X X HME OTHER 2168 ICE CAP OR COLLAR PUR X X HME OTHER 2176 KIDNEY, DIALYSATE DELIVERY SYST. KIDNEY MACH MO X X HME OTHER 2176 KIDNEY, DIALYSATE DELIVERY SYST. KIDNEY MACH PUR X X HME OTHER 2184 PACEMAKER MONITOR, SELF CONTAINED, WITH DIG/VIS CHECK SYSTEM MO X X HME OTHER 2184 PACEMAKER MONITOR, SELF CONTAINED, WITH DIG/VIS CHECK SYSTEM PUR X X HME OTHER 2185 PACEMAKER MONITOR, SELF-CONT'D, (WITH AUD & VIS CHECK SYSTEM) MO X X HME OTHER 2185 PACEMAKER MONITOR, SELF-CONT'D, (WITH AUD & VIS CHECK SYSTEM) PUR X X HME OTHER 2187 PARAFFIN BATH UNIT, PORT (E0235) PUR X HME OTHER 2191 PATIENT LIFT (E0625), KARTOP, BATHROOM OR TOILET PUR X X HME OTHER 2189 PATIENT LIFT (E0635), ELEC W/ SEAT OR SLING PUR X HME OTHER 2555 PATIENT LIFT, CUSTOM (E1399) PUR X X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- HME OTHER 2102 PILLOW, CERVICAL PUR X X HME OTHER 2195 PRES ALARM FOR DIALYSIS MO X X HME OTHER 2195 PRES ALARM FOR DIALYSIS PUR X X HME OTHER 2199 PUMP (E0236) FOR WATER CIRCULATING PAD PUR X X HME OTHER 2163 PUMP, HEPARIN INFUSION FOR DIALYSIS MO X X HME OTHER 2163 PUMP, HEPARIN INFUSION FOR DIALYSIS PUR X X HME OTHER 2173 PUMP, INFUSION, IMPLANTABLE, NON-PROGRAMMABLE MO X X HME OTHER 2173 PUMP, INFUSION, IMPLANTABLE, NON-PROGRAMMABLE PUR X X HME OTHER 2174 PUMP, INFUSION, IMPLANTABLE, PROGRAMMABLE MO X X HME OTHER 2174 PUMP, INFUSION, IMPLANTABLE, PROGRAMMABLE PUR X X HME OTHER 2188 PUMP, INFUSION, PARENTERAL, STATIONARY SINGLE OR MULTI-CHANNEL MO X X HME OTHER 2188 PUMP, INFUSION, PARENTERAL, STATIONARY SINGLE OR MULTI-CHANNEL PUR X X HME OTHER 2200 RECIPROCATING PERITONEAL DIALYSIS SYS MO X X HME OTHER 2200 RECIPROCATING PERITONEAL DIALYSIS SYS PUR X X HME OTHER 2201 REPL COMPONENTS FOR OWNED HEMODIALYSIS/ MO X X PERITONEAL DIAL MACH HME OTHER 2201 REPL COMPONENTS FOR OWNED HEMODIALYSIS/ PUR X X PERITONEAL DIAL MACH HME OTHER 2202 RESTRAINTS (E0710), ANY TYPE (BODY, CHEST, MO X X WRIST OR ANKLE) HME OTHER 2202 RESTRAINTS (E0710), ANY TYPE (BODY, CHEST, PUR X X WRIST OR ANKLE) HME OTHER 2203 REVERSE OSMOSIS WATER PURIFICATION SYS MO X X HME OTHER 2203 REVERSE OSMOSIS WATER PURIFICATION SYS PUR X X HME OTHER 2204 SAFETY EQUIP (E0700) (E.G., BELT, HARNESS OR VEST FOR VEHICLES MO X X HME OTHER 2204 SAFETY EQUIP (E0700) (E.G., BELT, HARNESS OR VEST FOR VEHICLES PUR X X HME OTHER 2395 SEAT LIFT CHAIR/MOTORIZED (E0627) PUR X X HME OTHER 2205 SEAT LIFT MECH (E0627) INCORPORATED INTO A PUR X X COMB LIFT-CHAIR MECH HME OTHER 2213 SEAT LIFT MECH ONLY, USE W/PATIENT OWNED MO X FURN-ELEC HME OTHER 2213 SEAT LIFT MECH ONLY, USE W/PATIENT OWNED PUR X FURN-ELEC HME OTHER 2214 SEAT LIFT MECH ONLY, USE W/PATIENT OWNED MO X FURN-NON-ELEC HME OTHER 2214 SEAT LIFT MECH ONLY, USE W/PATIENT OWNED PUR X FURN-NON-ELEC HME OTHER 2562 SHOWER, HAND HELD (E1399) PUR X X HME OTHER 2216 SORBENT CARTRIDGES, PER CASE MO X X HME OTHER 2216 SORBENT CARTRIDGES, PER CASE PUR X X HME OTHER 2855 THERAPY EQUIPMENT, CUSTOM (E1399) PUR X HME OTHER 2220 TRANSDUCER PROTECTORS/FLUID BARRIERS, MO X X ANY SIZE, EACH HME OTHER 2220 TRANSDUCER PROTECTORS/FLUID BARRIERS, PUR X X ANY SIZE, EACH HME OTHER 2221 ULTRAVIOLET CABINET (E0690), APPROPRIATE MO X FOR HOME USE HME OTHER 2221 ULTRAVIOLET CABINET (E0690), APPROPRIATE PUR X FOR HOME USE HME OTHER 2222 UNIPUNCTURE CONTROL SYS FOR DIALYSIS MO X X HME OTHER 2222 UNIPUNCTURE CONTROL SYS FOR DIALYSIS PUR X X HME OTHER 7188 WALKER BASKET VINYL COATED (A9900) PUR X HME OTHER 7189 WALKER POUCH (A9900) LTWT W/ POCKETS PUR X HME OTHER 2225 WATER SOFTENING SYS MO X X HME OTHER 2225 WATER SOFTENING SYS PUR X X HME OTHER 2226 WEARABLE ARTIFICIAL KIDNEY MO X X HME OTHER 2226 WEARABLE ARTIFICIAL KIDNEY PUR X X HME OTHER 2061 WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE) PUR X X HME OTHER 2062 WHIRLPOOL, PORT (OVERTUB TYPE) (E1300) MO X HME OTHER 2062 WHIRLPOOL, PORT (OVERTUB TYPE) (E1300) PUR X HME OTHER 6873 WOUND SUCTION DEVICE (K0538) PD X HME OTHER 7914 DRESSING SET, FOR WOUND SUCTION DEVICE (K0539) PUR X HME OTHER 7915 CANISTER SET, FOR WOUND SUCTION DEVICE (K0540) PUR X HME STIM 2157 STIMULATOR (E0755), ELECTRONIC SALIVARY REFLEX, NON INVASIVE PUR X X HME STIM 2157 STIMULATOR, ELECTRONIC SALIVARY REFLEX, NON MO X INVASIVE (E0755) HME STIM 2123 STIMULATOR, OSTEOGENIC, SURGICALLY IMPLANTED MO X X HME STIM 2123 STIMULATOR, OSTEOGENIC, SURGICALLY IMPLANTED PUR X X HME STIM 2172 STIMULATOR, PELVIC FLOOR INCONTINENCE MO X TREATMENT SYS HME STIM 2172 STIMULATOR, PELVIC FLOOR INCONTINENCE PUR X TREATMENT SYS HME STIM_BO 2124 STIMULATOR, OSTEOGENIC NON-INVASIVE, SPINAL MO X APPLICATIONS (E0748) HME STIM_BO 2124 STIMULATOR, OSTEOGENIC NON-INVASIVE, SPINAL PUR X APPLICATIONS (E0748) HME STIM_BO 6784 STIMULATOR, OSTEOGENIC, NON - INVA PUR X HME STIM_BO 2122 STIMULATOR, OSTEOGENIC, NON-INVASIVE (E0747) MO X HME STIM_BO 2122 STIMULATOR, OSTEOGENIC, NON-INVASIVE (E0747) PUR X HME STIM_BO 6875 STIMULATOR, OSTEOGENIC, ULTRASOUND PUR X HME SUP 2607 APPLICATOR COTTON TIP 3" OR 6" N/STRL 1000/BX EA X X (A4649A) HME SUP 2607 APPLICATOR COTTON TIP 3" OR 6" N/STRL 1000/BX UN X X (A4649A) HME SUP 2608 APPLICATOR COTTON TIP 6" STRL 200/BX SH EA X X (A4649B) HME SUP 2608 APPLICATOR COTTON TIP 6" STRL 200/BX SH UN X X (A4649B) HME SUP 2609 APPLICATOR, DRESS COTTON UN X X HME SUP 2611 BAG, URINARY (LEG) UN X X HME SUP 2616 BELT, RIB EA X X HME SUP 7173 BREAST PUMP COOLER/CARRIER (A9900) F/LACTINA PUR X X (MEDELA) HME SUP 2618 BRIEF, INCONTINENCE EA X X HME SUP 2624 CATHETER, MENTOR, SELF 408 UN X X HME SUP 2713 CATHETERIZATION MIRROR, SELF UN X X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- HME SUP 2643 DISINFECTANT, DEM EA X X HME SUP 2645 DRESSING, LYOFOAM, 3.5X2.5 EA X X HME SUP 2655 ENTERAL FORMULAE, CAT REPLETE EA X HME SUP 2661 ENTERAL PEDIASURE W/FI EA X HME SUP 3713 ERECTION SYSTEM, VACUUM (K0163) EA X HME SUP 2672 FOAM, RESTON REHAB EA X X HME SUP 2674 GAUZE SPONGE 4X4 6PLY IV STRL, EACH (A6402) EA X X HME SUP 2675 GAUZE, MEDICATED PADS EA X X HME SUP 2673 GAUZE, NON-ADHESIVE, TELFA, 3X4 EA X X HME SUP 2676 GAUZE, NON-IMPREGNATED EA X X HME SUP 2677 GAUZE, NON-IMPREGNATED, 16" PAD EA X X HME SUP 2684 GLOVE EXAM LTX NON-STERILE 100/BX BAX (A4927) UN X X HME SUP 2678 GLOVE EXAM STERILE 100/BX (A4927) UN X X HME SUP 2679 GLOVES, EXAM, LARGE EA X X HME SUP 2680 GLOVES, EXAM, MEDIUM EA X X HME SUP 2681 GLOVES, EXAM, POWDERLESS, LARGE EA X X HME SUP 2682 GLOVES, EXAM, POWDERLESS, MEDIUM EA X X HME SUP 2683 GLOVES, STERILE, POWDERFREE EA X X HME SUP 2698 LUBRICANT, SURGICAL UN X X HME SUP 2473 NON-COVERED SUPPLIES EA X X HME SUP 2605 PREP, ALCOHOL OR PEROXIDE EA X X HME SUP 2606 PREP, ALCOHOL WIPES UN X X HME SUP 2644 PREP, HYDROGEN PEROXIDE EA X X HME SUP 2617 PUMP KIT, BREAST, DOUBLE UN X HME SUP 2725 REMOVER, ADHESIVE UN X X HME SUP 2728 SALINE (A7019) 0.9% UNIT DOSE UN X X HME SUP 2528 SIDE RAIL PADDING (A9900) PUR X HME SUP 2733 SOLUTION, CONTROL III UN X X HME SUP 2740 SPONGE, 6PLY, 2X2 UN X X HME SUP 2741 SPONGE, DRESS IV EA X X HME SUP 2741 SPONGE, DRESS IV UN X X HME SUP 2742 STOCKINGS, COMPRESSION UN X X HME SUP 2749 SUPPLIES, MEDICATION UN X X HME SUP 2755 TAPE MICROFOAM PER 18 SQ INCHES (A6265) EA X X HME SUP 2755 TAPE MICROFOAM PER 18 SQ INCHES (A6265) UN X X HME SUP 2756 TAPE, CLOTH 1/2" UN X X HME SUP 2757 TAPE, DERMICLEAR UN X X HME SUP 2758 TAPE, DRESS, DURAPORE, 1" UN X X HME SUP 2759 TAPE, DRESS, DURAPORE, 2" UN X X HME SUP 2760 TAPE, DRESS, TRANSPORE, 2" UN X X HME SUP 2767 TRACH, BRUSH PIPECLEAN UN X X HME SUP 2768 TRACHTRAY KIT STARTER W/SUPPLIES (A4625) UN X X HME SUP 2230 TRANSFER BOARD OR DEVICE (E0972) PUR X HME SUP 2796 VINEGAR UN X X HME SUP 2797 WATER, STERILE UN X X HME SUP 2801 WIPES, BABY EA X X HME SUP 2802 WIPES, SKIN BARRIER UN X X HME WC-CUST 2247 BATTERY CHARGER (E1066) PUR X HME WC-CUST 2255 BATTERY, DEEP CYCLE (E1069) PUR X HME WC-CUST 7604 CUSTOM POWER ADULT W/C ASSESSMENT EA X HME WC-CUST 7674 CUSTOM W/C REVIEW EA X HME WC-CUST 2288 SCOOTER, THREE WHEEL, STANDARD (STD) (E1230) MO X HME WC-CUST 2288 SCOOTER, THREE WHEEL, STANDARD (STD) (E1230) MS X HME WC-CUST 2288 SCOOTER, THREE WHEEL, STANDARD (STD) (E1230) PUR X HME WC-CUST 2288 SCOOTER, THREE WHEEL, STANDARD (STD) (E1230) RENPR X HME WC-CUST 2282 W/C MOTORIZED , FIX ARMS, SWING AWAY DETACH MO X FOOT RESTS (E1212) HME WC-CUST 2282 W/C MOTORIZED , FIX ARMS, SWING AWAY DETACH PUR X FOOT RESTS (E1212) HME WC-CUST 2279 W/C MOTORIZED, DETACH ARMS , S/AWAY DETACH MO X FOOT RESTS (E1211) HME WC-CUST 2279 W/C MOTORIZED, DETACH ARMS , S/AWAY DETACH PUR X FOOT RESTS (E1211) HME WC-CUST 2280 W/C MOTORIZED, DETACH ARMS S/AWAY, DETACH MO X ELEV LEG REST (E1213) HME WC-CUST 2280 W/C MOTORIZED, DETACH ARMS S/AWAY, DETACH PUR X ELEV LEG REST (E1213) HME WC-CUST 2281 W/C MOTORIZED, FIX ARMS, S/AWAY DETACH ELEV MO X LEG RESTS (E1210) HME WC-CUST 2281 W/C MOTORIZED, FIX ARMS, S/AWAY DETACH ELEV PUR X LEG RESTS (E1210) HME WC-CUST 2287 W/C POWER ATTACHMENT (E1065) PUR X HME WC-CUST 7768 W/C REPAIRS - CUSTOM (E1340) PUR X HME WC-CUST 2579 W/C XXWIDE (E1220) MO X HME WC-CUST 2579 W/C XXWIDE (E1220) MS X HME WC-CUST 2579 W/C XXWIDE (E1220) PD X HME WC-CUST 7702 W/C, CUSHION ALTERN8, ALTERNATING CUSHION (K108) PUR X HME WC-CUST 7506 W/C, CUSTOM MANUAL ADULT (E1399) PUR X HME WC-CUST 7504 W/C, CUSTOM MANUAL PEDIATRIC (E1399) PUR X HME WC-CUST 7507 W/C, CUSTOM POWER ADULT (E1399) PUR X HME WC-CUST 7505 W/C, CUSTOM POWER PEDIATRIC (E1399) PUR X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- HME WC-STD 2249 BELT, SAFETY (E0979) W/ VELCRO CLOSURE, W/C PUR X HME WC-STD 2249 BELT, SAFETY W/ VELCRO CLOSURE, W/C (E0979) MO X HME WC-STD 2292 SAFETY VEST (E0980), W/C PUR X HME WC-STD 2292 SAFETY VEST, W/C (E0980) MO X HME WC-STD 2139 TRAY (E0950) MO X HME WC-STD 2139 TRAY (E0950) PUR X HME WC-STD 2254 W/C (E1399) COMMODE SEAT PADDED PUR X HME WC-STD 2254 W/C COMMODE SEAT PADDED (E1399) MO X HME WC-STD 2283 W/C NARROWING DEVICE MO X HME WC-STD 2283 W/C NARROWING DEVICE PUR X HME WC-STD 2231 W/C PART GRADE AID FOR WC MO X HME WC-STD 2231 W/C PART GRADE AID FOR WC PUR X HME WDCARE 2536 RX WOUND CARE $1.00,(E1399) EA X HME MISC NOVA PENS X HOSP ALL ALL HOSPICE SERVICE X LAB SUP 1421 SUPPLIES EA X X * SELF-INECTABLES THAT ARE ADMIXED WITH DILUENT AND ADMINISTERED VIA INTRAVENOUS INFUSION ARE INCLUDED IN MED THE CAPITATION PAYMENT. MED BRM 7016 ALDESLEUKIN (INTERLEUKIN-2)(22MU VIAL) VIAL X MED BRM 7705 ANAKINRA (100MG VIAL) VIAL X MED BRM 7686 DARBEPOEITIN ALFA (0.025 MG/ML) 1ML VIAL VIAL X MED BRM 7687 DARBEPOEITIN ALFA (0.04 MG/ML) 1ML VIAL VIAL X MED BRM 7688 DARBEPOEITIN ALFA (0.06 MG/ML) 1ML VIAL VIAL X MED BRM 7684 DARBEPOEITIN ALFA (0.1 MG/ML) 1ML VIAL VIAL X MED BRM 7685 DARBEPOEITIN ALFA (0.2 MG/ML) 1ML VIAL VIAL X MED BRM 7771 DARBEPOETIN ALFA (300MCG PER 1ML VIAL) VIAL X MED BRM 1487 EPOETIN ALFA UN X MED BRM 7110 EPOETIN ALFA (10,000 UNIT VIAL) VIAL X MED BRM 7017 EPOETIN ALFA (2,000 UNIT VIAL) VIAL X MED BRM 7119 EPOETIN ALFA (20,000 UNIT VIAL) VIAL X MED BRM 7095 EPOETIN ALFA (4,000 UNIT VIAL) VIAL X MED BRM 7524 EPOETIN ALFA (40,000 UNIT VIAL) VIAL X MED BRM 7069 EPOTIN ALFA (3,000 UNIT VIAL) VIAL X MED BRM 1488 FILGRASTIM (G-CSF) MCG X MED BRM 7018 FILGRASTIM (G-CSF) (300 MCG VIAL) VIAL X MED BRM 7070 FILGRASTIM (G-CSF) (480MCG VIAL) VIAL X MED BRM 7578 FILGRASTIM SINGLEJECT (300MCG PER 0.5ML SYRINGE) VIAL X MED BRM 7577 FILGRASTIM SINGLEJECT (480MCG PER 0.8ML SYRINGE) VIAL X MED BRM 6805 GLATIRAMER ACETATE MG X MED BRM 7019 GLATIRAMER ACETATE (20MG VIAL) VIAL X MED BRM 7020 INTERFERON ALFA 2A (3MU VIAL) VIAL X MED BRM 7071 INTERFERON ALFA 2A (6MU VIAL) VIAL X MED BRM 7096 INTERFERON ALFA 2A (9MU VIAL) VIAL X MED BRM 7097 INTERFERON ALFA 2B (10MU VIAL) VIAL X MED BRM 7109 INTERFERON ALFA 2B (18 MU VIAL) VIAL X MED BRM 7117 INTERFERON ALFA 2B (25MU VIAL) VIAL X MED BRM 7541 INTERFERON ALFA 2B (3MU PER 0.2ML 1.5ML PEN) VIAL X MED BRM 7021 INTERFERON ALFA 2B (3MU VIAL) VIAL X MED BRM 7118 INTERFERON ALFA 2B (50 MU VIAL) VIAL X MED BRM 7538 INTERFERON ALFA 2B (5MU PER 0.2ML 1.5ML PEN) VIAL X MED BRM 7103 INTERFERON ALFA 2B (5MU VIAL) VIAL X MED BRM 7514 INTERFERON ALFA 2B (60MU PEN) VIAL X MED BRM 7497 INTERFERON ALFA 2B 30MU KIT (6 X 5MU VIAL/SRN) KIT X MED BRM 7680 INTERFERON ALFA 2B KIT (6 X 10MU VIAL/SRN) KIT X MED BRM 6964 INTERFERON ALFA 2B/RIBAVIRIN 42 CAPS (REBETRON EA X 600 DOSE REDUCE) MED BRM 6963 INTERFERON ALFA 2B/RIBAVIRIN 70 CAPS (REBETRON EA X 1000 FOR <75KG) MED BRM 6962 INTERFERON ALFA 2B/RIBAVIRIN 84 CAPS (REBETRON EA X 1200 FOR >75KG) MED BRM 7022 INTERFERON ALFA N3 (5MU VIAL) VIAL X MED BRM 7072 INTERFERON ALFACON-1 (15MCG PER 0.5ML VIAL) VIAL X MED BRM 7023 INTERFERON ALFACON-1 (9MCG PER 0.3ML VIAL) VIAL X MED BRM 7113 INTERFERON BETA 1A (33 MCG SYR/VIAL) VIAL X MED BRM 7714 INTERFERON BETA 1A (REBIF)(22MCG PER 0.5ML SYRINGE) VIAL X MED BRM 7715 INTERFERON BETA 1A (REBIF)(44MCG PER 0.5ML SYRINGE) VIAL X MED BRM 7024 INTERFERON BETA 1A 132MCG KIT (4 X 33MCG VIALS) KIT X MED BRM 7025 INTERFERON BETA 1B (0.3MG = 9.6MU VIAL) VIAL X MED BRM 7026 INTERFERON GAMMA 1B (3MU VIAL) VIAL X MED BRM 7027 OPRELVEKIN (INTERLEUKIN-11)(5MG VIAL) VIAL X MED BRM 7713 PEGFILGRASTIM (G-CSF)(6MG PER 0.6ML SYRINGE) VIAL X MED BRM 7776 PEGINTERFERON ALFA-2A (180 MCG VIAL) VIAL X MED BRM 7777 PEGINTERFERON ALFA-2A (180 MCG VIAL, 4 VIAL KIT) VIAL X MED BRM 7666 PEGINTERFERON ALFA-2B (0.074MG KIT) VIAL X MED BRM 7601 PEGINTERFERON ALFA-2B (0.118MG KIT) VIAL X MED BRM 7667 PEGINTERFERON ALFA-2B (0.177MG KIT) VIAL X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- MED BRM 7668 PEGINTERFERON ALFA-2B (0.222MG KIT) VIAL X MED BRM 1490 SARGRAMOSTIM (GM-CSF) MCG X MED BRM 7073 SARGRAMOSTIM (GM-CSF) (500MCG VIAL) VIAL X MED BRM 7028 SARGRAMOSTIM (GM-CSF)(250MCG VIAL) VIAL X MED CERZYME 7074 ALGLUCERASE (400 UNITS 5ML VIAL) VIAL X MED CERZYME 7030 ALGLUCERASE (50 UNITS PER 5 ML VIAL) VIAL X MED CERZYME 7032 IMIGLUCERASE (200 UNIT VIAL) VIAL X MED CERZYME 7496 IMIGLUCERASE (400 U VIAL) VIAL X MED CERZYME 7303 IMIGLUCERASE, PER UNIT UN X MED CHEMO 7908 ALEMTUZUMAB (CAMPATH) 30MG PER VIAL KIT X (3 VIAL KIT) MED CHEMO 7140 AMIFOSTINE (3 X 500MG VIAL) VIAL X MED CHEMO 7139 AMIFOSTINE (500MG VIAL) VIAL X MED CHEMO 7575 ARSENIC TRIOXIDE (10MG PER 10ML VIAL) VIAL X MED CHEMO 7481 ASPARAGINASE (10,000 UN VIAL) VIAL X MED CHEMO 1493 BLEOMYCIN SULFATE UN X MED CHEMO 7401 BLEOMYCIN SULFATE (15 UNIT VIAL) VIAL X MED CHEMO 7402 BLEOMYCIN SULFATE (30 UNIT VIAL) VIAL X MED CHEMO 6791 CARBOPLATIN MG X MED CHEMO 7404 CARBOPLATIN (150MG VIAL) VIAL X MED CHEMO 7405 CARBOPLATIN (450MG VIAL) VIAL X MED CHEMO 7403 CARBOPLATIN (50MG VIAL) VIAL X MED CHEMO 1494 CARMUSTINE MG X MED CHEMO 7406 CARMUSTINE (100MG VIAL) VIAL X MED CHEMO 1495 CISPLATIN MG X MED CHEMO 7408 CISPLATIN (100MG PER 100ML VIAL) VIAL X MED CHEMO 7407 CISPLATIN (50MG PER 50ML VIAL) VIAL X MED CHEMO 1496 CLADRIBINE MG X MED CHEMO 7409 CLADRIBINE (10MG PER 10ML VIAL) VIAL X MED CHEMO 1499 DACARBAZINE MG X MED CHEMO 7419 DACARBAZINE (200MG VIAL) VIAL X MED CHEMO 1500 DACTINOMYCIN MCG X MED CHEMO 7420 DACTINOMYCIN (500MCG VIAL) VIAL X MED CHEMO 7422 DAUNORUBICIN CITRATE LIPOSOME (50MG PER 25ML VIAL) VIAL X MED CHEMO 1501 DAUNORUBICIN HYDROCHLORIDE MG X MED CHEMO 7421 DAUNORUBICIN HYDROCHLORIDE (20MG VIAL) VIAL X MED CHEMO 6799 DAUNORUBICIN LIPOSOMAL MG X MED CHEMO 7502 DOCETAXEL (20MG VIAL) VIAL X MED CHEMO 7503 DOCETAXEL (80MG VIAL) VIAL X MED CHEMO 2487 DOXIL MG X MED CHEMO 7423 DOXORUBICIN LIPOSOME (20MG PER 10ML VIAL) VIAL X MED CHEMO 7769 EPIRUBICIN HYDROCHLORIDE 200MG (100ML VIAL) VIAL X MED CHEMO 7770 EPIRUBICIN HYDROCHLORIDE 50MG (25ML VIAL) VIAL X MED CHEMO 1503 ETOPOSIDE MG X MED CHEMO 7430 ETOPOSIDE (1000MG PER 50ML VIAL) VIAL X MED CHEMO 7427 ETOPOSIDE (100MG PER 5ML VIAL) VIAL X MED CHEMO 7428 ETOPOSIDE (150MG PER 7.5ML VIAL) VIAL X MED CHEMO 7429 ETOPOSIDE (500MG PER 25ML VIAL) VIAL X MED CHEMO 1504 FLOXURIDINE MG X MED CHEMO 7431 FLOXURIDINE (500MG VIAL) VIAL X MED CHEMO 1505 FLUDARABINE PHOSPHATE MG X MED CHEMO 7432 FLUDARABINE PHOSPHATE (50MG VIAL) VIAL X MED CHEMO 2853 GEMCITABINE HYDROCHLORIDE MG X MED CHEMO 7437 GEMCITABINE HYDROCHLORIDE (1000MG VIAL) VIAL X MED CHEMO 7436 GEMCITABINE HYDROCHLORIDE (200MG VIAL) VIAL X MED CHEMO 2492 IDARUBICIN MG X MED CHEMO 2493 IDARUBICIN (MULTIPLE 2ND) MG X MED CHEMO 7439 IDARUBICIN HYDROCHLORIDE (10MG VIAL) VIAL X MED CHEMO 7440 IDARUBICIN HYDROCHLORIDE (20MG VIAL) VIAL X MED CHEMO 7438 IDARUBICIN HYDROCHLORIDE (5MG VIAL) VIAL X MED CHEMO 7528 IFOSFAMIDE/MESNA (10GM-10GM PER KIT) VIAL X MED CHEMO 6986 IFOSFAMIDE/MESNA (5GM-3GM PER KIT) VIAL X MED CHEMO 7531 IFOSFAMIDE/MESNA (6GM-6GM PER KIT) VIAL X MED CHEMO 6807 IRINOTECAN HYDROCHLORIDE MG X MED CHEMO 7442 IRINOTECAN HYDROCHLORIDE (100MG PER 5ML VIAL) VIAL X MED CHEMO 7441 IRINOTECAN HYDROCHLORIDE (40MG PER 2ML VIAL) VIAL X MED CHEMO 1512 MECHLORETHAMINE HYDROCHLORIDE MG X MED CHEMO 7446 MECHLORETHAMINE HYDROCHLORIDE (10MG VIAL) VIAL X MED CHEMO 7765 MELPHALAN VIAL X MED CHEMO 2411 MESNA MG X MED CHEMO 7447 MESNA (1000MG PER 10ML VIAL) VIAL X MED CHEMO 1515 MITOMYCIN MG X MED CHEMO 7452 MITOMYCIN (20MG VIAL) VIAL X MED CHEMO 7453 MITOMYCIN (40MG VIAL) VIAL X MED CHEMO 7451 MITOMYCIN (5MG VIAL) VIAL X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- MED CHEMO 6815 MITOXANTRONE MG X MED CHEMO 7454 MITOXANTRONE (20MG PER 10ML VIAL) VIAL X MED CHEMO 7455 MITOXANTRONE (25MG PER 12.5ML VIAL) VIAL X MED CHEMO 7456 MITOXANTRONE (30MG PER 15ML VIAL) VIAL X MED CHEMO 7764 OXALIPLATIN (50MG VIAL) VIAL X MED CHEMO 7761 OXALPLATIN (100MG VIAL) VIAL X MED CHEMO 1516 PACLITAXEL MG X MED CHEMO 7458 PACLITAXEL (100.2MG PER 16.7ML VIAL) VIAL X MED CHEMO 7459 PACLITAXEL (300MG PER 50ML VIAL) VIAL X MED CHEMO 7457 PACLITAXEL (30MG PER 5ML VIAL) VIAL X MED CHEMO 1517 PEGASPARGASE UN X MED CHEMO 7460 PEGASPARGASE (3750 UNITS PER 5ML VIAL) VIAL X MED CHEMO 1519 PLICAMYCIN MCG X MED CHEMO 7461 PLICAMYCIN (2500 MCG VIAL) VIAL X MED CHEMO 7132 RITUXIMAB (100MG PER 10ML VIAL) VIAL X MED CHEMO 7133 RITUXIMAB (500MG PER 50ML VIAL) VIAL X MED CHEMO 1520 STREPTOZOCIN MG X MED CHEMO 7462 STREPTOZOCIN (1GM VIAL) VIAL X MED CHEMO 1521 TENIPOSIDE MG X MED CHEMO 7474 TENIPOSIDE (50MG PER 5ML VIAL) VIAL X MED CHEMO 1522 THIOTEPA MG X MED CHEMO 7463 THIOTEPA (15MG VIAL) VIAL X MED CHEMO 2831 TOPOTECAN MG X MED CHEMO 7464 TOPOTECAN HYDROCHLORIDE (4MG VIAL) VIAL X MED CHEMO 7501 TRASTUZUMAB (440MG VIAL) VIAL X MED CHEMO 6679 VINORELBINE TARTRATE MG X MED CHEMO 7469 VINORELBINE TARTRATE (10MG PER 1ML VIAL) VIAL X MED CHEMO 7470 VINORELBINE TARTRATE (50MG PER 5ML VIAL) VIAL X MED ENT 1525 ENTERAL FORMULAE: CALORICALLY DENSE INTACT CAN X MED ENT 1525 ENTERAL FORMULAE: CALORICALLY DENSE INTACT ML X MED ENT 1526 ENTERAL FORMULAE: DEFINED FORMULAE FOR SPECIAL NEEDS CAN X MED ENT 1526 ENTERAL FORMULAE: DEFINED FORMULAE FOR SPECIAL NEEDS ML X MED ENT 1527 ENTERAL FORMULAE: HYDROLYZED PROTEIN/AMINO ACIDS CAN X MED ENT 1527 ENTERAL FORMULAE: HYDROLYZED PROTEIN/AMINO ACIDS ML X MED ENT 1528 ENTERAL FORMULAE: MODULAR COMPONENTS CAN X MED ENT 1528 ENTERAL FORMULAE: MODULAR COMPONENTS ML X MED ENT 1529 ENTERAL FORMULAE: NATURAL INTACT PROTEIN/PROTEIN CAN X MED ENT 1529 ENTERAL FORMULAE: NATURAL INTACT PROTEIN/PROTEIN ML X MED ENT 2413 ENTERAL FORMULAE: NON-SPECIFIED CAN X MED ENT 2413 ENTERAL FORMULAE: NON-SPECIFIED ML X MED ENT 2413 ENTERAL FORMULAE: NON-SPECIFIED PD X MED ENT 2414 ENTERAL FORMULAE: NON-SPECIFIED - FULL SERVICE CAN X MED ENT 2414 ENTERAL FORMULAE: NON-SPECIFIED - FULL SERVICE ML X MED ENT 1530 ENTERAL FORMULAE: SEMI-SYNTHETICS CAN X MED ENT 1530 ENTERAL FORMULAE: SEMI-SYNTHETICS ML X MED ENT 1531 ENTERAL FORMULAE: STANDARD NUTRIENTS CAN X MED ENT 1531 ENTERAL FORMULAE: STANDARD NUTRIENTS ML X MED FACTOR 6750 ANTIHIBITOR -- PROPLEX UN X MED FACTOR 6748 ANTIHIBITOR (J7196) AUTOPLEX UN X MED FACTOR 6749 ANTIHIBITOR (J7196) FEIBA UN X MED FACTOR 6744 FACTOR IX (J7194) ALFANINE UN X MED FACTOR 6747 FACTOR IX (J7194) BEBULIN UN X MED FACTOR 6745 FACTOR IX (J7194) KONYNE UN X MED FACTOR 6743 FACTOR IX (J7194) MONONINE UN X MED FACTOR 6746 FACTOR IX (J7194) PROFILNINE UN X MED FACTOR 6891 FACTOR IX RECOM (J7194) BENEFIX UN X MED FACTOR 7599 FACTOR VII -- NOVOSEVEN (AUTH IN 1200 OR 4800 QTY) MCG X MED FACTOR 7134 FACTOR VII (NOVOSEVEN 1200MCG VIAL) VIAL X MED FACTOR 7135 FACTOR VII (NOVOSEVEN 4800MCG VIAL) VIAL X MED FACTOR 6739 FACTOR VIII HIPUR (J7190) ALFANATE UN X MED FACTOR 6741 FACTOR VIII HIPUR (J7190) HUMATE UN X MED FACTOR 6740 FACTOR VIII HIPUR (J7190) KOATE UN X MED FACTOR 6742 FACTOR VIII HIPUR (J7191) HYATE UN X MED FACTOR 6736 FACTOR VIII MONO (J7190) HEMOPHIL UN X MED FACTOR 6737 FACTOR VIII MONO (J7190) MONOCLATE UN X MED FACTOR 6738 FACTOR VIII MONO (J7190) RED CROSS METHOD-M UN X MED FACTOR 7598 FACTOR VIII MONOCLONAL -- MONARC-M UN X MED FACTOR 6732 FACTOR VIII RECOM (J7192) BIOCLATE UN X MED FACTOR 6733 FACTOR VIII RECOM (J7192) HELIXATE UN X MED FACTOR 6735 FACTOR VIII RECOM (J7192) KOGENATE UN X MED FACTOR 6734 FACTOR VIII RECOM (J7192) RECOMBINATE UN X MED FACTOR 7909 FACTOR VIII RECOMBINANT - ADVATE UN X MED FACTOR 7572 FACTOR VIII RECOMBINANT - HELIXATE FS UN X MED FACTOR 7596 FACTOR VIII RECOMBINANT -- KOGENATE FS UN X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- MED FACTOR 7597 FACTOR VIII RECOMBINANT -- REFACTO UN X MED HORM 7142 SERMORELIN ACETATE (GH-RELEASING HORMONE) (0.5MG VIAL) VIAL X MED HORM 7143 SERMORELIN ACETATE (GH-RELEASING HORMONE) (1MG VIAL) VIAL X MED HORM 1489 SOMATREM MG X MED HORM 7075 SOMATREM (10MG VIAL) VIAL X MED HORM 7033 SOMATREM (5MG VIAL) VIAL X MED HORM 7545 SOMATROPIN (.8MG VIAL)(MINIQUICK) VIAL X MED HORM 7746 SOMATROPIN (0.4MG SYR)(GENOTROPIN) VIAL X MED HORM 7747 SOMATROPIN (0.6MG SYR)(GENOTROPIN) VIAL X MED HORM 7748 SOMATROPIN (1.0MG SYR)(GENOTROPIN) VIAL X MED HORM 7749 SOMATROPIN (1.2MG SYR)(GENOTROPIN) VIAL X MED HORM 7750 SOMATROPIN (1.4MG SYR)(GENOTROPIN) VIAL X MED HORM 7751 SOMATROPIN (1.6MG SYR)(GENOTROPIN) VIAL X MED HORM 7752 SOMATROPIN (1.8MG SYR)(GENOTROPIN) VIAL X MED HORM 7753 SOMATROPIN (2.0MG SYR)(GENOTROPIN) VIAL X MED HORM 7744 SOMATROPIN (24MG VIAL)(HUMOTROPE) VIAL X MED HORM 7754 SOMATROPIN (5MG CARTRIDGE)(NORDITROPIN) VIAL X MED HORM 7758 SOMATROPIN (5MG VIAL)(HUMOTROPE) VIAL X MED HORM 7755 SOMATROPIN (5MG/VIAL)(SAIZEN) VIAL X MED HORM 7757 SOMATROPIN (5MG/VIAL)(SEROSTIM) VIAL X MED HORM 7743 SOMATROPIN (6MG VIAL)(HUMOTROPE) VIAL X MED HORM 7756 SOMATROPIN (8.8MG/VIAL)(SAIZEN) VIAL X MED HORM 6672 SOMATROPIN (RDNA ORIGIN) MG X MED HORM 7076 SOMATROPIN (RDNA ORIGIN) (10MG VIAL) VIAL X MED HORM 7115 SOMATROPIN (RDNA ORIGIN) (13.8 MG CARTRIDGE/VIAL) VIAL X MED HORM 7114 SOMATROPIN (RDNA ORIGIN) (5.8 MG CARTRIDGE/VIAL) VIAL X MED HORM 7034 SOMATROPIN (RDNA ORIGIN) (5MG VIAL) VIAL X MED HORM 7123 SOMATROPIN (RDNA ORIGIN)(1.5MG CARTRIDGE/VIAL) VIAL X MED HORM 7559 SOMATROPIN (RDNA ORIGIN)(12MG CARTRIDGE/VIAL) VIAL X MED HORM 7669 SOMATROPIN (RDNA ORIGIN)(15MG/1.5ML CARTRIDGE) VIAL X MED HORM 7122 SOMATROPIN (RDNA ORIGIN)(4MG VIAL) VIAL X MED HORM 7121 SOMATROPIN (RDNA ORIGIN)(6MG VIAL) VIAL X MED HORM 7124 SOMATROPIN (RDNA ORIGIN)(8 MG VIAL) VIAL X MED HORM 7741 SOMATROPIN AQ (10MG CARTRIDGE/VIAL)(NUTROPIN) VIAL X MED HORM 7740 SOMATROPIN AQ (10MG VIAL)(NUTROPIN) VIAL X MED HORM 7562 SOMATROPIN DEPOT (RDNA ORIGIN) (13.5MG VIAL) VIAL X MED HORM 7563 SOMATROPIN DEPOT (RDNA ORIGIN) (18MG VIAL) VIAL X MED HORM 7564 SOMATROPIN DEPOT (RDNA ORIGIN) (22.5MG VIAL) VIAL X MED INJOT 7035 ACETYLCYSTEINE (10% 10ML VIAL) VIAL X MED INJOT 7077 ACETYLCYSTEINE (20% 10ML VIAL) VIAL X MED INJOT 7789 ADALIMUMAB (HUMIRA)(40MG PER 0.8ML SYRINGE) VIAL X MED INJOT 7912 AGALSIDASE BETA (FABRAZYME) 35MG VIAL VIAL X MED INJOT 2824 ALBUTEROL INHALER EA X MED INJOT 6787 ALBUTEROL SULFATE SOLUTION ML X MED INJOT 7078 ALPROSTADIL (10MCG VIAL) VIAL X MED INJOT 7098 ALPROSTADIL (20MCG VIAL) VIAL X MED INJOT 7036 ALPROSTADIL (5MCG VIAL) VIAL X MED INJOT 7543 ALTEPLASE, RECOMBINANT MG X MED INJOT 7537 ALTEPLASE, RECOMBINANT (50MG VIAL) VIAL X MED INJOT 7542 ALTEPLASE, RECOMBINANT (50MG VIAL) VIAL X MED INJOT 7790 ANAKINRA (KINERET)(100MG PER .67ML SYRINGE) VIAL X MED INJOT 7397 ATROPINE SULFATE (1MG PER 1ML VIAL) VIAL X MED INJOT 7015 BACITRACIN (50,000 U VIAL) VIAL X MED INJOT 7037 BCG VACCINE (50MG VIAL) VIAL X MED INJOT 2819 BETAMETHASONE PHOSPHATE MG X MED INJOT 6973 BETAMETHOSONE ACETATE/BETAMETHOSONE SOD PHOS VIAL X (15MG PER 5ML VIAL) MED INJOT 6790 BITOLTEROL MESYLATE EA X MED INJOT 7108 BOTULINUM TOXIN TYPE A (100 UNIT VIAL) VIAL X MED INJOT 7727 BOTULINUM TOXIN TYPE B (2500 U PER 0.5ML) VIAL X MED INJOT 2483 CALCITONIN SALMON UN X MED INJOT 7038 CALCITRIOL (1MCG PER 1 ML VIAL) VIAL X MED INJOT 2826 CHORIONIC GONADATROPIN (HCG) UN X MED INJOT 7675 COLCHICINE (1MG VIAL) VIAL X MED INJOT 7039 CORTICOTROPIN (400 UNITS PER 5ML VIAL) VIAL X MED INJOT 6884 DALTEPARIN SODIUM MG X MED INJOT 6884 DALTEPARIN SODIUM UN X MED INJOT 6937 DANAPAROID SODIUM (750U) VIAL X MED INJOT 6938 DANAPAROID SODIUM (750U) (MULTIPLE 2ND) VIAL X MED INJOT 7041 DEPO-TESTADIOL (10ML VIAL) VIAL X MED INJOT 7532 DESMOPRESSIN (STIMATE) NASAL SPRAY 2.5ML VIAL X MED INJOT 7079 DESMOPRESSIN ACETATE (15MCG VIAL) VIAL X MED INJOT 7533 DESMOPRESSIN ACETATE (30MCG PER 2ML VIAL) VIAL X MED INJOT 7530 DESMOPRESSIN ACETATE (40MCG PER 10ML VIAL) VIAL X MED INJOT 7042 DESMOPRESSIN ACETATE (4MCG VIAL) VIAL X MED INJOT 7005 DEXRAZONE (250MG VIAL) VIAL X MED INJOT 2825 DIMENHYDRINATE MG X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- MED INJOT 7044 DIMERCAPROL (10% 3ML VIAL) VIAL X MED INJOT 7742 DORNASE ALFA (30AMP/VIAL)(PULMOZYME) VIAL X MED INJOT 2823 DORNASE ALFA (PULMOZYME) MG X MED INJOT 1611 ENOXAPRIN SODIUM MG X MED INJOT 1986 ENOXAPRIN SODIUM (MULTIPLE 2ND) MG X MED INJOT 6677 ESTRADIOL CYPIONATE MG X MED INJOT 7045 ESTRADIOL CYPIONATE (25MG VIAL) VIAL X MED INJOT 7080 ESTRADIOL CYPIONATE (50MG VIAL) VIAL X MED INJOT 7679 ESTRADIOL MEDROXYPROGESTERONE (0.5ML VIAL) VIAL X MED INJOT 7046 ESTRADIOL VALERATE (200MG VIAL) VIAL X MED INJOT 7081 ESTRADIOL VALERATE (400MG VIAL) VIAL X MED INJOT 7002 ESTROGENS, CONJUGATED (25MG VIAL) VIAL X MED INJOT 7006 ETANERCEPT 4PK (4 X 25MG) (ENBREL) VIAL X MED INJOT 7006 ETANERCEPT 4PK (4 X 25MG) (ENBREL) KIT X MED INJOT 7521 ETHACRYNATE SODIUM (50MG VIAL) VIAL X MED INJOT 7004 FOLLITROPIN ALFA (75IU VIAL) VIAL X MED INJOT 7719 FONDAPARINUX SODIUM (2.5MG PER 0.5ML SYRINGE) VIAL X MED INJOT 7082 GOLD SODIUM THIOMALATE (500MG VIAL) VIAL X MED INJOT 7048 GOLD SODIUM THIOMALATE (50MG VIAL) VIAL X MED INJOT 2830 GONADORELIN ACETATE MG X MED INJOT 7720 GONADORELIN HYDROCHLORIDE (FACTREL)(0.1MG POWDER) VIAL X MED INJOT 6959 GONADOTROPIN, CHORIONIC UN X MED INJOT 7083 GONADOTROPIN, CHORIONIC (10,000 UNIT VIAL) VIAL X MED INJOT 7049 GONADOTROPIN, CHORIONIC (5,000 UNIT VIAL) VIAL X MED INJOT 6826 GOSERELIN ACETATE MG X MED INJOT 6899 HEPATITIS A VACCINE, INACTIVATED P ML X MED INJOT 7050 HEPATITIS B IMMUNE GLOBULIN (0.5ML VIAL) VIAL X MED INJOT 7084 HEPATITIS B IMMUNE GLOBULIN (1ML VIAL) VIAL X MED INJOT 7099 HEPATITIS B IMMUNE GLOBULIN (5ML VIAL) VIAL X MED INJOT 7051 HISTOPLASMIN (1:100 1ML VIAL) VIAL X MED INJOT 6676 HISTRELIN ACETATE EA X MED INJOT 1563 HUMAN INSULIN ML X MED INJOT 7671 HUMAN INSULIN, LISPRO (100UN/ML 10ML VIAL) VIAL X MED INJOT 7549 HYALURONATE, SODIUM (20MG PER 2ML VIAL) VIAL X MED INJOT 1564 HYDROXYPROGESTERONE CAPROATE MG X MED INJOT 7131 HYLAN POLYMERS A & B (16MG PER 2ML VIAL) VIAL X MED INJOT 7009 HYLAN POLYMERS A&B (3 X 2ML) VIAL X MED INJOT 6999 INFLIXIMAB (100MG VIAL) VIAL X MED INJOT 7000 INFLUENZA VIRUS VACCINE (45MCG VIAL) VIAL X MED INJOT 6806 IPRATROPIUM BROMIDE EA X MED INJOT 7697 IRON SUCROSE 100MG (5ML VIAL) VIAL X MED INJOT 1539 IRRIGATING SOLUTIONS LITER X MED INJOT 2833 KETOROLAC TROMETHAMINE MG X MED INJOT 7911 LARONIDASE (ALDURAZYME) 5ML VIAL VIAL X MED INJOT 1511 LEUPROLIDE ACETATE EA X MED INJOT 7399 LEUPROLIDE ACETATE -- PED (11.25 MG/VIAL) VIAL X MED INJOT 7010 LEUPROLIDE ACETATE -- PED (15MG/VIAL) VIAL X MED INJOT 7007 LEUPROLIDE ACETATE -- PED (7.5MG/VIAL) VIAL X MED INJOT 6971 LEUPROLIDE ACETATE 11.25 MG EA X MED INJOT 6855 LEUPROLIDE ACETATE 2.8ML VIAL (5MG/ML) EA X MED INJOT 6854 LEUPROLIDE ACETATE 3.75 MG EA X MED INJOT 7762 LEUPROLIDE ACETATE DEPOT (22.5MG) VIAL X MED INJOT 7672 LEUPROLIDE ACETATE DEPOT (30MG VIAL) VIAL X MED INJOT 7052 LIVER DERIVATIVE COMPLEX (510MG PER 20ML VIAL) VIAL X MED INJOT 7085 MEDROXYPROGESTERONE ACETATE (1000MG VIAL) VIAL X MED INJOT 7053 MEDROXYPROGESTERONE ACETATE (150MG VIAL) VIAL X MED INJOT 7100 MEDROXYPROGESTERONE ACETATE (4000MG VIAL) VIAL X MED INJOT 2827 MENOTROPINS (HMG) UN X MED INJOT 7054 MENOTROPINS (HMG) (75 UNIT VIAL) VIAL X MED INJOT 6685 METHYLENE BLUE ML X MED INJOT 7055 METHYLPREDNISOLONE ACETATE (40MG VIAL) VIAL X MED INJOT 7086 METHYLPREDNISOLONE ACETATE (80MG VIAL) VIAL X MED INJOT 2499 NANDROLONE DECANOATE MG X MED INJOT 7571 NEOSTIGMINE METHYLSULFATE (10MG PER 10ML VIAL) VIAL X MED INJOT 7570 NEOSTIGMINE METHYLSULFATE (5MG PER 10ML VIAL) VIAL X MED INJOT 2500 OCTREOTIDE MCG X MED INJOT 7093 OCTREOTIDE ACETATE (100MCG VIAL) VIAL X MED INJOT 7708 OCTREOTIDE ACETATE (5000MCG VIAL) VIAL X MED INJOT 7065 OCTREOTIDE ACETATE (50MCG VIAL) VIAL X MED INJOT 7476 OCTREOTIDE LAR DEPOT (10MG VIAL) VIAL X MED INJOT 7477 OCTREOTIDE LAR DEPOT (20MG VIAL) VIAL X MED INJOT 7478 OCTREOTIDE LAR DEPOT (30MG VIAL) VIAL X MED INJOT 7910 OMALIZUMAB (XOLAIR) 150MG PER VIAL VIAL X MED INJOT 6972 PALIVIZUMAB (100 MG/VIAL) VIAL X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- MED INJOT 7513 PALIVIZUMAB (50 MG/VIAL) VIAL X MED INJOT 7087 PAPAVERINE HYDROCHLORIDE (300MG VIAL) VIAL X MED INJOT 7056 PAPAVERINE HYDROCHLORIDE (60MG VIAL) VIAL X MED INJOT 7519 PEGADEMASE BOVINE (375 UNITS PER 1.5ML VIAL) VIAL X MED INJOT 6820 PHENTOLAMINE MESYLATE MG X MED INJOT 7199 PNEUMOCOCCAL VACCINE (575MCG PER 0.5ML VIAL) VIAL X MED INJOT 7057 PROGESTERONE IN OIL (500MG VIAL) VIAL X MED INJOT 6990 SINCALIDE (KINEVAC) (5MCG VIAL) VIAL X MED INJOT 6821 SUMATRIPTAN SUCCINATE MG X MED INJOT 7058 SUMATRIPTAN SUCCINATE (6MG VIAL) VIAL X MED INJOT 7779 TERIPARATIDE (750 MCG PER 3ML VIAL) VIAL X MED INJOT 2508 TESTOSTERONE MG X MED INJOT 7059 TESTOSTERONE CYPIONATE (1,000MG VIAL) VIAL X MED INJOT 7088 TESTOSTERONE CYPIONATE (2,000MG VIAL) VIAL X MED INJOT 7120 TESTOSTERONE CYPIONATE (200 MG VIAL) VIAL X MED INJOT 7600 THERACYS BCG VACCINE (81MG) VIAL X MED INJOT 7014 THYROTROPIN ALFA (2 X 1.1 MG KIT) KIT X MED INJOT 7677 TINZAPARIN SODIUM (40,000 UNITS PER 2ML VIAL) VIAL X MED INJOT 7724 TREPROSTINIL SODIUM 10MG/ML VIAL X MED INJOT 7721 TREPROSTINIL SODIUM 1MG/ML VIAL X MED INJOT 7722 TREPROSTINIL SODIUM 2.5MG/ML VIAL X MED INJOT 7723 TREPROSTINIL SODIUM 5MG/ML VIAL X MED INJOT 7089 TRIAMCINOLONE DIACETATE (200MG VIAL) VIAL X MED INJOT 7060 TRIAMCINOLONE DIACETATE (40MG VIAL) VIAL X MED INJOT 7090 UROFOLLITROPIN (150 UNIT VIAL) VIAL X MED INJOT 7061 UROFOLLITROPIN (75 UNIT VIAL) VIAL X MED INJOT 7913 ZEMAIRA (1GM PER 50ML VIAL) VIAL X MED SYNAGIS 6972 PALIVIZUMAB (100 MG/VIAL) MG X ORTH ALL ALL ORTHOTIC DEVICES / SERVICES (HCPCS WITH L-CODES) X X ORTH ARCH SUPPORTS X X ORTH BOOTS X X ORTH BRACES X X ORTH COLLARS X X ORTH ELASTIC WRAP X X ORTH GAUNTLET X X ORTH GIRDLES X X ORTH HALOS X X ORTH HEEL CUPS X X ORTH INSOLES X X ORTH MASTECTOMY BRAS X X ORTH RIB BELTS X X ORTH SHOES X X ORTH SLINGS X X ORTH SPLINTS X X ORTH STUMP SOCKS X X ORTH SUPPORT HOSE X X ORTH SUPPORTS X X ORTH TRUSSES X X ORTH VESTS X X PROST ALL ALL PROSTHETIC DEVICES - BODY PART REPLACEMENTS X X RESP RESP EQUIP 2588 MONITOR, VITAL SIGNS (E1399) MO X RESP EQUIP 6775 OXIMETRY TEST (E1399) PD X RESP EQUIP 6775 OXIMETRY TEST (E1399) PUR X RESP EQUIP 2373 PERCUSSOR (E0480), ELEC OR PNEUM, HOME MODEL MO X RESP EQUIP 2373 PERCUSSOR (E0480), ELEC OR PNEUM, HOME MODEL PUR X RESP EQUIP 2373 PERCUSSOR (E0480), ELEC OR PNEUM, HOME MODEL RENPR X RESP EQUIP 2567 PNEUMOGRAM (*E1399) PUR X RESP EQUIP 2380 POSTURAL DRAINAGE BOARD (E0606) PUR X X RESP EQUIP 2592 SLEEP STUDY, ADULT (E1399) PUR X RESP EQUIP 2391 VAPORIZER, ROOM TYPE (E0605) PUR X RESP MISC AEROCHAMBERS X RESP MISC AIR PURIFIERS X RESP MISC CROUP/ O2 TENTS X RESP MISC INCUBATORS X RESP MISC IPPB MACHINES X RESP MISC NASAL ASPIRATORS X RESP MISC ROOM HUMIDIFIERS/DEHUMIDIFIERS X RESP MISC VAPORIZERS X RESP NEB* 2571 NEBULIZER (E0575), ULTRASONIC, AC/DC MO X RESP NEB* 2571 NEBULIZER (E0575), ULTRASONIC, AC/DC PUR X RESP NEB* 2571 NEBULIZER (E0575), ULTRASONIC, AC/DC RENPR X RESP NEB* 2338 NEBULIZER; ULTRASONIC (E0575) MO X RESP NEB* 2338 NEBULIZER; ULTRASONIC (E0575) PUR X
EXHIBIT XVII. CONTRACT EXCLUSIONS DOCUMENT EXCLUSION CATEGORY ------------------------------------------- ----------------------------------------------------- NOT DELIVERY MEDICALLY CONTRACTUAL CAT TYPE CODE DESCRIPT UOM CHANNEL NECESSARY NOT HME DIAGNOSTIC EXCLUSION ---------------------------------------------------------------------------------------------------------------------------------- RESP NEB* 2338 NEBULIZER; ULTRASONIC (E0575) RENPR X RESP NEB* 2561 PEAK FLOW METER (E1399) PUR X X RESP OXYGEN 2529 O2 ANALYZER (A9900) MO X RESP OXYGEN 2529 O2 ANALYZER (A9900) PUR X RESP VEST_TH 6876 PERCUSSION VEST (A9900), THERAPY PUR X RESP VEST_TH 6774 THERAPY PERCUSSION, GENERATOR ONLY MO X RESP VEST_TH 6774 THERAPY PERCUSSION, GENERATOR ONLY PUR X THH OTHER 2845 X-RAY, CHEST EA X X THH UNSKILL 1617 COMPANION/LIVE IN PD X THH UNSKILL 1617 COMPANION/LIVE IN HR X THH UNSKILL 1617 COMPANION/LIVE IN VI X THH UNSKILL 1619 HOMEMAKER HR X THH WDCARE 2548 PRESCRIPTION WOUND CARE EA X WHS OTHER 2558 CRITICAL PATHWAY, HYPERTENSION PD X WHS OTHER 2559 CRITICAL PATHWAY, PREECLAMPSIA PD X WHS SKILLED 1650 HUAM/PERINATAL NURSING SERVICES LEVEL 1 PD X WHS SKILLED 1651 HUAM/PERINATAL NURSING SERVICES LEVEL 2 PD X WHS SKILLED 1652 HUAM/PERINATAL NURSING SERVICES LEVEL 3 PD X WHS SKILLED 1654 POST PARTUM WELL BABY/WELL MOM HR X WHS SKILLED 1654 POST PARTUM WELL BABY/WELL MOM PD X
EXHIBIT XVIII CLINICAL SERVICE MANAGEMENT DELEGATION GRID
------------------------------------------------------------------------------------------------------------------------------------ MCA responsibilities CIGNA responsibilities Rationale ------------------------------------------------------------------------------------------------------------------------------------ Eligibility verification Provide regular member updates MCA should periodically verify if the electronically "ongoing member is still eligible. ------------------------------------------------------------------------------------------------------------------------------------ Benefits verification Respond through customer service inquiries Varying benefit packages ------------------------------------------------------------------------------------------------------------------------------------ Home health, DME and Infusion criteria Clinical Resource Unit feedback and MCA has the expertise in this development with input from practicing recommendations to MCA related to benefit specialty area. physicians and approval by their Quality interpretaion in the application of MCA Committee clinical criteria. CIGNA annual oversight review and approval of criteria used by MCA to make review determinations. ------------------------------------------------------------------------------------------------------------------------------------ Central intake for home health, DME and Route calls to MCA Easy for providers and members. infusion services. ------------------------------------------------------------------------------------------------------------------------------------ Collection of enough clinical information from None Intake must consist of gathering providers (any extenuating circumstances) to enough information to make a decision make a coverage determination or evidence to about coverage. support that efforts were made to obtain the clinical information. ------------------------------------------------------------------------------------------------------------------------------------ Initial approval of covered services according None to established criteria and protocols ------------------------------------------------------------------------------------------------------------------------------------ Referral of all urgent requests for Receive the faxed request and respond to Some states have a 1 day turn around non-covered services or services not meeting MCA within the NCQA timeframes. on all requests once all information approved clinical criteria requirements to the Make a determination of coverage and is gathered healthplan within 1 hour of receiving all issue denial letters with proper pertinent information. Refer non-urgent notification when indicated. requests of the same to the healthplan the (during initial phase of "partial" same day. delegation) ------------------------------------------------------------------------------------------------------------------------------------ Send approval letters to all members where state Provide template letters to MCA MCA has real time access to members mandate exists in compliance with regulatory receiving services. requirements. ------------------------------------------------------------------------------------------------------------------------------------ Submit all claims and encounters to CIGNA for Track and identify members to CIGNA of CIGNA pays claims and has access all tracking member benefit limits those reaching benefit limits paid claims for specific member. ------------------------------------------------------------------------------------------------------------------------------------ Submit all claims and encounters to CIGNA for Notify members in writing when they are Same as above tracking member benefit limits reaching their benefit maximums ------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------ Provide authorizations for ongoing cases None Aspect of managing ongoing care. according to established criteria and available benefits. ------------------------------------------------------------------------------------------------------------------------------------ Early identification and referral of complex Accept cases for evaluation by case Important for continuity of care and cases receiving services to healthplan case management management of ALL aspects of the and managers according to established criteria members needs process ------------------------------------------------------------------------------------------------------------------------------------ Refer all experimental or investigational TEC Assessment will review according to CIGNA does not delegate this function. equipment or services to CIGNA TEC Assessment CIGNA protocols for evaluation prior to providing the service. ------------------------------------------------------------------------------------------------------------------------------------ Establishes Overutilization and Underutilization Provide oversight of the process Capitated entities must be aware of thresholds and measures on a regular basis. trends and take action with providers as necessary. ------------------------------------------------------------------------------------------------------------------------------------ Coordinates pre-certification requirements for Defines which services are non-capitated Some services will not be included in all non-capitated services and responds to FFS requests to meet NCQA the capitated arrangement and FFS with the healthplan standards pre-certification may be required. according to NCQA timelines. ------------------------------------------------------------------------------------------------------------------------------------ Tracks all services that are "rent to Establishes parameters for transitioning More efficiently manage DME costs. purchase" and transitions to purchase rental items to purchase. according to contractually agreed upon parameters. ------------------------------------------------------------------------------------------------------------------------------------ Conducts Network Assessment of the home health Reviews adequacy of the MCA Network in Identifies opportunities based on network according to the CIGNA membership and combination with member and provider changing membership and customer unique needs of the membership and reports complaints and satisfaction. satisfaction. annually to CIGNA. ------------------------------------------------------------------------------------------------------------------------------------ Credentials network providers according to Provide CIGNA standards for credentialing Delegated function. CIGNA standards. of home health providers ------------------------------------------------------------------------------------------------------------------------------------
EXHIBIT XIX MCA REPRESENTED PROVIDER APPLICATION PROPRIETARY AND CONFIDENTIAL THE PROVIDER CREDENTIALING APPLICATION KIT CONTAINS COMPANY POLICIES RELATED TO THE PROVIDER NETWORK OF GENTIVA CARECENTRIX. THIS DOCUMENT AND THE INFORMATION CONTAINED HEREIN ARE THE PROPERTY OF AND SUBJECT TO THE RIGHTS (INCLUDING COPYRIGHT) OF GENTIVA CARECENTRIX. NEITHER THIS DOCUMENT NOR ITS INFORMATION MAY BE DISCLOSED TO ANYONE OR USED FOR ANY PURPOSE EXCEPT AS EXPRESSLY AUTHORIZED IN WRITING BY GENTIVA CARECENTRIX. UNAUTHORIZED DISCLOSURE OR USE MAY RESULT IN CIVIL LIABILITY AND CRIMINAL PENALTIES. COPYING OF THE KIT CONTENTS, EXCEPT AS DIRECTED FOR SUBMISSION OR OTHERWISE MAKING THE MATERIALS AVAILABLE TO UNAUTHORIZED PERSONS IS PROHIBITED. *** (c) 1995 Gentiva CareCentrix All Rights Reserved Printed in USA TABLE OF CONTENTS I. Introduction II. CareCentrix As a Health Care Strategy III. Gentiva Corporation Background IV. Mission and Vision Statements V. Application Instructions VI. Conditions of Review VII. Inquiries VIII. Provider Applicant Application Section I. Provider Profile and Service Information Section II. Provider Qualifications IX. Authorization and Certification Statements X. Document Transmittal XI. Provider Agreement I. INTRODUCTION Thank you for your interest in becoming a credentialed provider in the Gentiva CareCentrix national home health care network. We are pleased to provide you with our PROVIDER CREDENTIALING APPLICATION KIT, which we hope you will complete and submit for consideration as a member in our integrated home health care network provider panel. You may currently have an existing contractual agreement with one or more Gentiva CareCentrix home health care branches. Those agreements bear no relationship to our network management line of business. EACH PROVIDER PARTICIPATING ON OUR INTEGRATED HOME HEALTH CARE NETWORK MUST BE CREDENTIALED. Therefore, you will need to complete and submit the enclosed application, which will be used to determine if your organization meets the established credentialing criteria. If your organization meets the credentialing criteria, and is selected to participate on our network provider panel, a contract pertaining to the relationship between your organization and Gentiva CareCentrix will need to be in place. Below you will find information regarding our network business strategy, a description of our network management line of business, the application and instructions for its completion, rates pertaining to the services and/or products you provide and an agreement for your signature. Please read and follow the instructions carefully and return all required documents to us within the time frame specified in the cover letter. II. NETWORK MANAGEMENT AS A HEALTH CARE STRATEGY "Network management" has existed in the United States for many years. Historically, health management organizations (HMOs) have delegated responsibility for the administration and management of specific benefits to contractors with focused expertise in specific clinical areas. Organizations providing these delegated services to managed health plans act as surrogates by developing networks of credentialed providers, designing clinical guidelines, managing utilization and administering benefits, services and products, evaluating effectiveness and efficiency and implementing correlated quality improvement initiatives, and reporting statistical data illustrating results, cost savings and outcomes to health plan customers. The need for managed care organizations (MCOs) to further delegate the development and management of provider networks is clear. As managed care penetration has increased in the market place, and networks of providers have developed, the demands upon the MCO have become overwhelming. The larger the network, the more time, expertise, effort and expense demanded of the MCO to manage groups of providers for any given coverage plan. Multiply this by the types and numbers of coverage within any given health plan and the number of health plans administered within an MCO, and the challenges faced by the MCO are evident. Therefore, our managed care customers are seeking new and innovative solutions to this problem. At Gentiva CareCentrix, we have responded by building the most advanced home care network available today. The Gentiva CareCentrix is a separate line of business that we believe offers a solution essential to the continuum of health care services in today's managed care arena. It is based upon: A. Managed care principles B. A customer-tailored provider panel C. Administrative simplicity D. Performance accountability E. Service consistency F. Risk sharing G. A philosophical shift from "vendor" to "provider/partner" III. GENTIVA BACKGROUND Gentiva Corporation is headquartered in Melville, New York and is a publicly held organization providing health care. Gentiva CareCentrix is in the forefront of two key elements of change: the move to managed care in the health care delivery system and the corporate restructuring within a more global economy. Gentiva CareCentrix has provided home health care services since 1971. Based upon industry sales, we are the largest home health care provider in North America. With over 600 locations and 175,000 caregivers throughout the United States and Canada, we offer a broad range of integrated services and care for more than 400,000 patients annually. Our health care division also offers diversified services such as our Flying Nurses(TM) and centrally coordinated programs to provide specially skilled health care personnel to support product sales, research and other clinical needs. We also take pride in being the nation's leading provider of management services to hospital-based home health agencies. As the industry's largest home health network manager, we currently provide a single source for managed nursing, home infusion, home medical equipment, respiratory therapy, rehabilitation, neonatal, pediatric, women's health and hospice services. Our network management business, housed within our health care division has the capacity to accommodate customer contracts covering more than 20 million lives. Greater than 5 million covered lives fall within capitated arrangements. We believe we are operating within an environment of great opportunity. Opportunity for home care and other post-acute health care solutions currently benefits from rapid growth of an aging population, continued advances in medical technology, managed care penetration into all aspects of health care delivery and reimbursement, and the sociological benefits of services delivered outside of traditional medical settings. As we continue to enhance and expand our service and information technology, it is with vision and commitment to our most recently developed line of business...network management. IV. MISSION AND VISION OUR MISSION STATEMENT Gentiva CareCentrix is a team of dedicated professionals committed to improving the quality of health care for patients and their families. We provide value to our entire spectrum of customers by exceeding expectations, controlling costs and ensuring quality outcomes. We set the standards that become the benchmark of our industry. OUR NETWORK VISION STATEMENT Gentiva CareCentrix will be the premier managed care delivery network. We will distinguish ourselves by offering customer-focused, specialized services and programs covering a broad continuum of health care. We are committed to leading the industry in: o Managed care o Customer consultation o Integrated services o High tech excellence o Information services o The Gold Standard To make our vision a reality, we will: o Develop and maintain a national network of qualified providers for each specialty service in all key markets that ensures services and product excellence and results in high customer satisfaction o Develop information systems and processes that support network management and facilitate information exchange among and between all network stakeholders o Implement sales and service strategies for targeted network customers and key markets that position us as the network manager of choice o Expand our network in the post-acute sector through market assessment, strategic business decisions and alliances o Collaborate with other industry leaders to develop and report customer satisfaction and performance measurements that meet the rigorous requirements of managed care organizations, NCQA and our own internal standards V. APPLICATION INSTRUCTIONS {PRIVATE} GUIDELINES FOR COMPLETING THE APPLICATION The PROVIDER CREDENTIALING APPLICATION is organized into two (2) major sections. The following guidelines and instructions are intended to assist you in both understanding how the data and information you provide will be used and directing you through the preparation process with a minimum of difficulty. We urge you to take this and the next page out of this package and keep it beside you while responding to each part of the application. We also encourage you to review this page before mailing your completed application to ensure that you have met all requirements as defined on this page and the following set of instructions. SECTION I, PROVIDER PROFILE AND SERVICE INFORMATION, entails four (4) pages (12, 13, 14 and 15). It seeks data regarding EACH SERVICE LOCATION of your organization. The data will be used with data from Section II to obtain a weighted credentialing score. If you are awarded membership on our provider panel, the data also will be used to identify and profile EACH service location participating in care delivery. For example, using computer software, provider selection for each network case is based upon first matching patient location zip code to provider type and location zip code. Therefore, it is vital that you ENTER ALL ZIP CODES EACH LOCATION IS ABLE TO SERVICE. After bringing up all providers of your service type by zip code match on the computer screen, the remainder of data you enter in this section will be used to profile each location's specific staffing and expertise. Therefore, it is important that you complete PAGES 12, 13, 14 AND 15, FOR EACH OF YOUR PROVIDER LOCATIONS. If any of your locations use SUBCONTRACTORS, you must complete SECTION I FOR EACH SUBCONTRACTOR AND ATTACH BEHIND THE SECTION I COMPLETED FOR THE CORE LOCATION. SECTION II, PROVIDER QUALIFICATIONS, seeks information about your organization AS A WHOLE. You need to complete ONLY ONE (1) SECTION II REGARDLESS OF THE NUMBER OF PROVIDER LOCATIONS you have. The responses provided in this Section will be used for purposes of obtaining a credentialing score. Complete the application AS APPLICABLE TO THE TYPE OF SERVICES OR PRODUCTS PROVIDED BY YOUR ORGANIZATION. In some cases, certain parts of one or more sections may not be applicable. We are aware of this and have adjusted our credentialing thresholds accordingly. However, all portions of the application, which are applicable, and all applicable attachments, must be completed and submitted. Page 30, APPLICATION DOCUMENT TRANSMITTAL, may be used as a guide to the attachments required to supplement the application. If one or more of the attachments is not applicable to your type of organization, please indicate "NA", or not applicable. SECTION COMPLETION INSTRUCTIONS o COMPLETING PROVIDER APPLICATION SECTION I - PROVIDER PROFILE & SERVICE INFORMATION o Complete each section as applicable for types of service you wish to provide. o Complete (1) PROFILE FOR EACH SITE/LOCATION that will provide care (PAGES 12, 13, 14 AND 15). o If you utilize SUB-CONTRACTORS, complete the full profile (PAGES 12, 13, 14 AND 15) for each sub-contractor used and ATTACH TO THE PROFILE OF THE CORE PROVIDER LOCATION. o Enter ALL ZIP CODES each service location on PAGE 12. o Statistical data should accurately reflect AN AVERAGE MONTH of patient volumes. o Data of sub-contractors should reflect their full capability and not be limited to those services/products provided only to your location. o COMPLETING PROVIDER SECTION II - PROVIDER QUALIFICATIONS o Complete ONE SECTION FOR YOUR ENTIRE ORGANIZATION. Mark each column as applicable to the types of services you wish to provide. o Fill in the appropriate square in INK to answer each question with a "yes", a "no" or "not applicable" response unless otherwise instructed. o If you attach any explanations or additional information on a separate piece of paper, AFFIX A CORRESPONDING REFERENCE number to identify the question to which the response is related. Limit response length as much as possible. o COMPLETING THE PROVIDER APPLICATION DOCUMENT TRANSMITTAL o Collect and submit IN DUPLICATE an original or copy of each and every APPLICABLE item listed on the form. o Return TWO (2) COPIES OF THE FORM AND THE APPLICABLE ATTACHMENTS with your completed application. o Omissions of applicable data/information will result in rejection of the application. o COMPLETING THE PROVIDER AGREEMENT (CONTRACT) o Review the terms and conditions as stated within the agreement. o Fill in the accurate LEGAL ENTITY NAME AND LOCATION on PAGE 1. DO NOT INSERT THE DATE you are completing the application. Upon full execution of the agreement, Gentiva CareCentrix will insert that date. Insert your federal tax ID number. IF MORE THAN ONE TAX ID NUMBER AND/OR LOCATION WILL BE CONTRACTED, INSERT THE PHRASE, "SEE SCHEDULE D," and attach a page labeled SCHEDULE D after Schedule B listing EACH LOCATION AND THE CORRESPONDING FEDERAL TAX ID NUMBER. o Fill in the appropriate ADDRESS AND FACSIMILE NUMBER FOR MAILING ANY NOTICE, DEMAND OR OTHER COMMUNICATION TO YOUR ORGANIZATION on PAGE 9 of the agreement. o Complete all schedules as instructed below. Upon award of provider status, you will receive under separate cover: o An EXECUTED AND DATED AGREEMENT with approved changes, and o A NETWORK PROVIDER MANUAL stipulating conditions of participation in full. c. SCHEDULE A: Place a check (X) before each service you intend to provide. d. SCHEDULE B: Place a check (X) before the appropriate service Attach the corresponding reimbursement schedule to Schedule B o Modification of terms and conditions as given, should be documented and provide alternate language on the contract or on a separate sheet of paper with referenced page and clause numbers. o If in agreement with the terms and conditions of the agreement, affix the appropriate signature and return in DUPLICATE. o COMPLETING THE AUTHORIZATION AND CERTIFICATION STATEMENTS o Review the authorization and certification statements on PAGE 28. o Affix the appropriate signature, title and date and return IN DUPLICATE. o SUBMITTING THE APPLICATION o Submit the completed application IN DUPLICATE with ONLY those attachments requested. o Do not place the application in a binder or other similar hard cover. o SUBMIT COMPLETED APPLICATIONS (A THROUGH E AS ABOVE) IN DUPLICATE TO THE ASSIGNED REVIEWER ON THE COVER LETTER OF THIS APPLICATION. VI. CONDITIONS OF REVIEW o Processing of applications will be initiated upon receipt of applications that are COMPLETE, LEGIBLE AND SUBMITTED IN DUPLICATE AS SPECIFIED ABOVE. o Applications completed and submitted as instructed shall be reviewed and processed based upon objective, weighted scoring criteria. o Applications meeting scoring threshold criteria shall be forwarded to the Provider Credentialing Committee for review, recommendation and determination. o The Provider Credentialing Committee reserves the right to request additional documentation, information and/or data, including an on-site visit, to verify application responses. o The Provider Credentialing Committee shall notify applicants of their credentialing status within 45 days of receipt of acceptable application or 5 business days following a final determination. o All submitted applications and contents therein shall be maintained in confidence and shall be provided to third parties only as indicated within the network Credentialing Policies and Procedures. o Applicants may request information from the Provider Relations Department regarding Credentialing Policies and Procedures. VII. INQUIRIES APPLICATION COMPLETION: GENTIVA HEALTH SERVICES ATTN: Rebecca Warren 3 HUNTINGTON QUADRANGLE 2S MELVILLE, NY 11747 Corporate Credentialing/Contracting Phone (631) 501-7131 FAX (913) 814-5759 LOCAL CONTRACTING AND NETWORK OPERATIONS: Karen Harkness Provider Relations Manager Phoenix Regional CareCentrix Center (602) 604-9241 DOLORES MULCAHY PROVIDER RELATIONS MANAGER Hartford Regional CareCentrix Center (860) 528-4038 Karen Harkness Provider Relations Manager Houston Regional CareCentrix Center (800) 453-8003 Dolores Mulcahy Provider Relations Manager Tampa Regional CareCentrix Center (800) 218-2505 VII. GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION I. PROVIDER PROFILE LEGAL NAME: OWNER(s) NAME(s) D/B/A: ADDRESS: REMIT TO ADDRESS: CONTACT NAME AND TITLE: PHYSICIAN OWNERSHIP? [ ] YES [ ] NO BUSINESS TELEPHONE NO: ( ) 24-HR TELEPHONE NO: ( ) FACSIMILE NO: ( ) FEDERAL TAX ID NO _______________ MY OFFICE IS A: [ ] Branch [ ]Satellite of:* [ ] Subcontractor to:* *_______________
Branch Name TYPE OF PROVIDER: (CHECK ALL THAT APPLY) [ ] Home Health Agency [ ] HIT - Pediatric [ ] Respiratory Products [ ] Pediatric HH Agency [ ] Ambulatory Infusion Center [ ] Respiratory Therapy [ ] Home Medical Equipment [ ] Rehab - Home [ ] Hospice - Facility [ ] HIT - Nursing [ ] Rehab - Pediatric [ ] Hospice - Home [ ] HIT - Products [ ] Rehab - Outpatient [ ] Women's Health [ ] HIT - Full Service [ ] Rehab - Subacute
HOURS OF OPERATION: M _______ T_______ W_______ T_______ F______ S_______ S_______ ON-CALL ARRANGEMENTS: [ ] Answering Service [ ] Live Clinician [ ] Voice Mail [ ] On-Call Hrs:
SERVICE AREA: (PLEASE COMPLETE ZIP CODE AND COUNTY TABLE BELOW) -------------------------------------------------------------------------------- COUNTY ZIP CODES -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION I. PROVIDER PROFILE ACCREDITATION/CERTIFICATION/LICENSURE ACCREDITATION SUMMARY (Attach copy of current full accreditation summary report and result of any focus surveys) CHECK ALL ACCREDITATIONS THAT YOUR ORGANIZATION CURRENTLY HOLDS: [ ] JCAHO [ ] CHAP [ ] CARF OTHER _______________________(SPECIFY)_______ Accreditation No._________________Grid Score (if applicable)_________________% ACCREDITATION DECISION CATEGORY [ ] Commendation [ ] Accreditation type 1 [ ] Conditional [ ] Pending* [ ] Scheduled* [ ] Planned* *___________indicate date INDICATE DATES OF CURRENT ACCREDITATION PERIOD:_____ /_____ to _____/_____ m y m y INDICATE EFFECTIVE DATES OF LAST ACCREDITATION PERIOD:_____/_____ to _____/_____ m y m y LIST ALL SERVICES FOR WHICH ACCREDITATION HAS BEEN AWARDED: [ ] Clinical respiratory [ ] Home health [ ] Personal care/support [ ] Rehabilitation [ ] Equipment management [ ] Hospice [ ] Pharmacy [ ] Other____________ INDICATE THE NUMBER OF TYPE I RECOMMENDATIONS RECEIVED FOR MOST CURRENT ACCREDITATION:_______________ HAVE ALL TYPE 1 RECOMMENDATIONS BEEN RESOLVED TO THE SATISFACTION OF THE APPROPRIATE ACCREDITING BODY? [ ] Yes [ ] No IF NO, ATTACH COPY OF ACTION PLAN TO RESOLVE CERTIFICATION SUMMARY (Attach copy of most recent Medicare/Medicaid Certification survey reports [where required]) Medicare A Provider #____________________ Effective Date_____________________ Medicare B Provider #____________________ Effective Date_____________________ Medicaid Provider #______________________ Effective Date_____________________ Other____________________________________ Effective Date_____________________ LICENSURE SUMMARY (Attach copy of most recent license survey reports [where applicable]) LIST ALL LICENSE NUMBER(S) (AS APPLICABLE): DEA______________________________________ Respiratory________________________ Pharmacy_________________________________ State Business_____________________ HHA/Nursing______________________________ Other______________________________ HME______________________________________ Other______________________________ INSURANCE SUMMARY (Attach copy of insurance certificate) CARRIER NAME COVERAGE LIMITS General Liability________________________ ___________________________________ Medical Malpractice______________________ ___________________________________ Employer's Liability_____________________ ___________________________________ Automobile Liability_____________________ ___________________________________ PROVIDE MONTHLY AVERAGE ACTIVE PATIENT STATISTICS FOR EACH LINE ITEM LISTED UNDER EACH SERVICE TYPE. IF <1, ENTER 0:
A. PATIENT & SUB-SPECIALTY/PRODUCT CENSUS -------------------------------------------------------------------------------------------------------- HOME RESPIRATORY HOME MEDICAL INFUSION THERAPY THERAPY EQUIPMENT AVG. CASE LOAD AVG. CASE LOAD AVG. CASE LOAD # pts # pts # pts -------------------------------------------------------------------------------------------------------- Anti-infective Oxygen Wheelchairs -------------------------------------------------------------------------------------------------------- Pain management Aerosol medications Ambulatory Aids -------------------------------------------------------------------------------------------------------- Chemotherapy Apnea Monitor CPM -------------------------------------------------------------------------------------------------------- TPN Ventilator Orthotics -------------------------------------------------------------------------------------------------------- Enteral CPAP, BIPAP, BIPAP S/T Prosthetics -------------------------------------------------------------------------------------------------------- Hydration Trach Care Multiple HME -------------------------------------------------------------------------------------------------------- IV Cath Access Only Clinical Monitoring/Assessment Phototherapy -------------------------------------------------------------------------------------------------------- Deferoxamine RT Testing (Sleep Studies, etc.) Custom Equipment -------------------------------------------------------------------------------------------------------- IVIG Supplies Only Supplies Only -------------------------------------------------------------------------------------------------------- Steroid Concentrator Beds -------------------------------------------------------------------------------------------------------- Hemophil Factors REHABILITATION HOSPICE -------------------------------------------------------------------------------------------------------- Dobutamine AVG. CASE LOAD # PTS AVG. CASE LOAD # PTS -------------------------------------------------------------------------------------------------------- Ceredase/cerezyme Amputations Cancer -------------------------------------------------------------------------------------------------------- Colony stimulating factor Burn injuries HIV -------------------------------------------------------------------------------------------------------- Interferon Cardiac Other (specify) -------------------------------------------------------------------------------------------------------- Growth Hormone Complex orthopedics Other (specify) -------------------------------------------------------------------------------------------------------- Multiple Therapy Joint replacements WOMEN'S HEALTH -------------------------------------------------------------------------------------------------------- Nursing Only Neuromuscular diseases AVG. CASE LOAD # PTS -------------------------------------------------------------------------------------------------------- Pediatric Infusion Spinal cord injuries High Risk OB - Level I -------------------------------------------------------------------------------------------------------- Other (specify) Strokes High Risk OB - Level 2 -------------------------------------------------------------------------------------------------------- Traumatic brain injuries High Risk OB - Level 3 -------------------------------------------------------------------------------------------------------- Pediatrics Low Risk OB -------------------------------------------------------------------------------------------------------- Adults HUAM -------------------------------------------------------------------------------------------------------- Other (specify) Prenatal Education --------------------------------------------------------------------------------------------------------
INDICATE NUMBERS AND TYPES OF NON-ADMINISTRATIVE PERSONNEL (DO NOT WRITE IN SHADED AREAS):
B. FULL TIME EQUIVALENTS BY SERVICE TYPE ---------------------------------------------------------------------------------- CAREGIVER TYPE INFUSION HOME HEALTH REHAB PEDI/NEONATE WOMEN SVCS ---------------------------------------------------------------------------------- EXAMPLE 1 8 2 2 2 ---------------------------------------------------------------------------------- RN ---------------------------------------------------------------------------------- HIGH TECH RN ---------------------------------------------------------------------------------- LPN/LVN ----------------------------------------------------------------------------------
---------------------------------------------------------------------------------- HHA/PCW ---------------------------------------------------------------------------------- HOMEMAKER/COMP ---------------------------------------------------------------------------------- PHARMACIST ---------------------------------------------------------------------------------- PHARM. TECH ---------------------------------------------------------------------------------- PT ---------------------------------------------------------------------------------- SLP ---------------------------------------------------------------------------------- OT ---------------------------------------------------------------------------------- REHAB PARAPROF ---------------------------------------------------------------------------------- RESP. THERAPIST ---------------------------------------------------------------------------------- MSW ---------------------------------------------------------------------------------- TECHNICIAN ---------------------------------------------------------------------------------- OTHER: ================================================================================== TOTAL ----------------------------------------------------------------------------------
INDICATE MONTHLY AVERAGE HOURS AND/OR VISITS FOR PAST TWO (2) MONTHS:
C. HOURS/VISITS CENSUS BY SERVICE TYPE TOTAL --------------------------------------------------------------------------------------------------- CAREGIVER TYPE V/H INFUSION ADULT/GERI REHAB PEDI/NEONATE WOMEN SVCS MO. AVG --------------------------------------------------------------------------------------------------- EXAMPLE: RN VST 50 77 22 28 24 201* --------------------------------------------------------------------------------------------------- HRS - 640 - 320 - 960 =================================================================================================== RN HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- HIGH TECH RN HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- LPN/VN HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- PT HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- SLP HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- OT HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- Resp. Therapist HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- CRTT HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- MSW HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- HHA/PCW HRS ---------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- HOMEMAKER HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- COMPANION HRS --------------------------------------------------------------------------------------------------- VST --------------------------------------------------------------------------------------------------- OTHER HRS --------------------------------------------------------------------------------------------------- VST ---------------------------------------------------------------------------------------------------
Visit definition: Procedure - specific care rendered in increments that usually do not exceed two hours. Hour's definition: Care rendered in blocks of time comprising no less than four (4) continuous hours. *Note: For the purpose of completing the table above, DO NOT convert hours to visits or visits to hours. Also make certain that your numbers are non-duplicative. For example, if you have a geriatric infusion Visit count the visit as EITHER geriatric OR infusion not both. o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT MANAGEMENT AND ORGANIZATION Y N N/A Y N N/A Y N N/A Y N N/A 1. Does your organization maintain bylaws, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] charter, articles of incorporation or constitution that delineate legal authority and responsibility? 2. Do you maintain written agreements to define [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the nature and scope of services provided if subcontracting patient services to other providers? Respond N/A if not using formally subcontracted or informally referred patient services. o Is your organization in compliance with state [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and federal employment laws? 4. Has your organization or any employee in your [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] organization ever been involved in any malpractice suits or decisions? If yes, explain. o Has your organization been involved in any [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] sanctions, investigations, or limitations of any kind imposed by any health care institution, professional health care society, Medicare, Medicaid, accrediting organization, managed care organization Better Business Bureau or regulatory authority within the past two years and/or have any complaints been filed with such institutions, societies, or authorities about your organization within the past two years? If yes, explain on a separate sheet of paper and label your response VIII.5.
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT MANAGEMENT AND ORGANIZATION CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A 6. Has your organization's license to practice or [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] do business, or your participation in Medicare, Medicaid, or any managed care organization ever been suspended, revoked, modified or terminated? If yes, explain and label your response as VIII.6. 7. Has your organization or any of its employees, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] owners, directors or officers ever been named as a defendant in a criminal action or civil false claims action in the past two years? If yes, explain and label your response as VIII.7. QUALITY IMPROVEMENT 8. Do you have a written quality improvement [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] program that is consistent with JCAHO/CHAP/CARF standards? Attach a current copy of the program and its results. 9. Do you include a budget line for quality [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] improvement activities? 10. Do you monitor indicators for each service [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] type you provide, e.g. infusion, home health, HME, respiratory therapy? 11. Do you track compliance with QI indicators, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] utilize action plans to follow-up with problems and implement changes as needed to improve performance? 12. Do you track problems, interventions and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] resolution of issues apart from QI indicator monitoring using incident reports and/or problem logs?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT QUALITY IMPROVEMENT CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A 13. Do you have a formal client satisfaction [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] survey process? Attach a copy of the survey and results for the past 12 months. EQUIPMENT MANAGEMENT FOR IV PUMPS 14. Do you have a designated "dirty area" for [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] storage of contaminated, reusable equipment? 15. Do you maintain functionally separate "clean" [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and "dirty" areas? 16. Can you produce documentation that routine [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] maintenance is performed/completed for all owned, leased and rented equipment? 17. Is back up equipment available to promote [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] uninterrupted service capability? Specify the type of back up equipment provided to patient. 18. Is all equipment recalibrated, cleaned and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] certified by a certified biomedical company or employed manufacturers' certified technician per manufacturers' recommendations? Name the certification firm or technician used. 19. Are written reports submitted at least TWICE [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] YEARLY to the FDA for any illness, injury or death related to any product or equipment?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT INFECTION/EXPOSURE CONTROL SAFETY/HAZARD COMMUNICATION Y N N/A Y N N/A Y N N/A Y N N/A 20. Do you have a designated infection control [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] coordinator? 21. Do you have a designated safety coordinator? [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 22. Do you comply with all OSHA, DOT and FDA [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] standards for hazardous materials management, transport and disposal? 23. Is a waste container provided to every [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] patient, when appropriate, e.g., Sharps, infectious, chemotherapy? 24. Are universal precautions practiced by all [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] applicable staff to decrease exposure to risk? 25. Do you document follow up to blood borne [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] pathogen exposure? 26. Are infection rates tracked and reported? [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Attach report for the past twelve (12) months. OPERATIONS 27. Specify your usual service/product delivery ______hours _______hours ______hours ______hours time once your organization receives benefit confirmation or coverage authorization and confirmed physician orders? 28. Do you track turn around time as part of your [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] performance improvement program?
o GENTIVA CARECENTIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT OPERATIONS CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A 29. Do you provide 24-hour answering service? [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 30. Are you capable of processing a referral [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] during non-business hours? 31. Check all staff types available on-call 24 [ ]RPH [ ]RN [ ]RN [ ]Tech hours a day, 7 days a week. Attach others on a [ ]RN [ ]HHA [ ]Driver [ ]Driver separate sheet of paper. [ ]Driver [ ]LP/VN [ ]RT [ ]CRTT 32. Is all patient information, including schedule [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] boards, out of public view, but accessible to all applicable personnel? 33. Is there a private area available for patient [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] related telephone calls? 34. Is patient/caregiver education provided and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] documented in the medical record? 35. Do you have documentation of interdisciplinary [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] communication based on patient's clinical status? 36. Are periodic patient assessments performed and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] communicated to the physician? 37. Do you have an Emergency Preparedness Plan [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] specific to your locale and service types that all personnel understand and can implement if required?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT OPERATIONS CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A 38. Have you ever used your Emergency Preparedness [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Plan? 39. Do you have an inventory control process to [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] manage the utilization of medication, supplies and equipment? 40. Is a current technical and medical reference [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] library maintained to support the services, medications, supplies and/or equipment provided to patients? 41. Do you provide delivery service when required? [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] PATIENT RECORDS 42. Are patient records maintained for all [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] patients and all services rendered? 43. Do you document multi-disciplinary care [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] conferences and care coordination with other providers? 44. Do you document the drug and food allergy [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] status on all patients? 45. Do you develop and maintain a [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] care/treatment/service plan for all patients? 46. Do you maintain a complete medication profile [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for every patient?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT PATIENT RECORDS CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A 47. Do you maintain a drug-monitoring plan and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] drug related problem list? 48. Do you maintain a copy of written patient [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] discharge instructions in closed medical records when appropriate for patients with ongoing health care or psychosocial needs? 49. Do you conduct patient record reviews as part [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] of your operations and clinical quality assessment process? 50. Do you have physician orders or prescriptions [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for each patient and for all services and products provided? PERSONNEL PRACTICES 51. Do you maintain current written position [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] descriptions for all employees? 52. Do you have written personnel [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] policies/procedures, e.g., employee handbook? 53. Do you maintain current and complete personnel [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] records for owners and staff? 54. Do all personnel files include signed [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] acknowledgement of a written confidentiality and conflict of interest policy?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT PERSONNEL PRACTICES CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A 55. Do you maintain documentation of employee [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] training and orientation? o Do you check and document applicant [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] employment history and references? 57. Do you conduct and document job specific [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] performance evaluations? 58. Do you verify and document, and can you [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] provide upon request, all appropriate licenses or certifications as required for each specific job/profession? 59. Do you maintain documentation of [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] qualifications to perform specific job responsibilities, e.g., discipline-specific SKILLS CHECKLIST? 60. Do you maintain and document a staff [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in-service program that teaches and/or reinforces operational standards, patient and staff safety, and technological and/or clinical practices updates? Attach sample in-service calendar for past year. 61. Do you maintain results of annual TB skin [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] tests or chest X-rays for all employees having patient contact? Note: More frequent testing may be required by new OSHA guidelines. 62. Do you document proof of continuing education [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] related to employees' specialty?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT PERSONNEL PRACTICES CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A o Do you maintain proof of hepatitis [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] immunization (or Hepatitis B Vaccine Declination) for all staff responsible for Category 1 procedures? 64. Can you verify and provide upon request, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] documentation of CPR certification as required for each specific job? 65. Identify classifications of employees required [ ]RPH [ ]RN [ ]RN [ ]Tech to maintain CPR certification. Attach others on a [ ]RN [ ]HHA [ ]Driver [ ]Driver separate sheet of paper. [ ]Driver [ ]LP/VN [ ]RT [ ]CRTT 66. Do you verify possession of a current driver's [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] license and automobile insurance coverage for all appropriate employees? 67. Do you have a completed I-9 Immigration form [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for every applicable employee? 68. Do you maintain and can you provide [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] documentation of employees' health status/examinations where required by state or local regulations? 69. Are your personnel practices consistent with [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] an Equal Employment Opportunity and Affirmative Action philosophy? PHARMACY COMPOUNDING SERVICES 70. Are your parenteral compounding policies and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] practices consistent with applicable JCAHO, CHAP, ASHP and USP standards? 71. Are all IV admixtures done in a laminar flow [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] hood?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT PHARMACY COMPOUNDING SERVICES CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A o Are all IV admixtures done in a class 100 [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] clean room/environment? 73. Are only IV compounding supplies stored near [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the hood or in the clear room? 74. Is corrugated cardboard stored outside of hood [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] room? 75. Are chemotherapy drugs stored separately from [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] other drugs? o Are maintenance logs completed for all [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] hood(s), refrigerator/freezer(s) and incubator(s)? 77. Is your horizontal laminar hood certified at [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] least annually? 78. Are laminar hood pre-filter inspections done [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] at least every 60 days? 79. Are all biohazard medications compounded in a [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] biological safety cabinet? If you do not provide chemotherapy, respond N/A to question 79 and 80. 80. Is your biological safety cabinet certified at [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] least every six months? 81. Is a batch quality assurance process part of [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the pharmacy quality control program?
o GENTIVA CARECENTRIX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT PHARMACY COMPOUNDING SERVICES CONTINUED Y N N/A Y N N/A Y N N/A Y N N/A 82. Are lot numbers of all pharmaceutical products [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] recorded for each dispensing? 83. Is a drug recall management process [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] established? 84. Are written compounding instructions used for [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] all admixtures? o Is a Controlled Substance Delivery and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Disposal process in place for all patients receiving these drugs? 86. Does a pharmacist verify every verbal [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] prescription PRIOR to dispensing? 87. Is there a pharmacist responsible for [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] selection and supervision of all technical personnel? 88. Does a pharmacist screen each medication order [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] for potential adverse effects or interactions with other medications on the complete patient profile?
[ ] GENTIVA CARECENTIRX PROVIDER APPLICATION SECTION II. PROVIDER QUALIFICATIONS
INFUSION HOME HEALTH CLINICAL HOME SERVICES AGENCY/REHAB/ RESPIRATORY MEDICAL PROVIDER THERAPY CO. PROVIDER EQUIPMENT DATA COLLECTION CAPABILITIES Y N N/A Y N N/A Y N N/A Y N N/A DO YOU HAVE THE CAPABILITY TO CAPTURE AND REPORT THE FOLLOWING DATA? 89. Authorization number [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 90. Patient name [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 91. Payer patient ID number [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 92. Group number [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 93. Date of service [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 94. CPT-4 and HCPCS Codes [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 95. Charge to Gentiva NetWORKS [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 96. Usual charge [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 97. Service provided [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 98. Service description [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 99. Visits provided by discipline [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 100. Total visits provided [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 101. Drug provided, including NDC number [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 102. Equipment provided, sorted by patient [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] category 103. Equipment provided, sorted by equipment [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] category 104. Equipment utilization duration [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 105. Equipment description [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 106. Referring physician name [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 107. Referring physician license number [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 108. Referring facility [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 109. Place of service [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]
IX. AUTHORIZATION AND CERTIFICATION STATEMENTS The applicant authorizes Gentiva CareCentrix or its representative to: 1. Consult with any third party who may have information regarding the applicant's professional qualifications, credentials, clinical or service delivery competence or any other matters reasonably having a bearing on the applicant's satisfactory performance. 2. Inspect or obtain any and all communications, reports, records, statements, documents, recommendations or disclosures including without limitation that relating to credit history or financial standing by or from third parties that may be relevant to determining applicant's qualification or performance. 3. Review historical claims information with data specific to the applicant's utilization patterns and compare the applicant's information with that of its peers, 4. Release said information, as indicated above in numbers 1, 2 and 3, to payers, hospitals, other healthcare providers and their agents who solicit such information for the purpose of evaluating network qualifications. 5. Conduct site visits at the applicant's site to determine the adequacy of facilities, office/branch procedures and related compliance to network standards, and 6. Obtain information from the applicant's present and past professional liability insurance carrier(s). Upon Gentiva CareCentrix request, the applicant authorizes the release of all communications, reports, records, statements, documents, recommendations or disclosures by or from all third parties as may be relevant to the network and/or its representatives to determine competency. The applicant certifies that the facts in all parts of this completed application are accurate and complete to the best of the applicant's knowledge and understands that if approved as a Network provider, falsified statements and/or responses on this application may be grounds for dismissal, contract termination and/or other legal action if indicated. (The applicant certifies that an authorized representative of the applying organization has read and understands the accompanying provider credentialing conditions of review.) THE APPLICANT AND GENTIVA CARECENTRIX MUTUALLY AGREE THAT THE APPLICATION INFORMATION AND MATERIALS BEING RECEIVED BY EITHER PARTY ARE CONFIDENTIAL AND ARE INTENDED FOR USE ONLY AS EXPLICITLY STATED. ANY OTHER USE OF INFORMATION AND MATERIALS BY EITHER PARTY IS EXPRESSLY PROHIBITED. ------------------------------------ ------------------- Authorized Applicant Representative (Typed or Printed) Title ------------------------------------ ------------------- Authorized Signature Date X. GENTIVA CARECENTIRX PROVIDER APPLICATION DOCUMENT TRANSMITTAL NOTE: APPLICATIONS THAT DO NOT INCLUDE EVERY ITEM LISTED BELOW WILL BE REJECTED. o Copy of State License/Certification and/or Inspection Report (CHECK TYPE) [ ]Pharmacy [ ]HHA/Nursing [ ]Manufacturer [ ]Distributor [ ]Medical Equipment [ ]Medicare [ ]Wholesaler and Inspection Report [ ]Other o Copy of Federal Registration/License (CHECK TYPE): [ ]DEA [ ]Wholesaler [ ]Manufacturer [ ]Other o Copy of most recent Accreditation, including all reports, summaries recommendations and grid score letter (CHECK TYPE): [ ]JCAHO [ ]CARF [ ]NONE [ ]CHAP [ ]OTHER:_______________________________________ o Copy of current general and professional liability insurance certificate. o Summary of quality improvement program key indicators and quality improvement results measuring indicators for past two years. o Copy of one full year of client satisfaction survey results. o Document describing all litigation; assignment of business; investigations of business or any directors, officers or employees; suspension, revocation or limitation of any license, certificates, provider status. o Copy of your organization's patient consent form and/or service agreement. o Any and all documents providing additional explanations as requested for of the provider qualifications (if applicable). o Completed Gentiva CareCentirx Provider Application. o Signed Gentiva CareCentrix Provider Agreement. o Signed Gentiva CareCentrix authorization and certification statement. REFERENCES: 1. o Dunn & Bradstreet report or audited financial statement o Name, address, telephone number and contact name of 2 vendors o Name, address, telephone number and contact name of 1 payor o Name and address of 1 bank o Name, address, telephone number and contact name of 2 referral sources o Name of largest account by dollar volume EXHIBIT XX CONFIDENTIALITY AGREEMENT CIGNA understands that as part of its relationship with MCA as reflected in a Managed Care Alliance Agreement dated __________, 2003 (the "Provider Agreement"), it may be granted access to certain confidential information, including protected health information, created and/or maintained by MCA. As a condition of CIGNA's relationship with MCA, CIGNA agrees that all information it obtains during the course of its relationship with MCA is strictly confidential, and CIGNA agrees to handle such information in accordance with the following requirements unless provided otherwise in the Provider Agreement. 1. NONDISCLOSURE/NONUSE. CIGNA agrees to treat all highly sensitive, confidential and proprietary information, communications, and data pertaining to MCA and/or MCA's patients, including, but not limited to, clinical and patient confidential and/or private information (i.e. diagnoses and treatments) ("Protected Health Information"), claim and payment information, and pricing and costs, (collectively, "Confidential Information"), which may be disclosed to, received and/or accessed by CIGNA, as confidential. No Confidential Information will be disclosed directly or indirectly to any other person without first obtaining the written consent of MCA. 2. DISCLOSURE TO CERTAIN PARTIES. CIGNA may, however, disclose and/or permit access to certain Confidential Information to those persons directly under CIGNA's control on a "need to know" basis, provided that all such persons will be directed and required to maintain the Confidential Information in confidence at all times, and to sign a Confidentiality and Security Agreement prior to accessing the Confidential Information. CIGNA agrees to indemnify and hold harmless MCA from and against any claim or loss sustained by MCA as a result of the unauthorized release or use of the Confidential Information by any such person. 3. COPYING CONFIDENTIAL INFORMATION. CIGNA will not make, or permit to be made, except for the purposes agreed upon, any copies, abstracts, or summaries of Confidential Information. MCA will retain title to all such documents and copies thereof. 4. SAFEGUARD. CIGNA agrees to take all reasonable precautions including the establishment of appropriate security controls and procedures, protection programs and protocols and disciplines to safeguard the confidential nature of the Confidential Information; provided, however, CIGNA will not be liable for disclosure of such information that: A. has passed into the public domain through no act or omission of CIGNA; B. is lawfully received by CIGNA from a third party under no obligation to keep such information confidential; C. is required to be disclosed by CIGNA pursuant to an order issued by a court of law or any federal, state or municipal regulatory or administrative agency; D. was in the possession of CIGNA prior to the date of this Agreement as evidenced by written records kept in the ordinary course of business by CIGNA or by proof of actual use of CIGNA. In the event of disclosure as required by law, CIGNA will notify MCA promptly so that MCA may seek a protective order or other appropriate remedy, and CIGNA will not oppose action by MCA to obtain any such order or remedy. 5. INJUNCTION. CIGNA acknowledges that failure to comply with the provisions of this Agreement would cause irreparable harm to MCA and that MCA's remedy at law for such breach would be inadequate. CIGNA agrees that if there is any material or threatened breach, MCA may, in addition to any other legal or equitable remedies available to it, obtain an injunction or restraining order to enjoin CIGNA from the breach or threatened breach of such covenants, without need to post bond. 6. ATTORNEY'S FEES. In the event MCA finds it necessary to employ legal counsel or to bring an action at law or other proceedings against CIGNA to enforce any of the terms, covenants, or conditions of this Agreement, and MCA prevails in any such action or other proceeding, MCA will be paid all reasonable attorney's fees by CIGNA. In the event a judgment is secured by the prevailing party, all attorney's fees, as determined by the court and not by a jury, will be included in any such judgement. 7. APPLICABLE LAW. This Agreement and the rights of the parties hereto will be governed and construed in accordance with the laws of the state of New York. 8. COMPLIANCE WITH HIPAA. In addition, to the extent required by the provisions of 42 U.S.C. 1171 et seq. enacted by the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated thereunder ("HIPAA"), CIGNA does hereby assure MCA that CIGNA will appropriately safeguard protected health information made available to or obtained by CIGNA. Without limiting the obligations of CIGNA otherwise set forth in this Agreement or imposed by applicable law, CIGNA hereby agrees to comply with applicable requirements of law relating to Protected Health Information to the extent MCA would be required to comply with such requirements. 9. AMENDMENT; WAIVER. This Agreement may not be amended except by written form signed by duly authorized representatives of both parties and specifically stating that it amends this Agreement and MCA will not be deemed to have waived any term or provision of this Agreement unless such waiver will be in writing signed by a duly authorized representative of MCA and specifically stating that it waives such term or provision. No failure or delay by MCA in exercising any right hereunder shall operate as a waiver thereof, nor shall any single or partial waiver preclude any further exercise thereof or of any other right hereunder. 10. BINDING EFFECT. This Agreement will inure to the benefit of, and will be binding upon, the parties and their respective successors and assigns. CIGNA has acknowledged its understanding of and agreement to the mutual promises written above by executing this Agreement. CIGNA HEALTH CORPORATION By: ---------------------------------- Name: -------------------------------- Title: ------------------------------- Date: -------------------------------- EXHIBIT XXI CIGNA NATIONAL CAPITATION HMO MARKET EXCLUSIONS CIGNA HEALTHCARE MEMBERS ENROLLED IN MANAGED CARE PRODUCTS (CHMO, FLEX, AND GATEKEEPER ) IN THE CIGNA HEALTHCARE AFFILIATE MARKETS LISTED BELOW, ARE EXCLUDED FROM THE TERMS AND CONDITIONS OF THIS AGREEMENT: CIGNA HealthCare of Massachusetts, Inc. CIGNA HealthCare of Maine, Inc. CIGNA HealthCare of North Carolina, Inc. CIGNA HealthCare of New Hampshire, Inc. CIGNA HealthCare of California, Inc. (Southern California Markets only) EXHIBIT XXII STANDARDS FOR DELEGATION OF UTILIZATION MANAGEMENT ACTIVITIES FOR CIGNA HEALTHCARE OF TEXAS, INC. ("CIGNA") (THE "STANDARDS") [Any and all capitalized terms not defined herein shall have the same meaning as in the managed care provider agreement between CIGNA and the delegatee (the Agreement).] 1. The delegatee shall be subject to a pre-delegation site review and evaluation of its utilization management program ("UM Program") for all delegated activities. 2. The delegatee shall maintain a written UM Program description which includes: A. a description of delegatee's 1) policies/procedures to evaluate Medical Necessity, 2) use of nationally recognized and locally approved criteria and information sources; and 3) process to review and approve services; B. a description of delegatee's mechanism to periodically update the UM Program description and the UM Program's policies and procedures; C. documented evidence of approval of the delegatee's UM Program by the delegatee's appropriate body of governance; D. a description of the roles and functions of delegatee's UM Program to include a definition of the roles and responsibilities of delegatee's UM Program staff; E. evidence demonstrating a utilization management work plan which responds to identified opportunities for improvement and action steps, as well as a process for, and evidence of, an annual evaluation of the UM Program. The delegatee shall provide annual reports as specified: (i) UM Program Description and Work Plan by March 31st of the current year. (ii) A written evaluation of delegatee's UM program for the previous year by March 31st of the current year. F. a description which specifically addresses behavioral health care; and G. a description of the transition process when benefits end or a practitioner's participation in the network terminates. 3. The delegatee's UM Program must have been operational for at least the 12-month period preceding the effective date of the delegation. 4. The delegatee's UM Program shall at a minimum comply in all respects with the requirements of an appropriate accrediting body designated by CIGNA (i.e. NCQA, JCAHO, etc.), the requirements established by CIGNA herein and in the Agreement and the requirements of applicable federal and state laws and regulations. The delegatee shall maintain all applicable licensures and certifications required to perform the delegated utilization management activities. The delegatee shall maintain appropriate records with respect to all utilization management activities for the duration of the Agreement and seven years thereafter. 5. The delegatee shall maintain adequate professional liability coverage as determined by CIGNA The delegatee shall not subcontract any of its utilization management responsibilities under its agreement with CIGNA unless otherwise agreed in writing by CIGNA. Any subcontractor approved by CIGNA shall be required to agree in writing to comply with all standards applicable to delegatee with regard to the subcontracted services. 6. The delegatee shall provide CIGNA with a copy of its written UM Program description upon request. Such UM Program description shall be submitted to CIGNA for review and approval prior to the effective date of the delegation and annually thereafter and shall not be materially modified without CIGNA's prior written approval. 7. The role of the Delegatee and its subcontractors is limited to performing certain UM activities delegated by CIGNA using standards approved by CIGNA, and which are in compliance with applicable federal and state laws and regulations. Delegatee hereby agrees to perform those UM activities identified by an "X" in the "Delegatee" column below and understands and acknowledges that its performance of such delegated UM activities is subject to CIGNA's oversight and monitoring. UM ACTIVITIES DELEGATEE CIGNA -------------------------------------------------------------------------------- Medical Policy Adoption of Criteria X X -------------------------------------------------------------------------------- Precertification - Inpatient Approvals X -------------------------------------------------------------------------------- Precertification - Inpatient Denials X -------------------------------------------------------------------------------- Precertification - Outpatient Approvals X -------------------------------------------------------------------------------- Precertification - Outpatient Denials X -------------------------------------------------------------------------------- Concurrent Review*- Approvals X -------------------------------------------------------------------------------- Concurrent Review*- Denials X -------------------------------------------------------------------------------- Discharge Planning X -------------------------------------------------------------------------------- Retrospective - Inpatient Approvals X -------------------------------------------------------------------------------- Retrospective - Outpatient Approvals X -------------------------------------------------------------------------------- Retrospective - Outpatient Denials X -------------------------------------------------------------------------------- Referral Management - Approvals X -------------------------------------------------------------------------------- Referral Management - Denials X -------------------------------------------------------------------------------- Out-of-Area Management X -------------------------------------------------------------------------------- Case Management* - Approvals X -------------------------------------------------------------------------------- Case Management* - Denials X -------------------------------------------------------------------------------- Disease Management X -------------------------------------------------------------------------------- Denials Benefit Coverage X -------------------------------------------------------------------------------- Appeals - First Level X -------------------------------------------------------------------------------- Member Satisfaction w/ UM X -------------------------------------------------------------------------------- Provider Satisfaction w/ UM X -------------------------------------------------------------------------------- Pharmacy Management X -------------------------------------------------------------------------------- Member Communication X -------------------------------------------------------------------------------- Monitoring Quality and Timeliness of X X Decisions -------------------------------------------------------------------------------- Inter-rater Reliability X -------------------------------------------------------------------------------- Technology Assessment X -------------------------------------------------------------------------------- * Definitions: CONCURRENT REVIEW- An assessment that determines medical necessity or appropriateness of services as they are being rendered, such as an assessment of the need for continued inpatient care for hospitalized patients. CASE MANAGEMENT- A process for identifying covered persons with specific health care needs in order to facilitate the development and implementation of a plan that efficiently uses health care resources to achieve optimum member outcome. RETROSPECTIVE REVIEW- Assessment of the appropriateness of medical services on a case by case or aggregate basis after the services have been provided. 8. With respect to each request for coverage of medical services for which the delegatee performs utilization management hereunder, the delegatee shall apply the utilization management criteria set forth in the Service Agreement applicable to the Participant for whom medical services have been requested. Criteria shall be objective and applied consistently based on the needs of the individual patient. 9. All information relating to delegatee's utilization management activities hereunder shall be confidential, shall not be disclosed to any third parties except as required by applicable federal and state law and except as required to fulfill delegatee's utilization management responsibilities hereunder, and shall be maintained in such a manner so that such information shall be protected from discovery and use in judicial or administrative proceedings to the fullest extent possible under applicable federal and state law. In the event that delegatee receives a subpoena, civil investigative demand or other similar process requesting disclosure of information relating to its utilization management activities hereunder, delegatee shall immediately notify CIGNA of such subpoena, demand or process so as to afford CIGNA with an adequate opportunity to seek an appropriate protective order should it choose to do so. 10. This exhibit, all information provided by CIGNA to delegatee pertaining to CIGNA's delegation of utilization management to delegatee and all data made known to delegatee relating to services rendered to Participants under the Agreement is confidential and proprietary information subject to the protections set forth in the confidentiality provision contained in delegatee's Agreement with CIGNA. In the event that delegatee receives a subpoena, civil investigative demand or other similar process requesting disclosure of such confidential and proprietary information, delegatee shall immediately notify CIGNA of such subpoena, demand or process so as to afford CIGNA with an adequate opportunity to seek an appropriate protective order should it choose to do so. 11. The delegatee shall have a full time medical director who provides oversight of the UM Program and: A. is licensed to practice medicine as required by the State of Texas; B. has a defined scope of responsibilities; and C. demonstrates evidence of their participation in the utilization management process. 12. The delegatee shall not authorize coverage for services requested to be provided by noncredentialed providers unless CIGNA's prior consent is obtained, except in an emergency. 13. All UM Program activities shall be supervised by appropriately qualified professionals including: A. use of a licensed physician to conduct medical review prior to any denial; and B. use of board certified specialists to assist in determining Medical Necessity and in preparing documentation to support the decision. 14. Total UM Program staff ratios (including nurses) shall be at least 1 per 40,000 Participants. The UM Program shall utilize clinical nurses (RN or LPN/LVN) licensed to practice nursing as required by the State of Texas with a ratio of at least 1 licensed clinical nurse per 150,000 Participants. The UM Program shall utilize physicians licensed to practice medicine as required by the State of Texas with a ratio of at least 1:150,000. The Total UM staffing ratio is determined by adding the number of all clinical and non-clinical staff and dividing by the total number of Participants. Non-clinical staff shall utilize protocols and criteria approved by the Medical Director and shall not make medical appropriateness/necessity decisions. All decisions of the non-clinical staff shall be supervised by clinical staff. Delegatee shall maintain appropriate levels of telephone line staffing for the utilization management activities required to be performed hereunder and shall satisfy the following standards: (a) the overall abandonment rate for the pre-certification telephone line shall be 5% or less; (b) the average speed of answer for the pre-certification telephone line shall be less than 30 seconds; (c) telephone prompts shall be clear and user friendly; and (d) a telephone message after hours shall give normal business hours information and after hours instructions. 15. The delegatee shall maintain a set of written utilization management decision protocols that are based on reasonable available medical evidence, are acceptable to and consistent with CIGNA protocols and indicate that: A. criteria for appropriateness of medical services are clearly documented, communicated to participating physicians, and available to the physician and Participants upon request; B. an appropriate mechanism is present for checking the consistency of application of criteria across physician and non-physician reviewers at least annually and opportunities for improvement are identified and resolved; and C. an appropriate mechanism is present for updating and approving review criteria periodically, actively practicing practitioners are involved in the development and adoption of the criteria and the time of the update is specified in protocol or policy. 16. In connection with all utilization management activities hereunder, the delegatee shall obtain all necessary information, including pertinent clinical information, and consult with the treating physician, as appropriate, and document such efforts. Emergency services, without precertification, must be covered where such services were necessary to screen and stabilize Participants in cases where a prudent layperson, acting reasonably, would have believed an emergency medical condition existed, when services were authorized by a delegatee representative, or as otherwise required by applicable federal and state law. 17. The Healthplan retains responsibility for rendering the final coverage determination on all services denied for medical necessity. The delegatee shall notify CIGNA as expeditiously as possible, but no later than the same business day, of any recommendation for denial of coverage. The notification shall include: A. documentation indicating who recommended denial, why, and any medical information used to render the recommendation; B. documentation that an explanation is provided to the applicable provider via telephone of the recommended denial. The delegatee shall not send any written communication, either via US mail or facsimile, to the requesting provider. CIGNA will notify the delegatee, the requesting provider, the PCP, and the Participant via letter which includes all information required by applicable federal and state law. CIGNA will process all requests for appeals, whether expedited or standard. In connection with any such appeal, the delegatee shall assist and cooperate with CIGNA and shall promptly provide all documentation reasonably requested by CIGNA to meet all accreditation and regulatory timeframe requirements. The delegatee shall notify the requesting provider via telephone of CIGNA's final determination with information regarding CIGNA's appeal process. 19. Delegatee's UM Program decisions shall be made in a timely manner. A. Delegatee's UM Program policies and procedures shall clearly define the maximum time frames for utilization management decisions. All utilization management decisions shall be made within the time frames that satisfy all applicable federal and state legal requirements, whichever time frame is earlier (i.e. Department of Insurance, Department of Corporations, HCFA, etc.). Delegatee shall implement adequate coverage arrangements to ensure compliance with applicable federal and state legal requirements at all times, including, but not limited to, adequate after hours, weekend and holiday coverage. B. Delegatee shall implement an appropriate mechanism to monitor and document timeliness of decisions which shall include: (1) Documentation to show Emergency requests are responded to as soon as possible and no later than within 2 hours, or within the time frame required by applicable federal and state law, if earlier; (2) Documentation to show urgent requests are responded to within 24 hours, or within the time frame required by applicable federal and state law, if earlier; and (3) Documentation to show routine requests are responded to within 2 working days, or within the time frame required by applicable federal and state law, if earlier. C. The delegatee shall monitor and analyze its compliance with timeliness requirements on a quarterly basis and take prompt action to meet or improve adherence to such requirements. 20. Except as otherwise agreed by CIGNA, CIGNA shall retain responsibility for responding to Participant inquiries or complaints. Delegatee shall notify CIGNA Member Services within 24 hours of any complaint or grievance filed with delegatee by or on behalf of any Participant. 21. The delegatee shall maintain a system acceptable to CIGNA to track authorizations, to evaluate the delegatee's compliance with CIGNA's utilization management requirements as set forth in the delegatee's Agreement and herein, to monitor providers for inappropriate utilization and to evaluate Participant satisfaction and provider satisfaction, and other measures of evaluation agreed upon by the parties. Delegatee shall submit reports to CIGNA, in a format acceptable to CIGNA reflecting the delegatee's performance under these measures of evaluation, including an action plan which addresses opportunities for improvement when applicable. On a monthly basis by the 15th of every month for the previous month's data, delegatee shall provide a report of referral approvals, non-emergency hospital admissions and elective outpatient procedures to include the following: a). Participant Name b). Participant ID# c). Date of Request d). Date of Determination e). Date of Notification to Provider f). Services Requested 22. CIGNA, its designee and any applicable governmental authorities or accrediting bodies shall have the right to conduct periodic audits of the delegatee's UM Program activities upon reasonable prior notice, and the delegatee shall cooperate with any such audits. In addition, the delegatee's performance of its utilization management activities hereunder may be measured by CIGNA at least annually. The delegatee shall cooperate with any such audits and shall provide any and all information reasonably requested by CIGNA in connection with such audits. Applicable performance measures include but are not limited to: A. Participant satisfaction survey results which indicate a significant overall satisfaction with the service provided and document an improvement process for any specific areas identified with satisfaction lower than 90%; B. Participant concerns, complaints and grievances do not exceed CIGNA averages in any six month period; and C. audits of utilization management activities show compliance with CIGNA, federal, state and accreditation requirements. CIGNA will provide delegatee with a written report detailing its findings with respect to any such audits. If such audits reveal any deficiencies, delegatee shall correct any deficiencies identified in such audit within 60 days of CIGNA's submission of the report detailing such deficiencies. Failure to correct any identified deficiencies within such 60 day period may be cause for revocation of the delegation set forth herein or termination of the Agreement. 23. Delegatee shall provide CIGNA with evidence of an appropriate internal control environment acceptable to CIGNA or a SAS70 audit of delegatee's utilization management operations on an annual basis. 24. Delegatee shall prepare and provide such periodic reports or other data as is reasonably requested by CIGNA, state and/or federal regulatory agency or accrediting entity relating to delegatee's utilization management activities, within the time frame given by CIGNA or the agency or entity. Delegatee shall participate in utilization management oversight activities (i.e., committee meetings, report submission) to the extent reasonably required by CIGNA. Delegatee shall provide CIGNA with any adverse event/sentinel diagnosis information relating to Participants within 5 business days of delegatee's receipt of such information. 25. Delegatee shall have a process in place to ensure appropriate utilization of services including identifying areas of over utilization and under utilization including: monitoring different types of data, establishing thresholds, conducting quantitative analysis and comparison to thresholds and working with CIGNA to implement actions to address issues that are identified by the CIGNA or by the delegatee. 26. If CIGNA determines that delegatee cannot meet its utilization management obligations, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in the Agreement shall be adjusted to the extent necessary, and delegatee shall cooperate and provide to CIGNA any information reasonably required to perform such activities. 27. All referrals shall be to Represented Providers, except where an Emergency requires otherwise or as otherwise required by applicable federal and state law. Except in an Emergency or as otherwise required by applicable federal and state law, delegatee shall require all Represented Providers to obtain authorization from delegatee prior to hospital admission of any Participant or outpatient surgical procedures. 28. All electronic data which delegatee maintains concerning the detail of all utilization management decisions made hereunder shall be made available and submitted to CIGNA using ANSI standard transaction formats or another mutually agreeable format in compliance with applicable state and federal law including, but not limited to, the Health Insurance Portability and Accountability Act (HIPAA) and Administrative Simplification. Such data shall be submitted to CIGNA at least monthly. If a non-ANSI format is agreed upon, delegatee shall cooperate with CIGNA in the development of the transmission format, frequency and protocol. 29. Delegatee shall maintain evidence that delegatee distributes a statement to all employees, contracted practitioners and providers affirming the following: E. UM decision making is based only on appropriateness of care and service. F. The delegatee does not compensate practitioners/providers/employees for denials. G. The delegatee does not offer incentives to encourage denials. H. The need for special concern about under utilization. 30. Delegatee shall indemnify, defend and hold harmless CIGNA and its affiliates from and against any and all liability, fines, penalties, damages and expense, including reasonable defense costs and legal fees, incurred by CIGNA in connection with claims or actions of any nature, governmental examinations, enforcement actions or other administrative proceedings, arising from delegatee's failure to perform its obligations under these Standards. 31. Confidentiality Delegatee shall comply with all applicable federal and state laws and regulations relating to the confidentiality of medical records and other individually identifiable health information, including but not limited to, the requirements specified below. A. Definitions Applicable to this Confidentiality Section "CONFIDENTIAL INFORMATION" shall mean (a) Individually Identifiable Health Information that is (i) transmitted by Electronic Media, (ii) maintained in any medium constituting Electronic Media; or (iii) transmitted or maintained in any other form or medium and (b) any Nonpublic Personal Financial Information, as that term is defined by the NAIC Model Privacy of Consumer Financial and Health Information Regulation (2000) issued pursuant to the Gramm Leach Bliley Act. "Confidential Information" shall not include (i) education records covered by the Family Educational Right and Privacy Act, as amended, 20 U.S.C. Section 1232g and (ii) records described in 20 U.S.C. Section 1232g(a)(4)(B)(iv). "DESIGNATED RECORD SET" shall mean a group of records maintained by or for CIGNA or a CIGNA Affiliate that is (i) the medical records and billing records about individuals maintained by or for CIGNA or a CIGNA Affiliate, (ii) the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or (iii) used, in whole or in part, by or for CIGNA or a CIGNA Affiliate to make decisions about individuals. As used herein, the term "RECORD" means any item, collection, or grouping of information that includes Confidential Information and is maintained, collected, used, or disseminated by or for CIGNA or a CIGNA Affiliate. "ELECTRONIC MEDIA" shall mean the mode of electronic transmissions. It includes the Internet, extranet (using Internet technology to link a business with information only accessible to collaborating parties), leased lines, dial-up lines, private networks, and those transmissions that are physically moved from one location to another using magnetic tape, disk, or compact disk media. "INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION" shall mean information that is a subset of health information, including demographic information collected from an individual, and (iv) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (v) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual; and (a) identifies the individual, or (b) with respect to which there is a reasonable basis to believe the information can be used to identify the individual; and (vi) relates to identifiable non-health information including but not limited to an individual's address, phone number and/or Social Security number. "PRIVACY STANDARDS" shall mean (a) the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder, including the Standard for Privacy of Individually Identifiable Health Information, 45 C.F.R. Parts 160 and 164, (b) the Gramm Leach Bliley Act and any applicable regulations governing privacy and confidentiality promulgated thereunder, and (c) other federal or state laws or regulations governing the use, disclosure, confidentiality, security or privacy of Confidential Information or other personally identifiable information. "SECRETARY" shall mean the Secretary of the Department of Health and Human Services. B. USE OF CONFIDENTIAL INFORMATION. Delegatee may use Confidential Information to carry out the obligations of delegatee set forth in the Agreement and these Standards or as required by federal or state law, subject to the provisions of Sections C. through N., below. Delegatee shall ensure that its directors, officers, employees, contractors and agents do not use Confidential Information received from CIGNA or a CIGNA Affiliate in any manner that would constitute a violation of the Privacy Standards if used in a similar manner by CIGNA or a CIGNA Affiliate. Delegatee shall not use Confidential Information for the purpose of creating de-identified information that will be used for any purpose other than to carry out the obligations of delegatee set forth in the Agreement or these Standards or as required by federal or state law. C. DISCLOSURE OF CONFIDENTIAL INFORMATION. Delegatee and its directors, officers, employees, contractors and agents shall not disclose Confidential Information received from CIGNA or a CIGNA Affiliate other than as is necessary to carry out the obligations of delegatee set forth in the Agreement or these Standards or as required by federal or state law, subject to the provisions of Sections C. through N., below. Confidential Information shall not be disclosed in any manner that would constitute a violation of the Privacy Standards if disclosed in a similar manner by CIGNA or a CIGNA Affiliate. D. SAFEGUARDS AGAINST MISUSE OF INFORMATION. Delegatee agrees that it will implement all appropriate safeguards to prevent the use or disclosure of Confidential Information in any manner other than pursuant to the terms and conditions of the Agreement and these Standards. E. REPORTING OF DISCLOSURES OF CONFIDENTIAL INFORMATION. Delegatee shall, within five (5) days of becoming aware of a loss, a suspected loss, or disclosure of Confidential Information in violation of the Agreement or these Standards by delegatee, its officers, directors, employees, contractors or agents or by a third party to which delegatee disclosed Confidential Information pursuant to Section C. of this Agreement, report any such disclosure to CIGNA's Privacy and Security Officers. This requirement will also apply to any loss, or suspected loss, of Confidential Information. F. AGREEMENTS WITH THIRD PARTIES. Delegatee shall enter into an agreement with any agent, subcontractor or other third party that will have access to Confidential Information that is received from, created or received by delegatee on behalf of CIGNA or a CIGNA Affiliate pursuant to which such third party agrees to be bound by the same restrictions, terms and conditions that apply to delegatee pursuant to this Agreement with respect to such Confidential Information. Under such agreement, the third party shall (a) provide reasonable assurances that such Confidential Information will be held confidential as provided pursuant to the Agreement and these Standards, (b) provide reasonable assurances that such Confidential Information will be disclosed only as required by federal or state law or for the purposes for which it was disclosed to such third party, and (c) immediately notify delegatee of any breaches of the confidentiality of the Confidential Information, to the extent it has obtained knowledge of such breach. G. ACCESS TO INFORMATION. Within five (5) business days of a request by CIGNA or a CIGNA Affiliate for access to Confidential Information about an individual contained in a Designated Record Set, delegatee shall make available to CIGNA or the CIGNA Affiliate such Confidential Information for so long as such information is maintained in the Designated Record Set. In the event any individual requests access to Confidential Information directly from delegatee, delegatee may not deny access to the Confidential Information requested. Rather, delegatee shall, within two (2) business days, forward such request to CIGNA. H. AVAILABILITY OF CONFIDENTIAL INFORMATION FOR AMENDMENT. Within ten (10) business days of receipt of a request from CIGNA or a CIGNA Affiliate for the amendment of an individual's Confidential Information or a record regarding an individual contained in a Designated Record Set (for so long as the Confidential Information is maintained in the Designated Record Set), delegatee shall provide such information to CIGNA or the CIGNA Affiliate for amendment and incorporate any such amendments in the Confidential Information as required by 45 C.F.R. Section 164.526. In the event that the request for the amendment of Confidential Information is made directly to the delegatee, delegatee may not deny the requested amendment. Rather, delegatee shall, within two (2) business days, forward such request to CIGNA. I. AUDIT. Upon reasonable notice, CIGNA or a CIGNA Affiliate may audit and inspect delegatee's internal practices and the books and records in delegatee's possession for the purpose of assessing delegatee's use and disclosure of Confidential Information received from CIGNA or a CIGNA Affiliate or created by delegatee on behalf of CIGNA or a CIGNA Affiliate. Such books and records shall be made available to CIGNA or a CIGNA Affiliate for its audit or inspection during regular business hours. J. ACCOUNTING OF DISCLOSURES. Within ten business (10) days of notice by CIGNA or a CIGNA Affiliate to delegatee that it has received a request for an accounting of disclosures of Confidential Information regarding an individual during the six (6) years prior to the date on which the accounting was requested, delegatee shall make available to CIGNA or the CIGNA Affiliate such information as is in delegatee's possession and is required for CIGNA or the CIGNA Affiliate to make the accounting required by 45 C.F.R. Section 164.528. At a minimum, delegatee shall provide CIGNA or the CIGNA Affiliate with the following information: (i) the date of the disclosure, (ii) the name of the entity or person who received the Confidential Information, and if known, the address of such entity or person, (iii) a brief description of the Confidential Information disclosed, and (iv) a brief statement of the purpose of such disclosure that includes an explanation of the basis for such disclosure. In the event the request for an accounting is delivered directly to delegatee, delegatee shall within two (2) business days forward such request to CIGNA. It shall be CIGNA's or the applicable CIGNA Affiliate's responsibility to prepare and deliver any such accounting requested. Delegatee hereby agrees to implement an appropriate record keeping process to enable it to comply with the requirements of this Section. K. AVAILABILITY OF BOOKS AND RECORDS. Delegatee hereby agrees to make its internal practices, books and records relating to the use and disclosure of Confidential Information received from, created or received by delegatee on behalf of CIGNA or a CIGNA Affiliate available to the Secretary for purposes of determining CIGNA's or CIGNA Affiliate's and delegatee's compliance with the Privacy Standards. L. RETURN OF RECORDS. Upon termination of the Agreement and at CIGNA's sole option, delegatee shall be required to either a) return to CIGNA or a CIGNA Affiliate all Confidential Information received from, created or received on behalf of CIGNA or a CIGNA Affiliate in all forms without retaining any copies; or b) maintain all such Confidential Information consistent with the requirements of this Section 31 for the period of time such information is required to be maintained by applicable law after which time delegatee shall destroy all such information in all forms maintained and shall not retain any copies of such information, or if such destruction is not feasible, extend the protections in this Section 31to such information and limit further uses and disclosures to those purposes that make the return or destruction of such information infeasible. M. AUTHORIZATION TO TERMINATE. Delegatee hereby authorizes CIGNA to terminate the Agreement if CIGNA determines that delegatee has violated a material term of this Section 31. N. INDEMNIFICATION Delegatee will defend, indemnify and hold harmless CIGNA and its affiliates and their directors, officers, and employees from any claims, loss, cost (including reasonable attorneys' fees and court costs) or liability resulting from delegatee's breach of this Section 31. Delegatee acknowledges receipt of CIGNA's above Standards for Delegation and, in accordance with the managed care provider agreement between CIGNA and delegatee, will comply with the terms and conditions set forth herein. --------------------------------- Delegatee's Name By ------------------------------ Its ----------------------------- CIGNA HealthCare of ______________ Inc. By ------------------------------ Its ------------------------------ EXHIBIT XXIII MANAGED CARE ALLIANCE AGREEMENT CREDENTIALING (Delegated Credentialing) 1. MCA shall be responsible for credentialing and recredentialing of all Represented Providers. 2. MCA's credentialing/recredentialing criteria shall, at a minimum, satisfy NCQA standards or the standards of another appropriate accrediting body designated by CIGNA, and the standards established by CIGNA. CIGNA reserves the right to disapprove, terminate or suspend any of MCA's Represented Providers if a Represented Provider does not meet CIGNA's requirements. 3. MCA shall review and externally verify the credentials of every Represented Provider at least once every three years. 4. MCA shall provide CIGNA with a summary of the credentials of each Represented Provider in a format acceptable to CIGNA and such other information as may reasonably be requested by CIGNA from time to time. 5. MCA shall require Represented Providers to represent and warrant that the information contained in their applications for participation is true and accurate and to agree to notify MCA promptly of any material change in the information on such application. MCA shall, in turn, immediately notify CIGNA of all such changes. 6. CIGNA may audit MCA's credentialing/recredentialing activities, including MCA's credentialing/recredentialing files. If CIGNA determines that MCA cannot meet its credentialing obligations set forth herein, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in this Agreement shall be renegotiated by the parties to reflect such change in responsibility. MCA shall cooperate and provide to CIGNA any information necessary to perform such activities. 7. MCA acknowledges that the credentialing and recredentialing performed by MCA pursuant to this Exhibit may be relied upon for Programs for which CIGNA or a CIGNA Affiliate contracts directly with Participating Providers. EXHIBIT XXIV CIGNA/GENTIVA FUTURE YEARS RATE METHODOLOGY YEARS 2005/2006 -------------------------------------------------------------------------------- * * Confidential Treatment Requested EXHIBITS: EXHIBIT 1A - REQUIRED DATA ELEMENTS PROGRAM ATTACHMENTS: HMO PROGRAM ATTACHMENT - CAPITATION EXHIBIT A - SCHEDULE OF CAPITATION RATES EXHIBIT B- MCA PAYMENT RESPONSIBILITY EXHIBIT C - UTILIZATION MANAGEMENT REQUIREMENTS HMO PROGRAM ATTACHMENT - FEE FOR SERVICE EXHIBIT A - REIMBURSEMENT FOR OTHER SERVICES PPO & INDEMNITY PROGRAM ATTACHMENT EXHIBIT A - REIMBURSEMENT FOR OTHER SERVICES GATEKEEPER PROGRAM ATTACHMENT - CAPITATION EXHIBIT A - SCHEDULE OF CAPITATION RATES EXHIBIT B - MCA PAYMENT RESPONSIBILITY EXHIBIT C - UTILIZATION MANAGEMENT REQUIREMENTS GATEKEEPER PROGRAM ATTACHMENT - FEE FOR SERVICE EXHIBIT A - REIMBURSEMENT FOR OTHER SERVICES EXHIBIT 1A MANAGED CARE ALLIANCE AGREEMENT REPRESENTED PROVIDER REQUIRED DATA ELEMENTS Upon request, MCA shall provide CIGNA with the following data elements for each Represented Provider: ANCILLARY PROVIDERS Full Name of Ancillary Physical Locations (Street Number, Street, Suite Number, City, State, Zip) Phone Numbers Billing Addresses and Phone Numbers Federal Tax ID Number(s) Ancillary Types (e.g., DME, Lab, Home Health, etc.) HMO PROGRAM ATTACHMENT TO MANAGED CARE ALLIANCE AGREEMENT (CAPITATION) PURPOSE The terms and provisions of this HMO Program Attachment and the Agreement are applicable to services rendered by MCA's Represented Providers to HMO Program Participants. As used in this Program Attachment, Participant means a HMO Program Participant. I. DEFINITIONS BASELINE ASSESSMENT means CIGNA's assessment of MCA's capacity to assume the obligations described in the Agreement and this Program Attachment in particular. CAPITATION PAYMENT means a periodic payment for certain covered Home Care Services that is made to MCA for each Participant who is a member of MCA's Patient Panel. CARVED OUT SERVICES means the following services (see Exhibit XIX): MEDICAL DIRECTOR means a physician designated by CIGNA to manage Quality Management and Utilization Management responsibilities, or that physician's designee. HMO PROGRAM PARTICIPANT means a Participant enrolled in a non-governmental, fully insured Standard HMO or Point of Service product and which product is underwritten based on a community rating methodology (i.e. community rating, community rating by class, adjusted community rating by class). This definition includes, but is not limited to, Participants covered under commercial HMO and Open Access plans issued by CIGNA. PATIENT PANEL means those HMO Program Participants for which MCA will receive a global Capitation Payment for all Home Care Services rendered. POINT OF SERVICE means a product offered pursuant to a Service Agreement which allows the Participant to choose, in addition to Standard HMO benefits, a lower level of benefits if the Participant receives Home Care Services from (i) a Participating Provider without a necessary authorization or (ii) from a non-Participating Provider, at the time such services are sought. PRIMARY CARE PHYSICIAN means a physician duly licensed to practice medicine who is a Participating Provider with CIGNA to provide Covered Services in the field of general medicine, internal medicine, family practice or pediatrics, and who has agreed to provide primary care physician services to Participants in accordance with HMO Program Requirements. STANDARD HMO means a product offered pursuant to a Service Agreement where Covered Services are available to Participants only from Participating Providers, except in the case of an Emergency or with the prior authorization of CIGNA or Affiliate where Covered Services are not available from Participating Providers. II. SERVICES AND COMPENSATION A. COVERED HOME CARE SERVICES 1. MCA, through its Represented Providers, shall provide all Home Care Services that are required by Participants in MCA's Patient Panel, for which such Participants are eligible, in accordance with the terms of this Agreement, this HMO Program Attachment and HMO Program Requirements. The compensation set forth in this HMO Program Attachment shall be payment in full for Home Care Services rendered to HMO Program Participants. 2. MCA, through its Represented Providers, shall arrange to provide Medically Necessary Home Care Services to Participants on a 24-hour per day, 7-day per week basis or arrange with other qualified providers (which meet all CIGNA and MCA credentialing requirements or other applicable guidelines) to provide such Medically Necessary Home Care Services to Participants. MCA shall require that such covering providers (a) are Participating Providers (unless otherwise agreed); (b) will not seek compensation from CIGNA for services for which MCA receives compensation hereunder; and (c) will not bill Participants for covered Home Care Services under any circumstances except for (i) Copayments, Deductibles or Coinsurance; (ii) the provision of services to a patient who is not eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit; and (iii) services provided to Participants that are not Home Care Services. (d) will direct the participant and/or the Represented Provider to obtain, authorization from CIGNA prior to all hospitalizations or referrals of Participants, except in Emergencies or for a Pre-Qualified Maternity Stay or as otherwise required by law. 3. MCA through its Represented Providers shall provide Home Care Services to all Participants in MCA's Patient Panel who are eligible to receive Home Care Services. 4. Subject to the terms and condition of this Agreement, MCA shall: a. Arrange for the provision of Home Care Services to Participants; b. Require Represented Providers to accept, treat, and otherwise render covered Home Care Services to Participants in the same manner, in accordance with the same standards, and with the same availability, as offered to other like patients. c. not close its network to any new Participants unless CIGNA expressly consents to such closure; 5. In no event shall MCA or Represented Providers be required to accept, treat, arrange for, or otherwise be obligated to render Home Care Services to Participants under this Agreement, even if medically appropriate, if: (a) the provision of such services to Participant would pose risk of bodily harm to the Participant or caregiver personnel of Represented Provider; (b) the provision of such services to Participant would be in violation of MCA's or Represented Provider's applicable license requirements or other applicable laws, and/or MCA policies, including but not limited to admission and discharge policies or discrimination policies; (c) MCA has not received the essential information to process a referral; (d) Participant repeatedly rejects the provision of services by a qualified Represented Provider selected by MCA and/or CIGNA has mutually agreed. (e) MCA and Represented Providers shall not differentiate or discriminate in the treatment of any Participant because of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, health status, handicap or source of payment. 6. A CIGNA Participating Physician or CIGNA will notify Provider's Network Manager of each referral for Covered Home Care Services for Participants in its Patient Panel. MCA will provide or arrange to provide for all Medically Necessary Covered Home Care Services for all such Participants, in accordance with the authorization and Utilization Management procedures set forth in Exhibit XVII. 7. MCA and CIGNA will jointly develop clinical pathways to establish a plan of treatment for more difficult Participant cases requiring Covered Home Care Services. B. CAPITATION PAYMENTS 1. On or before the 15th day of each month, CIGNA or its designee shall pay MCA a monthly Capitation Payment for each Participant in MCA's Patient Panel. THE CAPITATION PAYMENT SHALL BE COMPENSATION FOR ALL HOME CARE SERVICES PROVIDED TO PARTICIPANTS IN THE PATIENT PANEL EXCEPT FOR CARVED OUT SERVICES as referenced in EXHIBIT XIX. The monthly capitation rates are set forth in Exhibit A. 2. If a Participant is added to MCA's Patient Panel on or before the 15th day of a month, a full month's Capitation Payment will be due for that Participant for that month. There will be no Capitation Payment due for Participants added after the 15th day of the month. 3. A full month's Capitation Payment will be due for the month of termination of a Participant if the Participant terminates after the 15th day of the month. If a Participant terminates on or before the 15th day of a month, no Capitation Payment will be due for the month of termination. 4. Where CIGNA, due to information delays, must make a retroactive addition or deletion to MCA's Patient Panel, a retroactive capitation adjustment shall be made concurrent therewith subject to Section II.B.6 of this HMO Program Attachment. In those instances where a Participant has been retroactively deleted and has received services from MCA after the effective date of deletion but prior to CIGNA informing MCA of such deletion, MCA may bill participant for such services rendered. 5. Any amendments of Capitation Payment rates, whether on an annual basis or upon changes in benefit designs, shall be in accordance with the amendment provisions of this Agreement, or as otherwise agreed to in writing by the parties. 6. Capitation Adjustment Process: a. Where CIGNA, due to information delays, must make a retroactive addition or deletion to MCA's Patient Panel, a retroactive capitation adjustment shall not exceed 6 months, nor shall a retroactive addition be added greater than 6 months. b. Services rendered to participants prior to the capitation period or following the capitation period may be billed to CIGNA directly, and shall be in accordance with Exhibit A of the HMO Program Attachment - Fee For Service, attached hereto. Standard Coordination of Benefits rules shall be applied. In the event that CIGNA is not identified as the payor, MCA may bill participant directly for services rendered during this time. c. For those Participants in the Providers patient panel, MCA shall have 120 days following the receipt of the monthly capitation payment, to notify CIGNA of any discrepancies in the capitation payment. The discrepancies shall be determined by the MCA through a review of the electronic eligibility and capitation roster documentation supplied by CIGNA. For all eligibility or capitation roster data that continues to be in a paper format, CIGNA will use its best efforts to move to an electronic basis. d. CIGNA shall investigate and validate capitation errors and notify Gentiva within 60 days the results of such investigation. e. Any necessary adjustments to capitation shall be made through the next scheduled capitation cycle. f. All adjustments to capitation payments shall be provided to MCA in writing, by CIGNA, no less than 30 days prior to the adjustment. 7. MCA guarantees that the Capitation Payment rates set forth in this Attachment are effective from the Effective Date of this Agreement. Notwithstanding the foregoing, the parties agree to meet to discuss possible adjustments to the Capitation Payment rates should any of the following circumstances occur during the term of this Attachment: a. treatments, products, supplies or equipment which are excluded from Covered Home Care Services for HMO Program Participants as of the Effective Date on the basis that they are considered Experimental are no longer considered Experimental and become a Covered Home Care Service for such Participants. b. shifts in treatment sites for Covered Home Care Service therapies occurring after the Effective Date result in a material change to the services which are Covered Home Care Services for HMO Program Participants. c. material changes are made to HMO Program Participants' Service Agreements after the Effective Date such that there is a material change to those Home Care Services which are Covered Home Care Services for such Participants. d. utilization associated with material changes in membership from which the base period was derived after the Effective Date of this Agreement results in a material change in HMO Program Participant volume under this Agreement which has a material financial impact on MCA. e. Any such adjustment of Capitation Payment rates shall only be made to the extent required to address the change in costs directly resulting from the above changed circumstance. 8. Leakage a. On a quarterly basis, CIGNA will provide MCA with leakage reports and the claims for Covered Home Care Services submitted by providers that are not Represented Provider's. MCA shall review the quarterly leakage reports provided by CIGNA to determine the need to contract with additional providers so as to reduce the leakage. MCA shall make a good faith effort to contract with identified providers in order to reduce the amount of leakage and it shall act promptly to contract with those providers identified as appropriate in order to reduce leakage. In an effort to better manage leakage and overall utilization, CIGNA will attempt to provide MCA, an overview of CIGNA's administration of out of network claims for Covered Home Care Services rendered to Participants. CIGNA also agrees to review the feasibility of adopting usual and customary charges for Covered Home Care Services. MCA commits to provide CIGNA all reasonable assistance in the development and implementation of the aforementioned process. b. The Parties shall meet quarterly (each April, July, October and January) to review the utilization of Covered Home Health Services that are not reimbursed on a capitated basis under this Agreement for the purpose of identifying opportunities to reduce this utilization and the Parties shall cooperate in good faith to effect such actions as they may agree upon to accomplish this objective. c. MCA shall meet with those referring physicians identified by CIGNA to educate them regarding the service provided by Represented Providers. 9. Insulin Pumps Effective January 1, 2004, MCA will use all reasonable commercial efforts to arrange for the provision of Dana brand devices and supplies for insulin pump orders on new referral authorizations. For Participants reimbursed according to a capitation methodology, MCA will bill CIGNA a fee-for-service charge for a rate differential for new non-Dana devices based upon a CIGNA authorization. Supplies for insulin pumps provided to participants reimbursed according to a capitation methodology prior to 1/1/04 shall not be subject to a fee for service charge or consideration. For all other Participants, billing for pumps and supplies shall be in accordance with the appropriate fee schedules. C. REPRESENTED PROVIDER PAYMENT/CLAIM AND ENCOUNTER DATA Represented Providers shall be reimbursed for covered Home Care Services rendered in accordance with the requirements set forth in Exhibit B. MCA shall provide CIGNA with the claim and/or encounter data as required in Exhibit B. D. FINANCIAL REPORTS 1. MCA represents and warrants that the information set forth in the CIGNA Baseline Assessment submitted to CIGNA by MCA prior to the execution of this Agreement is true and accurate. MCA shall promptly notify CIGNA of any material changes in the information contained in such Baseline Assessment within thirty (30) days of becoming aware of such change. 2. MCA shall provide CIGNA with the following financial reports on a timely basis: a) MCA's annual audited financial reports, including, but not limited to, MCA's audited annual income statement and balance sheet; b) quarterly financial reports including an income statement, balance sheet and any other reports identifying payments made to Represented Providers in the preceding quarter and the incurred but not reported claims as of the end of the preceding quarter in sufficient detail to determine if payments have been made in accordance with this Agreement and applicable law; c) any financial reports required by applicable regulatory authorities; and d) such other financial reports as are reasonably requested by CIGNA. 3. MCA shall notify CIGNA immediately of any of MCA's material payment defaults with respect to any of MCA's creditors if MCA reasonably determines that any such payment defaults would affect the provision of services to the HMO Program Participants. E. ASSIGNMENT AND IDENTIFICATION OF PARTICIPANTS MCA shall comply with the requirements of and shall participate in CIGNA's procedures with respect to the assignment and identification of Participants as outlined in the HMO Program Requirements. F. REIMBURSEMENT OF CIGNA EXPENDITURES In the event that MCA does not arrange for the provision of Home Care Services to HMO Program Participants as required by Section II.A.1 through II.A.4 of this HMO Program Attachment, Payor may arrange for and/or reimburse for such Home Care Service and shall be entitled to recover from MCA any expenditure made, or recover any cost incurred, including, but not limited to, any reasonable administrative costs, in arranging or reimbursing such covered Home Care Service. An amount sufficient to compensate for such expenditures and costs may be deducted from the payments due to MCA under this Agreement; provided that, CIGNA shall provide MCA with written notice and full disclosure of costs incurred prior to any such deductions. This provision shall survive the termination of this Agreement for a period of one (1) year. G. OTHER REQUIREMENTS MCA and its Represented Providers shall use best efforts to prescribe or authorize the substitution of generic pharmaceuticals when appropriate and shall cooperate with CIGNA's formulary and HMO Program Requirements regarding the substitution of generic pharmaceuticals. H. TRANSFERS In a timeframe to be mutually agreed upon the parties, CIGNA will provide to MCA all information reasonably required by MCA in order to accomplish transition, but nothing herein shall require MCA to purchase or assume payments for any Durable Medical Equipment (DME/HME), which has been previously placed with any Participant. CIGNA agrees to work with MCA to identify those Participants that are in possession of DME/HME and for which CIGNA has made payment on a rental basis for such DME/HME, and advise MCA of the same. MCA shall be relieved of any obligation to assume financial responsibility for DME/HME that MCA determines to be DME/HME that is routinely purchased or converted to purchase, or that does not meet CIGNA/MCA Durable Medical Equipment Guidelines for Medical Necessity, and such DME/HME shall be converted to purchase at CIGNA's expense prior to the transition of Participants to MCA. However, MCA shall assume responsibility for the continued maintenance of the DME/HME. I. LIMITATIONS ON BILLING PARTICIPANTS 1. MCA hereby agrees and shall require its Represented Providers to agree that in no event, including, but not limited to non-payment by CIGNA, CIGNA's insolvency or breach of this Agreement, shall MCA or any Represented Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Participants or persons other than CIGNA or MCA for Home Care Services. This provision shall not prohibit collection of (i) any applicable Copayments, Deductibles or Coinsurance; (ii) payments for services provided to a patient who is no longer eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit; or (iii) payments for services provided to Participants that are not Home Care Services. 2. MCA further agrees that this provision shall survive the termination of this Agreement regardless of the cause giving rise to such termination and shall be construed to be for the benefit of Participants, and that this provision supersedes any oral or written agreement to the contrary now existing or hereafter entered into between MCA or Represented Providers and the Participant or persons acting on the Participant's behalf. 3. Any modification, additions, or deletion to the provisions of this hold harmless clause shall become effective on a date no earlier than fifteen (15) days after the applicable state regulatory agency has received written notice of such proposed change. 4. MCA shall not charge, and MCA shall require that its Represented Providers not charge, a Participant for a service which is not Medically Necessary unless in advance of the provision of such service, the Participant is notified that the service may not be covered and the Participant acknowledges in writing that he or she shall be responsible for payment of charges for such service. J. UTILIZATION MANAGEMENT MCA shall perform and comply with the Utilization Management requirements set forth in Exhibits XVII and XXI. K. CIGNA VISION/JOINT STEERING COMMITTEE Any and all services rendered by MCA and its Represented Providers under this Agreement shall be consistent with CIGNA's vision to provide or arrange to provide quality health care at a reasonable cost. Each party agrees to designate representatives, the number and identity of which shall be agreed upon by the parties, to participate in a Joint Steering Committee. The Joint Steering Committee shall meet on a periodic basis, but no less frequently than twice yearly, for the purpose of discussing the status of each party's performance under this Agreement and to resolve any complaints or problems with such performance. L. GUARANTEE OF PROVISION OF COVERED SERVICES 1. Throughout the term of this Agreement and for six (6) months following the termination of this Agreement, MCA shall secure and maintain an irrevocable letter(s) of credit in favor of CIGNA in an amount and form acceptable to CIGNA, for all states in which such a letter of credit is required by state law, regulation, statute, or as required by state insurance/HMO regulators. 2. CIGNA shall have the right to make immediate demand for payment under the irrevocable letter(s) of credit in the event that MCA has failed to pay any amounts due and owing to CIGNA, Represented Providers or others in accordance with MCA's obligations under this Agreement. 3. Prior to each anniversary date of this Agreement, CIGNA will evaluate the adequacy of the amount of the irrevocable letter(s) of credit by reviewing any and all state laws, regulations, and statutes. The amount of the irrevocable letter(s) of credit required to be maintained by MCA for the next contract year shall be a minimum of the amount equal to the individual state requirements for the contract year. 4. At least thirty (30) days prior to each anniversary date of this Agreement, CIGNA will advise MCA of the amount of the irrevocable letter of credit required to be maintained by MCA for the next contract year as calculated pursuant to subsection 3 above. MCA shall secure an irrevocable letter of credit in such amount and in a form acceptable to CIGNA prior to the anniversary date. M. PERFORMANCE FEEDBACK 1. CIGNA may provide feedback to MCA for MCA's own use in assessing and enhancing Represented Providers' performance with regard to quality of care, patient satisfaction and efficient practice. 2. For purposes of providing helpful performance feedback, CIGNA may perform telephone surveys and analyze medical costs of Participants in MCA's HMO Patient Panel. Subject to any applicable confidentiality limitations, CIGNA may also from time to time review a sample of medical records and provide performance feedback on past treatment. N. REIMBURSEMENT FOR COVERED SERVICES RENDERED TO PARTICIPANTS OUTSIDE OF PATIENT PANEL/OPT OUT SERVICES In the event that MCA's Represented Providers render Home Care Services to Participants outside of MCA's Patient Panel or services covered pursuant to a Participant's opt out benefits, MCA shall be reimbursed for such services at the rates established in the HMO Program Attachment - Fee For Service, attached hereto, less applicable Coinsurance, Copayments and Deductibles. Only those charges for Home Care Services billed in accordance with CIGNA's standard claim coding and bundling methodology will be allowed. O. REPRESENTED PROVIDER ACCEPTANCE OF PAYMENT. MCA represents and warrants that each and every Represented Provider has contractually agreed with MCA to accept as payment in full due from CIGNA and its Affiliates for Home Care Services rendered to Patient Panel Participants by that Provider the amounts that the Represented Provider is entitled to receive from MCA. MCA will indemnify and hold harmless Patient Panel Participants, CIGNA and its Affiliates from any claim for payment for Home Care Services rendered to Patient Panel Participants by each Represented Provider, unless the claim arises from CIGNA's wrongful failure to pay MCA for Home Care Services. EXHIBIT A HMO PROGRAM ATTACHMENT - CAPITATION SCHEDULE OF CAPITATION RATES CAPITATION RATES EFFECTIVE 1/1/04 - 12/31/04 These are the capitation rates that apply to services rendered to Patient Panel Participants enrolled in HMO Programs. An "HMO Program" means a non-governmental, fully insured HMO or Point of Service product that is underwritten based on a community rating methodology (i.e. community rating, community rating by class, adjusted community rating by class). -------------------------------------------------------------------------------- Gentiva Homehealth Infusion and DME/HME Capitation Rate PMPM -------------------------------------------------------------------------------- All Commercial HMO Capitated * Affiliates -------------------------------------------------------------------------------- * Confidential treatment requested EXHIBIT B HMO PROGRAM ATTACHMENT - CAPITATION PAYMENT RESPONSIBILITIES (MCA distributes payments) MCA shall pay Represented Providers for covered Home Care Services rendered hereunder in accordance with this Exhibit and the terms of the Agreement. 1. MCA shall pay Represented Providers for covered Home Care Services rendered hereunder in accordance with CIGNA's payment administration standards and any other standards set forth in applicable laws and regulations, including but not limited to, ERISA. MCA agrees to reimburse Represented Providers for covered Home Care Services within the time frames set forth in applicable law AND the time frames specified in MCA's provider agreements with its Represented Providers. CIGNA may withhold all or a portion of MCA's reimbursement if MCA repeatedly fails to reimburse Represented Providers on a timely basis. MCA's obligations with regard to payment for covered Home Care Services rendered hereunder shall survive the termination of this Agreement with respect to any covered Home Care Services rendered by Represented Providers during the term of this Agreement and with respect to any covered Home Care Services Represented Providers are obligated by this Agreement to provide after termination of this Agreement. 2. With reasonable notice, MCA agrees to allow CIGNA representatives to conduct on-site reviews of MCA's payment administration facilities. Such reviews shall be for the sole purpose of evaluating MCA's performance of its payment responsibilities under this Agreement, including, but not limited to, ascertaining the quality and timeliness of MCA's payment processing. MCA agrees to correct any deficiencies detected during such reviews within sixty (60) days of CIGNA's submission of a written report detailing such deficiencies. 3. If CIGNA determines that MCA cannot meet its payment administration obligations set forth herein, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in this Agreement shall be renegotiated by the parties to reflect such change in responsibility. MCA shall cooperate and provide to CIGNA any information necessary to perform such activities. 4. MCA shall be responsible for the production of all applicable tax reporting documents (e.g., 1099s) for Represented Providers. Such documents shall be produced in a format and within the time frames set forth in applicable state and federal laws and/or regulations. 5. MCA shall require that Represented Providers submit claims for covered Home Care Services rendered to Participants in other Programs for which CIGNA has retained payment responsibility directly to CIGNA in accordance with the applicable Program Attachment and Program Requirements. 6. MCA shall produce explanations of payments for Represented Providers with respect to those services rendered by Represented Providers to Participants for which an explanation of benefits is customarily provided or legally required. Such explanations of payments shall be in a format and contain data elements acceptable to CIGNA. 7. MCA shall develop and deliver training programs for Represented Providers which outline MCA's billing and reimbursement processes. MCA shall make best efforts to ensure that Represented Providers avoid submitting requests for payment to CIGNA for those covered Home Care Services rendered to Participants for whom MCA has payment responsibility. 8. MCA shall provide CIGNA with encounter data showing all services provided to each Participant for whom MCA receives Capitation Payments in a format and frequency mutually acceptable to both parties, but no less frequently than monthly. CIGNA may elect to withhold payment of MCA's compensation if MCA fails to submit encounter data in accordance with this Agreement. EXHIBIT C HMO PROGRAM ATTACHMENT - CAPITATION UTILIZATION MANAGEMENT (partial delegation of utilization management) 1. MCA will assist CIGNA in the implementation of its Utilization Management program. Any Utilization Management program activities performed by MCA shall be in accordance with CIGNA's standards, NCQA standards or the standards of another appropriate accrediting body designated by CIGNA, and Program Requirements. MCA shall maintain any licensure required in connection with such activities. 2. MCA shall prepare such periodic reports or other data as reasonably requested by CIGNA relating to its Utilization Management activities in a format acceptable to CIGNA. 3. MCA shall not materially modify its Utilization Management activities without CIGNA's prior approval. 4. CIGNA shall have the right to audit MCA's Utilization Management activities upon reasonable prior notice. MCA shall cooperate with any such audits. 5. If CIGNA determines that MCA cannot meet its Utilization Management obligations set forth herein, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in this Agreement shall be renegotiated by the parties to reflect such change in responsibility. MCA shall cooperate and provide to CIGNA any information necessary to perform such activities. 6. All referrals shall be to Represented Providers, except where an Emergency requires otherwise, in other cases where the referral is specifically authorized by CIGNA's Medical Director or his/her designee or MCA's medical director, if permitted by CIGNA to make such authorizations, or as otherwise required by law. Except in an Emergency or for a Pre-Qualified Maternity Stay or in those instances where prior authorization is prohibited by federal or state laws or regulations, MCA shall require all Represented Providers to obtain authorization from CIGNA or MCA, if permitted by CIGNA to make such authorizations, prior to hospital admission of any Participant or outpatient surgical procedures. 7. The parties acknowledge and agree that CIGNA or Payor shall have final decision making authority with regard to appeals of utilization management decisions. HMO PROGRAM ATTACHMENT TO MANAGED CARE ALLIANCE AGREEMENT (FEE-FOR-SERVICE) PURPOSE The terms and provisions of this HMO Program Attachment and the Agreement are applicable to services rendered by MCA's Represented Providers to HMO Program Participants. As used in this Program Attachment, Participant means a HMO Program Participant. I. DEFINITIONS HMO PROGRAM PARTICIPANT means a Participant enrolled in a non-governmental, fully insured Standard HMO or Point of Service product and which product is underwritten based on a community rating methodology (i.e. community rating, community rating by class, adjusted community rating by class). This definition includes, but is not limited to, Participants covered under commercial HMO and Open Access and Open Access Plus plans issued by CIGNA. MEDICAL DIRECTOR means a physician designated by CIGNA to manage Quality Management and Utilization Management responsibilities, or that physician's designee. PATIENT PANEL means those Participants who have been designated or have otherwise been assigned to one or more of MCA's Represented Providers as the primary source for certain Covered Services pursuant to a Service Agreement or HMO Program Requirements, and for which MCA will be reimbursed on a fee-for-service basis. POINT OF SERVICE means a product offered pursuant to a Service Agreement which allows the Participant to choose, in addition to Standard HMO benefits, a lower level of benefits if the Participant receives Home Care Services from (i) a Participating Provider without a necessary authorization or (ii) from a non-Participating Provider, at the time such services are sought. PRIMARY CARE PHYSICIAN means a physician duly licensed to practice medicine who is a Participating Provider with CIGNA to provide Covered Services in the field of general medicine, internal medicine, family practice or pediatrics, and who has agreed to provide primary care physician services to Participants in accordance with HMO Program Requirements. STANDARD HMO means a product offered pursuant to a Service Agreement where Covered Services are available to Participants only from Participating Providers, except in the case of an Emergency or with the prior authorization of CIGNA or Affiliate where Covered Services are not available from Participating Providers. II. PARTIES' OBLIGATIONS A. SERVICES 1. MCA, through its Represented Providers, shall provide all Home Care Services that are required by Participants in MCA's Patient Panel, for which such Participants are eligible, in accordance with the terms of this Agreement, this HMO Program Attachment and HMO Program Requirements. The compensation set forth in this HMO Program Attachment shall be payment in full for Home Care Services rendered to HMO Program Participants. 2. MCA, through its Represented Providers, shall arrange to provide Medically Necessary Home Care Services to Participants on a 24-hour per day, 7-day per week basis or arrange with other qualified providers (which meet all CIGNA and MCA credentialing requirements or other applicable guidelines) to provide such Medically Necessary Home Care Services to Participants. MCA shall require that such covering providers (a) are Participating Providers (unless otherwise agreed); (b) will not seek compensation from CIGNA for services for which MCA receives compensation hereunder; and (c) will not bill Participants for covered Home Care Services under any circumstances except for (i) Copayments, Deductibles or Coinsurance; (ii) the provision of services to a patient who is not eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit; and (iii) services provided to Participants that are not Home Care Services. (d) will direct the participant and/or the Represented Provider to obtain, authorization from CIGNA prior to all hospitalizations or referrals of Participants, except in Emergencies or for a Pre-Qualified Maternity Stay or as otherwise required by law. 3. MCA through its Represented Providers shall provide Home Care Services to all Participants in MCA's Patient Panel who are eligible to receive Home Care Services. 4. Subject to the terms and conditions of this Agreement, MCA shall: (a) Arrange for the provision of Home Care Services to Participants; (b) Require Represented Providers to accept, treat, and otherwise render covered Home Care Services to Participants in the same manner, in accordance with the same standards, and with the same availability, as offered to other like patients. (c) not close its network to any new Participants unless CIGNA expressly consents to such closure; In no event shall MCA or Represented Providers be required to accept, treat, arrange for, or otherwise be obligated to render Home Care Services to Participants under this Agreement, even if medically appropriate, if: (a) the provision of such services to Participant would pose risk of bodily harm to the Participant or caregiver personnel of Represented Provider; (b) the provision of such services to Participant would be in violation of MCA's or Represented Provider's applicable license requirements or other applicable laws, and/or MCA policies, including but not limited to admission and discharge policies or discrimination policies; (c) MCA has not received the essential information to process a referral; (d) Participant repeatedly rejects the provision of services by a qualified Represented Provider selected by MCA and/or CIGNA has mutually agreed. MCA and Represented Providers shall not differentiate or discriminate in the treatment of any Participant because of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, health status, handicap or source of payment. 5. Except in an Emergency or for a Pre-Qualified Maternity Stay or in those instances where prior authorization is prohibited by federal or state laws or regulations, prior authorization by a Participant's Primary Care Physician or CIGNA as prescribed by HMO Program Requirements is required for payment of covered Home Care Services rendered to Participants. All referrals shall be to Participating Providers, except where an Emergency requires otherwise, in other cases where Medical Director specifically authorizes the referral or except as required by law. B. COMPENSATION AND BILLING 1. Reimbursement for Home Care Services rendered by Represented Providers shall be in accordance with the following rates, less applicable Copayments, Deductibles or Coinsurance: a. Reimbursement for Home Care services arranged by MCA and rendered by Represented Providers shall be in accordance with Exhibit A SCHEDULES 1A, 2A, AND 3A attached hereto. b. MCA will indemnify and hold harmless Payors, CIGNA and its Affiliates from any claim for payment in excess of the specified amounts for Home Care Services rendered to Participants by each Represented Provider, unless the claim arises from a Payor's wrongful failure to pay MCA for covered Home Care Services. 2. Payors shall agree to deduct any Copayments, Deductibles, or Coinsurance required by the Service Agreement from payment due. Deduction for the Copayment, Deductible or Coinsurance shall be determined on the basis of the contracted rate. 3. Reimbursement for Home Care Services rendered hereunder shall be made by CIGNA or its designees to MCA. MCA shall bill for covered Home Care Services according to the following: a. MCA shall submit claims on the appropriate claim form for all covered Home Care Services within one hundred twenty (120) days of the date those services are rendered. Claims received after this one hundred twenty (120) day period may be denied for payment. MCA shall submit claims to the location described in applicable Program Requirements. b. Any amount owing under this Agreement shall be paid within thirty (30) days after receipt of a complete claim, unless additional required information is requested within the thirty (30) day period, or the claim involves coordination of benefits, except as otherwise provided in this Agreement. 4. MCA and its Represented Providers shall not charge a Participant for a service which is not Medically Necessary unless, in advance of the provision of such service, the Participant is notified that the service may not be covered and the Participant acknowledges in writing that he or she shall be responsible for payment of charges for such service. 5. MCA will and shall require its Represented Providers to look solely to Payor for compensation for covered Home Care Services except for Copayments, Deductibles or Coinsurance. MCA agrees, for itself and on behalf of each Represented Provider, that whether or not there is any unresolved dispute for payment, under no circumstances will MCA or any Represented Provider directly or indirectly make any charges or claims, other than for Copayments, Deductibles or Coinsurance against any Participants or their representatives for covered Home Care Services and that this provision survives termination of this Agreement for services rendered prior to such termination. This provision shall not prohibit collection of (i) any applicable Copayments, Deductibles, or Coinsurance, (ii) payments for services provided to a patient who is no longer eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit (iii) payment for services provided to Participants, which are not Home Care Services. This paragraph is to be interpreted for the benefit of Participants and does not diminish the obligation of Payor to make payments to Represented Providers according to the terms of this Agreement. 6. The rates set forth herein shall apply to all services rendered to Participants in the HMO Program. 7. Only those charges for Home Care Services billed in accordance with CIGNA's standard claim coding and bundling methodology will be allowed. C. OTHER REQUIREMENTS MCA and its Represented Providers shall use best efforts to prescribe or authorize the substitution of generic pharmaceuticals when appropriate and shall cooperate with CIGNA's formulary and HMO Program Requirements regarding the substitution of generic pharmaceuticals. EXHIBIT A HMO PROGRAM ATTACHMENT - FEE FOR SERVICE REIMBURSEMENT FOR OTHER SERVICES RATE AREA DESIGNATIONS: -------------------------------------------------------------------------- STATE RATE AREA RATE DESIGNATION -------------------------------------------------------------------------- Alabama LOW 3 -------------------------------------------------------------------------- Alaska HIGH 1 -------------------------------------------------------------------------- Arizona MEDIUM 2 -------------------------------------------------------------------------- Arkansas LOW 3 -------------------------------------------------------------------------- California HIGH 1 -------------------------------------------------------------------------- Colorado MEDIUM 2 -------------------------------------------------------------------------- Connecticut MEDIUM 2 -------------------------------------------------------------------------- Delaware LOW 3 -------------------------------------------------------------------------- District of Columbia HIGH 1 -------------------------------------------------------------------------- Florida MEDIUM 2 -------------------------------------------------------------------------- Georgia MEDIUM 2 -------------------------------------------------------------------------- Hawaii HIGH 1 -------------------------------------------------------------------------- Idaho LOW 3 -------------------------------------------------------------------------- Illinois HIGH 1 -------------------------------------------------------------------------- Indiana LOW 3 -------------------------------------------------------------------------- Iowa LOW 3 -------------------------------------------------------------------------- Kansas LOW 3 -------------------------------------------------------------------------- Kentucky LOW 3 -------------------------------------------------------------------------- Louisiana MEDIUM 2 -------------------------------------------------------------------------- Maine LOW 3 -------------------------------------------------------------------------- Maryland MEDIUM 2 -------------------------------------------------------------------------- Massachusetts HIGH 1 -------------------------------------------------------------------------- Michigan LOW 3 -------------------------------------------------------------------------- Minnesota LOW 3 -------------------------------------------------------------------------- Mississippi LOW 3 -------------------------------------------------------------------------- Missouri MEDIUM 2 -------------------------------------------------------------------------- Montana LOW 3 -------------------------------------------------------------------------- Nebraska LOW 3 -------------------------------------------------------------------------- Nevada LOW 3 -------------------------------------------------------------------------- New Hampshire LOW 3 -------------------------------------------------------------------------- New Jersey MEDIUM 2 -------------------------------------------------------------------------- New Mexico LOW 3 -------------------------------------------------------------------------- New York MEDIUM 2 -------------------------------------------------------------------------- North Carolina MEDIUM 2 -------------------------------------------------------------------------- North Dakota MEDIUM 2 -------------------------------------------------------------------------- Ohio MEDIUM 2 -------------------------------------------------------------------------- Oklahoma LOW 3 -------------------------------------------------------------------------- Oregon MEDIUM 2 -------------------------------------------------------------------------- Pennsylvania MEDIUM 2 -------------------------------------------------------------------------- Rhode Island MEDIUM 2 -------------------------------------------------------------------------- South Carolina MEDIUM 2 -------------------------------------------------------------------------- -------------------------------------------------------------------------- South Dakota LOW 3 -------------------------------------------------------------------------- Tennessee MEDIUM 2 -------------------------------------------------------------------------- Texas HIGH 1 -------------------------------------------------------------------------- Utah MEDIUM 2 -------------------------------------------------------------------------- Vermont LOW 3 -------------------------------------------------------------------------- Virginia MEDIUM 2 -------------------------------------------------------------------------- Washington MEDIUM 2 -------------------------------------------------------------------------- West Virginia LOW 3 -------------------------------------------------------------------------- Wisconsin LOW 3 -------------------------------------------------------------------------- Wyoming LOW 3 -------------------------------------------------------------------------- TRADITIONAL HOME HEALTH SERVICES: RATES EFFECTIVE JANUARY 1, 2004 - DECEMBER 31, 2004 THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE BOTH VISIT AND HOURLY RATES. Notes 1, 2, 3, 4, 5 and 6 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- VISIT HOUR VISIT HOUR VISIT HOUR -------------------------------------------------------------------------------------------------------------- CERTIFIED NURSES AIDE * * * * * * -------------------------------------------------------------------------------------------------------------- HOME HEALTH AIDE * * * * * * -------------------------------------------------------------------------------------------------------------- LVN/LPN * * * * * * -------------------------------------------------------------------------------------------------------------- LVN/LPN - HIGH TECH * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC HIGH TECH LVN/LPN * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC HIGH TECH RN * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC LVN/LPN * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC RN * * * * * * -------------------------------------------------------------------------------------------------------------- RN * * * * * * -------------------------------------------------------------------------------------------------------------- RN HIGH TECH INFUSION * * * * * * -------------------------------------------------------------------------------------------------------------- RN HIGH TECH OTHER * * * * * * --------------------------------------------------------------------------------------------------------------
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE VISIT ONLY RATES. Notes 1, 3, 4, 5, 7 and 8 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- VISIT HOUR VISIT HOUR VISIT HOUR -------------------------------------------------------------------------------------------------------------- DIABETIC NURSE * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- DIETITIAN * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- ENTEROSTOMAL THERAPIST * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- MATERNAL CHILD HEALTH * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- MEDICAL SOCIAL WORKER * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- OCCUPATIONAL THERAPIST * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- OCCUPATIONAL THERAPIST ASSISTANT * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- PHLEBOTOMIST * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- PHOTOTHERAPY PACKAGE SERVICE * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- PHYSICAL THERAPIST * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- PHYSICAL THERAPIST ASSISTANT * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- PSYCHIATRIC NURSE * N/A * N/A * N/A --------------------------------------------------------------------------------------------------------------
* Confidential treatment requested -------------------------------------------------------------------------------------------------------------- REHABILITATION NURSE * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- RESPIRATORY THERAPIST * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- RESPIRATORY THERAPIST - CPAP Clinic * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- RN ASSESSMENT, INITIAL * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- RN SKILLED NURSING VISIT-EXTENSIVE * N/A * N/A * N/A -------------------------------------------------------------------------------------------------------------- SPEECH THERAPIST * N/A * N/A * N/A --------------------------------------------------------------------------------------------------------------
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE HAS HOURLY ONLY RATES. Notes 3, 4 and 5 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- VISIT HOUR VISIT HOUR VISIT HOUR -------------------------------------------------------------------------------------------------------------- HOMEMAKER N/A * N/A * N/A * --------------------------------------------------------------------------------------------------------------
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE IS PRICED ON A PER DIEM BASIS. Notes 3, 4 and 5 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- PER DIEM PER DIEM PER DIEM -------------------------------------------------------------------------------------------------------------- COMPANION/LIVE IN * * * --------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * * * HOME INFUSION RATES: RATES EFFECTIVE JANUARY 1, 2004 - DECEMBER 31, 2004 THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE PRICED AS A PERCENTAGE DISCOUNT OFF AWP (IF APPLICABLE), AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
-------------------------------------------------------------------------------------------------------------- PRIMARY OR PRIMARY OR PRIMARY OR MULTIPLE THERAPY MULTIPLE THERAPY MULTIPLE THERAPY PER DIEM DISPENSING FEE DRUG DISCOUNT OFF AWP -------------------------------------------------------------------------------------------------------------- Ancillary Drugs * * * ------------------------------------------------------------------------------------------------------------- Biological Response Modifiers * * * ------------------------------------------------------------------------------------------------------------- Cardiac (Inotropic) Therapy * * * ------------------------------------------------------------------------------------------------------------- Chelation Therapy * * * ------------------------------------------------------------------------------------------------------------- Chemotherapy * * * ------------------------------------------------------------------------------------------------------------- Enteral Therapy * * * ------------------------------------------------------------------------------------------------------------- Enzyme Therapy * * * ------------------------------------------------------------------------------------------------------------- Growth Hormone * * * ------------------------------------------------------------------------------------------------------------- IV Immune Globulin * * * -------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ------------------------------------------------------------------------------------------------------------- Other Injectable Therapies * * * ------------------------------------------------------------------------------------------------------------- Other Infusion Therapies * * * ------------------------------------------------------------------------------------------------------------- Pain Management Therapy * * * ------------------------------------------------------------------------------------------------------------- Steroid Therapy * * * ------------------------------------------------------------------------------------------------------------- Thrombolytic (Anticoagulation) Therapy * * * ------------------------------------------------------------------------------------------------------------- Synagis * * * ------------------------------------------------------------------------------------------------------------- Remodulin Therapy * * * -------------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE PRICED AS A PERCENTAGE DISCOUNT OFF AWP, AND THERE IS A PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
-------------------------------------------------------------------------------------------------------------- PER DIEM DRUG DISCOUNT OFF AWP -------------------------------------------------------------------------------------------------------------- Anti-Infectives - Primary Anti-Infective * * -------------------------------------------------------------------------------------------------------------- Anti-Infectives - Multiple Anti-Infective * * --------------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATE EXCLUDES DRUGS. DRUGS ARE PRICED PER VIAL, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
-------------------------------------------------------------------------------------------------------------- PRIMARY OR MULTIPLE THERAPY PER DIEM COST OF DRUG -------------------------------------------------------------------------------------------------------------- Flolan Therapy * -------------------------------------------------------------------------------------------------------------- Flolan 0.5 mg vial * -------------------------------------------------------------------------------------------------------------- Flolan 1.5 mg vial * -------------------------------------------------------------------------------------------------------------- Flolan diluent vial * --------------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES INCLUDE DRUGS, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
-------------------------------------------------------------------------------------------------------------- PRIMARY OR MULTIPLE THERAPY PER DIEM -------------------------------------------------------------------------------------------------------------- Enteral Therapy * -------------------------------------------------------------------------------------------------------------- Hydration Therapy * -------------------------------------------------------------------------------------------------------------- Total Parenteral Nutrition * --------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * * * Confidential treatment requested THE FOLLOWING ARE FOR THE STATED ITEM ONLY. UNLESS OTHERWISE NOTED, NURSING, SUPPLIES, ETC. ARE NOT INCLUDED. -------------------------------------------------------------------------------------------------------------- Blood Transfusion per Unit (Tubing, Filters) * -------------------------------------------------------------------------------------------------------------- Catheter Care Per Diem * -------------------------------------------------------------------------------------------------------------- Midline Insertion (Catheter & Supplies) * -------------------------------------------------------------------------------------------------------------- PICC Line Insertion (Catheter & Supplies) * -------------------------------------------------------------------------------------------------------------- Blood Product * --------------------------------------------------------------------------------------------------------------
FACTOR CONCENTRATES
-------------------------------------------------------------------------------------------------------------- Vial price Unit Price -------------------------------------------------------------------------------------------------------------- FACTOR VII -------------------------------------------------------------------------------------------------------------- Novoseven 1200MCG Vial * * -------------------------------------------------------------------------------------------------------------- Novoseven 4800MCG Vial * * -------------------------------------------------------------------------------------------------------------- Novoseven in 1200MCG or 4800MCG QTY * * -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- FACTOR VIII (RECOMBINANT) -------------------------------------------------------------------------------------------------------------- Recombinate * * -------------------------------------------------------------------------------------------------------------- Kogenate or Helixate * * -------------------------------------------------------------------------------------------------------------- Bioclate * * -------------------------------------------------------------------------------------------------------------- Helixate FS * * -------------------------------------------------------------------------------------------------------------- Kogenate FS * * -------------------------------------------------------------------------------------------------------------- Refacto * * -------------------------------------------------------------------------------------------------------------- Advate * * -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- FACTOR VIII (MONOCLONAL) -------------------------------------------------------------------------------------------------------------- Hemofil-M or A. R. C. Method M * * -------------------------------------------------------------------------------------------------------------- Monoclate P * * -------------------------------------------------------------------------------------------------------------- Monarc-M * * -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- FACTOR VIII (OTHER) -------------------------------------------------------------------------------------------------------------- Koate * * -------------------------------------------------------------------------------------------------------------- Humate * * -------------------------------------------------------------------------------------------------------------- Alphanate SDHT * * -------------------------------------------------------------------------------------------------------------- FACTOR IX (RECOMBINANT) -------------------------------------------------------------------------------------------------------------- BeneFix * * -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- FACTOR IX (MONOCLONAL/HIGH PURITY) --------------------------------------------------------------------------------------------------------------
* Confidential treatment requested -------------------------------------------------------------------------------------------------------------- Mononine * * -------------------------------------------------------------------------------------------------------------- Alphanine * * -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- FACTOR IX (OTHER) -------------------------------------------------------------------------------------------------------------- Konyne - 80 * * -------------------------------------------------------------------------------------------------------------- Proplex T * * -------------------------------------------------------------------------------------------------------------- Bebulin * * -------------------------------------------------------------------------------------------------------------- Profilnine SD * * -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- ANTI-INHIBITOR COMPLEX -------------------------------------------------------------------------------------------------------------- Autoplex-T * * -------------------------------------------------------------------------------------------------------------- Feiba-VH * * -------------------------------------------------------------------------------------------------------------- Hyate-C * * -------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- HEMOSTATIC AGENTS -------------------------------------------------------------------------------------------------------------- DDAVP - 10ml vial * * -------------------------------------------------------------------------------------------------------------- Stimate - 2.5ml vial * * --------------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit; 24-hour on-call clinical support; home infusion monitoring system; product delivery nationwide; patient training, education, and evaluation DME/HOME RESPIRATORY RATES: RATES EFFECTIVE JANUARY 1, 2004 - MARCH 31, 2004
---------------------------------------------------------------------------------------------------------------- HCPCS CHC GENTIVA CODE CODE CODE DESCRIPTION PURCHASE PRICE RENTAL PRICE DAILY PRICE ---------------------------------------------------------------------------------------------------------------- A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) * W/STETH & CUFF ---------------------------------------------------------------------------------------------------------------- A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), * AUTOMATIC ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK * ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7553 FULL FACE (A9900) MIRAGE * CPAP/BIPAP MASK ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP * MASK INCL GLD SEAL, PHANTM, MONARCH ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP * MASK (PROFILE OR SIMPICITY) ---------------------------------------------------------------------------------------------------------------- B9002 HI531 2570 PUMP, ENTERAL (B9002) * * ---------------------------------------------------------------------------------------------------------------- B9998 DM590 6828 ENTERAL SUPPLIES (B9998) * * ---------------------------------------------------------------------------------------------------------------- DM590 DM570 7551 BACK-PACK (E1399), FOR * PORTABLE ENTERAL PUMP ---------------------------------------------------------------------------------------------------------------- A4615 DM590 2522 CANNULA, NASAL * ---------------------------------------------------------------------------------------------------------------- B9002 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * * ---------------------------------------------------------------------------------------------------------------- A7034 DM590 7508 MASK, CPAP GEL OR SILICONE * (K0183) ---------------------------------------------------------------------------------------------------------------- E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP * ---------------------------------------------------------------------------------------------------------------- E0105 E0105 2021 CANE, QUAD (E0105) OR THREE * PRONG, ADJ OR FIX, W/ TIPS ---------------------------------------------------------------------------------------------------------------- E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ * OR FIX, PAIR, W/ TIPS, GRIPS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR * FIX, EACH, W/ TIP AND GRIPS ---------------------------------------------------------------------------------------------------------------- E0112 E0112 2027 CRUTCHES UNDERARM, WOOD (E0112), * ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0114 E0114 2026 CRUTCHES UNDERARM, ALUM (E0114), * ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0130 E0130 2037 WALKER, RIGID (E0130) (PICKUP), * ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0135 E0135 2036 WALKER, FOLDING (E0135) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0141 E0141 2040 WALKER, WHEELED (E0141), W/OUT * SEAT ---------------------------------------------------------------------------------------------------------------- E0142 DM570 2034 RIGID WALKER (E0142), WHEELED, * W/ SEAT, ---------------------------------------------------------------------------------------------------------------- E0143 E0143 2029 WALKER FOLDING, WHEELED (E0143), * W/OUT SEAT ---------------------------------------------------------------------------------------------------------------- E0145 DM570 2039 WALKER (E0145), WHEELED, * W/ SEAT AND CRUTCH ATTACHMENTS ---------------------------------------------------------------------------------------------------------------- E0146 DM570 2038 WALKER, WHEELED, W/ SEAT (E0146) * ---------------------------------------------------------------------------------------------------------------- E0147 E0147 2030 WALKER HVY DUT (E0147), MULT * BRAKING SYS, VAR WHEEL RESISTANCE ---------------------------------------------------------------------------------------------------------------- E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT * (E0153), FOREARM EA ---------------------------------------------------------------------------------------------------------------- E0154 E0154 2033 WALKER PLATFORM ATTACHMENT * (E0154), EA ---------------------------------------------------------------------------------------------------------------- E0155 E0155 2041 WALKER WHEEL ATTACHMENT * (E0155), RIGID (PICKUP) WALKER ---------------------------------------------------------------------------------------------------------------- E0156 DM570 2035 WALKER SEAT ATTACHMENT (E0156) * ---------------------------------------------------------------------------------------------------------------- E0157 E0157 2022 WALKER, CRUTCH ATTACHMENT * (E0157), EACH ---------------------------------------------------------------------------------------------------------------- E0158 E0158 2031 WALKER LEG EXTENSIONS (E0158) * ---------------------------------------------------------------------------------------------------------------- E0163 E0163 2047 COMMODE CHAIR, STATIONARY * (E0163), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0164 E0164 2045 COMMODE CHAIR, MOBILE * (E0164), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2046 COMMODE CHAIR (E0165), * STATIONARY, W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2591 COMMODE, XXWIDE(E0165) * ---------------------------------------------------------------------------------------------------------------- E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, * W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN * (E0167) ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE * PAD, NON-POSITIONING ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2394 REPLACEMENT PAD (E0176) * ALTERNATING PRESS ---------------------------------------------------------------------------------------------------------------- E0177 E0177 2224 CUSHION OR WATER PRESS PAD * (E0177), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0178 E0178 2160 CUSHION OR GEL PRESS PAD * (E0178), NONPOSITIONING ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE * PAD, NONPOSTIONING ---------------------------------------------------------------------------------------------------------------- E0180 E0180 2196 PUMP (E0180), ALTERNATING * * PRESSURES W/PAD ---------------------------------------------------------------------------------------------------------------- E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS * * W/PAD, HVY DUTY ---------------------------------------------------------------------------------------------------------------- E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) * ---------------------------------------------------------------------------------------------------------------- E0185 E0185 2076 MATTRESS (E0185), GEL OR * GEL-LIKE PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) * ---------------------------------------------------------------------------------------------------------------- E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) * ---------------------------------------------------------------------------------------------------------------- E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) * ---------------------------------------------------------------------------------------------------------------- E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN * (E0189), ANY SIZE ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2573 CUSHION, JAY FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND * * POSITIONING EQUALIZATION ---------------------------------------------------------------------------------------------------------------- E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), * * * INCL. BED ---------------------------------------------------------------------------------------------------------------- E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * * * ---------------------------------------------------------------------------------------------------------------- E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) * ---------------------------------------------------------------------------------------------------------------- E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD * (E0197) ---------------------------------------------------------------------------------------------------------------- E0198 E0198 2100 MATTRESS (E0198), WATER * PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD * (E0199) ---------------------------------------------------------------------------------------------------------------- E0200 E0200 2228 HEAT LAMP (E0200), W/OUT STAND, * INCL/BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) * * (E0202), LIGHT WIT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET * * (E0202) ---------------------------------------------------------------------------------------------------------------- E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, * INCL/ BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0210 DM570 2156 HEATING PAD, STANDARD (E0210) * ---------------------------------------------------------------------------------------------------------------- E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, * MOIST ---------------------------------------------------------------------------------------------------------------- E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * * ---------------------------------------------------------------------------------------------------------------- E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) * ---------------------------------------------------------------------------------------------------------------- E0236 DM570 2199 PUMP (E0236) FOR WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0237 DM570 2223 HEAT COLD WATER (E0237) * CIRCULATING PAD W/PUMP ---------------------------------------------------------------------------------------------------------------- E0238 DM570 2179 HEATING PAD (E0238), MOIST, * NON-ELECTRIC ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, * L-SHAPE ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2043 BATH TUB RAIL, WALL, UNSPECIFIED * SIZE ---------------------------------------------------------------------------------------------------------------- E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE * (E0242) ---------------------------------------------------------------------------------------------------------------- E0243 DM570 2056 TOILET RAIL, EACH (E0243) * ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH * ARMS ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2052 TOILET SEAT, RAISED (E0244) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2575 BATH BENCH WITH BACK (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2578 TRANSFER BENCH, NON-PADDED * (E0245) ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) * ---------------------------------------------------------------------------------------------------------------- E0246 DM570 2057 TRANSFER TUB RAIL(E0246), * ATTACHMENT ---------------------------------------------------------------------------------------------------------------- E0249 DM570 2186 HEAT UNIT (E0249), WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/O MATTRESS ---------------------------------------------------------------------------------------------------------------- E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) * ---------------------------------------------------------------------------------------------------------------- E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) * ---------------------------------------------------------------------------------------------------------------- E0273 DM570 2068 BED BOARD (E1399) * ---------------------------------------------------------------------------------------------------------------- E0274 DM570 2097 OVER-BED TABLE (E0274) * ---------------------------------------------------------------------------------------------------------------- E0275 E0275 2071 BED PAN, STANDARD (E0275), METAL * OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0276 E0276 2070 BED PAN, FRACTURE (E0276), METAL * OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, * * ALT PRESSURE ---------------------------------------------------------------------------------------------------------------- E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) * * ---------------------------------------------------------------------------------------------------------------- E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, * * HI-LO, W/OUT S/ RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, * * HI-LO, NO SIDE RAILS, NO MATTRESS ---------------------------------------------------------------------------------------------------------------- E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0305 E0305 2073 BED SIDE RAILS (E0305), HALF * LENGTH ---------------------------------------------------------------------------------------------------------------- E0310 E0310 2072 BED SIDE RAILS (E0310), FULL * LENGTH ---------------------------------------------------------------------------------------------------------------- E0315 DM570 2067 BED ACCESSORIES: BOARDS OR * TABLES, ANY TYPE ---------------------------------------------------------------------------------------------------------------- E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, * ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0326 E0326 2059 URINAL; FEMALE (E0326), * JUG-TYPE, ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0372 E0372 7008 MATTRESS (E0372) POWERED AIR * * * OVERLAY ---------------------------------------------------------------------------------------------------------------- E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), * PER POUND ---------------------------------------------------------------------------------------------------------------- E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS * SYSTEM ONLY, UP TO 23 CUBIC FEET ---------------------------------------------------------------------------------------------------------------- E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR * * GAS, RENT ---------------------------------------------------------------------------------------------------------------- E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) * ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT * * (E0431) W/CONSERV DEVICE, NO CONTENT ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) * ---------------------------------------------------------------------------------------------------------------- E0434 E0434 2377 O2 SYS PORT LIQUID,RENT (E0434) * ---------------------------------------------------------------------------------------------------------------- E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH * * (E0435) ---------------------------------------------------------------------------------------------------------------- E0439 E0439 2388 O2 SYS STATIONARY (E0439) * * LIQUID, RENT ---------------------------------------------------------------------------------------------------------------- E0440 E0440 2387 O2 SYS STATIONARY (E0440) * LIQUID, PURCH ---------------------------------------------------------------------------------------------------------------- E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER * (E0400), 200-300 CUBIC FT ---------------------------------------------------------------------------------------------------------------- E0444 E0444 2379 O2 CONTENTS, PORT LIQUID * (E0444), PER UNIT (1 UNIT = 1 LB.) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7555 POSITIVE PRESSURE VENTS * * (E0450)(E.G. T-BIRD) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 2392 VENTILATOR VOLUME (E0450), * * STATIONARY OR PORT ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) * * EMERGENCY BACKUP UNIT ---------------------------------------------------------------------------------------------------------------- E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) * * ASSIST DEVICE,(BIPAP) ---------------------------------------------------------------------------------------------------------------- E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); * * FOR USE 12 HOURS OR LESS PER DAY ---------------------------------------------------------------------------------------------------------------- E0455 E0455 2372 O2 TENT (E0455), EXCLUDING * * CROUP OR PEDIATRIC TENTS ---------------------------------------------------------------------------------------------------------------- E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * * ---------------------------------------------------------------------------------------------------------------- E0459 E0459 2324 CHEST WRAP (E0459) * * ---------------------------------------------------------------------------------------------------------------- E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE * * PRESSURE, PORTABLE OR STATIONARY ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR * * PNEUM, HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0500 E0500 2333 IPPB, W/ BUILT-IN NEB (E0500) * * MAN OR AUTO VALVES; INT/EXT POWER ---------------------------------------------------------------------------------------------------------------- E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR * * EXTENSIV SUP/ HUMID W/ IPPB OR O2 ---------------------------------------------------------------------------------------------------------------- E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, * GLASS, FOR USE W/ REG OR FLOWMETER ---------------------------------------------------------------------------------------------------------------- E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * * ---------------------------------------------------------------------------------------------------------------- E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) * * ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * * ---------------------------------------------------------------------------------------------------------------- E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR * * AND HEATER ---------------------------------------------------------------------------------------------------------------- E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * * ---------------------------------------------------------------------------------------------------------------- E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0601 E0601 2326 CONTINUOUS POSITVE (E0601) * * AIRWAY PRESSURE DEVICE (CPAP) ---------------------------------------------------------------------------------------------------------------- E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * * ---------------------------------------------------------------------------------------------------------------- E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) * ---------------------------------------------------------------------------------------------------------------- E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) * ---------------------------------------------------------------------------------------------------------------- E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) * ACCUCHEK AD ---------------------------------------------------------------------------------------------------------------- E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) * ---------------------------------------------------------------------------------------------------------------- E0618 E0608 2322 APNEA MONITOR (E0608) * * ---------------------------------------------------------------------------------------------------------------- E0619 E0608 2576 APNEA MONITOR (E0608) W/MEM * * (INCL SMART) ---------------------------------------------------------------------------------------------------------------- E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) * W/SPECIAL FEATURES ---------------------------------------------------------------------------------------------------------------- E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR * SEAT, CANVAS OR NYLON ---------------------------------------------------------------------------------------------------------------- E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, * BATHROOM OR TOILET ---------------------------------------------------------------------------------------------------------------- E0627 E0627 4553 HIP CHAIR (E0627) * * ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED * (E0627) ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2205 SEAT LIFT MECH (E0627) * INCORPORATED INTO A COMB LIFT-CHAIR MECH ---------------------------------------------------------------------------------------------------------------- E0630 E0630 2190 PATIENT LIFT, HYDRAULIC * * (E0630), W/ SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ * SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0650 E0650 2192 PNEUM COMPRESSOR (E0650), * * NON-SEG HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG * * HOME MODEL W/OUT CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG * * HOME MODEL W/ CALIB GRAD PRES ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0655 E0655 2182 PNEUM COMPRESSOR (E0655), * NON-SEG APPLIANCE, HALF ARM ---------------------------------------------------------------------------------------------------------------- E0660 E0660 2181 PNEUM COMPRESSOR (E0660), * NON-SEG APPLIANCE, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0665 E0665 2180 PNEUM COMPRESSOR (E0665), * NON-SEG APPLIANCE, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0666 E0666 2183 PNEUM COMPRESSOR (E0666), * NON-SEG APPLIANCE, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, * FULL LEG ---------------------------------------------------------------------------------------------------------------- E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, * FULL ARM ---------------------------------------------------------------------------------------------------------------- E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, * HALF LEG ---------------------------------------------------------------------------------------------------------------- E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, * HALF ARM ---------------------------------------------------------------------------------------------------------------- E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG * GRAD PRESS, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG * GRAD PRESS, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG * GRAD PRESS, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), * APPROPRIATE FOR HOME USE ---------------------------------------------------------------------------------------------------------------- E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., * BELT, HARNESS OR VEST) ---------------------------------------------------------------------------------------------------------------- E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE * (BODY, CHEST, WRIST OR ANKLE) ---------------------------------------------------------------------------------------------------------------- E0720 E0720 2219 TENS (E0720), TWO LEAD, * * LOCALIZED STIMULATION ---------------------------------------------------------------------------------------------------------------- E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER * * AREA/MULTIPLE NERVE STIMULATION ---------------------------------------------------------------------------------------------------------------- E0731 E0731 2159 TENS OR NMES (E0731), CONDUCTIVE * * GARMENT ---------------------------------------------------------------------------------------------------------------- E0744 E0744 2120 STIMULATOR (E0744), * * NEUROMUSCULAR FOR SCOLIOSIS ---------------------------------------------------------------------------------------------------------------- E0745 E0745 2121 STIMULATOR (E0745), * * NEUROMUSCULAR, ELECTRONIC SHOCK UNIT ---------------------------------------------------------------------------------------------------------------- E0745 E0745 6915 STIMULATOR FOUR CH (E0745), * * NEUROMUSCULAR ---------------------------------------------------------------------------------------------------------------- E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), * * BIOFEEDBACK DEVICE ---------------------------------------------------------------------------------------------------------------- E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, * NON-INVASIVE ---------------------------------------------------------------------------------------------------------------- E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC * NON-INVASIVE, SPINAL APPLICATIONS ---------------------------------------------------------------------------------------------------------------- E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC * SALIVARY REFLEX, NON INVASIVE ---------------------------------------------------------------------------------------------------------------- E0776 E0776 2175 IV POLE (E0776) * * ---------------------------------------------------------------------------------------------------------------- E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY * INFUSION, MINIMED, INSULIN ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7925 PUMP, EXT INFUSION, MINIMED * PREMIUM, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 6771 PUMP (E0784), INSULIN EXT * INFUSION DISETRONICS OR OTHER ---------------------------------------------------------------------------------------------------------------- E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH * * TO HEADBOARD, CERVICAL TRACTION ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0850 E0850 2134 TRACTION STAND (E0850), FREE * * STANDING, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR * * STAND ---------------------------------------------------------------------------------------------------------------- E0860 E0860 2130 TRACTION EQUIP (E0860), * * OVERDOOR, CERVICAL ---------------------------------------------------------------------------------------------------------------- E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH * * TO FOOTBOARD, EXTREMITY, BUCKS ---------------------------------------------------------------------------------------------------------------- E0880 E0880 2135 TRACTION STAND (E0880) * * FREE/STAND EXTREMITY TRACTION, EG, BUCK'S ---------------------------------------------------------------------------------------------------------------- E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH * * TO FOOTBOARD, PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0900 E0900 2136 TRACTION STAND (E0900) FREE/ * * STAND PELVIC TRACTION,(EG, BUCK'S) ---------------------------------------------------------------------------------------------------------------- E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT * * HELPER, ATTACH TO BED W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH * * TO BED, INCLUDING WEIGHTS ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE * * * DEVICE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE * * * DEVICE, ANKLE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE * * * DEVICE, ELBOW ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE * * * DEVICE, HAND ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE * * * DEVICE, SHOULDER ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE * * * DEVICE, WRIST ---------------------------------------------------------------------------------------------------------------- E0940 E0940 2137 TRAPEZE BAR (E0940), FREE * * STANDING, COMPLETE W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0941 E0941 2116 TRACTION DEVICE (E0941), * * GRAVITY ASSISTED ---------------------------------------------------------------------------------------------------------------- E0942 E0942 2101 HARNESS/HALTER (E0942), * * CERVICAL HEAD ---------------------------------------------------------------------------------------------------------------- E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, * * BOOT ---------------------------------------------------------------------------------------------------------------- E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT * * ---------------------------------------------------------------------------------------------------------------- E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL * * W/ CROSS BARS, ATTACH TO BED ---------------------------------------------------------------------------------------------------------------- E0947 E0947 2113 FRACTURE FRAME (E0947), * * ATTACHMENTS FOR COMPLEX PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0948 E0948 2112 FRACTURE FRAME (E0948) * * ATTACHMENTS FOR COMPLEX CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0950 DM570 2139 TRAY (E0950) * * ---------------------------------------------------------------------------------------------------------------- E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO * * CONVERT ANY W/C TO ONE ARM DRIVE ---------------------------------------------------------------------------------------------------------------- E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) * * (COMPENSATE FOR TRANS OF WEIGHT) ---------------------------------------------------------------------------------------------------------------- E0962 E0962 2232 CUSHION FOR WC 1" (E0962) * * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0963 E0963 2233 CUSHION FOR WC 2" (E0963) * * ---------------------------------------------------------------------------------------------------------------- E0964 E0964 2234 CUSHION FOR WC 3" (E0964) * * ---------------------------------------------------------------------------------------------------------------- E0965 E0965 2235 CUSHION FOR WC 4" (E0965) * * ---------------------------------------------------------------------------------------------------------------- E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) * * ---------------------------------------------------------------------------------------------------------------- E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) * * ---------------------------------------------------------------------------------------------------------------- E0978 E0978 2248 BELT, SAFETY (E0978) W/ * * AIRPLANE BUCKLE, W/C ---------------------------------------------------------------------------------------------------------------- E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO * * CLOSURE, W/C ---------------------------------------------------------------------------------------------------------------- E0980 DM570 2292 SAFETY VEST (E0980), W/C * * ---------------------------------------------------------------------------------------------------------------- E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ * * CASTORS 5" OR GREATER ---------------------------------------------------------------------------------------------------------------- E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1060 E1060 2259 W/C FULL/REC (E1070), DETACH * * ARMS, SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) * * ---------------------------------------------------------------------------------------------------------------- E1066 E1066 2247 BATTERY CHARGER (E1066) * * ---------------------------------------------------------------------------------------------------------------- E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) * * ---------------------------------------------------------------------------------------------------------------- E1070 E1070 2258 W/C FULL/REC (E1060), DETACH * * ARMS, SWING AWAY DET/ ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, * * SWING AWAY DETACH ABLE ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, * * SWING AWAY DETACH ABLE FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), * * FIX ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), * * D/ ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), * * FIX ARMS, S/AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1090 E1090 2267 W/C HI STRENGTH LT-WG (E1090), * * DETACH ARMS, S/AWAY D/FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * * ---------------------------------------------------------------------------------------------------------------- E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), * * DETACH ARMS S/AWAY DETACH ELEVAT LEGS ---------------------------------------------------------------------------------------------------------------- E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), * * DETACH ARMS S/AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1100 E1100 2296 W/C SEMI-RECLINING (E1100), * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1110 E1110 2295 W/C SEMI-RECLINING (E1110), * * DETACH ARMS ELEV LEG REST ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1130 E1130 2303 W/C STANDARD (E1130), FIX OR * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING * * AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2396 W/C (E1160), W/FIX ARMS * * REMOVABLE FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, * * W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH * * ARMS W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH * * ARMS SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH * * ARMS SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL * * LENGTH ARMS, S/AWAY D/FOOTREST ---------------------------------------------------------------------------------------------------------------- E1210 E1210 2281 W/C MOTORIZED (E1210), FIX * * ARMS, S/AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH * * ARMS, S/AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1212 E1212 2282 W/C MOTORIZED (E1212), FIX * * ARMS, SWING AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH * * ARMS S/AWAY, DETACH ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2551 W/C CUSTOM (E1220) * * ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2579 W/C XXWIDE (E1220) * * * ---------------------------------------------------------------------------------------------------------------- E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 * * WHEEL ---------------------------------------------------------------------------------------------------------------- E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS * * SWING AWAY DETACH, ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH * * ARMS ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1285 E1285 2274 W/C HVY DUTY (E1285), FIX * * ARMS, SWING AWAY DETACH FOOTREST ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH * * ARMS SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, * * ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1300 DM570 2062 WHIRLPOOL (E1300), PORT * * (OVERTUB TYPE) ---------------------------------------------------------------------------------------------------------------- E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT * * (BUILT-IN TYPE) ---------------------------------------------------------------------------------------------------------------- E1353 E1353 2381 O2 REGULATOR (E1353) * * ---------------------------------------------------------------------------------------------------------------- E1355 E1355 2384 CYLINDER STAND/RACK (E1355) * * ---------------------------------------------------------------------------------------------------------------- E1372 E1372 2331 IMMERSION EXT HEATER (E1372) * * FOR NEBULIZER ---------------------------------------------------------------------------------------------------------------- E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL * * COMPRESSOR, W/ LIMITED FLOW ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2568 ADAPTER (A9900), AC/DC * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2552 BATH LIFT (E1399), CUSTOM * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2563 BED WEDGE (E1399), 12" * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), * * CUSTOM ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL * * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2565 COMMODE (E1399), DROP ARM, * * HEAVY DUTY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), * * MISCELLANEOUS ---------------------------------------------------------------------------------------------------------------- E1399 E1220 2584 GERI CHAIR (E1399), THREE * * POSITION RECLINING ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6780 HOLTER MONITOR (G0004) * * ---------------------------------------------------------------------------------------------------------------- E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, * * XLONG, W/MATTRESS & SIDE RAILS ---------------------------------------------------------------------------------------------------------------- E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2588 MONITOR (E1399), VITAL SIGNS * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2529 O2 ANALYZER (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6775 OXIMETRY TEST (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2561 PEAK FLOW METER (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4559 PEDIATRIC WALKER (E1399) * * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2567 PNEUMOGRAM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2553 POSITIONING, CUSTOM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2526 PULSE OXIMETER (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2562 SHOWER, HAND HELD (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW * * VOLTAGE OR INTERFERENTIAL ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM * * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR * * ONLY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7505 W/C, CUSTOM (E1399) POWER * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2564 WALKER (E1399), HEAVY DUTY, * * EXTRA WIDE ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2585 WALKER (E1399), HEMI * * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 6873 WOUND SUCTION DEVICE (K0538) * * * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION * * DEVICE (K0539) ---------------------------------------------------------------------------------------------------------------- K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION * * DEVICE (K0540) ---------------------------------------------------------------------------------------------------------------- E1400 E1390 2361 O2 CONC (E1390), MANUF SPEC * * MAXFLOWRATE = 2 LTS PER MIN@85% ---------------------------------------------------------------------------------------------------------------- G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) * * ---------------------------------------------------------------------------------------------------------------- K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) * * ---------------------------------------------------------------------------------------------------------------- K0183 DM590 2516 CPAP MASK (K0183) * * ---------------------------------------------------------------------------------------------------------------- K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) * * REPLACEMENT FOR NASAL APP/ DVC, PAIR ---------------------------------------------------------------------------------------------------------------- K0185 DM590 2514 CPAP HEADGEAR (K0185) * * ---------------------------------------------------------------------------------------------------------------- K0186 DM590 2513 CPAP CHIN STRAP (K0186) * * ---------------------------------------------------------------------------------------------------------------- K0187 DM590 2512 CPAP TUBING (K0187) * * ---------------------------------------------------------------------------------------------------------------- K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE * * ---------------------------------------------------------------------------------------------------------------- K0189 DM590 2510 CPAP FILTER (A9900), * * NON-DISPOSABLE ---------------------------------------------------------------------------------------------------------------- K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL * * ---------------------------------------------------------------------------------------------------------------- K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, * * EQUIVALENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC * * * AIR THERAPY ---------------------------------------------------------------------------------------------------------------- A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 * * SCOOP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL SECRETION MOBIL DEVICE * * * ---------------------------------------------------------------------------------------------------------------- E0168B A9900 7643 COMMODE (E0168B) HVY DUTY * * BEDSIDE CHAIR 251-450 LBS. ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP * * ARM 451-850 LBS. ---------------------------------------------------------------------------------------------------------------- A6234 HH591 7626 DRESSING <16 SQ IN (A6234) * * HYDROCOLLOID DRESSING, EA ---------------------------------------------------------------------------------------------------------------- A6258 HH591 7627 DRESSING >16 SQ IN (A6258) * * TRANSPAREN FILM, EA ---------------------------------------------------------------------------------------------------------------- A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN * * (A46203) SELF ADH, EA ---------------------------------------------------------------------------------------------------------------- B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE * * F/KANGAROO PUMP ---------------------------------------------------------------------------------------------------------------- B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP * * BASIC ---------------------------------------------------------------------------------------------------------------- B9998D DM590 7657 ENT (B9998D) FARRELL GASTRIC * * RELIEF VLV ---------------------------------------------------------------------------------------------------------------- B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET * * ---------------------------------------------------------------------------------------------------------------- B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY * * SIZE MIC-KEY OR HIDE A PORT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL * * NOSE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7660 IPPB (E1399) UNIV SET UP * * W/MANIFOLD NEBULIZER ---------------------------------------------------------------------------------------------------------------- K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7641 MECHANICAL SCALE (E1399) * * PEDIATRIC/NEONATAL ---------------------------------------------------------------------------------------------------------------- A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL * * W/STR H20 1L BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7663 O2 CONNECTOR (E1399) * * SIMS/IRRIGATION NOZZLE BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7615 O2 HUMIDIFIER (E1399) * * AQUA+NEONATAL EA HUD ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER * * ANGLED STERILE ---------------------------------------------------------------------------------------------------------------- L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS * * ---------------------------------------------------------------------------------------------------------------- A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG * * 1L BAX ---------------------------------------------------------------------------------------------------------------- A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & * * TUBING ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA * * ---------------------------------------------------------------------------------------------------------------- A6265 HH591 7628 TAPE ALL TYPES (A6265) * * EXCLUDING MICROFOAM, PER 18 SQ INCHES ---------------------------------------------------------------------------------------------------------------- A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA * * ELECTROSTATIC ---------------------------------------------------------------------------------------------------------------- A4623 A9900 7618 TRACH INNER (A4623) CANNULA * * ---------------------------------------------------------------------------------------------------------------- A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR * * OR HOLDER ---------------------------------------------------------------------------------------------------------------- A7010 A9900 7662 TUBING (A7010) AEROSOL * * CORRUGATED PER FOOT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD * * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7630 VENT BATTERY CHARGER (A9900) * * 12V GEL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR * * ADULT OMNIFLEX DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S * * ELECTOSTATIC MAL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7634 VENT THERMOMETER (E1399) W/ * * ADAPTER ---------------------------------------------------------------------------------------------------------------- K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP * * BLK 10/PK ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7635 WALKER BASKET (E1399) VINYL * * COATED ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0159 A9900 7640 WALKER BRAKE (E0159) ATTACHMENT * * ---------------------------------------------------------------------------------------------------------------- E0148 A9900 7636 WALKER HVY DUTY (E0148) FOLDING * * X-WIDE ---------------------------------------------------------------------------------------------------------------- E0149 A9900 7637 WALKER HVY DUTY (E0149) W/ * * WHEELS ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER * * CABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7646 CPAP (E1399) EXHALATION PORT * * DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7647 CPAP (E1399) FUSE KIT * * INTERNATIONAL A/C ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER * * KIT DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER * * REUSABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7650 CPAP (E1399) HUMIDIFIER * * MOUNTING TRAY ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7652 CPAP (E1399) POWER CORD * * F/ARIA-SYNC ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE * * TAP ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) * * ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7565 CPAP SHORT TUBING (A9900) * * ---------------------------------------------------------------------------------------------------------------- E0601 E0601 7690 VENT, CONTINUOUS POSITIVE * * (E0500) AIRWAY PRESSURE DEVICE ---------------------------------------------------------------------------------------------------------------- E0452 E0452 7691 VENT, BILEVEL INTERMITTENT * * (E0500) ASSIST DEVICE (BIPAP) ---------------------------------------------------------------------------------------------------------------- E0747 DM570 6875 STIMULATOR, OSTEOGENIC, * * ULTRASOUND ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7695 GEL/SILICON GOLD SEAL * * CPAP/BIPAP MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ * * BACKUP RATE (K0533) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT * * (E1399) ---------------------------------------------------------------------------------------------------------------- HH591 HH591 7704 PUMP, EXT INFUSION, DANA * * DIABECARE, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, * * INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR * * USE WITH BREEZE MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A7036 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) * * ---------------------------------------------------------------------------------------------------------------- E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) * * ----------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances: ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2731 SHIPPING AND HANDLING FEES * * ----------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment: ---------------------------------------------------------------------------------------------------------------- E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) * * SERVICE REQUIRING SKILL OF A TECH ---------------------------------------------------------------------------------------------------------------- E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4552 MISCELLANEOUS SUPPLIES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2589 REPAIR (E1399), RESPIRATORY * * EQUIPMENT ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4549 TENS/APNEA SUPPLIES * * ----------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * DME/HOME RESPIRATORY RATES: RATES EFFECTIVE APRIL 1, 2004 - DECEMBER 31, 2004
---------------------------------------------------------------------------------------------------------------- HCPCS CHC GENTIVA CODE CODE CODE DESCRIPTION PURCHASE PRICE RENTAL PRICE DAILY PRICE ---------------------------------------------------------------------------------------------------------------- A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) * W/STETH & CUFF ---------------------------------------------------------------------------------------------------------------- A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), * AUTOMATIC ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK * ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7553 FULL FACE (A9900) MIRAGE * CPAP/BIPAP MASK ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP * MASK INCL GLD SEAL, PHANTM, MONARCH ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP * MASK (PROFILE OR SIMPICITY) ---------------------------------------------------------------------------------------------------------------- B9002 HI531 2570 PUMP, ENTERAL (B9002) * * ---------------------------------------------------------------------------------------------------------------- B9998 DM590 6828 ENTERAL SUPPLIES (B9998) * ---------------------------------------------------------------------------------------------------------------- DM590 DM570 7551 BACK-PACK (E1399), FOR * PORTABLE ENTERAL PUMP ---------------------------------------------------------------------------------------------------------------- A4615 DM590 2522 CANNULA, NASAL * ---------------------------------------------------------------------------------------------------------------- B9002 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * * ---------------------------------------------------------------------------------------------------------------- A7034 DM590 7508 MASK, CPAP GEL OR SILICONE * (K0183) ---------------------------------------------------------------------------------------------------------------- E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP * ---------------------------------------------------------------------------------------------------------------- E0105 E0105 2021 CANE, QUAD (E0105) OR THREE * PRONG, ADJ OR FIX, W/ TIPS ---------------------------------------------------------------------------------------------------------------- E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ * OR FIX, PAIR, W/ TIPS, GRIPS ---------------------------------------------------------------------------------------------------------------- E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR * FIX, EACH, W/ TIP AND GRIPS ---------------------------------------------------------------------------------------------------------------- E0112 E0112 2027 CRUTCHES UNDERARM, WOOD * (E0112), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0114 E0114 2026 CRUTCHES UNDERARM, ALUM (E0114), * ADJ OR FIX, PAIR, COMPLETE ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0130 E0130 2037 WALKER, RIGID (E0130) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0135 E0135 2036 WALKER, FOLDING (E0135) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0141 E0141 2040 WALKER, WHEELED (E0141), W/OUT * SEAT ---------------------------------------------------------------------------------------------------------------- E0142 DM570 2034 RIGID WALKER (E0142), WHEELED, * W/ SEAT, ---------------------------------------------------------------------------------------------------------------- E0143 E0143 2029 WALKER FOLDING, WHEELED * (E0143), W/OUT SEAT ---------------------------------------------------------------------------------------------------------------- E0145 DM570 2039 WALKER (E0145), WHEELED, W/ * SEAT AND CRUTCH ATTACHMENTS ---------------------------------------------------------------------------------------------------------------- E0146 DM570 2038 WALKER, WHEELED, W/ SEAT (E0146) * ---------------------------------------------------------------------------------------------------------------- E0147 E0147 2030 WALKER HVY DUT (E0147), MULT * BRAKING SYS, VAR WHEEL RESISTANCE ---------------------------------------------------------------------------------------------------------------- E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT * (E0153), FOREARM EA ---------------------------------------------------------------------------------------------------------------- E0154 E0154 2033 WALKER PLATFORM ATTACHMENT * (E0154), EA ---------------------------------------------------------------------------------------------------------------- E0155 E0155 2041 WALKER WHEEL ATTACHMENT (E0155), * RIGID (PICKUP) WALKER ---------------------------------------------------------------------------------------------------------------- E0156 DM570 2035 WALKER SEAT ATTACHMENT (E0156) * ---------------------------------------------------------------------------------------------------------------- E0157 E0157 2022 WALKER, CRUTCH ATTACHMENT * (E0157), EACH ---------------------------------------------------------------------------------------------------------------- E0158 E0158 2031 WALKER LEG EXTENSIONS (E0158) * ---------------------------------------------------------------------------------------------------------------- E0163 E0163 2047 COMMODE CHAIR, STATIONARY * (E0163), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0164 E0164 2045 COMMODE CHAIR, MOBILE * (E0164), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2046 COMMODE CHAIR (E0165), * STATIONARY, W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2591 COMMODE, XXWIDE(E0165) * ---------------------------------------------------------------------------------------------------------------- E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, * W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN * (E0167) ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE * PAD, NON-POSITIONING ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2394 REPLACEMENT PAD (E0176) * ALTERNATING PRESS ---------------------------------------------------------------------------------------------------------------- E0177 E0177 2224 CUSHION OR WATER PRESS PAD * (E0177), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0178 E0178 2160 CUSHION OR GEL PRESS PAD * (E0178), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE * PAD, NONPOSTIONING ---------------------------------------------------------------------------------------------------------------- E0180 E0180 2196 PUMP (E0180), ALTERNATING * * PRESSURES W/PAD ---------------------------------------------------------------------------------------------------------------- E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS * * W/PAD, HVY DUTY ---------------------------------------------------------------------------------------------------------------- E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) * ---------------------------------------------------------------------------------------------------------------- E0185 E0185 2076 MATTRESS (E0185), GEL OR * GEL-LIKE PRESSURE PAD ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) * ---------------------------------------------------------------------------------------------------------------- E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) * ---------------------------------------------------------------------------------------------------------------- E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) * ---------------------------------------------------------------------------------------------------------------- E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN * (E0189), ANY SIZE ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2573 CUSHION, JAY FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND * * POSITIONING EQUALIZATION ---------------------------------------------------------------------------------------------------------------- E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), * * * INCL. BED ---------------------------------------------------------------------------------------------------------------- E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * * * ---------------------------------------------------------------------------------------------------------------- E0270 E1399 6887 HOSPITAL BED INSTITUTIONAL * * * ---------------------------------------------------------------------------------------------------------------- E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) * ---------------------------------------------------------------------------------------------------------------- E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD * (E0197) ---------------------------------------------------------------------------------------------------------------- E0198 E0198 2100 MATTRESS (E0198), WATER * PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD * (E0199) ---------------------------------------------------------------------------------------------------------------- E0200 E0200 2228 HEAT LAMP (E0200), W/OUT * STAND, INCL/BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) * * (E0202), LIGHT WIT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET * * (E0202) ---------------------------------------------------------------------------------------------------------------- E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, * INCL/ BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0210 DM570 2156 HEATING PAD, STANDARD (E0210) * ---------------------------------------------------------------------------------------------------------------- E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, * MOIST ---------------------------------------------------------------------------------------------------------------- E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * * ---------------------------------------------------------------------------------------------------------------- E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) * ---------------------------------------------------------------------------------------------------------------- E0236 DM570 2199 PUMP (E0236) FOR WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0237 DM570 2223 HEAT COLD WATER (E0237) * CIRCULATING PAD W/PUMP ---------------------------------------------------------------------------------------------------------------- E0238 DM570 2179 HEATING PAD (E0238), MOIST, * NON-ELECTRIC ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, * L-SHAPE ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2043 BATH TUB RAIL, WALL, * UNSPECIFIED SIZE ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE * (E0242) ---------------------------------------------------------------------------------------------------------------- E0243 DM570 2056 TOILET RAIL, EACH (E0243) * ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH * ARMS ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2052 TOILET SEAT, RAISED (E0244) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2575 BATH BENCH WITH BACK (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2578 TRANSFER BENCH, NON-PADDED * (E0245) ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) * ---------------------------------------------------------------------------------------------------------------- E0246 DM570 2057 TRANSFER TUB RAIL(E0246), * ATTACHMENT ---------------------------------------------------------------------------------------------------------------- E0249 DM570 2186 HEAT UNIT (E0249), WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/O MATTRESS ---------------------------------------------------------------------------------------------------------------- E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, W/ * * SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, W/ * * SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) * ---------------------------------------------------------------------------------------------------------------- E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) * ---------------------------------------------------------------------------------------------------------------- E0273 DM570 2068 BED BOARD (E1399) * ---------------------------------------------------------------------------------------------------------------- E0274 DM570 2097 OVER-BED TABLE (E0274) * ---------------------------------------------------------------------------------------------------------------- E0275 E0275 2071 BED PAN, STANDARD (E0275), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0276 E0276 2070 BED PAN, FRACTURE (E0276), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, * * * ALT PRESSURE ---------------------------------------------------------------------------------------------------------------- E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) * * ---------------------------------------------------------------------------------------------------------------- E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, * * HI-LO, W/OUT S/ RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, * * HI-LO, NO SIDE RAILS, NO MATTRESS ---------------------------------------------------------------------------------------------------------------- E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0305 E0305 2073 BED SIDE RAILS (E0305), HALF * * LENGTH ---------------------------------------------------------------------------------------------------------------- E0310 E0310 2072 BED SIDE RAILS (E0310), FULL * LENGTH ---------------------------------------------------------------------------------------------------------------- E0315 DM570 2067 BED ACCESSORIES: BOARDS OR * TABLES, ANY TYPE ---------------------------------------------------------------------------------------------------------------- E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, * ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0326 E0326 2059 URINAL; FEMALE (E0326), * JUG-TYPE, ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0372 E0372 7008 MATTRESS (E0372) POWERED AIR * * * OVERLAY ---------------------------------------------------------------------------------------------------------------- E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), * PER POUND ---------------------------------------------------------------------------------------------------------------- E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS * SYSTEM ONLY, UP TO 23 CUBIC FEET ---------------------------------------------------------------------------------------------------------------- E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR * * GAS, RENT ---------------------------------------------------------------------------------------------------------------- E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) * * ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT * * (E0431) W/CONSERV DEVICE,NO CONTENT ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) * * ---------------------------------------------------------------------------------------------------------------- E0434 E0434 2377 O2 SYS PORT LIQUID,RENT (E0434) * * ---------------------------------------------------------------------------------------------------------------- E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH * * (E0435) ---------------------------------------------------------------------------------------------------------------- E0439 E0439 2388 O2 SYS STATIONARY (E0439) * * LIQUID, RENT ---------------------------------------------------------------------------------------------------------------- E0440 E0440 2387 O2 SYS STATIONARY (E0440) * * LIQUID, PURCH ---------------------------------------------------------------------------------------------------------------- E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER * * (E0400), 200-300 CUBIC FT ---------------------------------------------------------------------------------------------------------------- E0444 E0444 2379 O2 CONTENTS, PORT LIQUID * * (E0444), PER UNIT (1 UNIT = 1 LB.) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7555 POSITIVE PRESSURE VENTS * * (E0450)(E.G. T-BIRD) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7926 POSITIVE PRESSURE VENTS, EMERGENCY BACKUP (E.G.T-BIRD) * (E0450) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 2392 VENTILATOR VOLUME (E0450), * * STATIONARY OR PORT ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) * * EMERGENCY BACKUP UNIT ---------------------------------------------------------------------------------------------------------------- E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) * * ASSIST DEVICE,(BIPAP) ---------------------------------------------------------------------------------------------------------------- E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); * * FOR USE 12 HOURS OR LESS PER DAY ---------------------------------------------------------------------------------------------------------------- E0455 E0455 2372 O2 TENT (E0455), EXCLUDING * * CROUP OR PEDIATRIC TENTS ---------------------------------------------------------------------------------------------------------------- E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * * ---------------------------------------------------------------------------------------------------------------- E0459 E0459 2324 CHEST WRAP (E0459) * * ---------------------------------------------------------------------------------------------------------------- E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE * * PRESSURE, PORTABLE OR STATIONARY ---------------------------------------------------------------------------------------------------------------- E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR * * PNEUM, HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0500 E0500 2333 IPPB, W/ BUILT-IN NEB (E0500) * * MAN OR AUTO VALVES; INT/EXT POWER ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR * * EXTENSIV SUP/ HUMID W/ IPPB OR O2 ---------------------------------------------------------------------------------------------------------------- E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, * GLASS, FOR USE W/ REG OR FLOWMETER ---------------------------------------------------------------------------------------------------------------- E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * * ---------------------------------------------------------------------------------------------------------------- E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) * * ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * * ---------------------------------------------------------------------------------------------------------------- E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR * * AND HEATER ---------------------------------------------------------------------------------------------------------------- E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * * ---------------------------------------------------------------------------------------------------------------- E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0601 E0601 2326 CONTINUOUS POSITVE (E0601) * * AIRWAY PRESSURE DEVICE (CPAP) ---------------------------------------------------------------------------------------------------------------- E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * * ---------------------------------------------------------------------------------------------------------------- E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) * ---------------------------------------------------------------------------------------------------------------- E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) * ---------------------------------------------------------------------------------------------------------------- E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) * ACCUCHEK AD ---------------------------------------------------------------------------------------------------------------- E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) * ---------------------------------------------------------------------------------------------------------------- E0618 E0608 2322 APNEA MONITOR (E0608) * * ---------------------------------------------------------------------------------------------------------------- E0619 E0608 2576 APNEA MONITOR (E0608) W/MEM * * (INCL SMART) ---------------------------------------------------------------------------------------------------------------- E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) * W/SPECIAL FEATURES ---------------------------------------------------------------------------------------------------------------- E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR * * SEAT, CANVAS OR NYLON ---------------------------------------------------------------------------------------------------------------- E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, * * BATHROOM OR TOILET ---------------------------------------------------------------------------------------------------------------- E0627 E0627 4553 HIP CHAIR (E0627) * * ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED * * (E0627) ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2205 SEAT LIFT MECH (E0627) * * INCORPORATED INTO A COMB LIFT-CHAIR MECH ---------------------------------------------------------------------------------------------------------------- E0630 E0630 2190 PATIENT LIFT, HYDRAULIC * * (E0630), W/ SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ * * SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0650 E0650 2192 PNEUM COMPRESSOR (E0650), * * NON-SEG HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG * * HOME MODEL W/OUT CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG * * HOME MODEL W/ CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0655 E0655 2182 PNEUM COMPRESSOR (E0655), * NON-SEG APPLIANCE, HALF ARM ---------------------------------------------------------------------------------------------------------------- E0660 E0660 2181 PNEUM COMPRESSOR (E0660), * NON-SEG APPLIANCE, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0665 E0665 2180 PNEUM COMPRESSOR (E0665), * NON-SEG APPLIANCE, FULL ARM ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0666 E0666 2183 PNEUM COMPRESSOR (E0666), * NON-SEG APPLIANCE, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, * FULL LEG ---------------------------------------------------------------------------------------------------------------- E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, * HALF LEG ---------------------------------------------------------------------------------------------------------------- E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, * HALF ARM ---------------------------------------------------------------------------------------------------------------- E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG * GRAD PRESS, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG * GRAD PRESS, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG * GRAD PRESS, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), * APPROPRIATE FOR HOME USE ---------------------------------------------------------------------------------------------------------------- E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., * BELT, HARNESS OR VEST) ---------------------------------------------------------------------------------------------------------------- E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE * (BODY, CHEST, WRIST OR ANKLE) ---------------------------------------------------------------------------------------------------------------- E0720 E0720 2219 TENS (E0720), TWO LEAD, * * LOCALIZED STIMULATION ---------------------------------------------------------------------------------------------------------------- E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER * * AREA/MULTIPLE NERVE STIMULATION ---------------------------------------------------------------------------------------------------------------- E0731 E0731 2159 TENS OR NMES (E0731), * * CONDUCTIVE GARMENT ---------------------------------------------------------------------------------------------------------------- E0744 E0744 2120 STIMULATOR (E0744), * * NEUROMUSCULAR FOR SCOLIOSIS ---------------------------------------------------------------------------------------------------------------- E0745 E0745 2120 STIMULATOR (E0745), * * NEUROMUSCULAR, ELECTRONIC SHOCK UNIT ---------------------------------------------------------------------------------------------------------------- E0745 E0745 6915 STIMULATOR FOUR CH (E0745), * * NEUROMUSCULAR ---------------------------------------------------------------------------------------------------------------- E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), * * BIOFEEDBACK DEVICE ---------------------------------------------------------------------------------------------------------------- E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, * NON-INVASIVE ---------------------------------------------------------------------------------------------------------------- E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC * NON-INVASIVE, SPINAL APPLICATIONS ---------------------------------------------------------------------------------------------------------------- E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC * SALIVARY REFLEX, NON INVASIVE ---------------------------------------------------------------------------------------------------------------- E0776 E0776 2175 IV POLE (E0776) * * ---------------------------------------------------------------------------------------------------------------- E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY * INFUSION, MINIMED, INSULIN ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7925 PUMP, EXT INFUSION, NON - DANA * PREMIUM, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 6771 PUMP (E0784), INSULIN EXT * INFUSION DISETRONICS OR OTHER ---------------------------------------------------------------------------------------------------------------- E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH * TO HEADBOARD, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0850 E0850 2134 TRACTION STAND (E0850), FREE * * STANDING, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR * * STAND ---------------------------------------------------------------------------------------------------------------- E0860 E0860 2130 TRACTION EQUIP (E0860), * OVERDOOR, CERVICAL ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH * * TO FOOTBOARD, EXTREMITY, BUCKS ---------------------------------------------------------------------------------------------------------------- E0880 E0880 2135 TRACTION STAND (E0880) * * FREE/STAND EXTREMITY TRACTION, EG, BUCK'S ---------------------------------------------------------------------------------------------------------------- E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH * * TO FOOTBOARD, PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0900 E0900 2136 TRACTION STAND (E0900) FREE/ * * STAND PELVIC TRACTION,( EG, BUCK'S) ---------------------------------------------------------------------------------------------------------------- E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT * * HELPER, ATTACH TO BED W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH * * TO BED, INCLUDING WEIGHTS ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE * DEVICE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ANKLE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ELBOW ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE * DEVICE, HAND ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE * DEVICE, SHOULDER ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE * DEVICE, WRIST ---------------------------------------------------------------------------------------------------------------- E0940 E0940 2137 TRAPEZE BAR (E0940), FREE * * STANDING, COMPLETE W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0941 E0941 2116 TRACTION DEVICE (E0941), * * GRAVITY ASSISTED ---------------------------------------------------------------------------------------------------------------- E0942 E0942 2101 HARNESS/HALTER (E0942), * * CERVICAL HEAD ---------------------------------------------------------------------------------------------------------------- E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, * * BOOT ---------------------------------------------------------------------------------------------------------------- E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT * * ---------------------------------------------------------------------------------------------------------------- E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL * * W/ CROSS BARS, ATTACH TO BED ---------------------------------------------------------------------------------------------------------------- E0947 E0947 2113 FRACTURE FRAME (E0947), * * ATTACHMENTS FOR COMPLEX PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0948 E0948 2112 FRACTURE FRAME (E0948) * * ATTACHMENTS FOR COMPLEX CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0950 DM570 2139 TRAY (E0950) * ---------------------------------------------------------------------------------------------------------------- E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO * CONVERT ANY W/C TO ONE ARM DRIVE ---------------------------------------------------------------------------------------------------------------- E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) * (COMPENSATE FOR TRANS OF WEIGHT) ---------------------------------------------------------------------------------------------------------------- E0962 E0962 2232 CUSHION FOR WC 1" (E0962) * ---------------------------------------------------------------------------------------------------------------- E0963 E0963 2233 CUSHION FOR WC 2" (E0963) * ---------------------------------------------------------------------------------------------------------------- E0964 E0964 2234 CUSHION FOR WC 3" (E0964) * ---------------------------------------------------------------------------------------------------------------- E0965 E0965 2235 CUSHION FOR WC 4" (E0965) * ---------------------------------------------------------------------------------------------------------------- E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) * ---------------------------------------------------------------------------------------------------------------- E0978 E0978 2248 BELT, SAFETY (E0978) W/ * AIRPLANE BUCKLE, W/C ---------------------------------------------------------------------------------------------------------------- E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO * CLOSURE, W/C ---------------------------------------------------------------------------------------------------------------- E0980 DM570 2292 SAFETY VEST (E0980), W/C * ---------------------------------------------------------------------------------------------------------------- E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ * * CASTORS 5" OR GREATER ---------------------------------------------------------------------------------------------------------------- E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1060 E1060 2259 W/C FULL/REC (E1070), DETACH * * ARMS, SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) * ---------------------------------------------------------------------------------------------------------------- E1066 E1066 2247 BATTERY CHARGER (E1066) * * ---------------------------------------------------------------------------------------------------------------- E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) * * ---------------------------------------------------------------------------------------------------------------- E1070 E1070 2258 W/C FULL/REC (E1060), DETACH * * ARMS, SWING AWAY DET/ ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, * * SWING AWAY DETACH ABLE ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, * * SWING AWAY DETACH ABLE FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), * * FIX ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), * * D/ ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), * * FIX ARMS, S/AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1090 E1090 2267 W/C HI STRENGTH LT-WG (E1090), * * DETACH ARMS, S/AWAY D/FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * * ---------------------------------------------------------------------------------------------------------------- E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), * * DETACH ARMS S/AWAY DETACH ELEVAT LEGS ---------------------------------------------------------------------------------------------------------------- E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), * * DETACH ARMS S/AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1100 E1100 2296 W/C SEMI-RECLINING (E1100), * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1110 E1110 2295 W/C SEMI-RECLINING (E1110), * * DETACH ARMS ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1130 E1130 2303 W/C STANDARD (E1130), FIX OR * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING * * AWAY DETACH FOOTRESTS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2396 W/C (E1160), W/FIX ARMS * * REMOVABLE FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, * * W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH * * ARMS W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH * * ARMS SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH * * ARMS SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL * * LENGTH ARMS, S/AWAY D/FOOTREST ---------------------------------------------------------------------------------------------------------------- E1210 E1210 2281 W/C MOTORIZED (E1210), FIX * * ARMS, S/AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH * * ARMS, S/AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1212 E1212 2282 W/C MOTORIZED (E1212), FIX * * ARMS, SWING AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH * * ARMS S/AWAY, DETACH ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2551 W/C CUSTOM (E1220) * * ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2579 W/C XXWIDE (E1220) * ---------------------------------------------------------------------------------------------------------------- E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 * * WHEEL ---------------------------------------------------------------------------------------------------------------- E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS * * SWING AWAY DETACH, ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH * * ARMS ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH * * ARMS SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1295 E1295 2272 W/C HVY DUTY (E1295), FIX * * ARMS, ELEV LEGREST ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1300 DM570 2062 WHIRLPOOL (E1300), PORT * * (OVERTUB TYPE) ---------------------------------------------------------------------------------------------------------------- E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT * * (BUILT-IN TYPE) ---------------------------------------------------------------------------------------------------------------- E1353 E1353 2381 O2 REGULATOR (E1353) * * ---------------------------------------------------------------------------------------------------------------- E1355 E1355 2384 CYLINDER STAND/RACK (E1355) * * ---------------------------------------------------------------------------------------------------------------- E1372 E1372 2331 IMMERSION EXT HEATER (E1372) * * FOR NEBULIZER ---------------------------------------------------------------------------------------------------------------- E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL * * COMPRESSOR, W/ LIMITED FLOW ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2568 ADAPTER (A9900), AC/DC * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2552 BATH LIFT (E1399), CUSTOM * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2563 BED WEDGE (E1399), 12" * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), * * CUSTOM ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2565 COMMODE (E1399), DROP ARM, * HEAVY DUTY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), * * MISCELLANEOUS ---------------------------------------------------------------------------------------------------------------- E1399 E1220 2584 GERI CHAIR (E1399), THREE * * POSITION RECLINING ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6780 HOLTER MONITOR (G0004) * ---------------------------------------------------------------------------------------------------------------- E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, * * XLONG, W/MATTRESS & SIDE RAILS ---------------------------------------------------------------------------------------------------------------- E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2588 MONITOR (E1399), VITAL SIGNS * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2529 O2 ANALYZER (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6775 OXIMETRY TEST (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2561 PEAK FLOW METER (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4559 PEDIATRIC WALKER (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2567 PNEUMOGRAM (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2553 POSITIONING, CUSTOM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2526 PULSE OXIMETER (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * * * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2562 SHOWER, HAND HELD (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW * * * VOLTAGE OR INTERFERENTIAL ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM * * * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR * * * ONLY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7505 W/C, CUSTOM (E1399) POWER * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2564 WALKER (E1399), HEAVY DUTY, * * * EXTRA WIDE ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2585 WALKER (E1399), HEMI * * * ---------------------------------------------------------------------------------------------------------------- K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) * * * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION * * * DEVICE (K0539) ---------------------------------------------------------------------------------------------------------------- K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION * * * DEVICE (K0540) ---------------------------------------------------------------------------------------------------------------- E1400 E1390 2361 O2 CONC (E1390),MANUF SPEC * * * MAXFLOWRATE = 2 LTS PER MIN@85% ---------------------------------------------------------------------------------------------------------------- G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) * * * ---------------------------------------------------------------------------------------------------------------- K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) * * * ---------------------------------------------------------------------------------------------------------------- K0183 DM590 2516 CPAP MASK (K0183) * * * ---------------------------------------------------------------------------------------------------------------- K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) * * * REPLACEMENT FOR NASAL APP/ DVC, PAIR ---------------------------------------------------------------------------------------------------------------- K0185 DM590 2514 CPAP HEADGEAR (K0185) * * * ---------------------------------------------------------------------------------------------------------------- K0186 DM590 2513 CPAP CHIN STRAP (K0186) * * * ---------------------------------------------------------------------------------------------------------------- K0187 DM590 2512 CPAP TUBING (K0187) * * * ---------------------------------------------------------------------------------------------------------------- K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE * * * ---------------------------------------------------------------------------------------------------------------- K0189 DM590 2510 CPAP FILTER (A9900), * * * NON-DISPOSABLE ---------------------------------------------------------------------------------------------------------------- K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL * * * ---------------------------------------------------------------------------------------------------------------- K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, * * * EQUIVALENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC * * * AIR THERAPY ---------------------------------------------------------------------------------------------------------------- A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 * * * SCOOP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL * * * SECRETION MOBIL DEVICE ---------------------------------------------------------------------------------------------------------------- E0168B A9900 7643 COMMODE (E0168B) HVY DUTY * BEDSIDE CHAIR 251-450 LBS. ---------------------------------------------------------------------------------------------------------------- E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP * ARM 451-850 LBS. ---------------------------------------------------------------------------------------------------------------- A6234 HH591 7626 DRESSING <16 SQ IN (A6234) * HYDROCOLLOID DRESSING, EA ---------------------------------------------------------------------------------------------------------------- A6258 HH591 7627 DRESSING >16 SQ IN (A6258) * TRANSPAREN FILM, EA ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN * (A46203) SELF ADH, EA ---------------------------------------------------------------------------------------------------------------- B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE * F/KANGAROO PUMP ---------------------------------------------------------------------------------------------------------------- B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP * BASIC ---------------------------------------------------------------------------------------------------------------- B9998D DM590 7657 ENT (B9998D) FARRELL GASTRIC * RELIEF VLV ---------------------------------------------------------------------------------------------------------------- B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET * ---------------------------------------------------------------------------------------------------------------- B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY * SIZE MIC-KEY OR HIDE A PORT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL * NOSE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7660 IPPB (E1399) UNIV SET UP * W/MANIFOLD NEBULIZER ---------------------------------------------------------------------------------------------------------------- K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7641 MECHANICAL SCALE (E1399) * PEDIATRIC/NEONATAL ---------------------------------------------------------------------------------------------------------------- A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL * W/STR H20 1L BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7663 O2 CONNECTOR (E1399) * SIMS/IRRIGATION NOZZLE BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7615 O2 HUMIDIFIER (E1399) * AQUA+NEONATAL EA HUD ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER * ANGLED STERILE ---------------------------------------------------------------------------------------------------------------- L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS * ---------------------------------------------------------------------------------------------------------------- A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG * 1L BAX ---------------------------------------------------------------------------------------------------------------- A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & * TUBING ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA * ---------------------------------------------------------------------------------------------------------------- A6265 HH591 7628 TAPE ALL TYPES (A6265) * EXCLUDING MICROFOAM, PER 18 SQ INCHES ---------------------------------------------------------------------------------------------------------------- A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA * ELECTROSTATIC ---------------------------------------------------------------------------------------------------------------- A4623 A9900 7618 TRACH INNER (A4623) CANNULA * ---------------------------------------------------------------------------------------------------------------- A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR * OR HOLDER ---------------------------------------------------------------------------------------------------------------- A7010 A9900 7662 TUBING (A7010) AEROSOL * CORRUGATED PER FOOT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7630 VENT BATTERY CHARGER (A9900) * 12V GEL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR * ADULT OMNIFLEX DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S * ELECTOSTATIC MAL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7634 VENT THERMOMETER (E1399) W/ * ADAPTER ---------------------------------------------------------------------------------------------------------------- K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP * BLK 10/PK ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7635 WALKER BASKET (E1399) VINYL * COATED ---------------------------------------------------------------------------------------------------------------- E0159 A9900 7640 WALKER BRAKE (E0159) ATTACHMENT * ---------------------------------------------------------------------------------------------------------------- E0148 A9900 7636 WALKER HVY DUTY (E0148) FOLDING * X-WIDE ---------------------------------------------------------------------------------------------------------------- E0149 A9900 7637 WALKER HVY DUTY (E0149) W/ * WHEELS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER * CABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7646 CPAP (E1399) EXHALATION PORT * DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7647 CPAP (E1399) FUSE KIT * INTERNATIONAL A/C ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER * KIT DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER * REUSABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7650 CPAP (E1399) HUMIDIFIER * MOUNTING TRAY ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7652 CPAP (E1399) POWER CORD * F/ARIA-SYNC ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE * TAP ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) * ---------------------------------------------------------------------------------------------------------------- A7037 DM590 7565 CPAP SHORT TUBING (A9900) * ---------------------------------------------------------------------------------------------------------------- E0601 E0601 7690 VENT, CONTINUOUS POSITIVE * * (E0500) AIRWAY PRESSURE DEVICE ---------------------------------------------------------------------------------------------------------------- E0452 E0452 7691 VENT, BILEVEL INTERMITTENT * * (E0500) ASSIST DEVICE (BIPAP) ---------------------------------------------------------------------------------------------------------------- E0747 DM570 6875 STIMULATOR, OSTEOGENIC, * ULTRASOUND ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7695 GEL/SILICON GOLD SEAL * CPAP/BIPAP MASK (A9900) ---------------------------------------------------------------------------------------------------------------- KO533 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ * * * BACKUP RATE (K0533) ---------------------------------------------------------------------------------------------------------------- E0434 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT * * * (E1399) ---------------------------------------------------------------------------------------------------------------- HH591 HH591 7704 PUMP, EXT INFUSION, DANA * * * DIABECARE, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, * * * INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR * * * USE WITH BREEZE MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A7036 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) * * * ---------------------------------------------------------------------------------------------------------------- E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) * * ----------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances: ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2731 SHIPPING AND HANDLING FEES * * ----------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment: ---------------------------------------------------------------------------------------------------------------- E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) * * SERVICE REQUIRING SKILL OF A TECH ---------------------------------------------------------------------------------------------------------------- E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4552 MISCELLANEOUS SUPPLIES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2589 REPAIR (E1399), RESPIRATORY * * EQUIPMENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4549 TENS/APNEA SUPPLIES * * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested NOTES: * * * * * * * Confidential treatment requested PPO & INDEMNITY PROGRAM ATTACHMENT TO MANAGED CARE ALLIANCE AGREEMENT PURPOSE The terms and provisions of this PPO & Indemnity Program Attachment and the Agreement are applicable to services rendered by MCA's Represented Providers to PPO & Indemnity Program Participants. I. PARTIES' OBLIGATIONS A. COMPENSATION AND BILLING 1. Reimbursement for Home Care Services rendered by Represented Providers shall be in accordance with the following rates, less applicable Copayments, Deductibles or Coinsurance: a. Reimbursement for Home Care services arranged by MCA and rendered by Represented Providers shall be in accordance with Exhibit B attached hereto. b. MCA will indemnify and hold harmless Payors, CIGNA and its Affiliates from any claim for payment in excess of the specified amounts for covered Home Care Services rendered to Participants by each Represented Provider, unless the claim arises from a Payor's wrongful failure to pay MCA for covered Home Care Services. 2. Payors shall agree to deduct any Copayments, Deductibles, or Coinsurance required by the Service Agreement from payment due. Deduction for the Copayment, Deductible or Coinsurance shall be determined on the basis of the contracted rate. 3. Reimbursement for Home Care Services rendered hereunder shall be made by CIGNA or its designees to MCA. MCA shall bill for covered Home Care Services according to the following: a. MCA shall submit claims on the appropriate claim form for all covered Home Care Services within one hundred twenty (120) days of the date those services are rendered. Claims received after this one hundred twenty (120) day period may be denied for payment. MCA shall submit claims to the location described in applicable Program Requirements. b. Any amount owing under this Agreement shall be paid within thirty (30) days after receipt of a complete claim, unless additional required information is requested within the thirty (30) day period, or the claim involves coordination of benefits, except as otherwise provided in this Agreement. 4. MCA and its Represented Providers shall not charge a Participant for a service which is not Medically Necessary unless the Participant is notified that the service may not be covered and the Participant acknowledges in writing that he or she shall be responsible for payment of charges for such service. 5. MCA will and shall require its Represented Providers to look solely to Payor for compensation for covered Home Care Services except for Copayments, Deductibles or Coinsurance. MCA agrees, for itself and on behalf of each Represented Provider, that whether or not there is any unresolved dispute for payment, under no circumstances will MCA or any Represented Provider directly or indirectly make any charges or claims, other than for Copayments, Deductibles or Coinsurance against any Participants or their representatives for covered Home Care Services and that this provision survives termination of this Agreement for services rendered prior to such termination. This provision shall not prohibit collection of (i) any applicable Copayments, Deductibles, or Coinsurance, (ii) payments for services provided to a patient who is no longer eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit (iii) payment for services provided to Participants, which are not Home Care Services. This paragraph is to be interpreted for the benefit of Participants and does not diminish the obligation of Payor to make payments to Represented Providers according to the terms of this Agreement. 6. The rates set forth herein shall apply to all services rendered to Participants in the PPO Program. 7. Only those charges for Home Care Services billed in accordance with CIGNA's standard claim coding and bundling methodology will be allowed. B. UTILIZATION MANAGEMENT 1. To promote the participation and effectiveness of Utilization Management, if MCA is responsible for initiating the pre-certification process as indicated by the Participant's ID card, MCA or Represented Providers shall notify CIGNA or its designated Utilization Management representative of any scheduled homecare admissions at least forty-eight (48) hours prior to such admission, or as soon as reasonably possible. MCA or Represented Providers shall notify the review organization of an Emergency admission(s) within one (1) working day following the admission(s). 2. Whenever any homecare admission has not been pre-certified, CIGNA or its designated Utilization Management representative may conduct retrospective review to determine whether services provided were Medically Necessary. 3. MCA may appeal a Utilization Management decision in accordance with the dispute resolution procedure set forth in the Agreement and Program Requirements. 4. Provider shall evaluate whether each Participant order or prescription it receives for Covered Home Care Services under this Program are Medically Necessary, utilizing Utilization Management guidelines mutually developed by the parties (see Exhibits XVII AND XX1). 5. Provider will notify CIGNA's Intracorp subsidiary of each referral it receives for Covered Home Care Services, that meets case management criteria as defined by MCA and Intracorp, and will coordinate with Intracorp in the provision of case management and concurrent inpatient utilization review services to Participants under this Program. The parties will determine the specific roles and responsibilities of CIGNA, Provider and Intracorp with respect to Utilization Management during the implementation process. 6. CIGNA will review claims submitted for Covered Home Care Services by Provider and Subcontractors under this Program to assure that all billed services were Medically Necessary, based on utilization review criteria mutually developed by both parties. If an individual at Intracorp (or its successor function) identified by CIGNA certifies to Provider the Medical Necessity of a particular service in advance of the provision of such service, CIGNA shall not retrospectively deny payment for such service on the basis of Medical Necessity. 7. Where CIGNA determines billed services not to be Medically Necessary and denies payment, Provider may appeal the payment denial in accordance with the appeal procedures described in the Program Requirements to this Program Attachment. C. 24 HOUR COVERAGE Subject to the terms of this agreement, MCA, through its Represented Providers, shall arrange to provide Medically Necessary Home Care Services to Participants on a 24-hour per day, 7-day per week basis or arrange with other qualified providers (which meet all CIGNA and MCA credentialing requirements and/or other guidelines) to provide such Medically Necessary Home Care Services to Participants. MCA shall require that such covering providers (a) are Participating Providers (unless otherwise agreed); (b) will not seek compensation from CIGNA for Home Care Services for which MCA or its Represented Providers receive compensation hereunder; (c) will not bill Participants for Home Care Services under any circumstances except for; (i) any applicable Copayments, Deductibles, or Coinsurance, (ii) payments for services provided to a patient who is no longer eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit (iii) payment for services provided to Participants, which are not Home Care Services; and (d) will direct the Participant and/or Represented Provider to obtain authorization from CIGNA prior to all hospitalizations or referrals of Participants, except in Emergencies or as otherwise required by law. EXHIBIT A PPO & INDEMNITY PROGRAM ATTACHMENT REIMBURSEMENT FOR OTHER SERVICES RATE AREA DESIGNATIONS: STATE RATE AREA RATE DESIGNATION -------------------------------------------------------------------------- Alabama LOW 3 -------------------------------------------------------------------------- Alaska HIGH 1 -------------------------------------------------------------------------- Arizona MEDIUM 2 -------------------------------------------------------------------------- Arkansas LOW 3 -------------------------------------------------------------------------- California HIGH 1 -------------------------------------------------------------------------- Colorado MEDIUM 2 -------------------------------------------------------------------------- Connecticut MEDIUM 2 -------------------------------------------------------------------------- Delaware LOW 3 -------------------------------------------------------------------------- District of Columbia HIGH 1 -------------------------------------------------------------------------- Florida MEDIUM 2 -------------------------------------------------------------------------- Georgia MEDIUM 2 -------------------------------------------------------------------------- Hawaii HIGH 1 -------------------------------------------------------------------------- Idaho LOW 3 -------------------------------------------------------------------------- Illinois HIGH 1 -------------------------------------------------------------------------- Indiana LOW 3 -------------------------------------------------------------------------- Iowa LOW 3 -------------------------------------------------------------------------- Kansas LOW 3 -------------------------------------------------------------------------- Kentucky LOW 3 -------------------------------------------------------------------------- Louisiana MEDIUM 2 -------------------------------------------------------------------------- Maine LOW 3 -------------------------------------------------------------------------- Maryland MEDIUM 2 -------------------------------------------------------------------------- Massachusetts HIGH 1 -------------------------------------------------------------------------- Michigan LOW 3 -------------------------------------------------------------------------- Minnesota LOW 3 -------------------------------------------------------------------------- Mississippi LOW 3 -------------------------------------------------------------------------- Missouri MEDIUM 2 -------------------------------------------------------------------------- Montana LOW 3 -------------------------------------------------------------------------- Nebraska LOW 3 -------------------------------------------------------------------------- Nevada LOW 3 -------------------------------------------------------------------------- New Hampshire LOW 3 -------------------------------------------------------------------------- New Jersey MEDIUM 2 -------------------------------------------------------------------------- New Mexico LOW 3 -------------------------------------------------------------------------- New York MEDIUM 2 -------------------------------------------------------------------------- North Carolina MEDIUM 2 -------------------------------------------------------------------------- North Dakota MEDIUM 2 -------------------------------------------------------------------------- Ohio MEDIUM 2 -------------------------------------------------------------------------- Oklahoma LOW 3 -------------------------------------------------------------------------- Oregon MEDIUM 2 -------------------------------------------------------------------------- Pennsylvania MEDIUM 2 -------------------------------------------------------------------------- Rhode Island MEDIUM 2 -------------------------------------------------------------------------- South Carolina MEDIUM 2 -------------------------------------------------------------------------- South Dakota LOW 3 -------------------------------------------------------------------------------- Tennessee MEDIUM 2 -------------------------------------------------------------------------------- Texas HIGH 1 -------------------------------------------------------------------------------- Utah MEDIUM 2 -------------------------------------------------------------------------------- Vermont LOW 3 -------------------------------------------------------------------------------- Virginia MEDIUM 2 -------------------------------------------------------------------------------- Washington MEDIUM 2 -------------------------------------------------------------------------------- West Virginia LOW 3 -------------------------------------------------------------------------------- Wisconsin LOW 3 -------------------------------------------------------------------------------- Wyoming LOW 3 -------------------------------------------------------------------------------- TRADITIONAL HOME HEALTH SERVICES RATES: RATES EFFECTIVE JANUARY 1, 2004 - DECEMBER 31, 2004 THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE BOTH VISIT AND HOURLY RATES. Notes 1, 2, 3, 4, 5 and 6 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- VISIT HOUR VISIT HOUR VISIT HOUR -------------------------------------------------------------------------------------------------------------- CERTIFIED NURSES AIDE * * * * * * -------------------------------------------------------------------------------------------------------------- HOME HEALTH AIDE * * * * * * -------------------------------------------------------------------------------------------------------------- LVN/LPN * * * * * * -------------------------------------------------------------------------------------------------------------- LVN/LPN - HIGH TECH * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC HIGH TECH LVN/LPN * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC HIGH TECH RN * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC LVN/LPN * * * * * * -------------------------------------------------------------------------------------------------------------- PEDIATRIC RN * * * * * * -------------------------------------------------------------------------------------------------------------- RN * * * * * * -------------------------------------------------------------------------------------------------------------- RN HIGH TECH INFUSION * * * * * * -------------------------------------------------------------------------------------------------------------- RN HIGH TECH OTHER * * * * * * --------------------------------------------------------------------------------------------------------------
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE VISIT ONLY RATES. Notes 1, 3, 4, 5, 7 and 8 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- VISIT HOUR VISIT HOUR VISIT HOUR -------------------------------------------------------------------------------------------------------------- DIABETIC NURSE * * * * * * -------------------------------------------------------------------------------------------------------------- DIETITIAN * * * * * * -------------------------------------------------------------------------------------------------------------- ENTEROSTOMAL THERAPIST * * * * * * -------------------------------------------------------------------------------------------------------------- MATERNAL CHILD HEALTH * * * * * * -------------------------------------------------------------------------------------------------------------- MEDICAL SOCIAL WORKER * * * * * * -------------------------------------------------------------------------------------------------------------- OCCUPATIONAL THERAPIST * * * * * * -------------------------------------------------------------------------------------------------------------- OCCUPATIONAL THERAPIST ASSISTANT * * * * * * -------------------------------------------------------------------------------------------------------------- PHLEBOTOMIST * * * * * * -------------------------------------------------------------------------------------------------------------- PHOTOTHERAPY PACKAGE SERVICE * * * * * * -------------------------------------------------------------------------------------------------------------- PHYSICAL THERAPIST * * * * * * -------------------------------------------------------------------------------------------------------------- PHYSICAL THERAPIST ASSISTANT * * * * * * -------------------------------------------------------------------------------------------------------------- PSYCHIATRIC NURSE * * * * * * -------------------------------------------------------------------------------------------------------------- REHABILITATION NURSE * * * * * * --------------------------------------------------------------------------------------------------------------
* Confidential treatment requested -------------------------------------------------------------------------------------------------------------- RESPIRATORY THERAPIST * * * * * * -------------------------------------------------------------------------------------------------------------- RESPIRATORY THERAPIST - CPAP Clinic * * * * * * -------------------------------------------------------------------------------------------------------------- RN ASSESSMENT, INITIAL * * * * * * -------------------------------------------------------------------------------------------------------------- RN SKILLED NURSING VISIT-EXTENSIVE * * * * * * -------------------------------------------------------------------------------------------------------------- SPEECH THERAPIST * * * * * * --------------------------------------------------------------------------------------------------------------
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE HAS HOURLY ONLY RATES. Notes 3, 4 and 5 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- VISIT HOUR VISIT HOUR VISIT HOUR -------------------------------------------------------------------------------------------------------------- HOMEMAKER * * * * * * --------------------------------------------------------------------------------------------------------------
THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE IS PRICED ON A PER DIEM BASIS. Notes 3, 4 and 5 apply
------------------------------------------------------------------- AREA 1 AREA 2 AREA 3 ------------------------------------------------------------------- PER DIEM PER DIEM PER DIEM -------------------------------------------------------------------------------------------------------------- COMPANION/LIVE IN * * * * * * --------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * * * HOME INFUSION RATES: RATES EFFECTIVE JANUARY 1, 2004 - DECEMBER 31, 2004 THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE PRICED AS A PERCENTAGE DISCOUNT OFF AWP (IF APPLICABLE), AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR PRIMARY OR PRIMARY OR MULTIPLE THERAPY MULTIPLE THERAPY MULTIPLE THERAPY PER DIEM DISPENSING FEE DRUG DISCOUNT OFF AWP ----------------------------------------------------------------------------------------------------------- Ancillary Drugs * * * ----------------------------------------------------------------------------------------------------------- Biological Response Modifiers * * * ----------------------------------------------------------------------------------------------------------- Cardiac (Inotropic) Therapy * * * ----------------------------------------------------------------------------------------------------------- Chelation Therapy * * * -----------------------------------------------------------------------------------------------------------
* Confidential treatment requested ----------------------------------------------------------------------------------------------------------- Chemotherapy * * * ----------------------------------------------------------------------------------------------------------- Enteral Therapy * * * ----------------------------------------------------------------------------------------------------------- Enzyme Therapy * * * ----------------------------------------------------------------------------------------------------------- Growth Hormone * * * ----------------------------------------------------------------------------------------------------------- IV Immune Globulin * * * ----------------------------------------------------------------------------------------------------------- Other Injectable Therapies * * * ----------------------------------------------------------------------------------------------------------- Other Infusion Therapies * * * ----------------------------------------------------------------------------------------------------------- Pain Management Therapy * * * ----------------------------------------------------------------------------------------------------------- Steroid Therapy * * * ----------------------------------------------------------------------------------------------------------- Thrombolytic (Anticoagulation) Therapy * * * ----------------------------------------------------------------------------------------------------------- Synagis * * * ----------------------------------------------------------------------------------------------------------- Remodulin Therapy * * * -----------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE PRICED AS A PERCENTAGE DISCOUNT OFF AWP, AND THERE IS A PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
----------------------------------------------------------------------------------------------------------- PER DIEM DRUG DISCOUNT OFF AWP ----------------------------------------------------------------------------------------------------------- Anti-Infectives - Primary Anti-Infective * * * ----------------------------------------------------------------------------------------------------------- Anti-Infectives - Multiple Anti-Infective * * * -----------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATE EXCLUDES DRUGS. DRUGS ARE PRICED PER VIAL, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
----------------------------------------------------------------------------------------------------------- PRIMARY OR MULTIPLE THERAPY PER DIEM COST OF DRUG ----------------------------------------------------------------------------------------------------------- Flolan Therapy * ----------------------------------------------------------------------------------------------------------- Flolan 0.5 mg vial * ----------------------------------------------------------------------------------------------------------- Flolan 1.5 mg vial * ----------------------------------------------------------------------------------------------------------- Flolan diluent vial * -----------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES INCLUDE DRUGS, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
----------------------------------------------------------------------------------------------------------- PRIMARY OR MULTIPLE THERAPY PER DIEM ----------------------------------------------------------------------------------------------------------- Enteral Therapy * ----------------------------------------------------------------------------------------------------------- Hydration Therapy * ----------------------------------------------------------------------------------------------------------- Total Parenteral Nutrition * -----------------------------------------------------------------------------------------------------------
NOTES: * * * Confidential treatment requested * * * * * THE FOLLOWING ARE FOR THE STATED ITEM ONLY. UNLESS OTHERWISE NOTED, NURSING, SUPPLIES, ETC. ARE NOT INCLUDED. ----------------------------------------------------------------------------------------------------------- Blood Transfusion per Unit (Tubing, Filters) * ----------------------------------------------------------------------------------------------------------- Catheter Care Per Diem * ----------------------------------------------------------------------------------------------------------- Midline Insertion (Catheter & Supplies) * ----------------------------------------------------------------------------------------------------------- PICC Line Insertion (Catheter & Supplies) * ----------------------------------------------------------------------------------------------------------- Blood Product * -----------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------- FACTOR CONCENTRATES ----------------------------------------------------------------------------------------------------------- Vial price Unit Price ----------------------------------------------------------------------------------------------------------- FACTOR VII ----------------------------------------------------------------------------------------------------------- Novoseven 1200MCG Vial * ----------------------------------------------------------------------------------------------------------- Novoseven 4800MCG Vial * ----------------------------------------------------------------------------------------------------------- Novoseven in 1200MCG or 4800MCG QTY * ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- FACTOR VIII (RECOMBINANT) ----------------------------------------------------------------------------------------------------------- Recombinate * ----------------------------------------------------------------------------------------------------------- Kogenate or Helixate * ----------------------------------------------------------------------------------------------------------- Bioclate * ----------------------------------------------------------------------------------------------------------- Helixate FS * ----------------------------------------------------------------------------------------------------------- Kogenate FS * ----------------------------------------------------------------------------------------------------------- Refacto * ----------------------------------------------------------------------------------------------------------- Advate * ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- FACTOR VIII (MONOCLONAL) ----------------------------------------------------------------------------------------------------------- Hemofil-M or A. R. C. Method M * ----------------------------------------------------------------------------------------------------------- Monoclate P * ----------------------------------------------------------------------------------------------------------- Monarc-M * ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- FACTOR VIII (OTHER) ----------------------------------------------------------------------------------------------------------- Koate * ----------------------------------------------------------------------------------------------------------- Humate * ----------------------------------------------------------------------------------------------------------- Alphanate SDHT * ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- FACTOR IX (RECOMBINANT) ----------------------------------------------------------------------------------------------------------- BeneFix * -----------------------------------------------------------------------------------------------------------
* Confidential treatment requested ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- FACTOR IX (MONOCLONAL/HIGH PURITY) ----------------------------------------------------------------------------------------------------------- Mononine * ----------------------------------------------------------------------------------------------------------- Alphanine * ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- FACTOR IX (OTHER) ----------------------------------------------------------------------------------------------------------- Konyne - 80 * ----------------------------------------------------------------------------------------------------------- Proplex T * ----------------------------------------------------------------------------------------------------------- Bebulin * ----------------------------------------------------------------------------------------------------------- Profilnine SD * ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- ANTI-INHIBITOR COMPLEX ----------------------------------------------------------------------------------------------------------- Autoplex-T * ----------------------------------------------------------------------------------------------------------- Feiba-VH * ----------------------------------------------------------------------------------------------------------- Hyate-C * ----------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- HEMOSTATIC AGENTS ----------------------------------------------------------------------------------------------------------- DDAVP - 10ml vial * ----------------------------------------------------------------------------------------------------------- Stimate - 2.5ml vial * -----------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit; 24-hour on-call clinical support; home infusion monitoring system; product delivery nationwide; patient training, education, and evaluation DME/HOME RESPIRATORY RATES: RATES EFFECTIVE JANUARY 1, 2004 - MARCH 31, 2004
---------------------------------------------------------------------------------------------------------------- HCPCS CHC CODE CODE GENTIVA CODE DESCRIPTION PURCHASE PRICE RENTAL PRICE DAILY PRICE ---------------------------------------------------------------------------------------------------------------- A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) * W/STETH & CUFF ---------------------------------------------------------------------------------------------------------------- A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), * AUTOMATIC ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK * ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7553 FULL FACE (A9900) MIRAGE * CPAP/BIPAP MASK ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP * MASK INCL GLD SEAL,PHANTM, MONARCH ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP * MASK (PROFILE OR SIMPICITY) ---------------------------------------------------------------------------------------------------------------- B9002 HI531 2570 PUMP, ENTERAL (B9002) * * ---------------------------------------------------------------------------------------------------------------- B9998 DM590 6828 ENTERAL SUPPLIES (B9998) * ---------------------------------------------------------------------------------------------------------------- DM590 DM570 7551 BACK-PACK (E1399), FOR PORTABLE * ENTERAL PUMP ---------------------------------------------------------------------------------------------------------------- A4615 DM590 2522 CANNULA, NASAL * ---------------------------------------------------------------------------------------------------------------- B9002 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * * ---------------------------------------------------------------------------------------------------------------- A7034 DM590 7508 MASK, CPAP GEL OR SILICONE * (K0183) ---------------------------------------------------------------------------------------------------------------- E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/TIP * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0105 E0105 2021 CANE, QUAD (E0105) OR THREE * PRONG, ADJ OR FIX, W/ TIPS ---------------------------------------------------------------------------------------------------------------- E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ * OR FIX, PAIR, W/ TIPS, GRIPS ---------------------------------------------------------------------------------------------------------------- E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR * FIX, EACH, W/ TIP AND GRIPS ---------------------------------------------------------------------------------------------------------------- E0112 E0112 2027 CRUTCHES UNDERARM, WOOD * (E0112), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0114 E0114 2026 CRUTCHES UNDERARM, ALUM (E0114), * ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0130 E0130 2037 WALKER, RIGID (E0130) (PICKUP), * ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0135 E0135 2036 WALKER, FOLDING (E0135) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0141 E0141 2040 WALKER, WHEELED (E0141), W/OUT * SEAT ---------------------------------------------------------------------------------------------------------------- E0142 DM570 2034 RIGID WALKER (E0142), WHEELED, * W/ SEAT, ---------------------------------------------------------------------------------------------------------------- E0143 E0143 2029 WALKER FOLDING, WHEELED (E0143), * W/OUT SEAT ---------------------------------------------------------------------------------------------------------------- E0145 DM570 2039 WALKER (E0145), WHEELED, W/ SEAT * AND CRUTCH ATTACHMENTS ---------------------------------------------------------------------------------------------------------------- E0146 DM570 2038 WALKER, WHEELED, W/ SEAT (E0146) * ---------------------------------------------------------------------------------------------------------------- E0147 E0147 2030 WALKER HVY DUT (E0147), MULT * BRAKING SYS, VAR WHEEL RESISTANCE ---------------------------------------------------------------------------------------------------------------- E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT * (E0153), FOREARM EA ---------------------------------------------------------------------------------------------------------------- E0154 E0154 2033 WALKER PLATFORM ATTACHMENT * (E0154), EA ---------------------------------------------------------------------------------------------------------------- E0155 E0155 2041 WALKER WHEEL ATTACHMENT (E0155), * RIGID (PICKUP) WALKER ---------------------------------------------------------------------------------------------------------------- E0156 DM570 2035 WALKER SEAT ATTACHMENT (E0156) * ---------------------------------------------------------------------------------------------------------------- E0157 E0157 2022 WALKER, CRUTCH ATTACHMENT * (E0157), EACH ---------------------------------------------------------------------------------------------------------------- E0158 E0158 2031 WALKER LEG EXTENSIONS (E0158) * ---------------------------------------------------------------------------------------------------------------- E0163 E0163 2047 COMMODE CHAIR, STATIONARY * (E0163), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0164 E0164 2045 COMMODE CHAIR, MOBILE (E0164), * W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2046 COMMODE CHAIR (E0165), * STATIONARY, W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2591 COMMODE, XXWIDE(E0165) * ---------------------------------------------------------------------------------------------------------------- E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, * W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN * (E0167) ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE * PAD, NON-POSITIONING ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2394 REPLACEMENT PAD (E0176) * ALTERNATING PRESS ---------------------------------------------------------------------------------------------------------------- E0177 E0177 2224 CUSHION OR WATER PRESS PAD * (E0177), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0178 E0178 2160 CUSHION OR GEL PRESS PAD * (E0178), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE * PAD, NONPOSTIONING ---------------------------------------------------------------------------------------------------------------- E0180 E0180 2196 PUMP (E0180), ALTERNATING * * PRESSURES W/PAD ---------------------------------------------------------------------------------------------------------------- E0181 E0181 2197 PUMP (E0181), ALTERNATING * * PRESS W/PAD, HVY DUTY ---------------------------------------------------------------------------------------------------------------- E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) * ---------------------------------------------------------------------------------------------------------------- E0185 E0185 2076 MATTRESS (E0185), GEL OR * GEL-LIKE PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) * ---------------------------------------------------------------------------------------------------------------- E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) * ---------------------------------------------------------------------------------------------------------------- E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) * ---------------------------------------------------------------------------------------------------------------- E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN * (E0189), ANY SIZE ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2573 CUSHION, JAY FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND * * POSITIONING EQUALIZATION ---------------------------------------------------------------------------------------------------------------- E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), * * * INCL. BED ---------------------------------------------------------------------------------------------------------------- E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * * * ---------------------------------------------------------------------------------------------------------------- E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) * ---------------------------------------------------------------------------------------------------------------- E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD * (E0197) ---------------------------------------------------------------------------------------------------------------- E0198 E0198 2100 MATTRESS (E0198), WATER PRESSURE * PAD ---------------------------------------------------------------------------------------------------------------- E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD * (E0199) ---------------------------------------------------------------------------------------------------------------- E0200 E0200 2228 HEAT LAMP (E0200), W/OUT STAND, * INCL/BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) * (E0202), LIGHT WIT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET * (E0202) ---------------------------------------------------------------------------------------------------------------- E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, * INCL/ BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0210 DM570 2156 HEATING PAD, STANDARD (E0210) * ---------------------------------------------------------------------------------------------------------------- E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, * MOIST ---------------------------------------------------------------------------------------------------------------- E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * * ---------------------------------------------------------------------------------------------------------------- E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) * ---------------------------------------------------------------------------------------------------------------- E0236 DM570 2199 PUMP (E0236) FOR WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0237 DM570 2223 HEAT COLD WATER (E0237) * CIRCULATING PAD W/PUMP ---------------------------------------------------------------------------------------------------------------- E0238 DM570 2179 HEATING PAD (E0238), MOIST, * NON-ELECTRIC ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, * L-SHAPE ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2043 BATH TUB RAIL, WALL, UNSPECIFIED * SIZE ---------------------------------------------------------------------------------------------------------------- E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE * (E0242) ---------------------------------------------------------------------------------------------------------------- E0243 DM570 2056 TOILET RAIL, EACH (E0243) * ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2587 TOILET SEAT (E0244) RAISED * WITH ARMS ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2052 TOILET SEAT, RAISED (E0244) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2575 BATH BENCH WITH BACK (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2578 TRANSFER BENCH, NON-PADDED * (E0245) ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) * ---------------------------------------------------------------------------------------------------------------- E0246 DM570 2057 TRANSFER TUB RAIL(E0246), * ATTACHMENT ---------------------------------------------------------------------------------------------------------------- E0249 DM570 2186 HEAT UNIT (E0249), WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/O MATTRESS ---------------------------------------------------------------------------------------------------------------- E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) * ---------------------------------------------------------------------------------------------------------------- E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) * ---------------------------------------------------------------------------------------------------------------- E0273 DM570 2068 BED BOARD (E1399) * ---------------------------------------------------------------------------------------------------------------- E0274 DM570 2097 OVER-BED TABLE (E0274) * ---------------------------------------------------------------------------------------------------------------- E0275 E0275 2071 BED PAN, STANDARD (E0275), METAL * OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0276 E0276 2070 BED PAN, FRACTURE (E0276), METAL * OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, * * ALT PRESSURE ---------------------------------------------------------------------------------------------------------------- E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) * ---------------------------------------------------------------------------------------------------------------- E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, * * HI-LO, W/OUT S/ RAILS, W/ MATTRESS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, * * HI-LO, NO SIDE RAILS, NO MATTRESS ---------------------------------------------------------------------------------------------------------------- E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0305 E0305 2073 BED SIDE RAILS (E0305), HALF * LENGTH ---------------------------------------------------------------------------------------------------------------- E0310 E0310 2072 BED SIDE RAILS (E0310), FULL * LENGTH ---------------------------------------------------------------------------------------------------------------- E0315 DM570 2067 BED ACCESSORIES: BOARDS OR * TABLES, ANY TYPE ---------------------------------------------------------------------------------------------------------------- E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, * ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0326 E0326 2059 URINAL; FEMALE (E0326), * JUG-TYPE, ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0372 E0372 7008 MATTRESS (E0372) POWERED AIR * * OVERLAY ---------------------------------------------------------------------------------------------------------------- E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), PER * POUND ---------------------------------------------------------------------------------------------------------------- E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS * SYSTEM ONLY, UP TO 23 CUBIC FEET ---------------------------------------------------------------------------------------------------------------- E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR * GAS, RENT ---------------------------------------------------------------------------------------------------------------- E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) * ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT * * (E0431) W/CONSERV DEVICE,NO CONTENT ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) * ---------------------------------------------------------------------------------------------------------------- E0434 E0434 2377 O2 SYS PORT LIQUID,RENT (E0434) * ---------------------------------------------------------------------------------------------------------------- E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH * (E0435) ---------------------------------------------------------------------------------------------------------------- E0439 E0439 2388 O2 SYS STATIONARY (E0439) * LIQUID, RENT ---------------------------------------------------------------------------------------------------------------- E0440 E0440 2387 O2 SYS STATIONARY (E0440) * LIQUID, PURCH ---------------------------------------------------------------------------------------------------------------- E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER * (E0400), 200-300 CUBIC FT ---------------------------------------------------------------------------------------------------------------- E0444 E0444 2379 O2 CONTENTS, PORT LIQUID * (E0444), PER UNIT (1 UNIT = 1 LB.) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7555 POSITIVE PRESSURE VENTS (E0450) * * (E.G. T-BIRD) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 2392 VENTILATOR VOLUME (E0450), * * STATIONARY OR PORT ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) * * EMERGENCY BACKUP UNIT ---------------------------------------------------------------------------------------------------------------- E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) * * ASSIST DEVICE,(BIPAP) ---------------------------------------------------------------------------------------------------------------- E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); * * FOR USE 12 HOURS OR LESS PER DAY ---------------------------------------------------------------------------------------------------------------- E0455 E0455 2372 O2 TENT (E0455), EXCLUDING * * CROUP OR PEDIATRIC TENTS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * * ---------------------------------------------------------------------------------------------------------------- E0459 E0459 2324 CHEST WRAP (E0459) * * ---------------------------------------------------------------------------------------------------------------- E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE * * PRESSURE , PORTABLE OR STATIONARY ---------------------------------------------------------------------------------------------------------------- E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR * * PNEUM, HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0500 E0500 2333 IPPB , W/ BUILT-IN NEB (E0500) * * MAN OR AUTO VALVES; INT/EXT POWER ---------------------------------------------------------------------------------------------------------------- E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR * * EXTENSIV SUP/ HUMID W/ IPPB OR O2 ---------------------------------------------------------------------------------------------------------------- E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, * * GLASS, FOR USE W/ REG OR FLOWMETER ---------------------------------------------------------------------------------------------------------------- E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * * ---------------------------------------------------------------------------------------------------------------- E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) * * ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * * ---------------------------------------------------------------------------------------------------------------- E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR * * AND HEATER ---------------------------------------------------------------------------------------------------------------- E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * * ---------------------------------------------------------------------------------------------------------------- E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0601 E0601 2326 CONTINUOUS POSITVE (E0601) * * AIRWAY PRESSURE DEVICE (CPAP) ---------------------------------------------------------------------------------------------------------------- E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * * ---------------------------------------------------------------------------------------------------------------- E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) * * ---------------------------------------------------------------------------------------------------------------- E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) * * ---------------------------------------------------------------------------------------------------------------- E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) * * ACCUCHEK AD ---------------------------------------------------------------------------------------------------------------- E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) * * ---------------------------------------------------------------------------------------------------------------- E0618 E0608 2322 APNEA MONITOR (E0608) * * ---------------------------------------------------------------------------------------------------------------- E0619 E0608 2576 APNEA MONITOR (E0608) W/MEM * * (INCL SMART) ---------------------------------------------------------------------------------------------------------------- E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) * * W/SPECIAL FEATURES ---------------------------------------------------------------------------------------------------------------- E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR * * SEAT, CANVAS OR NYLON ---------------------------------------------------------------------------------------------------------------- E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, * * BATHROOM OR TOILET ---------------------------------------------------------------------------------------------------------------- E0627 E0627 4553 HIP CHAIR (E0627) * * ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED * (E0627) ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2205 SEAT LIFT MECH (E0627) * INCORPORATED INTO A COMB LIFT-CHAIR MECH ---------------------------------------------------------------------------------------------------------------- E0630 E0630 2190 PATIENT LIFT, HYDRAULIC (E0630), * * W/ SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ * SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0650 E0650 2192 PNEUM COMPRESSOR (E0650), * * NON-SEG HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG * * HOME MODEL W/OUT CALIB GRAD PRES ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG * * HOME MODEL W/ CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0655 E0655 2182 PNEUM COMPRESSOR (E0655), * NON-SEG APPLIANCE, HALF ARM ---------------------------------------------------------------------------------------------------------------- E0660 E0660 2181 PNEUM COMPRESSOR (E0660), * NON-SEG APPLIANCE, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0665 E0665 2180 PNEUM COMPRESSOR (E0665), * NON-SEG APPLIANCE, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0666 E0666 2183 PNEUM COMPRESSOR (E0666), * NON-SEG APPLIANCE, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, * FULL LEG ---------------------------------------------------------------------------------------------------------------- E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, * FULL ARM ---------------------------------------------------------------------------------------------------------------- E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, * HALF LEG ---------------------------------------------------------------------------------------------------------------- E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, * HALF ARM ---------------------------------------------------------------------------------------------------------------- E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG * GRAD PRESS, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG * GRAD PRESS, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG * GRAD PRESS, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), * APPROPRIATE FOR HOME USE ---------------------------------------------------------------------------------------------------------------- E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., * BELT, HARNESS OR VEST) ---------------------------------------------------------------------------------------------------------------- E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE * (BODY, CHEST, WRIST OR ANKLE) ---------------------------------------------------------------------------------------------------------------- E0720 E0720 2219 TENS (E0720), TWO LEAD, * * LOCALIZED STIMULATION ---------------------------------------------------------------------------------------------------------------- E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER * * AREA/MULTIPLE NERVE STIMULATION ---------------------------------------------------------------------------------------------------------------- E0731 E0731 2159 TENS OR NMES (E0731), CONDUCTIVE * GARMENT ---------------------------------------------------------------------------------------------------------------- E0744 E0744 2120 STIMULATOR (E0744), * * NEUROMUSCULAR FOR SCOLIOSIS ---------------------------------------------------------------------------------------------------------------- E0745 E0745 2121 STIMULATOR (E0745), * * NEUROMUSCULAR, ELECTRONIC SHOCK UNIT ---------------------------------------------------------------------------------------------------------------- E0745 E0745 6915 STIMULATOR FOUR CH (E0745), * * NEUROMUSCULAR ---------------------------------------------------------------------------------------------------------------- E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), * * BIOFEEDBACK DEVICE ---------------------------------------------------------------------------------------------------------------- E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, * NON-INVASIVE ---------------------------------------------------------------------------------------------------------------- E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC * NON-INVASIVE, SPINAL APPLICATIONS ---------------------------------------------------------------------------------------------------------------- E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC * SALIVARY REFLEX, NON INVASIVE ---------------------------------------------------------------------------------------------------------------- E0776 E0776 2175 IV POLE (E0776) * * ---------------------------------------------------------------------------------------------------------------- E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY * INFUSION, MINIMED, INSULIN ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7925 PUMP, EXT INFUSION, MINIMED * PREMIUM, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 6771 PUMP (E0784), INSULIN EXT * INFUSION DISETRONICS OR OTHER ---------------------------------------------------------------------------------------------------------------- E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH * TO HEADBOARD, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0850 E0850 2134 TRACTION STAND (E0850), FREE * * STANDING, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR * * STAND ---------------------------------------------------------------------------------------------------------------- E0860 E0860 2130 TRACTION EQUIP (E0860), * * OVERDOOR, CERVICAL ---------------------------------------------------------------------------------------------------------------- E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH * * TO FOOTBOARD, EXTREMITY, BUCKS ---------------------------------------------------------------------------------------------------------------- E0880 E0880 2135 TRACTION STAND (E0880) * * FREE/STAND EXTREMITY TRACTION, EG, BUCK'S ---------------------------------------------------------------------------------------------------------------- E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH * * TO FOOTBOARD, PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0900 E0900 2136 TRACTION STAND (E0900) FREE/ * * STAND PELVIC TRACTION,(EG, BUCK'S) ---------------------------------------------------------------------------------------------------------------- E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT * * HELPER, ATTACH TO BED W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH * * TO BED, INCLUDING WEIGHTS ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE * DEVICE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ANKLE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ELBOW ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE * DEVICE, HAND ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE * DEVICE, SHOULDER ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE * DEVICE, WRIST ---------------------------------------------------------------------------------------------------------------- E0940 E0940 2137 TRAPEZE BAR (E0940), FREE * * STANDING, COMPLETE W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0941 E0941 2116 TRACTION DEVICE (E0941), GRAVITY * * ASSISTED ---------------------------------------------------------------------------------------------------------------- E0942 E0942 2101 HARNESS/HALTER (E0942), CERVICAL * HEAD ---------------------------------------------------------------------------------------------------------------- E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, * BOOT ---------------------------------------------------------------------------------------------------------------- E0945 DM570 2110 HARNESS (E0945), EXTREMITY * BELT ---------------------------------------------------------------------------------------------------------------- E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL W/ * * CROSS BARS, ATTACH TO BED ---------------------------------------------------------------------------------------------------------------- E0947 E0947 2113 FRACTURE FRAME (E0947), * ATTACHMENTS FOR COMPLEX PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0948 E0948 2112 FRACTURE FRAME (E0948) * * ATTACHMENTS FOR COMPLEX CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0950 DM570 2139 TRAY (E0950) * ---------------------------------------------------------------------------------------------------------------- E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO * CONVERT ANY W/C TO ONE ARM DRIVE ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) * (COMPENSATE FOR TRANS OF WEIGHT) ---------------------------------------------------------------------------------------------------------------- E0962 E0962 2232 CUSHION FOR WC 1" (E0962) * ---------------------------------------------------------------------------------------------------------------- E0963 E0963 2233 CUSHION FOR WC 2" (E0963) * ---------------------------------------------------------------------------------------------------------------- E0964 E0964 2234 CUSHION FOR WC 3" (E0964) * ---------------------------------------------------------------------------------------------------------------- E0965 E0965 2235 CUSHION FOR WC 4" (E0965) * ---------------------------------------------------------------------------------------------------------------- E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) * ---------------------------------------------------------------------------------------------------------------- E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) * ---------------------------------------------------------------------------------------------------------------- E0978 E0978 2248 BELT, SAFETY (E0978) W/ AIRPLANE * BUCKLE, W/C ---------------------------------------------------------------------------------------------------------------- E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO * CLOSURE, W/C ---------------------------------------------------------------------------------------------------------------- E0980 DM570 2292 SAFETY VEST (E0980), W/C * ---------------------------------------------------------------------------------------------------------------- E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ * * CASTORS 5" OR GREATER ---------------------------------------------------------------------------------------------------------------- E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1060 E1060 2259 W/C FULL/REC (E1070), DETACH * * ARMS, SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) * ---------------------------------------------------------------------------------------------------------------- E1066 E1066 2247 BATTERY CHARGER (E1066) * ---------------------------------------------------------------------------------------------------------------- E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) * ---------------------------------------------------------------------------------------------------------------- E1070 E1070 2258 W/C FULL/REC (E1060), DETACH * * ARMS, SWING AWAY DET/ ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, * * SWING AWAY DETACH ABLE ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, * * SWING AWAY DETACH ABLE FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), * * FIX ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), * * D/ ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), * * FIX ARMS, S/AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1090 E1090 2267 W/C HI STRENGTH LT-WG (E1090), * * DETACH ARMS, S/AWAY D/FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * * ---------------------------------------------------------------------------------------------------------------- E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), * * DETACH ARMS S/AWAY DETACH ELEVAT LEGS ---------------------------------------------------------------------------------------------------------------- E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), * * DETACH ARMS S/AWAY DETACH FOOTRESTS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1100 E1100 2296 W/C SEMI-RECLINING (E1100), * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1110 E1110 2295 W/C SEMI-RECLINING (E1110), * * DETACH ARMS ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1130 E1130 2303 W/C STANDARD (E1130), FIX OR * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING * * AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2396 W/C (E1160), W/FIX ARMS * * REMOVABLE FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, * * W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH ARMS * * W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH ARMS * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH ARMS * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL * * LENGTH ARMS, S/AWAY D/FOOTREST ---------------------------------------------------------------------------------------------------------------- E1210 E1210 2281 W/C MOTORIZED (E1210), FIX ARMS, * * S/AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH * * ARMS , S/AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1212 E1212 2282 W/C MOTORIZED (E1212) ,FIX ARMS, * * SWING AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH * * ARMS S/AWAY, DETACH ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2551 W/C CUSTOM (E1220) * ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2579 W/C XXWIDE (E1220) * ---------------------------------------------------------------------------------------------------------------- E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 * * WHEEL ---------------------------------------------------------------------------------------------------------------- E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS * * SWING AWAY DETACH, ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH * * ARMS ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH * * ARMS SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, * * ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1300 DM570 2062 WHIRLPOOL (E1300), PORT (OVERTUB * TYPE) ---------------------------------------------------------------------------------------------------------------- E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT * (BUILT-IN TYPE) ---------------------------------------------------------------------------------------------------------------- E1353 E1353 2381 O2 REGULATOR (E1353) * * ---------------------------------------------------------------------------------------------------------------- E1355 E1355 2384 CYLINDER STAND/RACK (E1355) * ---------------------------------------------------------------------------------------------------------------- E1372 E1372 2331 IMMERSION EXT HEATER (E1372) FOR * * NEBULIZER ---------------------------------------------------------------------------------------------------------------- E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL * COMPRESSOR, W/ LIMITED FLOW ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2568 ADAPTER (A9900), AC/DC * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2552 BATH LIFT (E1399), CUSTOM * --------------------------------------------------------------------------------------------------------------- - E1399 DM570 2563 BED WEDGE (E1399), 12" * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2856 BEDROOM EQUIPMENT (E1399),CUSTOM * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2565 COMMODE (E1399), DROP ARM, HEAVY * DUTY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), * MISCELLANEOUS ---------------------------------------------------------------------------------------------------------------- E1399 E1220 2584 GERI CHAIR (E1399), THREE * * POSITION RECLINING ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6780 HOLTER MONITOR (G0004) * * ---------------------------------------------------------------------------------------------------------------- E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, * * XLONG, W/MATTRESS & SIDE RAILS ---------------------------------------------------------------------------------------------------------------- E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2588 MONITOR (E1399), VITAL SIGNS * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2529 O2 ANALYZER (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6775 OXIMETRY TEST (E1399) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2561 PEAK FLOW METER (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4559 PEDIATRIC WALKER (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2567 PNEUMOGRAM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2553 POSITIONING, CUSTOM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2526 PULSE OXIMETER (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2527 PULSE OXIMETER W/ PROBE * * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2562 SHOWER, HAND HELD (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW * * VOLTAGE OR INTERFERENTIAL ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR * * ONLY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7505 W/C, CUSTOM (E1399) POWER * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2564 WALKER (E1399), HEAVY DUTY, * EXTRA WIDE ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2585 WALKER (E1399), HEMI * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 6873 WOUND SUCTION DEVICE (K0538) * * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION * DEVICE (K0539) ---------------------------------------------------------------------------------------------------------------- K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION * DEVICE (K0540) ---------------------------------------------------------------------------------------------------------------- E1400 E1390 2361 O2 CONC (E1390),MANUF SPEC * * MAXFLOWRATE = 2 LTS PER MIN@85% ---------------------------------------------------------------------------------------------------------------- G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) * ---------------------------------------------------------------------------------------------------------------- K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) * ---------------------------------------------------------------------------------------------------------------- K0183 DM590 2516 CPAP MASK (K0183) * ---------------------------------------------------------------------------------------------------------------- K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) * REPLACEMENT FOR NASAL APP/ DVC, PAIR ---------------------------------------------------------------------------------------------------------------- K0185 DM590 2514 CPAP HEADGEAR (K0185) * ---------------------------------------------------------------------------------------------------------------- K0186 DM590 2513 CPAP CHIN STRAP (K0186) * ---------------------------------------------------------------------------------------------------------------- K0187 DM590 2512 CPAP TUBING (K0187) * ---------------------------------------------------------------------------------------------------------------- K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE * ---------------------------------------------------------------------------------------------------------------- K0189 DM590 2510 CPAP FILTER (A9900), * NON-DISPOSABLE ---------------------------------------------------------------------------------------------------------------- K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL * ---------------------------------------------------------------------------------------------------------------- K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, * * EQUIVALENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC * * AIR THERAPY ---------------------------------------------------------------------------------------------------------------- A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 * SCOOP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL * SECRETION MOBIL DEVICE ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0168B A9900 7643 COMMODE (E0168B) HVY DUTY * BEDSIDE CHAIR 251-450 LBS. ---------------------------------------------------------------------------------------------------------------- E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP * ARM 451-850 LBS. ---------------------------------------------------------------------------------------------------------------- A6234 HH591 7626 DRESSING <16 SQ IN (A6234) * HYDROCOLLOID DRESSING, EA ---------------------------------------------------------------------------------------------------------------- A6258 HH591 7627 DRESSING >16 SQ IN (A6258) * TRANSPAREN FILM, EA ---------------------------------------------------------------------------------------------------------------- A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN * (A46203) SELF ADH, EA ---------------------------------------------------------------------------------------------------------------- B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE * F/KANGAROO PUMP ---------------------------------------------------------------------------------------------------------------- B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP * BASIC ---------------------------------------------------------------------------------------------------------------- B9998D DM590 7657 ENT (B9998D) FARRELL GASTRIC * RELIEF VLV ---------------------------------------------------------------------------------------------------------------- B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET * ---------------------------------------------------------------------------------------------------------------- B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY * SIZE MIC-KEY OR HIDE A PORT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL * NOSE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7660 IPPB (E1399) UNIV SET UP * W/MANIFOLD NEBULIZER ---------------------------------------------------------------------------------------------------------------- K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7641 MECHANICAL SCALE (E1399) * PEDIATRIC/NEONATAL ---------------------------------------------------------------------------------------------------------------- A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL * W/STR H20 1L BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7663 O2 CONNECTOR (E1399) * SIMS/IRRIGATION NOZZLE BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7615 O2 HUMIDIFIER (E1399) * AQUA+NEONATAL EA HUD ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER ANGLED * STERILE ---------------------------------------------------------------------------------------------------------------- L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS * ---------------------------------------------------------------------------------------------------------------- A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG 1L * BAX ---------------------------------------------------------------------------------------------------------------- A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & * TUBING ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA * ---------------------------------------------------------------------------------------------------------------- A6265 HH591 7628 TAPE ALL TYPES (A6265) EXCLUDING * MICROFOAM, PER 18 SQ INCHES ---------------------------------------------------------------------------------------------------------------- A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA * ELECTROSTATIC ---------------------------------------------------------------------------------------------------------------- A4623 A9900 7618 TRACH INNER (A4623) CANNULA * ---------------------------------------------------------------------------------------------------------------- A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR * OR HOLDER ---------------------------------------------------------------------------------------------------------------- A7010 A9900 7662 TUBING (A7010) AEROSOL * CORRUGATED PER FOOT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7630 VENT BATTERY CHARGER (A9900) 12V * GEL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR * ADULT OMNIFLEX DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S * ELECTOSTATIC MAL ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7634 VENT THERMOMETER (E1399) W/ * ADAPTER ---------------------------------------------------------------------------------------------------------------- K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP * BLK 10/PK ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7635 WALKER BASKET (E1399) VINYL * COATED ---------------------------------------------------------------------------------------------------------------- E0159 A9900 7640 WALKER BRAKE (E0159) ATTACHMENT * ---------------------------------------------------------------------------------------------------------------- E0148 A9900 7636 WALKER HVY DUTY (E0148) FOLDING * X-WIDE ---------------------------------------------------------------------------------------------------------------- E0149 A9900 7637 WALKER HVY DUTY (E0149) W/ * WHEELS ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER * CABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7646 CPAP (E1399) EXHALATION PORT * DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7647 CPAP (E1399) FUSE KIT * INTERNATIONAL A/C ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER * KIT DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER * REUSABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7650 CPAP (E1399) HUMIDIFIER MOUNTING * TRAY ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7652 CPAP (E1399) POWER CORD * F/ARIA-SYNC ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE * TAP ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) * ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7565 CPAP SHORT TUBING (A9900) * ---------------------------------------------------------------------------------------------------------------- E0601 E0601 7690 VENT, CONTINUOUS POSITIVE * * (E0500) AIRWAY PRESSURE DEVICE ---------------------------------------------------------------------------------------------------------------- E0452 E0452 7691 VENT, BILEVEL INTERMITTENT * * (E0500) ASSIST DEVICE (BIPAP) ---------------------------------------------------------------------------------------------------------------- E0747 DM570 6875 STIMULATOR, OSTEOGENIC, * * ULTRASOUND ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7695 GEL/SILICON GOLD SEAL CPAP/BIPAP * * MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ * * BACKUP RATE (K0533) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT * (E1399) ---------------------------------------------------------------------------------------------------------------- HH591 HH591 7704 PUMP, EXT INFUSION, DANA * DIABECARE, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, * INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR * USE WITH BREEZE MASK (A9900) ---------------------------------------------------------------------------------------------------------------- DM590 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) * ---------------------------------------------------------------------------------------------------------------- E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) * ----------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances: ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2731 SHIPPING AND HANDLING FEES * * ----------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment: ---------------------------------------------------------------------------------------------------------------- E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) * * SERVICE REQUIRING SKILL OF A TECH ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4552 MISCELLANEOUS SUPPLIES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2589 REPAIR (E1399), RESPIRATORY * * EQUIPMENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4549 TENS/APNEA SUPPLIES * * ----------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * * DME/HOME RESPIRATORY RATES: RATES EFFECTIVE APRIL 1, 2004 - DECEMBER 31, 2004
---------------------------------------------------------------------------------------------------------------- HCPCS CHC GENTIVA CODE CODE CODE DESCRIPTION PURCHASE PRICE RENTAL PRICE DAILY PRICE ---------------------------------------------------------------------------------------------------------------- A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) * W/STETH & CUFF ---------------------------------------------------------------------------------------------------------------- A4670 DM590 2518 MONITOR, BLOOD PRESSURE * (A4670), AUTOMATIC ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7553 FULL FACE (A9900) MIRAGE * CPAP/BIPAP MASK ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP * MASK INCL GLD SEAL,PHANTM,MONARCH ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP * MASK (PROFILE OR SIMPICITY) ---------------------------------------------------------------------------------------------------------------- B9002 HI531 2570 PUMP, ENTERAL (B9002) * * ---------------------------------------------------------------------------------------------------------------- B9998 DM590 6828 ENTERAL SUPPLIES (B9998) * ---------------------------------------------------------------------------------------------------------------- DM590 DM570 7551 BACK-PACK (E1399), FOR * PORTABLE ENTERAL PUMP ---------------------------------------------------------------------------------------------------------------- A4615 DM590 2522 CANNULA, NASAL * ---------------------------------------------------------------------------------------------------------------- B9002 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * * ---------------------------------------------------------------------------------------------------------------- A7034 DM590 7508 MASK, CPAP GEL OR SILICONE * (K0183) ---------------------------------------------------------------------------------------------------------------- E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP * ---------------------------------------------------------------------------------------------------------------- E0105 E0105 2021 CANE, QUAD (E0105) OR THREE * PRONG, ADJ OR FIX, W/ TIPS ---------------------------------------------------------------------------------------------------------------- E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ * OR FIX, PAIR, W/ TIPS, GRIPS ---------------------------------------------------------------------------------------------------------------- E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR * FIX, EACH, W/ TIP AND GRIPS ---------------------------------------------------------------------------------------------------------------- E0112 E0112 2027 CRUTCHES UNDERARM, WOOD * (E0112), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), * ADJ OR FIX, EACH, COMPLETE ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0114 E0114 2026 CRUTCHES UNDERARM, ALUM * (E0114), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0130 E0130 2037 WALKER, RIGID (E0130) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0135 E0135 2036 WALKER, FOLDING (E0135) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0141 E0141 2040 WALKER, WHEELED (E0141), W/OUT * SEAT ---------------------------------------------------------------------------------------------------------------- E0142 DM570 2034 RIGID WALKER (E0142), WHEELED, * W/ SEAT, ---------------------------------------------------------------------------------------------------------------- E0143 E0143 2029 WALKER FOLDING, WHEELED * (E0143), W/OUT SEAT ---------------------------------------------------------------------------------------------------------------- E0145 DM570 2039 WALKER (E0145), WHEELED, W/ * SEAT AND CRUTCH ATTACHMENTS ---------------------------------------------------------------------------------------------------------------- E0146 DM570 2038 WALKER, WHEELED, W/ SEAT (E0146) * ---------------------------------------------------------------------------------------------------------------- E0147 E0147 2030 WALKER HVY DUT (E0147), MULT * BRAKING SYS, VAR WHEEL RESISTANCE ---------------------------------------------------------------------------------------------------------------- E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT * (E0153), FOREARM EA ---------------------------------------------------------------------------------------------------------------- E0154 E0154 2033 WALKER PLATFORM ATTACHMENT * (E0154), EA ---------------------------------------------------------------------------------------------------------------- E0155 E0155 2041 WALKER WHEEL ATTACHMENT * (E0155), RIGID (PICKUP) WALKER ---------------------------------------------------------------------------------------------------------------- E0156 DM570 2035 WALKER SEAT ATTACHMENT (E0156) * ---------------------------------------------------------------------------------------------------------------- E0157 E0157 2022 WALKER, CRUTCH ATTACHMENT * (E0157), EACH ---------------------------------------------------------------------------------------------------------------- E0158 E0158 2031 WALKER LEG EXTENSIONS (E0158) * ---------------------------------------------------------------------------------------------------------------- E0163 E0163 2047 COMMODE CHAIR, STATIONARY * (E0163), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0164 E0164 2045 COMMODE CHAIR, MOBILE * (E0164), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2046 COMMODE CHAIR (E0165), * STATIONARY, W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2591 COMMODE, XXWIDE(E0165) * ---------------------------------------------------------------------------------------------------------------- E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, * W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN * (E0167) ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE * PAD, NON-POSITIONING ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2394 REPLACEMENT PAD (E0176) * ALTERNATING PRESS ---------------------------------------------------------------------------------------------------------------- E0177 E0177 2224 CUSHION OR WATER PRESS PAD * (E0177), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0178 E0178 2160 CUSHION OR GEL PRESS PAD * (E0178), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE * PAD, NONPOSTIONING ---------------------------------------------------------------------------------------------------------------- E0180 E0180 2196 PUMP (E0180), ALTERNATING * * PRESSURES W/PAD ---------------------------------------------------------------------------------------------------------------- E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS * * W/PAD, HVY DUTY ---------------------------------------------------------------------------------------------------------------- E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0185 E0185 2076 MATTRESS (E0185), GEL OR * GEL-LIKE PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) * ---------------------------------------------------------------------------------------------------------------- E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) * ---------------------------------------------------------------------------------------------------------------- E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) * ---------------------------------------------------------------------------------------------------------------- E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN * (E0189), ANY SIZE ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2573 CUSHION, JAY FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND * * POSITIONING EQUALIZATION ---------------------------------------------------------------------------------------------------------------- E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), * * * INCL. BED ---------------------------------------------------------------------------------------------------------------- E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * * ---------------------------------------------------------------------------------------------------------------- E0270 E1399 6887 HOSPITAL BED INSTITUTIONAL * * ---------------------------------------------------------------------------------------------------------------- E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) * ---------------------------------------------------------------------------------------------------------------- E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD * (E0197) ---------------------------------------------------------------------------------------------------------------- E0198 E0198 2100 MATTRESS (E0198), WATER * PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD * (E0199) ---------------------------------------------------------------------------------------------------------------- E0200 E0200 2228 HEAT LAMP (E0200), W/OUT * STAND, INCL/BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) * (E0202), LIGHT WIT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET * (E0202) ---------------------------------------------------------------------------------------------------------------- E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, * INCL/ BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0210 DM570 2156 HEATING PAD, STANDARD (E0210) * ---------------------------------------------------------------------------------------------------------------- E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, * MOIST ---------------------------------------------------------------------------------------------------------------- E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * * ---------------------------------------------------------------------------------------------------------------- E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) * ---------------------------------------------------------------------------------------------------------------- E0236 DM570 2199 PUMP (E0236) FOR WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0237 DM570 2223 HEAT COLD WATER (E0237) * CIRCULATING PAD W/PUMP ---------------------------------------------------------------------------------------------------------------- E0238 DM570 2179 HEATING PAD (E0238), MOIST, * NON-ELECTRIC ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, * L-SHAPE ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2043 BATH TUB RAIL, WALL, * UNSPECIFIED SIZE ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE * (E0242) ---------------------------------------------------------------------------------------------------------------- E0243 DM570 2056 TOILET RAIL, EACH (E0243) * ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH * ARMS ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2052 TOILET SEAT, RAISED (E0244) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2575 BATH BENCH WITH BACK (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2578 TRANSFER BENCH, NON-PADDED * (E0245) ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) * ---------------------------------------------------------------------------------------------------------------- E0246 DM570 2057 TRANSFER TUB RAIL(E0246), * ATTACHMENT ---------------------------------------------------------------------------------------------------------------- E0249 DM570 2186 HEAT UNIT (E0249), WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/O MATTRESS ---------------------------------------------------------------------------------------------------------------- E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, W/ * * SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, W/ * * SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) * ---------------------------------------------------------------------------------------------------------------- E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) * ---------------------------------------------------------------------------------------------------------------- E0273 DM570 2068 BED BOARD (E1399) * ---------------------------------------------------------------------------------------------------------------- E0274 DM570 2097 OVER-BED TABLE (E0274) * ---------------------------------------------------------------------------------------------------------------- E0275 E0275 2071 BED PAN, STANDARD (E0275), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0276 E0276 2070 BED PAN, FRACTURE (E0276), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, * * * ALT PRESSURE ---------------------------------------------------------------------------------------------------------------- E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) * ---------------------------------------------------------------------------------------------------------------- E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, * * HI-LO, W/OUT S/ RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, * * HI-LO, NO SIDE RAILS, NO MATTRESS ---------------------------------------------------------------------------------------------------------------- E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0305 E0305 2073 BED SIDE RAILS (E0305), HALF * LENGTH ---------------------------------------------------------------------------------------------------------------- E0310 E0310 2072 BED SIDE RAILS (E0310), FULL * LENGTH ---------------------------------------------------------------------------------------------------------------- E0315 DM570 2067 BED ACCESSORIES: BOARDS OR * TABLES, ANY TYPE ---------------------------------------------------------------------------------------------------------------- E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, * ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0326 E0326 2059 URINAL; FEMALE (E0326), * JUG-TYPE, ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0372 E0372 7008 MATTRESS (E0372) POWERED AIR * * OVERLAY ---------------------------------------------------------------------------------------------------------------- E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), * PER POUND ---------------------------------------------------------------------------------------------------------------- E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS * SYSTEM ONLY, UP TO 23 CUBIC FEET ---------------------------------------------------------------------------------------------------------------- E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR * GAS, RENT ---------------------------------------------------------------------------------------------------------------- E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) * * ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT * * (E0431) W/CONSERV DEVICE,NO CONTENT ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) * ---------------------------------------------------------------------------------------------------------------- E0434 E0434 2377 O2 SYS PORT LIQUID,RENT (E0434) * ---------------------------------------------------------------------------------------------------------------- E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH * (E0435) ---------------------------------------------------------------------------------------------------------------- E0439 E0439 2388 O2 SYS STATIONARY (E0439) * LIQUID, RENT ---------------------------------------------------------------------------------------------------------------- E0440 E0440 2387 O2 SYS STATIONARY (E0440) * LIQUID, PURCH ---------------------------------------------------------------------------------------------------------------- E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER * (E0400), 200-300 CUBIC FT ---------------------------------------------------------------------------------------------------------------- E0444 E0444 2379 O2 CONTENTS, PORT LIQUID * (E0444), PER UNIT (1 UNIT = 1 LB.) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7555 POSITIVE PRESSURE VENTS * * (E0450)(E.G. T-BIRD) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7926 POSITIVE PRESSURE VENTS, * EMERGENCY BACKUP (E.G. T-BIRD)(E0450) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 2392 VENTILATOR VOLUME (E0450), * * STATIONARY OR PORT ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) * * EMERGENCY BACKUP UNIT ---------------------------------------------------------------------------------------------------------------- E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) * * ASSIST DEVICE,(BIPAP) ---------------------------------------------------------------------------------------------------------------- E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); * * FOR USE 12 HOURS OR LESS PER DAY ---------------------------------------------------------------------------------------------------------------- E0455 E0455 2372 O2 TENT (E0455), EXCLUDING * * CROUP OR PEDIATRIC TENTS ---------------------------------------------------------------------------------------------------------------- E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * * ---------------------------------------------------------------------------------------------------------------- E0459 E0459 2324 CHEST WRAP (E0459) * * ---------------------------------------------------------------------------------------------------------------- E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE * * PRESSURE , PORTABLE OR STATIONARY ---------------------------------------------------------------------------------------------------------------- E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR * * PNEUM, HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0500 E0500 2333 IPPB , W/ BUILT-IN NEB (E0500) * * MAN OR AUTO VALVES; INT/EXT POWER ---------------------------------------------------------------------------------------------------------------- E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR * * EXTENSIV SUP/ HUMID W/ IPPB OR O2 ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, * * GLASS, FOR USE W/ REG OR FLOWMETER ---------------------------------------------------------------------------------------------------------------- E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * * ---------------------------------------------------------------------------------------------------------------- E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) * * ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * * ---------------------------------------------------------------------------------------------------------------- E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR * * AND HEATER ---------------------------------------------------------------------------------------------------------------- E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * * ---------------------------------------------------------------------------------------------------------------- E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0601 E0601 2326 CONTINUOUS POSITVE (E0601) * * AIRWAY PRESSURE DEVICE (CPAP) ---------------------------------------------------------------------------------------------------------------- E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * * ---------------------------------------------------------------------------------------------------------------- E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) * ---------------------------------------------------------------------------------------------------------------- E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) * ---------------------------------------------------------------------------------------------------------------- E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) * ACCUCHEK AD ---------------------------------------------------------------------------------------------------------------- E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) * ---------------------------------------------------------------------------------------------------------------- E0618 E0608 2322 APNEA MONITOR (E0608) * * ---------------------------------------------------------------------------------------------------------------- E0619 E0608 2576 APNEA MONITOR (E0608) W/MEM * * (INCL SMART) ---------------------------------------------------------------------------------------------------------------- E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) * W/SPECIAL FEATURES ---------------------------------------------------------------------------------------------------------------- E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR * SEAT, CANVAS OR NYLON ---------------------------------------------------------------------------------------------------------------- E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, * * BATHROOM OR TOILET ---------------------------------------------------------------------------------------------------------------- E0627 E0627 4553 HIP CHAIR (E0627) * * ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED * (E0627) ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2205 SEAT LIFT MECH (E0627) * INCORPORATED INTO A COMB LIFT-CHAIR MECH ---------------------------------------------------------------------------------------------------------------- E0630 E0630 2190 PATIENT LIFT, HYDRAULIC * * (E0630), W/ SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ * SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0650 E0650 2192 PNEUM COMPRESSOR (E0650), * * NON-SEG HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG * * HOME MODEL W/OUT CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG * * HOME MODEL W/ CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0655 E0655 2182 PNEUM COMPRESSOR (E0655), * NON-SEG APPLIANCE, HALF ARM ---------------------------------------------------------------------------------------------------------------- E0660 E0660 2181 PNEUM COMPRESSOR (E0660), * NON-SEG APPLIANCE, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0665 E0665 2180 PNEUM COMPRESSOR (E0665), * NON-SEG APPLIANCE, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0666 E0666 2183 PNEUM COMPRESSOR (E0666), * NON-SEG APPLIANCE, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, * FULL LEG ---------------------------------------------------------------------------------------------------------------- E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, * FULL ARM ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, * HALF LEG ---------------------------------------------------------------------------------------------------------------- E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, * HALF ARM ---------------------------------------------------------------------------------------------------------------- E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG * GRAD PRESS, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG * GRAD PRESS, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG * GRAD PRESS, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), * APPROPRIATE FOR HOME USE ---------------------------------------------------------------------------------------------------------------- E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., * BELT, HARNESS OR VEST) ---------------------------------------------------------------------------------------------------------------- E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE * (BODY, CHEST, WRIST OR ANKLE) ---------------------------------------------------------------------------------------------------------------- E0720 E0720 2219 TENS (E0720), TWO LEAD, * * LOCALIZED STIMULATION ---------------------------------------------------------------------------------------------------------------- E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER * * AREA/MULTIPLE NERVE STIMULATION ---------------------------------------------------------------------------------------------------------------- E0731 E0731 2159 TENS OR NMES (E0731), * CONDUCTIVE GARMENT ---------------------------------------------------------------------------------------------------------------- E0744 E0744 2120 STIMULATOR (E0744), * * NEUROMUSCULAR FOR SCOLIOSIS ---------------------------------------------------------------------------------------------------------------- E0745 E0745 2120 STIMULATOR (E0745), * * NEUROMUSCULAR, ELECTRONIC SHOCK UNIT ---------------------------------------------------------------------------------------------------------------- E0745 E0745 6915 STIMULATOR FOUR CH (E0745), * * NEUROMUSCULAR ---------------------------------------------------------------------------------------------------------------- E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), * * BIOFEEDBACK DEVICE ---------------------------------------------------------------------------------------------------------------- E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, * NON-INVASIVE ---------------------------------------------------------------------------------------------------------------- E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC * NON-INVASIVE, SPINAL APPLICATIONS ---------------------------------------------------------------------------------------------------------------- E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC * SALIVARY REFLEX, NON INVASIVE ---------------------------------------------------------------------------------------------------------------- E0776 E0776 2175 IV POLE (E0776) * * ---------------------------------------------------------------------------------------------------------------- E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY * INFUSION, MINIMED, INSULIN ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7925 PUMP, EXT INFUSION, NON - DANA * PREMIUM, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 6771 PUMP (E0784), INSULIN EXT * INFUSION DISETRONICS OR OTHER ---------------------------------------------------------------------------------------------------------------- E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH * TO HEADBOARD, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0850 E0850 2134 TRACTION STAND (E0850), FREE * * STANDING, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR * * STAND ---------------------------------------------------------------------------------------------------------------- E0860 E0860 2130 TRACTION EQUIP (E0860), * OVERDOOR, CERVICAL ---------------------------------------------------------------------------------------------------------------- E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH * * TO FOOTBOARD, EXTREMITY, BUCKS ---------------------------------------------------------------------------------------------------------------- E0880 E0880 2135 TRACTION STAND (E0880) * * FREE/STAND EXTREMITY TRACTION, EG, BUCK'S ---------------------------------------------------------------------------------------------------------------- E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH * * TO FOOTBOARD, PELVIC TRACTION ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0900 E0900 2136 TRACTION STAND (E0900) FREE/ * * STAND PELVIC TRACTION,( EG, BUCK'S) ---------------------------------------------------------------------------------------------------------------- E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT * * HELPER, ATTACH TO BED W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH * * TO BED, INCLUDING WEIGHTS ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE * DEVICE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ANKLE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ELBOW ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE * DEVICE, HAND ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE * DEVICE, SHOULDER ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE * DEVICE, WRIST ---------------------------------------------------------------------------------------------------------------- E0940 E0940 2137 TRAPEZE BAR (E0940), FREE * * STANDING, COMPLETE W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0941 E0941 2116 TRACTION DEVICE (E0941), * * GRAVITY ASSISTED ---------------------------------------------------------------------------------------------------------------- E0942 E0942 2101 HARNESS/HALTER (E0942), * CERVICAL HEAD ---------------------------------------------------------------------------------------------------------------- E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, * BOOT ---------------------------------------------------------------------------------------------------------------- E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT * ---------------------------------------------------------------------------------------------------------------- E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL * * W/ CROSS BARS, ATTACH TO BED ---------------------------------------------------------------------------------------------------------------- E0947 E0947 2113 FRACTURE FRAME (E0947), * * ATTACHMENTS FOR COMPLEX PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0948 E0948 2112 FRACTURE FRAME (E0948) * * ATTACHMENTS FOR COMPLEX CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0950 DM570 2139 TRAY (E0950) * ---------------------------------------------------------------------------------------------------------------- E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO * CONVERT ANY W/C TO ONE ARM DRIVE ---------------------------------------------------------------------------------------------------------------- E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) * (COMPENSATE FOR TRANS OF WEIGHT) ---------------------------------------------------------------------------------------------------------------- E0962 E0962 2232 CUSHION FOR WC 1" (E0962) * ---------------------------------------------------------------------------------------------------------------- E0963 E0963 2233 CUSHION FOR WC 2" (E0963) * ---------------------------------------------------------------------------------------------------------------- E0964 E0964 2234 CUSHION FOR WC 3" (E0964) * ---------------------------------------------------------------------------------------------------------------- E0965 E0965 2235 CUSHION FOR WC 4" (E0965) * ---------------------------------------------------------------------------------------------------------------- E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) * ---------------------------------------------------------------------------------------------------------------- E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) * ---------------------------------------------------------------------------------------------------------------- E0978 E0978 2248 BELT, SAFETY (E0978) W/ * AIRPLANE BUCKLE, W/C ---------------------------------------------------------------------------------------------------------------- E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO * CLOSURE, W/C ---------------------------------------------------------------------------------------------------------------- E0980 DM570 2292 SAFETY VEST (E0980), W/C * ---------------------------------------------------------------------------------------------------------------- E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ * * CASTORS 5" OR GREATER ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1060 E1060 2259 W/C FULL/REC (E1070), DETACH * * ARMS, SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) * ---------------------------------------------------------------------------------------------------------------- E1066 E1066 2247 BATTERY CHARGER (E1066) * ---------------------------------------------------------------------------------------------------------------- E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) * ---------------------------------------------------------------------------------------------------------------- E1070 E1070 2258 W/C FULL/REC (E1060), DETACH * * ARMS, SWING AWAY DET/ ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, * * SWING AWAY DETACH ABLE ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, * * SWING AWAY DETACH ABLE FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), * * FIX ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), * * D/ ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), * * FIX ARMS, S/AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1090 E1090 2267 W/C HI STRENGTH LT-WG (E1090), * * DETACH ARMS, S/AWAY D/FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * * ---------------------------------------------------------------------------------------------------------------- E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), * * DETACH ARMS S/AWAY DETACH ELEVAT LEGS ---------------------------------------------------------------------------------------------------------------- E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), * * DETACH ARMS S/AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1100 E1100 2296 W/C SEMI-RECLINING (E1100), * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1110 E1110 2295 W/C SEMI-RECLINING (E1110), * * DETACH ARMS ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1130 E1130 2303 W/C STANDARD (E1130), FIX OR * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING * * AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2396 W/C (E1160), W/FIX ARMS * * REMOVABLE FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, * * W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH * * ARMS W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH * * ARMS SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH * * ARMS SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL * * LENGTH ARMS, S/AWAY D/FOOTREST ---------------------------------------------------------------------------------------------------------------- E1210 E1210 2281 W/C MOTORIZED (E1210), FIX * * ARMS, S/AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH * * ARMS , S/AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1212 E1212 2282 W/C MOTORIZED (E1212) , FIX * * ARMS, SWING AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH * * ARMS S/AWAY, DETACH ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2551 W/C CUSTOM (E1220) * * ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2579 W/C XXWIDE (E1220) * ---------------------------------------------------------------------------------------------------------------- E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 * * WHEEL ---------------------------------------------------------------------------------------------------------------- E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS * * SWING AWAY DETACH, ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH * * ARMS ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH * * ARMS SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, * * ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1300 DM570 2062 WHIRLPOOL (E1300), PORT * (OVERTUB TYPE) ---------------------------------------------------------------------------------------------------------------- E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT * * (BUILT-IN TYPE) ---------------------------------------------------------------------------------------------------------------- E1353 E1353 2381 O2 REGULATOR (E1353) * * * ---------------------------------------------------------------------------------------------------------------- E1355 E1355 2384 CYLINDER STAND/RACK (E1355) * ---------------------------------------------------------------------------------------------------------------- E1372 E1372 2331 IMMERSION EXT HEATER (E1372) * * FOR NEBULIZER ---------------------------------------------------------------------------------------------------------------- E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL * COMPRESSOR, W/ LIMITED FLOW ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2568 ADAPTER (A9900), AC/DC * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2552 BATH LIFT (E1399), CUSTOM * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2563 BED WEDGE (E1399), 12" * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), * CUSTOM ---------------------------------------------------------------------------------------------------------------- E0603 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * * ---------------------------------------------------------------------------------------------------------------- E0604 DM570 2581 BREAST PUMP, INSTITUTIONAL * (E1399) ---------------------------------------------------------------------------------------------------------------- E0602 E1399 2580 BREAST PUMP, MANUAL (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2565 COMMODE (E1399), DROP ARM, * HEAVY DUTY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), * MISCELLANEOUS ---------------------------------------------------------------------------------------------------------------- E1399 E1220 2584 GERI CHAIR (E1399), THREE * POSITION RECLINING ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6780 HOLTER MONITOR (G0004) * ---------------------------------------------------------------------------------------------------------------- E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, * * XLONG, W/MATTRESS & SIDE RAILS ---------------------------------------------------------------------------------------------------------------- E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2588 MONITOR (E1399), VITAL SIGNS * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2529 O2 ANALYZER (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * * ---------------------------------------------------------------------------------------------------------------- E0455 DM570 6775 OXIMETRY TEST (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2561 PEAK FLOW METER (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4559 PEDIATRIC WALKER (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2567 PNEUMOGRAM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2553 POSITIONING, CUSTOM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2526 PULSE OXIMETER (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2562 SHOWER, HAND HELD (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW * * VOLTAGE OR INTERFERENTIAL ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR * * ONLY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL * * PEDIATRIC ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7505 W/C, CUSTOM (E1399) POWER * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2564 WALKER (E1399), HEAVY DUTY, * EXTRA WIDE ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2585 WALKER (E1399), HEMI * ---------------------------------------------------------------------------------------------------------------- K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) * * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION * DEVICE (K0539) ---------------------------------------------------------------------------------------------------------------- K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION * DEVICE (K0540) ---------------------------------------------------------------------------------------------------------------- E1400 E1390 2361 O2 CONC (E1390),MANUF SPEC * * MAXFLOWRATE = 2 LTS PER MIN@85% ---------------------------------------------------------------------------------------------------------------- G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) * ---------------------------------------------------------------------------------------------------------------- K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) * ---------------------------------------------------------------------------------------------------------------- K0183 DM590 2516 CPAP MASK (K0183) * ---------------------------------------------------------------------------------------------------------------- K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) * REPLACEMENT FOR NASAL APP/ DVC, PAIR ---------------------------------------------------------------------------------------------------------------- K0185 DM590 2514 CPAP HEADGEAR (K0185) * ---------------------------------------------------------------------------------------------------------------- K0186 DM590 2513 CPAP CHIN STRAP (K0186) * ---------------------------------------------------------------------------------------------------------------- K0187 DM590 2512 CPAP TUBING (K0187) * ---------------------------------------------------------------------------------------------------------------- K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE * ---------------------------------------------------------------------------------------------------------------- K0189 DM590 2510 CPAP FILTER (A9900), * NON-DISPOSABLE ---------------------------------------------------------------------------------------------------------------- K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL * ---------------------------------------------------------------------------------------------------------------- K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, * EQUIVALENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC * AIR THERAPY ---------------------------------------------------------------------------------------------------------------- A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 * SCOOP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL * SECRETION MOBIL DEVICE ---------------------------------------------------------------------------------------------------------------- E0168B A9900 7643 COMMODE (E0168B) HVY DUTY * BEDSIDE CHAIR 251-450 LBS. ---------------------------------------------------------------------------------------------------------------- E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP * ARM 451-850 LBS. ---------------------------------------------------------------------------------------------------------------- A6234 HH591 7626 DRESSING <16 SQ IN (A6234) * HYDROCOLLOID DRESSING, EA ---------------------------------------------------------------------------------------------------------------- A6258 HH591 7627 DRESSING >16 SQ IN (A6258) * TRANSPAREN FILM, EA ---------------------------------------------------------------------------------------------------------------- A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN * (A46203) SELF ADH, EA ---------------------------------------------------------------------------------------------------------------- B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE * F/KANGAROO PUMP ---------------------------------------------------------------------------------------------------------------- B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP * BASIC ---------------------------------------------------------------------------------------------------------------- B9998D DM590 7657 ENT (B9998D) FARRELL GASTRIC * RELIEF VLV ---------------------------------------------------------------------------------------------------------------- B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET * ---------------------------------------------------------------------------------------------------------------- B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY * SIZE MIC-KEY OR HIDE A PORT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL * NOSE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7660 IPPB (E1399) UNIV SET UP * W/MANIFOLD NEBULIZER ---------------------------------------------------------------------------------------------------------------- K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7641 MECHANICAL SCALE (E1399) * PEDIATRIC/NEONATAL ---------------------------------------------------------------------------------------------------------------- A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL * W/STR H20 1L BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7663 O2 CONNECTOR (E1399) * SIMS/IRRIGATION NOZZLE BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7615 O2 HUMIDIFIER (E1399) * AQUA+NEONATAL EA HUD ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER * ANGLED STERILE ---------------------------------------------------------------------------------------------------------------- L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS * ---------------------------------------------------------------------------------------------------------------- A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG * 1L BAX ---------------------------------------------------------------------------------------------------------------- A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & * TUBING ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA * ---------------------------------------------------------------------------------------------------------------- A6265 HH591 7628 TAPE ALL TYPES (A6265) * EXCLUDING MICROFOAM, PER 18 SQ INCHES ---------------------------------------------------------------------------------------------------------------- A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA * ELECTROSTATIC ---------------------------------------------------------------------------------------------------------------- A4623 A9900 7618 TRACH INNER (A4623) CANNULA * ---------------------------------------------------------------------------------------------------------------- A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR * OR HOLDER ---------------------------------------------------------------------------------------------------------------- A7010 A9900 7662 TUBING (A7010) AEROSOL * CORRUGATED PER FOOT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7630 VENT BATTERY CHARGER (A9900) * 12V GEL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR * ADULT OMNIFLEX DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S * ELECTOSTATIC MAL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7634 VENT THERMOMETER (E1399) W/ * ADAPTER ---------------------------------------------------------------------------------------------------------------- K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP * BLK 10/PK ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7635 WALKER BASKET (E1399) VINYL * COATED ---------------------------------------------------------------------------------------------------------------- E0159 A9900 7640 WALKER BRAKE (E0159) ATTACHMENT * ---------------------------------------------------------------------------------------------------------------- E0148 A9900 7636 WALKER HVY DUTY (E0148) FOLDING * X-WIDE ---------------------------------------------------------------------------------------------------------------- E0149 A9900 7637 WALKER HVY DUTY (E0149) W/ * WHEELS ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER * CABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7646 CPAP (E1399) EXHALATION PORT * DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7647 CPAP (E1399) FUSE KIT * INTERNATIONAL A/C ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER * KIT DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER * REUSABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7650 CPAP (E1399) HUMIDIFIER * MOUNTING TRAY ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7652 CPAP (E1399) POWER CORD * F/ARIA-SYNC ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE * TAP ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7565 CPAP SHORT TUBING (A9900) * ---------------------------------------------------------------------------------------------------------------- E0601 E0601 7690 VENT, CONTINUOUS POSITIVE * * (E0500) AIRWAY PRESSURE DEVICE ---------------------------------------------------------------------------------------------------------------- E0452 E0452 7691 VENT, BILEVEL INTERMITTENT * * (E0500) ASSIST DEVICE (BIPAP) ---------------------------------------------------------------------------------------------------------------- E0747 DM570 6875 STIMULATOR, OSTEOGENIC, * ULTRASOUND ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7695 GEL/SILICON GOLD SEAL * CPAP/BIPAP MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ * * BACKUP RATE (K0533) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT * * (E1399) ---------------------------------------------------------------------------------------------------------------- HH591 HH591 7704 PUMP, EXT INFUSION, DANA * DIABECARE, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, * INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR * USE WITH BREEZE MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A7036 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) * ---------------------------------------------------------------------------------------------------------------- E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) * ----------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances: ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2731 SHIPPING AND HANDLING FEES * ----------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment: ---------------------------------------------------------------------------------------------------------------- E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) * SERVICE REQUIRING SKILL OF A TECH ---------------------------------------------------------------------------------------------------------------- E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4552 MISCELLANEOUS SUPPLIES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2589 REPAIR (E1399), RESPIRATORY * * EQUIPMENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4549 TENS/APNEA SUPPLIES * * ----------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * * Confidential treatment requested GATEKEEPER PROGRAM ATTACHMENT TO MANAGED CARE ALLIANCE AGREEMENT (CAPITATION) PURPOSE The terms and provisions of this Gatekeeper Program Attachment and the Agreement are applicable to services rendered by MCA's Represented Providers to Gatekeeper Program Participants. As used in this Program Attachment, Participant means a Gatekeeper Program Participant. HMO Program Requirements shall apply to Covered Services provided to Gatekeeper Program Participants. I. DEFINITIONS BASELINE ASSESSMENT means CIGNA's assessment of MCA's capacity to assume the obligations described in the Agreement and this Program Attachment in particular. CAPITATION PAYMENT means a periodic payment for certain covered Home Care Services that is made to MCA for each Participant who is a member of MCA's Patient Panel. CARVED OUT SERVICES means the following services: EXHIBIT XIX. GATEKEEPER PROGRAM PARTICIPANT means a Participant, other than a HMO Program Participant, enrolled in either (i) a product which includes fully insured Standard HMO, Point of Service, or Gatekeeper PPO benefits and which product is underwritten by a licensed insurance company based on an experience rating methodology, or (ii) a self funded product which includes Standard HMO, Point of Service, or Gatekeeper PPO benefits. This definition includes, but is not limited to, Participants covered under FlexCare, True Access and Open Access plans insured/administered by Connecticut General Life Insurance Company. GATEKEEPER PPO means a product offered pursuant to a Service Agreement which provides the Participant with an incentive to obtain Covered Services from Participating Providers and which generally requires the Participant to obtain an authorization from their Primary Care Physician in order to access such Covered Services from Participating Providers. HMO PROGRAM PARTICIPANT means a Participant enrolled in a non-governmental, fully insured Standard HMO or Point of Service product and which product is underwritten based on a community rating methodology (i.e. community rating, community rating by class, adjusted community rating by class). This definition includes, but is not limited to, Participants covered under commercial HMO and Open Access plans issued by CIGNA. MEDICAL DIRECTOR means a physician designated by CIGNA to manage Quality Management and Utilization Management responsibilities, or that physician's designee. PATIENT PANEL means those Gatekeeper Program Participants for which MCA will receive a global Capitation Payment for all Home Care Services rendered. POINT OF SERVICE means a product offered pursuant to a Service Agreement which allows the Participant to choose, in addition to Standard HMO benefits, a lower level of benefits if the Participant receives Covered Services from (i) a Participating Provider without a necessary authorization or (ii) from a non-Participating Provider, at the time such services are sought. PRIMARY CARE PHYSICIAN means a physician duly licensed to practice medicine who is a Participating Provider with CIGNA to provide Covered Services in the field of general medicine, internal medicine, family practice or pediatrics, and who has agreed to provide primary care physician services to Participants in accordance with HMO Program Requirements. STANDARD HMO means a product offered pursuant to a Service Agreement where Covered Services are available to Participants only from Participating Providers, except in the case of an Emergency or with the prior authorization of CIGNA or Affiliate where Covered Services are not available from Participating Providers. II. SERVICES AND COMPENSATION A. COVERED HOME CARE SERVICES 1. MCA, through its Represented Providers, shall provide all Home Care Services that are required by Participants in MCA's Patient Panel, for which such Participants are eligible, in accordance with the terms of this Agreement, this Gatekeeper Program Attachment and HMO Program Requirements. The compensation set forth in this Gatekeeper Program Attachment shall be payment in full for Home Care Services rendered to Gatekeeper Program Participants. 2. MCA, through its Represented Providers, shall arrange to provide Medically Necessary Home Care Services to Participants on a 24-hour per day, 7-day per week basis or arrange with other qualified providers (which meet all CIGNA and MCA credentialing requirements or other applicable guidelines) to provide such Medically Necessary Home Care Services to Participants. MCA shall require that such covering providers (a) are Participating Providers (unless otherwise agreed); (b) will not seek compensation from CIGNA for services for which MCA receives compensation hereunder; and (c) will not bill Participants for covered Home Care Services under any circumstances except for (i) Copayments, Deductibles or Coinsurance; (ii) the provision of services to a patient who is not eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit; and (iii) services provided to Participants that are not Home Care Services. (d) will direct the participant and/or the Represented Provider to obtain, authorization from CIGNA prior to all hospitalizations or referrals of Participants, except in Emergencies or for a Pre-Qualified Maternity Stay or as otherwise required by law. 3. MCA through its Represented Providers shall provide Home Care Services to all Participants in MCA's Patient Panel who are eligible to receive Home Care Services. 4. Subject to the terms and condition of this Agreement, MCA shall: a. Arrange for the provision of Home Care Services to Participants; b. Require Represented Providers to accept, treat, and otherwise render covered Home Care Services to Participants in the same manner, in accordance with the same standards, and with the same availability, as offered to other like patients. c. not close its network to any new Participants unless CIGNA expressly consents to such closure; 5. In no event shall MCA or Represented Providers be required to accept, treat, arrange for, or otherwise be obligated to render Home Care Services to Participants under this Agreement, even if medically appropriate, if: a. the provision of such services to Participant would pose risk of bodily harm to the Participant or caregiver personnel of Represented Provider; b. the provision of such services to Participant would be in violation of MCA's or Represented Provider's applicable license requirements or other applicable laws, and/or MCA policies, including but not limited to admission and discharge policies or discrimination policies; c. MCA has not received the essential information to process a referral; d. Participant repeatedly rejects the provision of services by a qualified Represented Provider selected by MCA and/or CIGNA has mutually agreed. e. MCA and Represented Providers shall not differentiate or discriminate in the treatment of any Participant because of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, health status, handicap or source of payment. 6. A CIGNA Participating Physician or CIGNA will notify MCA of each referral for Covered Home Care Services for Participants in its Patient Panel. MCA will provide or arrange to provide for all Medically Necessary Covered Home Care Services for all such Participants, in accordance with the authorization and Utilization Management procedures set forth in Exhibit XVII. 7. MCA and CIGNA will jointly develop clinical pathways to establish a plan of treatment for more difficult Participant cases requiring Covered Home Care Services. B. CAPITATION PAYMENTS 1. On or before the 15th day of each month, CIGNA or its designee shall pay MCA a monthly Capitation Payment for each Participant in MCA's Patient Panel. THE CAPITATION PAYMENT SHALL BE COMPENSATION FOR ALL HOME CARE SERVICES PROVIDED TO PARTICIPANTS IN THE PATIENT PANEL EXCEPT FOR CARVED OUT SERVICES as referenced in exhibit XIX. The monthly capitation rates are set forth in Exhibit A. 2. If a Participant is added to MCA's Patient Panel on or before the 15th day of a month, a full month's Capitation Payment will be due for that Participant for that month. There will be no Capitation Payment due for Participants added after the 15th day of the month. 3. A full month's Capitation Payment will be due for the month of termination of a Participant if the Participant terminates after the 15th day of the month. If a Participant terminates on or before the 15th day of a month, no Capitation Payment will be due for the month of termination. 4. Where CIGNA, due to information delays, must make a retroactive addition or deletion to MCA's Patient Panel, a retroactive capitation adjustment shall be made concurrent therewith subject to Section II.B.6 of this Gatekeeper Program Attachment. In those instances where a Participant has been retroactively deleted and has received services from MCA after the effective date of deletion but prior to CIGNA informing MCA of such deletion, MCA may bill participant for such services rendered. 5. Any amendments of Capitation Payment rates, whether on an annual basis or upon changes in benefit designs, shall be in accordance with the amendment provisions of this Agreement, or as otherwise agreed to in writing by the parties. 6. Capitation Adjustment Process: a. Where CIGNA, due to information delays, must make a retroactive addition or deletion to MCA's Patient Panel, a retroactive capitation adjustment shall not exceed 6 months, nor shall a retroactive addition be added greater than 6 months. b. Services rendered to participants prior to the capitation period or following the capitation period may be billed to CIGNA directly, and shall be in accordance with Exhibit A of the Gatekeeper Program Attachment - Fee For Service, attached hereto. Standard Coordination of Benefits rules shall be applied. In the event that CIGNA is not identified as the payor, MCA may bill participant directly for services rendered during this time. c. For those Participants in the Providers patient panel, MCA shall have 120 days following the receipt of the monthly capitation payment, to notify CIGNA of any discrepancies in the capitation payment. The discrepancies shall be determined by the MCA through a review of the electronic eligibility and capitation roster documentation supplied by CIGNA. For all eligibility or capitation roster data that continues to be in a paper format, CIGNA will use its best efforts to move to an electronic basis. d. CIGNA shall investigate and validate capitation errors and notify Gentiva within 60 days the results of such investigation. e. Any necessary adjustments to capitation shall be made through the next scheduled capitation cycle. f. All adjustments to capitation payments shall be provided to MCA in writing, by CIGNA, no less than 30 days prior to the adjustment. 7. MCA guarantees that the Capitation Payment rates set forth in this Attachment are effective from the Effective Date of this Agreement. Notwithstanding the foregoing, the parties agree to meet to discuss possible adjustments to the Capitation Payment rates should any of the following circumstances occur during the term of this Attachment: a. treatments, products, supplies or equipment which are excluded from Covered Home Care Services for Gatekeeper Program Participants as of the Effective Date on the basis that they are considered Experimental are no longer considered Experimental and become a Covered Home Care Service for such Participants. b. shifts in treatment sites for Covered Home Care Service therapies occurring after the Effective Date result in a material change to the services which are Covered Home Care Services for Gatekeeper Program Participants. c. material changes are made to Gatekeeper Program Participants' Service Agreements after the Effective Date such that there is a material change to those Home Care Services which are Covered Home Care Services for such Participants. d. utilization associated with material changes in membership from which the base period was derived after the Effective Date of this Agreement results in a material change in Gatekeeper Program Participant volume under this Agreement which has a material financial impact on MCA. e. Any such adjustment of Capitation Payment rates shall only be made to the extent required to address the change in costs directly resulting from the above changed circumstance. 8. Leakage a. On a quarterly basis, CIGNA will provide MCA with leakage reports and the claims for Covered Home Care Services submitted by providers that are not Represented Provider's. MCA shall review the quarterly leakage reports provided by CIGNA to determine the need to contract with additional providers so as to reduce the leakage. MCA shall make a good faith effort to contract with identified providers in order to reduce the amount of leakage and it shall act promptly to contract with those providers identified as appropriate in order to reduce leakage. In an effort to better manage leakage and overall utilization, CIGNA will attempt to provide MCA, an overview of CIGNA's administration of out of network claims for Covered Home Care Services rendered to Participants. CIGNA also agrees to review the feasibility of adopting usual and customary charges for Covered Home Care Services. MCA commits to provide CIGNA all reasonable assistance in the development and implementation of the aforementioned process. b. The Parties shall meet quarterly (each April, July, October and January) to review the utilization of Covered Home Health Services that are not reimbursed on a capitated basis under this Agreement for the purpose of identifying opportunities to reduce this utilization and the Parties shall cooperate in good faith to effect such actions as they may agree upon to accomplish this objective. c. MCA shall meet with those referring physicians identified by CIGNA to educate them regarding the service provided by Represented Providers. 9. Insulin Pumps Effective January 1, 2004, MCA will use all reasonable commercial efforts to arrange for the provision of Dana brand devices and supplies for insulin pump orders on new referral authorizations. For Participants reimbursed according to a capitation methodology, MCA will bill CIGNA a fee-for-service charge for a rate differential for new non-Dana devices based upon a CIGNA authorization. Supplies for insulin pumps provided to participants reimbursed according to a capitation methodology prior to 1/1/04 shall not be subject to a fee for service charge or consideration. For all other Participants, billing for pumps and supplies shall be in accordance with the appropriate fee schedules. C. REPRESENTED PROVIDER PAYMENT/CLAIM AND ENCOUNTER DATA Represented Providers shall be reimbursed for covered Home Care Services rendered in accordance with the requirements set forth in Exhibit B. MCA shall provide CIGNA with the claim and/or encounter data as required in EXHIBITS II. & IV. D. FINANCIAL REPORTS 1. MCA represents and warrants that the information set forth in the CIGNA Baseline Assessment submitted to CIGNA by MCA prior to the execution of this Agreement is true and accurate. MCA shall promptly notify CIGNA of any material changes in the information contained in such Baseline Assessment within thirty (30) days of becoming aware of such change. 2. MCA shall provide CIGNA with the following financial reports on a timely basis: a) MCA's annual audited financial reports, including, but not limited to, MCA's audited annual income statement and balance sheet; b) quarterly financial reports including an income statement, balance sheet and any other reports identifying payments made to Represented Providers in the preceding quarter and the incurred but not reported claims as of the end of the preceding quarter in sufficient detail to determine if payments have been made in accordance with this Agreement and applicable law; c) any financial reports required by applicable regulatory authorities; and d) such other financial reports as are reasonably requested by CIGNA. 3. MCA shall notify CIGNA immediately of any of MCA's material payment defaults, with respect to any of MCA's creditors if MCA reasonably determines that any such payment defaults would affect the provision of services to the Gatekeeper Program Participant. E. ASSIGNMENT AND IDENTIFICATION OF PARTICIPANTS MCA shall comply with the requirements of and shall participate in CIGNA's procedures with respect to the assignment and identification of Participants as outlined in the HMO Program Requirements. F. REIMBURSEMENT OF CIGNA EXPENDITURES In the event that MCA does not arrange for the provision of Home Care Services to Gatekeeper Program Participants as required by Section II.A.1 through II.A.4 of this Gatekeeper Program Attachment, Payor may arrange for and/or reimburse for such covered Home Care Service and shall be entitled to recover from MCA any expenditure made, or recover any cost incurred, including, but not limited to, any reasonable administrative costs, in arranging or reimbursing such covered Home Care Service. An amount sufficient to compensate for such expenditures and costs may be deducted from the payments due to MCA under this Agreement. CIGNA shall provide MCA with written notice and full disclosure of costs incurred prior to any such deductions. This provision shall survive the termination of this Agreement for a period of one year. G. OTHER REQUIREMENTS MCA and its Represented Providers shall use best efforts to prescribe or authorize the substitution of generic pharmaceuticals when appropriate and shall cooperate with CIGNA's formulary and HMO Program Requirements regarding the substitution of generic pharmaceuticals. H. TRANSFERS In a timeframe to be mutually agreed upon the parties, CIGNA will provide to MCA all information reasonably required by MCA in order to accomplish transition, but nothing herein shall require MCA to purchase or assume payments for any durable medical equipment (HME/DME), which has been previously placed with any CIGNA Participant. CIGNA agrees to work with MCA to identify those Participants that are in possession of HME/DME and for which CIGNA has made payment on a rental basis for such DME/HME, and advise MCA of the same. MCA shall be relieved of any obligation to assume financial responsibility for DME/HME that MCA determines to be DME/HME that is routinely purchased or converted to purchase, or that does not meet CIGNA/MCA Durable Medical Equipment Guidelines for Medical Necessity, and such DME/HME shall be converted to purchase at CIGNA's expense prior to the transition of Participants to MCA. However, MCA shall assume responsibility for the continued maintenance of the DME/HME. I. LIMITATIONS ON BILLING PARTICIPANTS 1. MCA hereby agrees and shall require its Represented Providers to agree that in no event, including, but not limited to non-payment by CIGNA, CIGNA's insolvency or breach of this Agreement, shall MCA or any Represented Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Participants or persons other than CIGNA or MCA for Home Care Services. This provision shall not prohibit collection of (i) any applicable Copayments, Deductibles or Coinsurance; (ii) payments for services provided to a patient who is no longer eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit; or (iii) payments for services provided to Participants that are not Home Care Services. 2. MCA further agrees that this provision shall survive the termination of this Agreement regardless of the cause giving rise to such termination and shall be construed to be for the benefit of Participants, and that this provision supersedes any oral or written agreement to the contrary now existing or hereafter entered into between MCA or Represented Providers and the Participant or persons acting on the Participant's behalf. 3. Any modification, additions, or deletion to the provisions of this hold harmless clause shall become effective on a date no earlier than fifteen (15) days after the applicable state regulatory agency has received written notice of such proposed change. 4. MCA shall not charge, and MCA shall require that its Represented Providers not charge, a Participant for a service which is not Medically Necessary unless, in advance of the provision of such service, the Participant is notified that the service may not be covered and the Participant acknowledges in writing that he or she shall be responsible for payment of charges for such service. J. UTILIZATION MANAGEMENT MCA shall perform and comply with the Utilization Management requirements set forth in Exhibits XVII and XXI. K. CIGNA VISION/JOINT STEERING COMMITTEE Any and all services rendered by MCA and its Represented Providers under this Agreement shall be consistent with CIGNA's vision to provide or arrange to provide quality health care at a reasonable cost. Each party agrees to designate representatives, the number and identity of which shall be agreed upon by the parties, to participate in a Joint Steering Committee. The Joint Steering Committee shall meet on a periodic basis, but no less frequently than twice yearly, for the purpose of discussing the status of each party's performance under this Agreement and to resolve any complaints or problems with such performance. L. GUARANTEE OF PROVISION OF COVERED SERVICES 1. Throughout the term of this Agreement and for six (6) months following the termination of this Agreement, MCA shall secure and maintain an irrevocable letter(s) of credit in favor of CIGNA in an amount and form acceptable to CIGNA, for all states in which such a letter of credit is required by state law, regulation, statute, or as required by state insurance/HMO regulators. 2. CIGNA shall have the right to make immediate demand for payment under the irrevocable letter(s)of credit in the event that MCA has failed to pay any amounts due and owing to CIGNA, Represented Providers or others in accordance with MCA's obligations under this Agreement. 3. Prior to each anniversary date of this Agreement, CIGNA will evaluate the adequacy of the amount of the irrevocable letter(s) of credit by reviewing any and all state laws, regulations, and statutes. The amount of the irrevocable letter(s) of credit required to be maintained by MCA for the next contract year shall be a minimum of the amount equal to the individual state requirements for the contract year. 4. At least thirty (30) days prior to each anniversary date of this Agreement, CIGNA will advise MCA of the amount of the irrevocable letter of credit required to be maintained by MCA for the next contract year as calculated pursuant to subsection 3 above. MCA shall secure an irrevocable letter of credit in such amount and in a form acceptable to CIGNA prior to the anniversary date. M. PERFORMANCE FEEDBACK 1. CIGNA may provide feedback to MCA for MCA's own use in assessing and enhancing Represented Providers' performance with regard to quality of care, patient satisfaction and efficient practice. 2. For purposes of providing helpful performance feedback, CIGNA may perform telephone surveys and analyze medical costs of Participants in MCA's Gatekeeper Patient Panel in comparison with physician peers. CIGNA may also from time to time review a sample of medical records and provide performance feedback on past treatment. N. REIMBURSEMENT FOR COVERED SERVICES RENDERED TO PARTICIPANTS OUTSIDE OF PATIENT PANEL/OPT OUT SERVICES In the event that MCA's Represented Providers render covered Home Care Services to Participants outside of MCA's Patient Panel or services covered pursuant to a Participant's opt out benefits, MCA shall be reimbursed for such services at the rates established in the Gatekeeper Program Attachment - Fee For Service, attached hereto, less applicable Coinsurance, Copayments and Deductibles. Only those charges for covered Home Care Services billed in accordance with CIGNA's standard claim coding and bundling methodology will be allowed. O. REPRESENTED PROVIDER ACCEPTANCE OF PAYMENT. MCA will indemnify and hold harmless Payors, CIGNA and its Affiliates from any claim for payment in excess of the specified amount for covered Home Care Services rendered to Participants by each Represented Provider, unless the claim arises from a Payor's wrongful failure to pay MCA for covered Home Care Services. EXHIBIT A GATEKEEPER PROGRAM ATTACHMENT - CAPITATION SCHEDULE OF CAPITATION RATES CAPITATION RATES EFFECTIVE 1/1/04 - 12/31/04 These are the capitation rates that apply to services rendered to Patient Panel Participants enrolled in Gatekeeper Programs. A "Gatekeeper Program" means (i) a product that includes fully insured Standard HMO, Point of Service, or Gatekeeper PPO benefits and which is underwritten by a licensed insurance company based on an experience rating methodology, or (ii) a self funded product which includes Standard HMO, Point of Service, or Gatekeeper PPO benefits. This definition includes, but is not limited to, Participants covered under FlexCare plans insured/administered by Connecticut General Life Insurance Company. --------------------------------------------------------------- Gentiva HomeHealth, Infusion, DME/HME Capitation Rates PMPM --------------------------------------------------------------- All Gatekeeper (FlexCare) Capitated Affiliates * --------------------------------------------------------------- * Confidential treatment requested EXHIBIT B GATEKEEPER PROGRAM ATTACHMENT - CAPITATION PAYMENT RESPONSIBILITIES (MCA distributes payments) MCA shall pay Represented Providers for covered Home Care Services rendered hereunder in accordance with this Exhibit and the terms of the Agreement. 1. MCA shall pay Represented Providers for covered Home Care Services rendered hereunder in accordance with CIGNA's payment administration standards and any other standards set forth in applicable laws and regulations, including but not limited to, ERISA. MCA agrees to reimburse Represented Providers for covered Home Care Services within the time frames set forth in applicable law AND the time frames specified in MCA's provider agreements with its Represented Providers. CIGNA may withhold all or a portion of MCA's reimbursement if MCA repeatedly fails to reimburse Represented Providers on a timely basis. MCA's obligations with regard to payment for covered Home Care Services rendered hereunder shall survive the termination of this Agreement with respect to any covered Home Care Services rendered by Represented Providers during the term of this Agreement and with respect to any covered Home Care Services Represented Providers are obligated by this Agreement to provide after termination of this Agreement. 2. With reasonable notice, MCA agrees to allow CIGNA representatives to conduct on-site reviews of MCA's payment administration facilities. Such reviews shall be for the sole purpose of evaluating MCA's performance of its payment responsibilities under this Agreement, including, but not limited to, ascertaining the quality and timeliness of MCA's payment processing. MCA agrees to correct any deficiencies detected during such reviews within sixty (60) days of CIGNA's submission of a written report detailing such deficiencies. 3. If CIGNA determines that MCA cannot meet its payment administration obligations set forth herein, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in this Agreement shall be renegotiated by the parties to reflect such change in responsibility. MCA shall cooperate and provide to CIGNA any information necessary to perform such activities. 4. MCA shall be responsible for the production of all applicable tax reporting documents (e.g., 1099s) for Represented Providers. Such documents shall be produced in a format and within the time frames set forth in applicable state and federal laws and/or regulations. 5. MCA shall require that Represented Providers submit claims for covered Home Care Services rendered to Participants in other Programs for which CIGNA or Payor has retained payment responsibility directly to CIGNA in accordance with the applicable Program Attachment and Program Requirements. 6. MCA shall produce explanations of payments for Represented Providers with respect to those services rendered by Represented Providers to Participants for which an explanation of benefits is customarily provided or legally required. Such explanations of payments shall be in a format and contain data elements acceptable to CIGNA. 7. MCA shall develop and deliver training programs for Represented Providers which outline MCA's billing and reimbursement processes. MCA shall make best efforts to ensure that Represented Providers avoid submitting requests for payment to CIGNA for those covered Home Care Services rendered to Participants for whom MCA has payment responsibility. 8. MCA shall provide CIGNA with encounter data showing all services provided to each Participant for whom MCA receives Capitation Payments in a format and frequency mutually acceptable to both parties, but no less frequently than monthly. CIGNA may elect to withhold payment of MCA's compensation if MCA fails to submit encounter data in accordance with this Agreement. EXHIBIT C GATEKEEPER PROGRAM ATTACHMENT - CAPITATION UTILIZATION MANAGEMENT (partial delegation of utilization management) 1. MCA will assist CIGNA in the implementation of its Utilization Management program. Any Utilization Management program activities performed by MCA shall be in accordance with CIGNA's standards, NCQA standards or the standards of another appropriate accrediting body designated by CIGNA, and Program Requirements. MCA shall maintain any licensure required in connection with such activities. 2. MCA shall prepare such periodic reports or other data as reasonably requested by CIGNA relating to its Utilization Management activities in a format acceptable to CIGNA. 3. MCA shall not materially modify its Utilization Management activities without CIGNA's prior approval. 4. CIGNA shall have the right to audit MCA's Utilization Management activities upon reasonable prior notice. MCA shall cooperate with any such audits. 5. If CIGNA determines that MCA cannot meet its Utilization Management obligations set forth herein, CIGNA may elect to assume responsibility for such activities. If CIGNA elects to assume responsibility for such activities, the rates set forth in this Agreement shall be renegotiated by the parties to reflect such change in responsibility. MCA shall cooperate and provide to CIGNA any information necessary to perform such activities. 6. All referrals shall be to Represented Providers, except where an Emergency requires otherwise, in other cases where the referral is specifically authorized by CIGNA's Medical Director or his/her designee or MCA's medical director, if permitted by CIGNA to make such authorizations, or as otherwise required by law. Except in an Emergency or for a Pre-Qualified Maternity Stay or in those instances where prior authorization is prohibited by federal or state laws or regulations, MCA shall require all Represented Providers to obtain authorization from CIGNA or MCA, if permitted by CIGNA to make such authorizations, prior to hospital admission of any Participant or outpatient surgical procedures. 7. The parties acknowledge and agree that CIGNA or Payor shall have final decision making authority with regard to appeals of utilization management decisions. GATEKEEPER PROGRAM ATTACHMENT TO MANAGED CARE ALLIANCE AGREEMENT (FEE-FOR-SERVICE) PURPOSE The terms and provisions of this Gatekeeper Program Attachment and the Agreement are applicable to services rendered by MCA's Represented Providers to Gatekeeper Program Participants. As used in this Program Attachment, Participant means a Gatekeeper Program Participant. HMO Program Requirements shall apply to covered Home Care Services provided to Gatekeeper Program Participants. I. DEFINITIONS GATEKEEPER PROGRAM PARTICIPANT means a Participant, other than a HMO Program Participant, enrolled in either (i) a product which includes fully insured Standard HMO, Point of Service, or Gatekeeper PPO benefits and which product is underwritten by a licensed insurance company based on an experience rating methodology, or (ii) a self funded product which includes Standard HMO, Point of Service, or Gatekeeper PPO benefits. This definition includes, but is not limited to, Participants covered under FlexCare, True Access Open Access and Open Access Plus plans insured/administered by Connecticut General Life Insurance Company. GATEKEEPER PPO means a product offered pursuant to a Service Agreement which provides the Participant with an incentive to obtain Covered Services from Participating Providers and which generally requires the Participant to obtain an authorization from their Primary Care Physician in order to access such Covered Services from Participating Providers. HMO PROGRAM PARTICIPANT means a Participant enrolled in a non-governmental, fully insured Standard HMO or Point of Service product and which product is underwritten based on a community rating methodology (i.e. community rating, community rating by class, adjusted community rating by class). This definition includes, but is not limited to, Participants covered under commercial HMO or Open Access and Open Access Plus plans issued by CIGNA. MEDICAL DIRECTOR means a physician designated by CIGNA to manage Quality Management and Utilization Management responsibilities, or that physician's designee. PATIENT PANEL means those Gatekeeper Program Participants who have designated or have otherwise been assigned to one or more of MCA's Represented Providers as the primary source for certain Covered Services pursuant to a Service Agreement or HMO Program Requirements, and for which MCA will be reimbursed on a fee-for-service basis. POINT OF SERVICE means a product offered pursuant to a Service Agreement which allows the Participant to choose, in addition to Standard HMO benefits, a lower level of benefits if the Participant receives Covered Services from (i) a Participating Provider without a necessary authorization or (ii) from a non-Participating Provider, at the time such services are sought. PRIMARY CARE PHYSICIAN means a physician duly licensed to practice medicine who is a Participating Provider with CIGNA to provide Covered Services in the fields of general medicine, internal medicine, family practice or pediatrics, and who has agreed to provide primary care physician services to Participants in accordance with HMO Program Requirements. STANDARD HMO means a product offered pursuant to a Service Agreement where Covered Services are available to Participants only from Participating Providers, except in the case of an Emergency or with the prior authorization of CIGNA or Affiliate where Covered Services are not available from Participating Providers. II. PARTIES' OBLIGATIONS A. SERVICES 1. MCA, through its Represented Providers, shall provide all Home Care Services that are required by Participants in MCA's Patient Panel, for which such Participants are eligible, in accordance with the terms of this Agreement, this Gatekeeper Program Attachment and HMO Program Requirements. The compensation set forth in this Gatekeeper Program Attachment shall be payment in full for Home Care Services rendered to Gatekeeper Program Participants. 2. MCA, through its Represented Providers, shall arrange to provide Medically Necessary Home Care Services to Participants on a 24-hour per day, 7-day per week basis or arrange with other qualified providers (which meet all CIGNA and MCA credentialing requirements or other applicable guidelines) to provide such Medically Necessary Home Care Services to Participants. MCA shall require that such covering providers (a) are Participating Providers (unless otherwise agreed); (b) will not seek compensation from CIGNA for services for which MCA receives compensation hereunder; and (c) will not bill Participants for covered Home Care Services under any circumstances except for (i) Copayments, Deductibles or Coinsurance; (ii) the provision of services to a patient who is not eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit; and (iii) services provided to Participants that are not Home Care Services. (d) will direct the participant and/or the Represented Provider to obtain, authorization from CIGNA prior to all hospitalizations or referrals of Participants, except in Emergencies or for a Pre-Qualified Maternity Stay or as otherwise required by law. 3. MCA through its Represented Providers shall provide Home Care Services to all Participants in MCA's Patient Panel who are eligible to receive Home Care Services. 4. Subject to the terms and condition of this Agreement, MCA shall: (a) Arrange for the provision of Home Care Services to Participants; (b) Require Represented Providers to accept, treat, and otherwise render covered Home Care Services to Participants in the same manner, in accordance with the same standards, and with the same availability, as offered to other like patients. (c) not close its network to any new Participants unless CIGNA expressly consents to such closure; In no event shall MCA or Represented Providers be required to accept, treat, arrange for, or otherwise be obligated to render Home Care Services to Participants under this Agreement, even if medically appropriate, if: (a) the provision of such services to Participant would pose risk of bodily harm to the Participant or caregiver personnel of Represented Provider; (b) the provision of such services to Participant would be in violation of MCA's or Represented Provider's applicable license requirements or other applicable laws, and/or MCA policies, including but not limited to admission and discharge policies or discrimination policies; (c) MCA has not received the essential information to process a referral; (d) Participant repeatedly rejects the provision of services by a qualified Represented Provider selected by MCA and/or CIGNA as mutually agreed. MCA and Represented Providers shall not differentiate or discriminate in the treatment of any Participant because of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, health status, handicap or source of payment. 5. Except in an Emergency or for a Pre-Qualified Maternity Stay or in those instances where prior authorization is prohibited by federal or state laws or regulations, prior authorization by a Participant's Primary Care Physician or CIGNA as prescribed by HMO Program Requirements is required for payment of covered Home Care Services rendered to Participants. All referrals shall be to Participating Providers, except where an Emergency requires otherwise, in other cases where Medical Director specifically authorizes the referral or except as required by law. B. COMPENSATION AND BILLING 1. Reimbursement for Home Care Services rendered by Represented Providers shall be in accordance with the following rates, less applicable Copayments, Deductibles or Coinsurance: a. Reimbursement for Home Care services arranged by MCA and rendered by Represented Providers shall be in accordance with Exhibit A attached hereto. b. MCA will indemnify and hold harmless Payors, CIGNA and its Affiliates from any claim for payment in excess of the specified amounts for Home Care Services rendered to Participants by each Represented Provider, unless the claim arises from a Payor's wrongful failure to pay MCA for covered Home Care Services. 2. Payors shall agree to deduct any Copayments, Deductibles, or Coinsurance required by the Service Agreement from payment due. Deduction for the Copayment, Deductible or Coinsurance shall be determined on the basis of the contracted rate. 3. Reimbursement for Home Care Services rendered hereunder shall be made by CIGNA or its designees to MCA. MCA shall bill for covered Home Care Services according to the following: a. MCA shall submit claims on the appropriate claim form for all covered Home Care Services within one hundred twenty (120) days of the date those services are rendered. Claims received after this one hundred twenty (120) day period may be denied for payment. MCA shall submit claims to the location described in applicable Program Requirements. b. Any amount owing under this Agreement shall be paid within thirty (30) days after receipt of a complete claim, unless additional required information is requested within the thirty (30) day period, or the claim involves coordination of benefits, except as otherwise provided in this Agreement. 4. MCA and its Represented Providers shall not charge a Participant for a service which is not Medically Necessary unless, in advance of the provision of such service, the Participant is notified that the service may not be covered and the Participant acknowledges in writing that he or she shall be responsible for payment of charges for such service. 5. MCA will and shall require its Represented Providers to look solely to Payor for compensation for covered Home Care Services except for Copayments, Deductibles or Coinsurance. MCA agrees, for itself and on behalf of each Represented Provider, that whether or not there is any unresolved dispute for payment, under no circumstances will MCA or any Represented Provider directly or indirectly make any charges or claims, other than for Copayments, Deductibles or Coinsurance against any Participants or their representatives for covered Home Care Services and that this provision survives termination of this Agreement for services rendered prior to such termination. This provision shall not prohibit collection of (i) any applicable Copayments, Deductibles, or Coinsurance, (ii) payments for services provided to a patient who is no longer eligible to receive Home Care Services, including but not limited to Participants that have reached their benefit limit (iii) payment for services provided to Participants, which are not Home Care Services. This paragraph is to be interpreted for the benefit of Participants and does not diminish the obligation of Payor to make payments to Represented Providers according to the terms of this Agreement. 6. The rates set forth herein shall apply to all services rendered to Participants in the Gatekeeper Program. 7. Only those charges for Home Care Services billed in accordance with CIGNA's standard claim coding and bundling methodology will be allowed. C. OTHER REQUIREMENTS MCA and its Represented Providers shall use best efforts to prescribe or authorize the substitution of generic pharmaceuticals when appropriate and shall cooperate with CIGNA's formulary and HMO Program Requirements regarding the substitution of generic pharmaceuticals. [THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK] EXHIBIT A GATEKEEPER PROGRAM ATTACHMENT - FEE FOR SERVICE REIMBURSEMENT FOR OTHER SERVICES RATE AREA DESIGNATIONS: -------------------------------------------------------------------------------- STATE RATE AREA RATE DESIGNATION -------------------------------------------------------------------------------- Alabama LOW 3 -------------------------------------------------------------------------------- Alaska HIGH 1 -------------------------------------------------------------------------------- Arizona MEDIUM 2 -------------------------------------------------------------------------------- Arkansas LOW 3 -------------------------------------------------------------------------------- California HIGH 1 -------------------------------------------------------------------------------- Colorado MEDIUM 2 -------------------------------------------------------------------------------- Connecticut MEDIUM 2 -------------------------------------------------------------------------------- Delaware LOW 3 -------------------------------------------------------------------------------- District of Columbia HIGH 1 -------------------------------------------------------------------------------- Florida MEDIUM 2 -------------------------------------------------------------------------------- Georgia MEDIUM 2 -------------------------------------------------------------------------------- Hawaii HIGH 1 -------------------------------------------------------------------------------- Idaho LOW 3 -------------------------------------------------------------------------------- Illinois HIGH 1 -------------------------------------------------------------------------------- Indiana LOW 3 -------------------------------------------------------------------------------- Iowa LOW 3 -------------------------------------------------------------------------------- Kansas LOW 3 -------------------------------------------------------------------------------- Kentucky LOW 3 -------------------------------------------------------------------------------- Louisiana MEDIUM 2 -------------------------------------------------------------------------------- Maine LOW 3 -------------------------------------------------------------------------------- Maryland MEDIUM 2 -------------------------------------------------------------------------------- Massachusetts HIGH 1 -------------------------------------------------------------------------------- Michigan LOW 3 -------------------------------------------------------------------------------- Minnesota LOW 3 -------------------------------------------------------------------------------- Mississippi LOW 3 -------------------------------------------------------------------------------- Missouri MEDIUM 2 -------------------------------------------------------------------------------- Montana LOW 3 -------------------------------------------------------------------------------- Nebraska LOW 3 -------------------------------------------------------------------------------- Nevada LOW 3 -------------------------------------------------------------------------------- New Hampshire LOW 3 -------------------------------------------------------------------------------- New Jersey MEDIUM 2 -------------------------------------------------------------------------------- New Mexico LOW 3 -------------------------------------------------------------------------------- New York MEDIUM 2 -------------------------------------------------------------------------------- North Carolina MEDIUM 2 -------------------------------------------------------------------------------- North Dakota MEDIUM 2 -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- Ohio MEDIUM 2 -------------------------------------------------------------------------------- Oklahoma LOW 3 -------------------------------------------------------------------------------- Oregon MEDIUM 2 -------------------------------------------------------------------------------- Pennsylvania MEDIUM 2 -------------------------------------------------------------------------------- Rhode Island MEDIUM 2 -------------------------------------------------------------------------------- South Carolina MEDIUM 2 -------------------------------------------------------------------------------- South Dakota LOW 3 -------------------------------------------------------------------------------- Tennessee MEDIUM 2 -------------------------------------------------------------------------------- Texas HIGH 1 -------------------------------------------------------------------------------- Utah MEDIUM 2 -------------------------------------------------------------------------------- Vermont LOW 3 -------------------------------------------------------------------------------- Virginia MEDIUM 2 -------------------------------------------------------------------------------- Washington MEDIUM 2 -------------------------------------------------------------------------------- West Virginia LOW 3 -------------------------------------------------------------------------------- Wisconsin LOW 3 -------------------------------------------------------------------------------- Wyoming LOW 3 -------------------------------------------------------------------------------- TRADITIONAL HOME HEALTH SERVICES: RATES EFFECTIVE JANUARY 1, 2004 - DECEMBER 31, 2004 THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE BOTH VISIT AND HOURLY RATES. Notes 1, 2, 3, 4, 5 and 6 apply AREA 1 AREA 2 AREA 3 ------------------------------------------ VISIT HOUR VISIT HOUR VISIT HOUR ------------------------------------------ CERTIFIED NURSES AIDE * * * * * * --------------------------------------------------------------------------- HOME HEALTH AIDE * * * * * * --------------------------------------------------------------------------- LVN/LPN * * * * * * --------------------------------------------------------------------------- LVN/LPN - HIGH TECH * * * * * * --------------------------------------------------------------------------- PEDIATRIC HIGH TECH LVN/LPN * * * * * * --------------------------------------------------------------------------- PEDIATRIC HIGH TECH RN * * * * * * --------------------------------------------------------------------------- PEDIATRIC LVN/LPN * * * * * * --------------------------------------------------------------------------- PEDIATRIC RN * * * * * * --------------------------------------------------------------------------- RN * * * * * * --------------------------------------------------------------------------- RN HIGH TECH INFUSION * * * * * * --------------------------------------------------------------------------- RN HIGH TECH OTHER * * * * * * --------------------------------------------------------------------------- THE FOLLOWING TRADITIONAL HOME HEALTH SERVICES HAVE VISIT ONLY RATES. Notes 1, 3, 4, 5, 7 and 8 apply AREA 1 AREA 2 AREA 3 ------------------------------------------ VISIT HOUR VISIT HOUR VISIT HOUR ------------------------------------------ DIABETIC NURSE * * * * * * -------------------------------------------------------------------------------- DIETITIAN * * * * * * -------------------------------------------------------------------------------- ENTEROSTOMAL THERAPIST * * * * * * -------------------------------------------------------------------------------- MATERNAL CHILD HEALTH * * * * * * * Confidential treatment requested -------------------------------------------------------------------------------- MEDICAL SOCIAL WORKER * * * * * * -------------------------------------------------------------------------------- OCCUPATIONAL THERAPIST * * * * * * -------------------------------------------------------------------------------- OCCUPATIONAL THERAPIST ASSISTANT * * * * * * -------------------------------------------------------------------------------- PHLEBOTOMIST * * * * * * -------------------------------------------------------------------------------- PHOTOTHERAPY PACKAGE SERVICE * * * * * * -------------------------------------------------------------------------------- PHYSICAL THERAPIST * * * * * * -------------------------------------------------------------------------------- PHYSICAL THERAPIST ASSISTANT * * * * * * -------------------------------------------------------------------------------- PSYCHIATRIC NURSE * * * * * * -------------------------------------------------------------------------------- REHABILITATION NURSE * * * * * * -------------------------------------------------------------------------------- RESPIRATORY THERAPIST * * * * * * -------------------------------------------------------------------------------- RESPIRATORY THERAPIST - CPAP Clinic * * * * * * -------------------------------------------------------------------------------- RN ASSESSMENT, INITIAL * * * * * * -------------------------------------------------------------------------------- RN SKILLED NURSING VISIT-EXTENSIVE * * * * * * -------------------------------------------------------------------------------- SPEECH THERAPIST * * * * * * -------------------------------------------------------------------------------- THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE HAS HOURLY ONLY RATES. Notes 3, 4 and 5 apply AREA 1 AREA 2 AREA 3 ------------------------------------------ VISIT HOUR VISIT HOUR VISIT HOUR ------------------------------------------ HOMEMAKER * * * * * * -------------------------------------------------------------------------------- THE FOLLOWING TRADITIONAL HOME HEALTH SERVICE IS PRICED ON A PER DIEM BASIS. Notes 3, 4 and 5 apply AREA 1 AREA 2 AREA 3 -------------------------------------------------- PER PER PER DIEM DIEM DIEM -------------------------------------------------- COMPANION/LIVE IN * * * * * * -------------------------------------------------------------------------------- NOTES: * * * * * * * * * Confidential treatment requested HOME INFUSION RATES: RATES EFFECTIVE JANUARY 1, 2004 - DECEMBER 31, 2004 THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE PRICED AS A PERCENTAGE DISCOUNT OFF AWP (IF APPLICABLE), AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR PRIMARY OR PRIMARY OR MULTIPLE THERAPY MULTIPLE THERAPY MULTIPLE THERAPY PER DIEM DISPENSING FEE DRUG DISCOUNT OFF AWP ------------------------------------------------------------- Ancillary Drugs * * * ---------------------------------------------------------------------------------------------------------------- Biological Response Modifiers * * * ---------------------------------------------------------------------------------------------------------------- Cardiac (Inotropic) Therapy * * * ---------------------------------------------------------------------------------------------------------------- Chelation Therapy * * * ---------------------------------------------------------------------------------------------------------------- Chemotherapy * * * ---------------------------------------------------------------------------------------------------------------- Enteral Therapy * * * ---------------------------------------------------------------------------------------------------------------- Enzyme Therapy * * * ---------------------------------------------------------------------------------------------------------------- Growth Hormone * * * ---------------------------------------------------------------------------------------------------------------- IV Immune Globulin * * * ---------------------------------------------------------------------------------------------------------------- Other Injectable Therapies * * * ---------------------------------------------------------------------------------------------------------------- Other Infusion Therapies * * * ---------------------------------------------------------------------------------------------------------------- Pain Management Therapy * * * ---------------------------------------------------------------------------------------------------------------- Steroid Therapy * * * ---------------------------------------------------------------------------------------------------------------- Thrombolytic (Anticoagulation) Therapy * * * ---------------------------------------------------------------------------------------------------------------- Synagis * * * ---------------------------------------------------------------------------------------------------------------- Remodulin Therapy * * * ----------------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES EXCLUDE DRUGS. DRUGS ARE PRICED AS A PERCENTAGE DISCOUNT OFF AWP, AND THERE IS A PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
PER DIEM DRUG DISCOUNT OFF AWP --------------------------------------------------------- Anti-Infectives - Primary Anti-Infective * * * ---------------------------------------------------------------------------------------------------------------- Anti-Infectives - Multiple Anti-Infective * * * ----------------------------------------------------------------------------------------------------------------
THE FOLLOWING HOME INFUSION THERAPY SERVICE RATE EXCLUDES DRUGS. DRUGS ARE PRICED PER VIAL, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE ANTI-INFECTIVE THERAPIES
PRIMARY OR MULTIPLE THERAPY PER DIEM COST OF DRUG --------------------------------------------------------- Flolan Therapy * ------------------------------------------------------------------------------------------------------------ Flolan 0.5 mg vial * ------------------------------------------------------------------------------------------------------------ Flolan 1.5 mg vial * ------------------------------------------------------------------------------------------------------------ Flolan diluent vial * ------------------------------------------------------------------------------------------------------------
* Confidential treatment requested THE FOLLOWING HOME INFUSION THERAPY SERVICE RATES INCLUDE DRUGS, AND THERE IS NO PRICE DIFFERENCE BETWEEN PRIMARY AND MULTIPLE THERAPIES
PRIMARY OR MULTIPLE THERAPY PER DIEM --------------------------------------------------------- Enteral Therapy * ------------------------------------------------------------------------------------------------------------ Hydration Therapy * ------------------------------------------------------------------------------------------------------------ Total Parenteral Nutrition * ------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * * THE FOLLOWING ARE FOR THE STATED ITEM ONLY. UNLESS OTHERWISE NOTED, NURSING, SUPPLIES, ETC. ARE NOT INCLUDED. ------------------------------------------------------------------------------------------------------------ Blood Transfusion per Unit (Tubing, Filters) * ------------------------------------------------------------------------------------------------------------ Catheter Care Per Diem * ------------------------------------------------------------------------------------------------------------ Midline Insertion (Catheter & Supplies) * ------------------------------------------------------------------------------------------------------------ PICC Line Insertion (Catheter & Supplies) * ------------------------------------------------------------------------------------------------------------ Blood Product * ------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------- * Confidential treatment requested FACTOR CONCENTRATES
Vial price Unit Price ----------------------------------------------------------------------------------------------------------- FACTOR VII ----------------------------------------------------------------------------------------------------------- Novoseven 1200MCG Vial * ----------------------------------------------------------------------------------------------------------- Novoseven 4800MCG Vial * ----------------------------------------------------------------------------------------------------------- Novoseven in 1200MCG or 4800MCG QTY * ----------------------------------------------------------------------------------------------------------- FACTOR VIII (RECOMBINANT) ----------------------------------------------------------------------------------------------------------- Recombinate * ----------------------------------------------------------------------------------------------------------- Kogenate or Helixate * ----------------------------------------------------------------------------------------------------------- Bioclate * ----------------------------------------------------------------------------------------------------------- Helixate FS * ----------------------------------------------------------------------------------------------------------- Kogenate FS * ----------------------------------------------------------------------------------------------------------- Refacto * ----------------------------------------------------------------------------------------------------------- Advate * ----------------------------------------------------------------------------------------------------------- FACTOR VIII (MONOCLONAL) ----------------------------------------------------------------------------------------------------------- Hemofil-M or A. R. C. Method M * ----------------------------------------------------------------------------------------------------------- Monoclate P * ----------------------------------------------------------------------------------------------------------- Monarc-M * ----------------------------------------------------------------------------------------------------------- FACTOR VIII (OTHER) ----------------------------------------------------------------------------------------------------------- Koate * ----------------------------------------------------------------------------------------------------------- Humate * ----------------------------------------------------------------------------------------------------------- Alphanate SDHT * ----------------------------------------------------------------------------------------------------------- FACTOR IX (RECOMBINANT) ----------------------------------------------------------------------------------------------------------- BeneFix * ----------------------------------------------------------------------------------------------------------- FACTOR IX (MONOCLONAL/HIGH PURITY) ----------------------------------------------------------------------------------------------------------- Mononine * ----------------------------------------------------------------------------------------------------------- Alphanine * ----------------------------------------------------------------------------------------------------------- FACTOR IX (OTHER) ----------------------------------------------------------------------------------------------------------- Konyne - 80 * ----------------------------------------------------------------------------------------------------------- Proplex T * ----------------------------------------------------------------------------------------------------------- Bebulin * ----------------------------------------------------------------------------------------------------------- Profilnine SD * ----------------------------------------------------------------------------------------------------------- ANTI-INHIBITOR COMPLEX ----------------------------------------------------------------------------------------------------------- Autoplex-T * -----------------------------------------------------------------------------------------------------------
* Confidential treatment requested ----------------------------------------------------------------------------------------------------------- Feiba-VH * ----------------------------------------------------------------------------------------------------------- Hyate-C * ----------------------------------------------------------------------------------------------------------- HEMOSTATIC AGENTS ----------------------------------------------------------------------------------------------------------- DDAVP - 10ml vial * ----------------------------------------------------------------------------------------------------------- Stimate - 2.5ml vial * -----------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit; 24-hour on-call clinical support; home infusion monitoring system; product delivery nationwide; patient training, education, and evaluation DME/HOME RESPIRATORY RATES: RATES EFFECTIVE JANUARY 1, 2004 - MARCH 31, 2004
HCPCS CHC GENTIVA CODE CODE CODE DESCRIPTION PURCHASE PRICE RENTAL PRICE DAILY PRICE ---------------------------------------------------------------------------------------------------------------- A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) * W/STETH & CUFF ---------------------------------------------------------------------------------------------------------------- A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), * AUTOMATIC ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK * ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7553 FULL FACE (A9900) MIRAGE * CPAP/BIPAP MASK ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP * MASK INCL GLD SEAL,PHANTM,MONARCH ---------------------------------------------------------------------------------------------------------------- A7034 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP * MASK (PROFILE OR SIMPICITY) ---------------------------------------------------------------------------------------------------------------- B9002 HI531 2570 PUMP, ENTERAL (B9002) * * ---------------------------------------------------------------------------------------------------------------- B9998 DM590 6828 ENTERAL SUPPLIES (B9998) * * ---------------------------------------------------------------------------------------------------------------- DM590 DM570 7551 BACK-PACK (E1399), FOR * PORTABLE ENTERAL PUMP ---------------------------------------------------------------------------------------------------------------- A4615 DM590 2522 CANNULA, NASAL * ---------------------------------------------------------------------------------------------------------------- B9002 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * * ---------------------------------------------------------------------------------------------------------------- A7034 DM590 7508 MASK, CPAP GEL OR SILICONE * (K0183) ---------------------------------------------------------------------------------------------------------------- E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP * ---------------------------------------------------------------------------------------------------------------- E0105 E0105 2021 CANE, QUAD (E0105) OR THREE * PRONG, ADJ OR FIX, W/ TIPS ---------------------------------------------------------------------------------------------------------------- E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ * OR FIX, PAIR, W/ TIPS, GRIPS ---------------------------------------------------------------------------------------------------------------- E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR * FIX, EACH, W/ TIP AND GRIPS ---------------------------------------------------------------------------------------------------------------- E0112 E0112 2027 CRUTCHES UNDERARM, WOOD * (E0112), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0114 E0114 2026 CRUTCHES UNDERARM, ALUM * (E0114), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0130 E0130 2037 WALKER, RIGID (E0130) * (PICKUP), ADJ OR FIX HEIGHT ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0135 E0135 2036 WALKER, FOLDING (E0135) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0141 E0141 2040 WALKER, WHEELED (E0141), W/OUT * SEAT ---------------------------------------------------------------------------------------------------------------- E0142 DM570 2034 RIGID WALKER (E0142), WHEELED, * W/ SEAT, ---------------------------------------------------------------------------------------------------------------- E0143 E0143 2029 WALKER FOLDING, WHEELED * (E0143), W/OUT SEAT ---------------------------------------------------------------------------------------------------------------- E0145 DM570 2039 WALKER (E0145), WHEELED, W/ * SEAT AND CRUTCH ATTACHMENTS ---------------------------------------------------------------------------------------------------------------- E0146 DM570 2038 WALKER, WHEELED, W/ SEAT (E0146) * ---------------------------------------------------------------------------------------------------------------- E0147 E0147 2030 WALKER HVY DUT (E0147), MULT * BRAKING SYS, VAR WHEEL RESISTANCE ---------------------------------------------------------------------------------------------------------------- E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT * (E0153), FOREARM EA ---------------------------------------------------------------------------------------------------------------- E0154 E0154 2033 WALKER PLATFORM ATTACHMENT * (E0154), EA ---------------------------------------------------------------------------------------------------------------- E0155 E0155 2041 WALKER WHEEL ATTACHMENT * (E0155), RIGID (PICKUP) WALKER ---------------------------------------------------------------------------------------------------------------- E0156 DM570 2035 WALKER SEAT ATTACHMENT (E0156) * ---------------------------------------------------------------------------------------------------------------- E0157 E0157 2022 WALKER, CRUTCH ATTACHMENT * (E0157), EACH ---------------------------------------------------------------------------------------------------------------- E0158 E0158 2031 WALKER LEG EXTENSIONS (E0158) * ---------------------------------------------------------------------------------------------------------------- E0163 E0163 2047 COMMODE CHAIR, STATIONARY * (E0163), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0164 E0164 2045 COMMODE CHAIR, MOBILE * (E0164), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2046 COMMODE CHAIR (E0165), * STATIONARY, W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2591 COMMODE, XXWIDE(E0165) * ---------------------------------------------------------------------------------------------------------------- E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, * W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN * (E0167) ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE * PAD, NON-POSITIONING ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2394 REPLACEMENT PAD (E0176) * ALTERNATING PRESS ---------------------------------------------------------------------------------------------------------------- E0177 E0177 2224 CUSHION OR WATER PRESS PAD * (E0177), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0178 E0178 2160 CUSHION OR GEL PRESS PAD * (E0178), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE * PAD, NONPOSTIONING ---------------------------------------------------------------------------------------------------------------- E0180 E0180 2196 PUMP (E0180), ALTERNATING * * PRESSURES W/PAD ---------------------------------------------------------------------------------------------------------------- E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS * * W/PAD, HVY DUTY ---------------------------------------------------------------------------------------------------------------- E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) * ---------------------------------------------------------------------------------------------------------------- E0185 E0185 2076 MATTRESS (E0185), GEL OR * GEL-LIKE PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) * ---------------------------------------------------------------------------------------------------------------- E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) * ---------------------------------------------------------------------------------------------------------------- E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN * * (E0189), ANY SIZE ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2573 CUSHION, JAY FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND * * POSITIONING EQUALIZATION ---------------------------------------------------------------------------------------------------------------- E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), * * * INCL. BED ---------------------------------------------------------------------------------------------------------------- E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * * * ---------------------------------------------------------------------------------------------------------------- E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) * ---------------------------------------------------------------------------------------------------------------- E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD * (E0197) ---------------------------------------------------------------------------------------------------------------- E0198 E0198 2100 MATTRESS (E0198), WATER * PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD * (E0199) ---------------------------------------------------------------------------------------------------------------- E0200 E0200 2228 HEAT LAMP (E0200), W/OUT * STAND, INCL/BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) * * (E0202), LIGHT WIT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET * * (E0202) ---------------------------------------------------------------------------------------------------------------- E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, * INCL/ BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0210 DM570 2156 HEATING PAD, STANDARD (E0210) * ---------------------------------------------------------------------------------------------------------------- E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, * MOIST ---------------------------------------------------------------------------------------------------------------- E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * * ---------------------------------------------------------------------------------------------------------------- E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) * ---------------------------------------------------------------------------------------------------------------- E0236 DM570 2199 PUMP (E0236) FOR WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0237 DM570 2223 HEAT COLD WATER (E0237) * CIRCULATING PAD W/PUMP ---------------------------------------------------------------------------------------------------------------- E0238 DM570 2179 HEATING PAD (E0238), MOIST, * NON-ELECTRIC ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, * L-SHAPE ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2043 BATH TUB RAIL, WALL, * UNSPECIFIED SIZE ---------------------------------------------------------------------------------------------------------------- E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE * (E0242) ---------------------------------------------------------------------------------------------------------------- E0243 DM570 2056 TOILET RAIL, EACH (E0243) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH * ARMS ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2052 TOILET SEAT, RAISED (E0244) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2575 BATH BENCH WITH BACK (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2578 TRANSFER BENCH, NON-PADDED * (E0245) ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) * ---------------------------------------------------------------------------------------------------------------- E0246 DM570 2057 TRANSFER TUB RAIL(E0246), * ATTACHMENT ---------------------------------------------------------------------------------------------------------------- E0249 DM570 2186 HEAT UNIT (E0249), WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/O MATTRESS ---------------------------------------------------------------------------------------------------------------- E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, W/ * * SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, W/ * * SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) * ---------------------------------------------------------------------------------------------------------------- E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) * ---------------------------------------------------------------------------------------------------------------- E0273 DM570 2068 BED BOARD (E1399) * ---------------------------------------------------------------------------------------------------------------- E0274 DM570 2097 OVER-BED TABLE (E0274) * ---------------------------------------------------------------------------------------------------------------- E0275 E0275 2071 BED PAN, STANDARD (E0275), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0276 E0276 2070 BED PAN, FRACTURE (E0276), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, * * ALT PRESSURE ---------------------------------------------------------------------------------------------------------------- E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) * * ---------------------------------------------------------------------------------------------------------------- E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, * * HI-LO, W/OUT S/ RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, * * HI-LO, NO SIDE RAILS, NO MATTRESS ---------------------------------------------------------------------------------------------------------------- E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0305 E0305 2073 BED SIDE RAILS (E0305), HALF * LENGTH ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0310 E0310 2072 BED SIDE RAILS (E0310), FULL * LENGTH ---------------------------------------------------------------------------------------------------------------- E0315 DM570 2067 BED ACCESSORIES: BOARDS OR * TABLES, ANY TYPE ---------------------------------------------------------------------------------------------------------------- E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, * ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0326 E0326 2059 URINAL; FEMALE (E0326), * JUG-TYPE, ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0372 E0372 7008 MATTRESS (E0372) POWERED AIR * * OVERLAY ---------------------------------------------------------------------------------------------------------------- E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), * PER POUND ---------------------------------------------------------------------------------------------------------------- E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS * SYSTEM ONLY, UP TO 23 CUBIC FEET ---------------------------------------------------------------------------------------------------------------- E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR * GAS, RENT ---------------------------------------------------------------------------------------------------------------- E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) * ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT * * (E0431) W/CONSERV DEVICE,NO CONTENT ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) * ---------------------------------------------------------------------------------------------------------------- E0434 E0434 2377 O2 SYS PORT LIQUID,RENT (E0434) * ---------------------------------------------------------------------------------------------------------------- E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH * (E0435) ---------------------------------------------------------------------------------------------------------------- E0439 E0439 2388 O2 SYS STATIONARY (E0439) * LIQUID, RENT ---------------------------------------------------------------------------------------------------------------- E0440 E0440 2387 O2 SYS STATIONARY (E0440) * LIQUID, PURCH ---------------------------------------------------------------------------------------------------------------- E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER * (E0400), 200-300 CUBIC FT ---------------------------------------------------------------------------------------------------------------- E0444 E0444 2379 O2 CONTENTS, PORT LIQUID * (E0444), PER UNIT (1 UNIT = 1 LB.) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7555 POSITIVE PRESSURE VENTS * (E0450)(E.G. T-BIRD) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 2392 VENTILATOR VOLUME (E0450), * * STATIONARY OR PORT ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) * * EMERGENCY BACKUP UNIT ---------------------------------------------------------------------------------------------------------------- E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) * * ASSIST DEVICE,(BIPAP) ---------------------------------------------------------------------------------------------------------------- E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); * * FOR USE 12 HOURS OR LESS PER DAY ---------------------------------------------------------------------------------------------------------------- E0455 E0455 2372 O2 TENT (E0455), EXCLUDING * * CROUP OR PEDIATRIC TENTS ---------------------------------------------------------------------------------------------------------------- E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * * ---------------------------------------------------------------------------------------------------------------- E0459 E0459 2324 CHEST WRAP (E0459) * * ---------------------------------------------------------------------------------------------------------------- E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE * * PRESSURE , PORTABLE OR STATIONARY ---------------------------------------------------------------------------------------------------------------- E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR * * PNEUM, HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0500 E0500 2333 IPPB , W/ BUILT-IN NEB (E0500) * * MAN OR AUTO VALVES; INT/EXT POWER ---------------------------------------------------------------------------------------------------------------- E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR * * EXTENSIV SUP/ HUMID W/ IPPB OR O2 ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, * * GLASS, FOR USE W/ REG OR FLOWMETER ---------------------------------------------------------------------------------------------------------------- E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * * ---------------------------------------------------------------------------------------------------------------- E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) * * ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * * ---------------------------------------------------------------------------------------------------------------- E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR * * AND HEATER ---------------------------------------------------------------------------------------------------------------- E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * ---------------------------------------------------------------------------------------------------------------- E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0601 E0601 2326 CONTINUOUS POSITVE (E0601) * * AIRWAY PRESSURE DEVICE (CPAP) ---------------------------------------------------------------------------------------------------------------- E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * * ---------------------------------------------------------------------------------------------------------------- E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) * ---------------------------------------------------------------------------------------------------------------- E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) * ---------------------------------------------------------------------------------------------------------------- E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) * ACCUCHEK AD ---------------------------------------------------------------------------------------------------------------- E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) * ---------------------------------------------------------------------------------------------------------------- E0618 E0608 2322 APNEA MONITOR (E0608) * * ---------------------------------------------------------------------------------------------------------------- E0619 E0608 2576 APNEA MONITOR (E0608) W/MEM * * (INCL SMART) ---------------------------------------------------------------------------------------------------------------- E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) * W/SPECIAL FEATURES ---------------------------------------------------------------------------------------------------------------- E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR * SEAT, CANVAS OR NYLON ---------------------------------------------------------------------------------------------------------------- E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, * BATHROOM OR TOILET ---------------------------------------------------------------------------------------------------------------- E0627 E0627 4553 HIP CHAIR (E0627) * * ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED * (E0627) ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2205 SEAT LIFT MECH (E0627) * INCORPORATED INTO A COMB LIFT-CHAIR MECH ---------------------------------------------------------------------------------------------------------------- E0630 E0630 2190 PATIENT LIFT, HYDRAULIC * * (E0630), W/ SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ * * SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0650 E0650 2192 PNEUM COMPRESSOR (E0650), * * NON-SEG HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG * * HOME MODEL W/OUT CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG * * HOME MODEL W/ CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0655 E0655 2182 PNEUM COMPRESSOR (E0655), * NON-SEG APPLIANCE, HALF ARM ---------------------------------------------------------------------------------------------------------------- E0660 E0660 2181 PNEUM COMPRESSOR (E0660), * NON-SEG APPLIANCE, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0665 E0665 2180 PNEUM COMPRESSOR (E0665), * NON-SEG APPLIANCE, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0666 E0666 2183 PNEUM COMPRESSOR (E0666), * NON-SEG APPLIANCE, HALF LEG ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, * FULL LEG ---------------------------------------------------------------------------------------------------------------- E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, * FULL ARM ---------------------------------------------------------------------------------------------------------------- E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, * HALF LEG ---------------------------------------------------------------------------------------------------------------- E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, * HALF ARM ---------------------------------------------------------------------------------------------------------------- E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG * GRAD PRESS, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG * GRAD PRESS, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG * GRAD PRESS, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), * APPROPRIATE FOR HOME USE ---------------------------------------------------------------------------------------------------------------- E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., * BELT, HARNESS OR VEST) ---------------------------------------------------------------------------------------------------------------- E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE * (BODY, CHEST, WRIST OR ANKLE) ---------------------------------------------------------------------------------------------------------------- E0720 E0720 2219 TENS (E0720), TWO LEAD, * * LOCALIZED STIMULATION ---------------------------------------------------------------------------------------------------------------- E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER * * AREA/MULTIPLE NERVE STIMULATION ---------------------------------------------------------------------------------------------------------------- E0731 E0731 2159 TENS OR NMES (E0731), * CONDUCTIVE GARMENT ---------------------------------------------------------------------------------------------------------------- E0744 E0744 2120 STIMULATOR (E0744), * * NEUROMUSCULAR FOR SCOLIOSIS ---------------------------------------------------------------------------------------------------------------- E0745 E0745 2121 STIMULATOR (E0745), * * NEUROMUSCULAR, ELECTRONIC SHOCK UNIT ---------------------------------------------------------------------------------------------------------------- E0745 E0745 6915 STIMULATOR FOUR CH (E0745), * * NEUROMUSCULAR ---------------------------------------------------------------------------------------------------------------- E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), * * BIOFEEDBACK DEVICE ---------------------------------------------------------------------------------------------------------------- E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, * NON-INVASIVE ---------------------------------------------------------------------------------------------------------------- E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC * NON-INVASIVE, SPINAL APPLICATIONS ---------------------------------------------------------------------------------------------------------------- E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC * SALIVARY REFLEX, NON INVASIVE ---------------------------------------------------------------------------------------------------------------- E0776 E0776 2175 IV POLE (E0776) * * ---------------------------------------------------------------------------------------------------------------- E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY * INFUSION, MINIMED, INSULIN ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7925 PUMP, EXT INFUSION, MINIMED * PREMIUM, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 6771 PUMP (E0784), INSULIN EXT * INFUSION DISETRONICS OR OTHER ---------------------------------------------------------------------------------------------------------------- E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH * TO HEADBOARD, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0850 E0850 2134 TRACTION STAND (E0850), FREE * * STANDING, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR * * STAND ---------------------------------------------------------------------------------------------------------------- E0860 E0860 2130 TRACTION EQUIP (E0860), * * OVERDOOR, CERVICAL ---------------------------------------------------------------------------------------------------------------- E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH * * TO FOOTBOARD, EXTREMITY, BUCKS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0880 E0880 2135 TRACTION STAND (E0880) * * FREE/STAND EXTREMITY TRACTION, EG, BUCK'S ---------------------------------------------------------------------------------------------------------------- E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH * * TO FOOTBOARD, PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0900 E0900 2136 TRACTION STAND (E0900) FREE/ * * STAND PELVIC TRACTION,( EG, BUCK'S) ---------------------------------------------------------------------------------------------------------------- E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT * * HELPER, ATTACH TO BED W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH * * TO BED, INCLUDING WEIGHTS ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE * DEVICE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ANKLE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ELBOW ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE * DEVICE, HAND ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE * DEVICE, SHOULDER ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE * DEVICE, WRIST ---------------------------------------------------------------------------------------------------------------- E0940 E0940 2137 TRAPEZE BAR (E0940), FREE * * STANDING, COMPLETE W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0941 E0941 2116 TRACTION DEVICE (E0941), * * GRAVITY ASSISTED ---------------------------------------------------------------------------------------------------------------- E0942 E0942 2101 HARNESS/HALTER (E0942), * CERVICAL HEAD ---------------------------------------------------------------------------------------------------------------- E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, * BOOT ---------------------------------------------------------------------------------------------------------------- E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT * ---------------------------------------------------------------------------------------------------------------- E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL * * W/ CROSS BARS, ATTACH TO BED ---------------------------------------------------------------------------------------------------------------- E0947 E0947 2113 FRACTURE FRAME (E0947), * ATTACHMENTS FOR COMPLEX PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0948 E0948 2112 FRACTURE FRAME (E0948) * * ATTACHMENTS FOR COMPLEX CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0950 DM570 2139 TRAY (E0950) * ---------------------------------------------------------------------------------------------------------------- E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO * CONVERT ANY W/C TO ONE ARM DRIVE ---------------------------------------------------------------------------------------------------------------- E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) * (COMPENSATE FOR TRANS OF WEIGHT) ---------------------------------------------------------------------------------------------------------------- E0962 E0962 2232 CUSHION FOR WC 1" (E0962) * ---------------------------------------------------------------------------------------------------------------- E0963 E0963 2233 CUSHION FOR WC 2" (E0963) * ---------------------------------------------------------------------------------------------------------------- E0964 E0964 2234 CUSHION FOR WC 3" (E0964) * ---------------------------------------------------------------------------------------------------------------- E0965 E0965 2235 CUSHION FOR WC 4" (E0965) * ---------------------------------------------------------------------------------------------------------------- E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) * ---------------------------------------------------------------------------------------------------------------- E0978 E0978 2248 BELT, SAFETY (E0978) W/ * AIRPLANE BUCKLE, W/C ---------------------------------------------------------------------------------------------------------------- E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO * CLOSURE, W/C ---------------------------------------------------------------------------------------------------------------- E0980 DM570 2292 SAFETY VEST (E0980), W/C * ---------------------------------------------------------------------------------------------------------------- E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ * * CASTORS 5" OR GREATER ---------------------------------------------------------------------------------------------------------------- E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1060 E1060 2259 W/C FULL/REC (E1070), DETACH * * ARMS, SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) * * ---------------------------------------------------------------------------------------------------------------- E1066 E1066 2247 BATTERY CHARGER (E1066) * * ---------------------------------------------------------------------------------------------------------------- E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) * * ---------------------------------------------------------------------------------------------------------------- E1070 E1070 2258 W/C FULL/REC (E1060), DETACH * * ARMS, SWING AWAY DET/ ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, * * SWING AWAY DETACH ABLE ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, * * SWING AWAY DETACH ABLE FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), * * FIX ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), * * D/ ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), * * FIX ARMS, S/AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1090 E1090 2267 W/C HI STRENGTH LT-WG (E1090), * * DETACH ARMS, S/AWAY D/FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * * ---------------------------------------------------------------------------------------------------------------- E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), * * DETACH ARMS S/AWAY DETACH ELEVAT LEGS ---------------------------------------------------------------------------------------------------------------- E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), * * DETACH ARMS S/AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1100 E1100 2296 W/C SEMI-RECLINING (E1100), * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1110 E1110 2295 W/C SEMI-RECLINING (E1110), * * DETACH ARMS ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1130 E1130 2303 W/C STANDARD (E1130), FIX OR * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING * * AWAY DETACH FOOTRESTS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2396 W/C (E1160), W/FIX ARMS * * REMOVABLE FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, * * W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH * * ARMS W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH * * ARMS SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH * * ARMS SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL * * LENGTH ARMS, S/AWAY D/FOOTREST ---------------------------------------------------------------------------------------------------------------- E1210 E1210 2281 W/C MOTORIZED (E1210), FIX * * ARMS, S/AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH * * ARMS , S/AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1212 E1212 2282 W/C MOTORIZED (E1212) , FIX * * * ARMS, SWING AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH * * * ARMS S/AWAY, DETACH ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2551 W/C CUSTOM (E1220) * * * ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2579 W/C XXWIDE (E1220) * * * ---------------------------------------------------------------------------------------------------------------- E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 * * * WHEEL ---------------------------------------------------------------------------------------------------------------- E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS * * SWING AWAY DETACH, ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH * * ARMS ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH * * ARMS SWING AWAY DETACH FOOTREST ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, * * ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1300 DM570 2062 WHIRLPOOL (E1300), PORT * * (OVERTUB TYPE) ---------------------------------------------------------------------------------------------------------------- E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT * * (BUILT-IN TYPE) ---------------------------------------------------------------------------------------------------------------- E1353 E1353 2381 O2 REGULATOR (E1353) * * ---------------------------------------------------------------------------------------------------------------- E1355 E1355 2384 CYLINDER STAND/RACK (E1355) * * ---------------------------------------------------------------------------------------------------------------- E1372 E1372 2331 IMMERSION EXT HEATER (E1372) * * FOR NEBULIZER ---------------------------------------------------------------------------------------------------------------- E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL * * * COMPRESSOR, W/ LIMITED FLOW ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2568 ADAPTER (A9900), AC/DC * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2552 BATH LIFT (E1399), CUSTOM * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2563 BED WEDGE (E1399), 12" * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), * * CUSTOM ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL * * * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2565 COMMODE (E1399), DROP ARM, * * * HEAVY DUTY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), * * MISCELLANEOUS ---------------------------------------------------------------------------------------------------------------- E1399 E1220 2584 GERI CHAIR (E1399), THREE * * * POSITION RECLINING ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6780 HOLTER MONITOR (G0004) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, * * * XLONG, W/MATTRESS & SIDE RAILS ---------------------------------------------------------------------------------------------------------------- E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2588 MONITOR (E1399), VITAL SIGNS * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2529 O2 ANALYZER (A9900) * * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6775 OXIMETRY TEST (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2561 PEAK FLOW METER (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4559 PEDIATRIC WALKER (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2567 PNEUMOGRAM (E1399) * * * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2553 POSITIONING, CUSTOM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2526 PULSE OXIMETER (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2562 SHOWER, HAND HELD (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW * * * VOLTAGE OR INTERFERENTIAL ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM * * * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR * * * ONLY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7505 W/C, CUSTOM (E1399) POWER * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2564 WALKER (E1399), HEAVY DUTY, * * * EXTRA WIDE ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2585 WALKER (E1399), HEMI * * * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 6873 WOUND SUCTION DEVICE (K0538) * * * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION * * * DEVICE (K0539) ---------------------------------------------------------------------------------------------------------------- K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION * * * DEVICE (K0540) ---------------------------------------------------------------------------------------------------------------- E1400 E1390 2361 O2 CONC (E1390),MANUF SPEC * * * MAXFLOWRATE = 2 LTS PER MIN@85% ---------------------------------------------------------------------------------------------------------------- G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) * * * ---------------------------------------------------------------------------------------------------------------- K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) * * * ---------------------------------------------------------------------------------------------------------------- K0183 DM590 2516 CPAP MASK (K0183) * * * ---------------------------------------------------------------------------------------------------------------- K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) * * * REPLACEMENT FOR NASAL APP/ DVC, PAIR ---------------------------------------------------------------------------------------------------------------- K0185 DM590 2514 CPAP HEADGEAR (K0185) * * ---------------------------------------------------------------------------------------------------------------- K0186 DM590 2513 CPAP CHIN STRAP (K0186) * * ---------------------------------------------------------------------------------------------------------------- K0187 DM590 2512 CPAP TUBING (K0187) * * ---------------------------------------------------------------------------------------------------------------- K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE * * ---------------------------------------------------------------------------------------------------------------- K0189 DM590 2510 CPAP FILTER (A9900), * * NON-DISPOSABLE ---------------------------------------------------------------------------------------------------------------- K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL * * ---------------------------------------------------------------------------------------------------------------- K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, * * EQUIVALENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC * * * AIR THERAPY ---------------------------------------------------------------------------------------------------------------- A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 * * SCOOP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL * * SECRETION MOBIL DEVICE ---------------------------------------------------------------------------------------------------------------- E0168B A9900 7643 COMMODE (E0168B) HVY DUTY * BEDSIDE CHAIR 251-450 LBS. ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP * ARM 451-850 LBS. ---------------------------------------------------------------------------------------------------------------- A6234 HH591 7626 DRESSING <16 SQ IN (A6234) * HYDROCOLLOID DRESSING, EA ---------------------------------------------------------------------------------------------------------------- A6258 HH591 7627 DRESSING >16 SQ IN (A6258) * TRANSPAREN FILM, EA ---------------------------------------------------------------------------------------------------------------- A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN * (A46203) SELF ADH, EA ---------------------------------------------------------------------------------------------------------------- B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE * F/KANGAROO PUMP ---------------------------------------------------------------------------------------------------------------- B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP * BASIC ---------------------------------------------------------------------------------------------------------------- B9998D DM590 7657 ENT (B9998D) FARRELL GASTRIC * RELIEF VLV ---------------------------------------------------------------------------------------------------------------- B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET * ---------------------------------------------------------------------------------------------------------------- B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY * SIZE MIC-KEY OR HIDE A PORT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL * NOSE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7660 IPPB (E1399) UNIV SET UP * W/MANIFOLD NEBULIZER ---------------------------------------------------------------------------------------------------------------- K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7641 MECHANICAL SCALE (E1399) * PEDIATRIC/NEONATAL ---------------------------------------------------------------------------------------------------------------- A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL * W/STR H20 1L BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7663 O2 CONNECTOR (E1399) * SIMS/IRRIGATION NOZZLE BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7615 O2 HUMIDIFIER (E1399) * AQUA+NEONATAL EA HUD ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER * ANGLED STERILE ---------------------------------------------------------------------------------------------------------------- L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS * ---------------------------------------------------------------------------------------------------------------- A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG * 1L BAX ---------------------------------------------------------------------------------------------------------------- A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & * TUBING ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA * ---------------------------------------------------------------------------------------------------------------- A6265 HH591 7628 TAPE ALL TYPES (A6265) * EXCLUDING MICROFOAM, PER 18 SQ INCHES ---------------------------------------------------------------------------------------------------------------- A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA * ELECTROSTATIC ---------------------------------------------------------------------------------------------------------------- A4623 A9900 7618 TRACH INNER (A4623) CANNULA * ---------------------------------------------------------------------------------------------------------------- A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR * OR HOLDER ---------------------------------------------------------------------------------------------------------------- A7010 A9900 7662 TUBING (A7010) AEROSOL * CORRUGATED PER FOOT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7630 VENT BATTERY CHARGER (A9900) * 12V GEL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR * ADULT OMNIFLEX DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S * ELECTOSTATIC MAL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7634 VENT THERMOMETER (E1399) W/ * ADAPTER ---------------------------------------------------------------------------------------------------------------- K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP * BLK 10/PK ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7635 WALKER BASKET (E1399) VINYL * COATED ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0159 A9900 7640 WALKER BRAKE (E0159) ATTACHMENT * ---------------------------------------------------------------------------------------------------------------- E0148 A9900 7636 WALKER HVY DUTY (E0148) FOLDING * X-WIDE ---------------------------------------------------------------------------------------------------------------- E0149 A9900 7637 WALKER HVY DUTY (E0149) W/ * WHEELS ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER * CABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7646 CPAP (E1399) EXHALATION PORT * DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7647 CPAP (E1399) FUSE KIT * INTERNATIONAL A/C ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER * KIT DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER * REUSABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7650 CPAP (E1399) HUMIDIFIER * MOUNTING TRAY ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7652 CPAP (E1399) POWER CORD * F/ARIA-SYNC ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE * TAP ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) * ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7565 CPAP SHORT TUBING (A9900) * ---------------------------------------------------------------------------------------------------------------- E0601 E0601 7690 VENT, CONTINUOUS POSITIVE * * (E0500) AIRWAY PRESSURE DEVICE ---------------------------------------------------------------------------------------------------------------- E0452 E0452 7691 VENT, BILEVEL INTERMITTENT * * (E0500) ASSIST DEVICE (BIPAP) ---------------------------------------------------------------------------------------------------------------- E0747 DM570 6875 STIMULATOR, OSTEOGENIC, * ULTRASOUND ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7695 GEL/SILICON GOLD SEAL * CPAP/BIPAP MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ * * BACKUP RATE (K0533) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT * * (E1399) ---------------------------------------------------------------------------------------------------------------- HH591 HH591 7704 PUMP, EXT INFUSION, DANA * DIABECARE, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, * INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR * USE WITH BREEZE MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A7036 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) * ---------------------------------------------------------------------------------------------------------------- E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) * ----------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances: ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2731 SHIPPING AND HANDLING FEES * * ----------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment: ---------------------------------------------------------------------------------------------------------------- E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) * * SERVICE REQUIRING SKILL OF A TECH ---------------------------------------------------------------------------------------------------------------- E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) * * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4552 MISCELLANEOUS SUPPLIES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2589 REPAIR (E1399), RESPIRATORY * * EQUIPMENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4549 TENS/APNEA SUPPLIES * * ----------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * DME/HOME RESPIRATORY RATES: RATES EFFECTIVE APRIL 1, 2004 - DECEMBER 31, 2004
HCPCS CHC GENTIVA CODE CODE CODE DESCRIPTION PURCHASE PRICE RENTAL PRICE DAILY PRICE ---------------------------------------------------------------------------------------------------------------- A4660 DM590 2520 MONITOR, BLOOD PRESSURE (A4660) * W/STETH & CUFF ---------------------------------------------------------------------------------------------------------------- A4670 DM590 2518 MONITOR, BLOOD PRESSURE (A4670), * AUTOMATIC ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7552 BREEZE (A9900) CPAP/BIPAP MASK * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7553 FULL FACE (A9900) MIRAGE * CPAP/BIPAP MASK ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7554 GEL/SILICON (A9900) CPAP/BIPAP * MASK INCL GLD SEAL,PHANTM,MONARCH ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7556 SPECIALTY (A9900) CPAP/BIPAP * MASK (PROFILE OR SIMPICITY) ---------------------------------------------------------------------------------------------------------------- B9002 HI531 2570 PUMP, ENTERAL (B9002) * * ---------------------------------------------------------------------------------------------------------------- B9998 DM590 6828 ENTERAL SUPPLIES (B9998) * ---------------------------------------------------------------------------------------------------------------- DM590 DM570 7551 BACK-PACK (E1399), FOR * PORTABLE ENTERAL PUMP ---------------------------------------------------------------------------------------------------------------- A4615 DM590 2522 CANNULA, NASAL * ---------------------------------------------------------------------------------------------------------------- B9002 DM590 7509 ENTERAL PUMP, PORTABLE (B9002) * * ---------------------------------------------------------------------------------------------------------------- A7034 DM590 7508 MASK, CPAP GEL OR SILICONE * (K0183) ---------------------------------------------------------------------------------------------------------------- E0100 E0100 2020 CANE (E0100), ADJ OR FIX, W/ TIP * ---------------------------------------------------------------------------------------------------------------- E0105 E0105 2021 CANE, QUAD (E0105) OR THREE * PRONG, ADJ OR FIX, W/ TIPS ---------------------------------------------------------------------------------------------------------------- E0110 E0110 2028 CRUTCHES, FOREARM (E0110), ADJ * OR FIX, PAIR, W/ TIPS, GRIPS ---------------------------------------------------------------------------------------------------------------- E0111 E0111 2023 CRUTCH FOREARM (E0111), ADJ OR * FIX, EACH, W/ TIP AND GRIPS ---------------------------------------------------------------------------------------------------------------- E0112 E0112 2027 CRUTCHES UNDERARM, WOOD * (E0112), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0113 E0113 2025 CRUTCH UNDERARM, WOOD (E0113), * ADJ OR FIX, EACH, COMPLETE ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0114 E0114 2026 CRUTCHES UNDERARM, ALUM * (E0114), ADJ OR FIX, PAIR, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0116 E0116 2024 CRUTCH UNDERARM, ALUM (E0116), * ADJ OR FIX, EACH, COMPLETE ---------------------------------------------------------------------------------------------------------------- E0130 E0130 2037 WALKER, RIGID (E0130) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0135 E0135 2036 WALKER, FOLDING (E0135) * (PICKUP), ADJ OR FIX HEIGHT ---------------------------------------------------------------------------------------------------------------- E0141 E0141 2040 WALKER, WHEELED (E0141), W/OUT * SEAT ---------------------------------------------------------------------------------------------------------------- E0142 DM570 2034 RIGID WALKER (E0142), WHEELED, * W/ SEAT, ---------------------------------------------------------------------------------------------------------------- E0143 E0143 2029 WALKER FOLDING, WHEELED * (E0143), W/OUT SEAT ---------------------------------------------------------------------------------------------------------------- E0145 DM570 2039 WALKER (E0145), WHEELED, W/ * SEAT AND CRUTCH ATTACHMENTS ---------------------------------------------------------------------------------------------------------------- E0146 DM570 2038 WALKER, WHEELED, W/ SEAT (E0146) * ---------------------------------------------------------------------------------------------------------------- E0147 E0147 2030 WALKER HVY DUT (E0147), MULT * BRAKING SYS, VAR WHEEL RESISTANCE ---------------------------------------------------------------------------------------------------------------- E0153 E0153 2032 CRUTCH PLATFORM ATTACHMENT * (E0153), FOREARM EA ---------------------------------------------------------------------------------------------------------------- E0154 E0154 2033 WALKER PLATFORM ATTACHMENT * (E0154), EA ---------------------------------------------------------------------------------------------------------------- E0155 E0155 2041 WALKER WHEEL ATTACHMENT * (E0155), RIGID (PICKUP) WALKER ---------------------------------------------------------------------------------------------------------------- E0156 DM570 2035 WALKER SEAT ATTACHMENT (E0156) * ---------------------------------------------------------------------------------------------------------------- E0157 E0157 2022 WALKER, CRUTCH ATTACHMENT * (E0157), EACH ---------------------------------------------------------------------------------------------------------------- E0158 E0158 2031 WALKER LEG EXTENSIONS (E0158) * ---------------------------------------------------------------------------------------------------------------- E0163 E0163 2047 COMMODE CHAIR, STATIONARY * (E0163), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0164 E0164 2045 COMMODE CHAIR, MOBILE * (E0164), W/ FIX ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2046 COMMODE CHAIR (E0165), * STATIONARY, W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0165 E0165 2591 COMMODE, XXWIDE(E0165) * ---------------------------------------------------------------------------------------------------------------- E0166 E0166 2044 COMMODE CHAIR (E0166), MOBILE, * W/ DETACH ARMS ---------------------------------------------------------------------------------------------------------------- E0167 E0167 2051 COMMODE CHAIR, PAIL OR PAN * (E0167) ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2142 CUSHION (E0176) OR AIR PRESSURE * PAD, NON-POSITIONING ---------------------------------------------------------------------------------------------------------------- E0176 E0176 2394 REPLACEMENT PAD (E0176) * ALTERNATING PRESS ---------------------------------------------------------------------------------------------------------------- E0177 E0177 2224 CUSHION OR WATER PRESS PAD * (E0177), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0178 E0178 2160 CUSHION OR GEL PRESS PAD * (E0178), NONPOSITIONING ---------------------------------------------------------------------------------------------------------------- E0179 E0179 2154 CUSHION (E0179) OR DRY PRESSURE * PAD, NONPOSTIONING ---------------------------------------------------------------------------------------------------------------- E0180 E0180 2196 PUMP (E0180), ALTERNATING * * PRESSURES W/PAD ---------------------------------------------------------------------------------------------------------------- E0181 E0181 2197 PUMP (E0181), ALTERNATING PRESS * * W/PAD, HVY DUTY ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0184 E0184 2074 MATTRESS, DRY PRESSURE (E0184) * ---------------------------------------------------------------------------------------------------------------- E0185 E0185 2076 MATTRESS (E0185), GEL OR * GEL-LIKE PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0186 E0186 2064 MATTRESS, AIR PRESSURE (E0186) * ---------------------------------------------------------------------------------------------------------------- E0187 E0187 2099 MATTRESS, WATER PRESSURE (E0187) * ---------------------------------------------------------------------------------------------------------------- E0188 DM570 2217 PAD, SYNTHETIC SHEEPSKIN (A9900) * ---------------------------------------------------------------------------------------------------------------- E0189 DM570 2177 PAD, LAMBSWOOL SHEEPSKIN * (E0189), ANY SIZE ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2573 CUSHION, JAY FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2572 CUSHION, ROHO FOR W/C (E0192) * * ---------------------------------------------------------------------------------------------------------------- E0192 E0192 2178 W/C PAD (E0192), LOW PRESS AND * * POSITIONING EQUALIZATION ---------------------------------------------------------------------------------------------------------------- E0193 E0193 2098 MATTRESS, LOW AIR LOSS (E0193), * * * INCL. BED ---------------------------------------------------------------------------------------------------------------- E0194 DM570 2063 AIR FLUIDIZED BED (E0194) * * ---------------------------------------------------------------------------------------------------------------- E0270 E1399 6887 HOSPITAL BED INSTITUTIONAL * * ---------------------------------------------------------------------------------------------------------------- E0196 E0196 2077 MATTRESS, GEL PRESSURE (E0196) * ---------------------------------------------------------------------------------------------------------------- E0197 E0197 2065 MATTRESS, AIR PRESSURE PAD * (E0197) ---------------------------------------------------------------------------------------------------------------- E0198 E0198 2100 MATTRESS (E0198), WATER * PRESSURE PAD ---------------------------------------------------------------------------------------------------------------- E0199 E0199 2075 MATTRESS, DRY PRESSURE PAD * (E0199) ---------------------------------------------------------------------------------------------------------------- E0200 E0200 2228 HEAT LAMP (E0200), W/OUT * STAND, INCL/BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2229 PHOTOTHERAPY (BILIRUBIN) * (E0202), LIGHT WIT ---------------------------------------------------------------------------------------------------------------- E0202 E0202 2524 PHOTOTHERAPY, BILI BLANKET * (E0202) ---------------------------------------------------------------------------------------------------------------- E0205 E0205 2227 HEAT LAMP (E0205), WITH STAND, * INCL/ BULB, OR INFRARED ELEMENT ---------------------------------------------------------------------------------------------------------------- E0210 DM570 2156 HEATING PAD, STANDARD (E0210) * ---------------------------------------------------------------------------------------------------------------- E0215 DM570 2155 HEATING PAD (E0215), ELECTRIC, * MOIST ---------------------------------------------------------------------------------------------------------------- E0218 DM570 2560 COLD THERAPY UNIT (E0218) * * * ---------------------------------------------------------------------------------------------------------------- E0235 DM570 2187 PARAFFIN BATH UNIT, PORT (E0235) * ---------------------------------------------------------------------------------------------------------------- E0236 DM570 2199 PUMP (E0236) FOR WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0237 DM570 2223 HEAT COLD WATER (E0237) * CIRCULATING PAD W/PUMP ---------------------------------------------------------------------------------------------------------------- E0238 DM570 2179 HEATING PAD (E0238), MOIST, * NON-ELECTRIC ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2867 BATH TUB RAIL (E0241), WALL, * L-SHAPE ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2862 BATH TUB RAIL, WALL, 12" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2863 BATH TUB RAIL, WALL, 16" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2864 BATH TUB RAIL, WALL, 18" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2865 BATH TUB RAIL, WALL, 24" (E0241) * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2866 BATH TUB RAIL, WALL, 36" (E0241) * ---------------------------------------------------------------------------------------------------------------- E0241 DM570 2043 BATH TUB RAIL, WALL, * UNSPECIFIED SIZE ---------------------------------------------------------------------------------------------------------------- E0242 DM570 2042 BATH TUB RAIL, FLOOR BASE * (E0242) ---------------------------------------------------------------------------------------------------------------- E0243 DM570 2056 TOILET RAIL, EACH (E0243) * ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2587 TOILET SEAT (E0244) RAISED WITH * ARMS ---------------------------------------------------------------------------------------------------------------- E0244 E0244 2052 TOILET SEAT, RAISED (E0244) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2575 BATH BENCH WITH BACK (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2058 BATH TUB STOOL OR BENCH (E0245) * ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2578 TRANSFER BENCH, NON-PADDED * (E0245) ---------------------------------------------------------------------------------------------------------------- E0245 DM570 2577 TRANSFER BENCH, PADDED (E0245) * ---------------------------------------------------------------------------------------------------------------- E0246 DM570 2057 TRANSFER TUB RAIL(E0246), * ATTACHMENT ---------------------------------------------------------------------------------------------------------------- E0249 DM570 2186 HEAT UNIT (E0249), WATER * CIRCULATING PAD ---------------------------------------------------------------------------------------------------------------- E0255 E0255 2090 HOSP BED (E0255), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0256 E0256 2091 HOSP BED (E0256), VAR HEIGHT, * * HI-LO, W/ SIDE RAILS, W/O MATTRESS ---------------------------------------------------------------------------------------------------------------- E0260 E0260 2083 HOSP BED (E0260), SEMI-ELEC, W/ * * SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0261 E0261 2084 HOSP BED (E0261), SEMI-ELEC, W/ * * SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0265 E0265 2086 HOSP BED (E0265), TOTAL ELEC, * * W/ SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0266 E0266 2087 HOSP BED (E0266), TOTAL ELEC, * * W/ SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0271 E0271 2096 MATTRESS, INNERSPRING (E0271) * ---------------------------------------------------------------------------------------------------------------- E0272 E0272 2095 MATTRESS, FOAM RUBBER (E0272) * ---------------------------------------------------------------------------------------------------------------- E0273 DM570 2068 BED BOARD (E1399) * ---------------------------------------------------------------------------------------------------------------- E0274 DM570 2097 OVER-BED TABLE (E0274) * ---------------------------------------------------------------------------------------------------------------- E0275 E0275 2071 BED PAN, STANDARD (E0275), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0276 E0276 2070 BED PAN, FRACTURE (E0276), * METAL OR PLASTIC ---------------------------------------------------------------------------------------------------------------- E0277 E0277 2066 MATTRESS (E0277), LOW AIR LOSS, * * * ALT PRESSURE ---------------------------------------------------------------------------------------------------------------- E0280 DM570 2069 BED CRADLE, ANY TYPE (E1399) * ---------------------------------------------------------------------------------------------------------------- E0292 E0292 2092 HOSP BED (E0292), VAR HEIGHT, * * HI-LO, W/OUT S/ RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0293 E0293 2093 HOSP BED (E0293), VAR HEIGHT, * * HI-LO, NO SIDE RAILS, NO MATTRESS ---------------------------------------------------------------------------------------------------------------- E0294 E0294 2085 HOSP BED (E0294), SEMI-ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0295 E0295 2094 HOSP BED (E0295), SEMI-ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0296 E0296 2089 HOSP BED (E0296), TOTAL ELEC, * * W/OUT SIDE RAILS, W/OUT MATTRESS ---------------------------------------------------------------------------------------------------------------- E0297 E0297 2088 HOSP BED (E0297), TOTAL ELEC, * * W/OUT SIDE RAILS, W/ MATTRESS ---------------------------------------------------------------------------------------------------------------- E0305 E0305 2073 BED SIDE RAILS (E0305), HALF * * * LENGTH ---------------------------------------------------------------------------------------------------------------- E0310 E0310 2072 BED SIDE RAILS (E0310), FULL * * * LENGTH ---------------------------------------------------------------------------------------------------------------- E0315 DM570 2067 BED ACCESSORIES: BOARDS OR * * TABLES, ANY TYPE ---------------------------------------------------------------------------------------------------------------- E0325 E0325 2060 URINAL; MALE (E0325), JUG-TYPE, * * * ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0326 E0326 2059 URINAL; FEMALE (E0326), * * * JUG-TYPE, ANY MATERIAL ---------------------------------------------------------------------------------------------------------------- E0372 E0372 7008 MATTRESS (E0372) POWERED AIR * * * OVERLAY ---------------------------------------------------------------------------------------------------------------- E0410 E0444 2369 O2 CONTENTS, LIQUID (E0444), * PER POUND ---------------------------------------------------------------------------------------------------------------- E0416 E0443 2371 O2 REFILL FOR PORT (E0443) GAS * SYSTEM ONLY, UP TO 23 CUBIC FEET ---------------------------------------------------------------------------------------------------------------- E0424 E0424 2385 O2 SYS STATIONARY (E0424) COMPR * * GAS, RENT ---------------------------------------------------------------------------------------------------------------- E0430 E0430 2374 O2 SYS PORT GAS, PURCH (E0430) * * ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2574 O2 SYS PORT GAS, LIGHTWEIGHT * * (E0431) W/CONSERV DEVICE,NO CONTENT ---------------------------------------------------------------------------------------------------------------- E0431 E0431 2375 O2 SYS PORT GAS, RENT (E0431) * * ---------------------------------------------------------------------------------------------------------------- E0434 E0434 2377 O2 SYS PORT LIQUID,RENT (E0434) * * ---------------------------------------------------------------------------------------------------------------- E0435 E0435 2376 O2 SYS PORT LIQUID, PURCH * * (E0435) ---------------------------------------------------------------------------------------------------------------- E0439 E0439 2388 O2 SYS STATIONARY (E0439) * LIQUID, RENT ---------------------------------------------------------------------------------------------------------------- E0440 E0440 2387 O2 SYS STATIONARY (E0440) * * LIQUID, PURCH ---------------------------------------------------------------------------------------------------------------- E0443 E0400 2869 O2 CONTENTS, H/K CYLINDER * * (E0400), 200-300 CUBIC FT ---------------------------------------------------------------------------------------------------------------- E0444 E0444 2379 O2 CONTENTS, PORT LIQUID * * (E0444), PER UNIT (1 UNIT = 1 LB.) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7555 POSITIVE PRESSURE VENTS * (E0450)(E.G. T-BIRD) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7926 POSITIVE PRESSURE VENTS, * * EMERGENCY BACKUP (E.G. T-BIRD) (E0450) ---------------------------------------------------------------------------------------------------------------- E0450 E0450 2392 VENTILATOR VOLUME (E0450), * * STATIONARY OR PORT ---------------------------------------------------------------------------------------------------------------- E0450 E0450 7522 VENTILATOR, VOLUME, (E0450) * * EMERGENCY BACKUP UNIT ---------------------------------------------------------------------------------------------------------------- E0452 E0452 2332 BILEVEL INTERMITTENT (E0452) * * ASSIST DEVICE,(BIPAP) ---------------------------------------------------------------------------------------------------------------- E0453 E0453 2390 VENTILATOR THERAPEUTIC (E0453); * * FOR USE 12 HOURS OR LESS PER DAY ---------------------------------------------------------------------------------------------------------------- E0455 E0455 2372 O2 TENT (E0455), EXCLUDING * * CROUP OR PEDIATRIC TENTS ---------------------------------------------------------------------------------------------------------------- E0457 E0457 2323 CHEST SHELL (CUIRASS) (E0457) * * ---------------------------------------------------------------------------------------------------------------- E0459 E0459 2324 CHEST WRAP (E0459) * * ---------------------------------------------------------------------------------------------------------------- E0460 E0460 2339 VENTILATOR (E0460), NEGATIVE * * PRESSURE, PORTABLE OR STATIONARY ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0480 DM570 2373 PERCUSSOR (E0480), ELEC OR * * PNEUM, HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0500 E0500 2333 IPPB, W/ BUILT-IN NEB (E0500) * * MAN OR AUTO VALVES; INT/EXT POWER ---------------------------------------------------------------------------------------------------------------- E0550 E0550 2328 HUMIDIFIER (E0550) DURABLE FOR * * EXTENSIV SUP/ HUMID W/ IPPB OR O2 ---------------------------------------------------------------------------------------------------------------- E0555 E0555 2330 HUMIDIFIER (E0555), DURABLE, * * GLASS, FOR USE W/ REG OR FLOWMETER ---------------------------------------------------------------------------------------------------------------- E0565 E0565 2325 COMPRESSOR, AIR POWER (E0565) * * ---------------------------------------------------------------------------------------------------------------- E0570 E0570 2336 NEBULIZER, W/ COMPRESSOR (E0570) * ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2571 NEBULIZER (E0575), ULTRASONIC, * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0575 DM570 2338 NEBULIZER; ULTRASONIC (E0575) * * ---------------------------------------------------------------------------------------------------------------- E0585 E0585 2337 NEBULIZER(E0585), W/ COMPRESSOR * * AND HEATER ---------------------------------------------------------------------------------------------------------------- E0600 E0600 2389 SUCTION PUMP (E0600), HOME MODEL * * ---------------------------------------------------------------------------------------------------------------- E0600 E0600 7523 SUCTION UNIT, (E0600), PORTABLE * * AC/DC ---------------------------------------------------------------------------------------------------------------- E0601 E0601 2326 CONTINUOUS POSITVE (E0601) * * AIRWAY PRESSURE DEVICE (CPAP) ---------------------------------------------------------------------------------------------------------------- E0601 E0601 6965 CPAP, SELF TITRATING (E0601) * * ---------------------------------------------------------------------------------------------------------------- E0605 DM570 2391 VAPORIZER, ROOM TYPE (E0605) * ---------------------------------------------------------------------------------------------------------------- E0606 DM570 2380 POSTURAL DRAINAGE BOARD (E0606) * ---------------------------------------------------------------------------------------------------------------- E0607 E0607 6874 MONITOR, B/GLUCOSE (E0607) * ACCUCHEK AD ---------------------------------------------------------------------------------------------------------------- E0607 E0607 2164 MONITOR, BLOOD GLUCOSE (E0607) * ---------------------------------------------------------------------------------------------------------------- E0618 E0608 2322 APNEA MONITOR (E0608) * * ---------------------------------------------------------------------------------------------------------------- E0619 E0608 2576 APNEA MONITOR (E0608) W/MEM * * (INCL SMART) ---------------------------------------------------------------------------------------------------------------- E0609 E0609 2146 MONITOR, BLOOD GLUCOSE (E0609) * W/SPECIAL FEATURES ---------------------------------------------------------------------------------------------------------------- E0621 E0621 2215 PATIENT LIFT (E0621), SLING OR * * SEAT, CANVAS OR NYLON ---------------------------------------------------------------------------------------------------------------- E0625 DM570 2191 PATIENT LIFT (E0625), KARTOP, * * BATHROOM OR TOILET ---------------------------------------------------------------------------------------------------------------- E0627 E0627 4553 HIP CHAIR (E0627) * * ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2395 SEAT LIFT CHAIR/MOTORIZED * * (E0627) ---------------------------------------------------------------------------------------------------------------- E0627 DM570 2205 SEAT LIFT MECH (E0627) * INCORPORATED INTO A COMB LIFT-CHAIR MECH ---------------------------------------------------------------------------------------------------------------- E0630 E0630 2190 PATIENT LIFT, HYDRAULIC * * (E0630), W/ SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0635 DM570 2189 PATIENT LIFT (E0635), ELEC W/ * * SEAT OR SLING ---------------------------------------------------------------------------------------------------------------- E0650 E0650 2192 PNEUM COMPRESSOR (E0650), * * NON-SEG HOME MODEL ---------------------------------------------------------------------------------------------------------------- E0651 E0651 2194 PNEUM COMPRESSOR (E0651), SEG * * HOME MODEL W/OUT CALIB GRAD PRES ---------------------------------------------------------------------------------------------------------------- E0652 E0652 2193 PNEUM COMPRESSOR (E0652), SEG * * HOME MODEL W/ CALIB GRAD PRES ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0655 E0655 2182 PNEUM COMPRESSOR (E0655), * NON-SEG APPLIANCE, HALF ARM ---------------------------------------------------------------------------------------------------------------- E0660 E0660 2181 PNEUM COMPRESSOR (E0660), * NON-SEG APPLIANCE, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0665 E0665 2180 PNEUM COMPRESSOR (E0665), * NON-SEG APPLIANCE, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0666 E0666 2183 PNEUM COMPRESSOR (E0666), * NON-SEG APPLIANCE, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0667 E0667 2210 PNEUM APPLIANCE (E0667), SEG, * FULL LEG ---------------------------------------------------------------------------------------------------------------- E0668 E0668 2209 PNEUM APPLIANCE (E0668), SEG, * FULL ARM ---------------------------------------------------------------------------------------------------------------- E0669 E0669 2212 PNEUM APPLIANCE (E0669), SEG, * HALF LEG ---------------------------------------------------------------------------------------------------------------- E0670 E0670 2211 PNEUM APPLIANCE (E0670), SEG, * HALF ARM ---------------------------------------------------------------------------------------------------------------- E0671 E0671 2207 PNEUM APPLIANCE (E0671), SEG * GRAD PRESS, FULL LEG ---------------------------------------------------------------------------------------------------------------- E0672 E0672 2206 PNEUM APPLIANCE (E0672), SEG * GRAD PRESS, FULL ARM ---------------------------------------------------------------------------------------------------------------- E0673 E0673 2208 PNEUM APPLIANCE (E0673), SEG * GRAD PRESS, HALF LEG ---------------------------------------------------------------------------------------------------------------- E0690 DM570 2221 ULTRAVIOLET CABINET (E0690), * APPROPRIATE FOR HOME USE ---------------------------------------------------------------------------------------------------------------- E0700 DM570 2204 SAFETY EQUIP (E0700) (E.G., * BELT, HARNESS OR VEST) ---------------------------------------------------------------------------------------------------------------- E0710 DM570 2202 RESTRAINTS (E0710), ANY TYPE * (BODY, CHEST, WRIST OR ANKLE) ---------------------------------------------------------------------------------------------------------------- E0720 E0720 2219 TENS (E0720), TWO LEAD, * * LOCALIZED STIMULATION ---------------------------------------------------------------------------------------------------------------- E0730 E0730 2218 TENS (E0730), FOUR LEAD, LARGER * * AREA/MULTIPLE NERVE STIMULATION ---------------------------------------------------------------------------------------------------------------- E0731 E0731 2159 TENS OR NMES (E0731), * * CONDUCTIVE GARMENT ---------------------------------------------------------------------------------------------------------------- E0744 E0744 2120 STIMULATOR (E0744), * * NEUROMUSCULAR FOR SCOLIOSIS ---------------------------------------------------------------------------------------------------------------- E0745 E0745 2120 STIMULATOR (E0745), * * NEUROMUSCULAR, ELECTRONIC SHOCK UNIT ---------------------------------------------------------------------------------------------------------------- E0745 E0745 6915 STIMULATOR FOUR CH (E0745), * * NEUROMUSCULAR ---------------------------------------------------------------------------------------------------------------- E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), * * BIOFEEDBACK DEVICE ---------------------------------------------------------------------------------------------------------------- E0747 DM570 2122 STIMULATOR (E0747), OSTEOGENIC, * NON-INVASIVE ---------------------------------------------------------------------------------------------------------------- E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC * NON-INVASIVE, SPINAL APPLICATIONS ---------------------------------------------------------------------------------------------------------------- E0755 DM570 2157 STIMULATOR (E0755), ELECTRONIC * SALIVARY REFLEX, NON INVASIVE ---------------------------------------------------------------------------------------------------------------- E0776 E0776 2175 IV POLE (E0776) * * ---------------------------------------------------------------------------------------------------------------- E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY * INFUSION, MINIMED, INSULIN ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7925 PUMP, EXT INFUSION, NON - DANA * PREMIUM, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 6771 PUMP (E0784), INSULIN EXT * INFUSION DISETRONICS OR OTHER ---------------------------------------------------------------------------------------------------------------- E0840 E0840 2133 TRACTION FRAME (E0840), ATTACH * TO HEADBOARD, CERVICAL TRACTION ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0850 E0850 2134 TRACTION STAND (E0850), FREE * * STANDING, CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0855 E0855 7484 TRACTION (E0855), W/O FRAME OR * * STAND ---------------------------------------------------------------------------------------------------------------- E0860 E0860 2130 TRACTION EQUIP (E0860), * * OVERDOOR, CERVICAL ---------------------------------------------------------------------------------------------------------------- E0870 E0870 2131 TRACTION FRAME (E0870), ATTACH * * TO FOOTBOARD, EXTREMITY, BUCKS ---------------------------------------------------------------------------------------------------------------- E0880 E0880 2135 TRACTION STAND (E0880) * * FREE/STAND EXTREMITY TRACTION, EG, BUCK'S ---------------------------------------------------------------------------------------------------------------- E0890 E0890 2132 TRACTION FRAME (E0890), ATTACH * * TO FOOTBOARD, PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0900 E0900 2136 TRACTION STAND (E0900) FREE/ * * STAND PELVIC TRACTION,( EG, BUCK'S) ---------------------------------------------------------------------------------------------------------------- E0910 E0910 2138 TRAPEZE BARS (E0910), A/K/A PT * * HELPER, ATTACH TO BED W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0920 E0920 2111 FRACTURE FRAME (E0920), ATTACH * * TO BED, INCLUDING WEIGHTS ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE * DEVICE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ANKLE ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE * DEVICE, ELBOW ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE * DEVICE, HAND ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE * DEVICE, SHOULDER ---------------------------------------------------------------------------------------------------------------- E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE * DEVICE, WRIST ---------------------------------------------------------------------------------------------------------------- E0940 E0940 2137 TRAPEZE BAR (E0940), FREE * * STANDING, COMPLETE W/ GRAB BAR ---------------------------------------------------------------------------------------------------------------- E0941 E0941 2116 TRACTION DEVICE (E0941), * * GRAVITY ASSISTED ---------------------------------------------------------------------------------------------------------------- E0942 E0942 2101 HARNESS/HALTER (E0942), * * CERVICAL HEAD ---------------------------------------------------------------------------------------------------------------- E0944 E0944 2126 HARNESS (E0944), PELVIC BELT, * * BOOT ---------------------------------------------------------------------------------------------------------------- E0945 DM570 2110 HARNESS (E0945), EXTREMITY BELT * * ---------------------------------------------------------------------------------------------------------------- E0946 E0946 2115 FRACTURE, FRAME (E0946), DUAL * * W/ CROSS BARS, ATTACH TO BED ---------------------------------------------------------------------------------------------------------------- E0947 E0947 2113 FRACTURE FRAME (E0947), * * ATTACHMENTS FOR COMPLEX PELVIC TRACTION ---------------------------------------------------------------------------------------------------------------- E0948 E0948 2112 FRACTURE FRAME (E0948) * * ATTACHMENTS FOR COMPLEX CERVICAL TRACTION ---------------------------------------------------------------------------------------------------------------- E0950 DM570 2139 TRAY (E0950) * ---------------------------------------------------------------------------------------------------------------- E0958 E0958 2307 W/C PART ATTACHMENT (E0958) TO * CONVERT ANY W/C TO ONE ARM DRIVE ---------------------------------------------------------------------------------------------------------------- E0959 E0959 2237 W/C PART AMPUTEE ADAPTER(E0959) * (COMPENSATE FOR TRANS OF WEIGHT) ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E0962 E0962 2232 CUSHION FOR WC 1" (E0962) * ---------------------------------------------------------------------------------------------------------------- E0963 E0963 2233 CUSHION FOR WC 2" (E0963) * ---------------------------------------------------------------------------------------------------------------- E0964 E0964 2234 CUSHION FOR WC 3" (E0964) * ---------------------------------------------------------------------------------------------------------------- E0965 E0965 2235 CUSHION FOR WC 4" (E0965) * ---------------------------------------------------------------------------------------------------------------- E0972 DM570 2230 TRANSFER BOARD OR DEVICE (E0972) * ---------------------------------------------------------------------------------------------------------------- E0977 E0977 2317 CUSHION, WEDGE FOR W/C (E0977) * ---------------------------------------------------------------------------------------------------------------- E0978 E0978 2248 BELT, SAFETY (E0978) W/ * AIRPLANE BUCKLE, W/C ---------------------------------------------------------------------------------------------------------------- E0979 DM570 2249 BELT, SAFETY (E0979) W/ VELCRO * CLOSURE, W/C ---------------------------------------------------------------------------------------------------------------- E0980 DM570 2292 SAFETY VEST (E0980), W/C * ---------------------------------------------------------------------------------------------------------------- E1031 E1031 2291 ROLLABOUT CHAIR (E1031), W/ * * CASTORS 5" OR GREATER ---------------------------------------------------------------------------------------------------------------- E1050 E1050 2260 W/C FULL/REC (E1050), FIX ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1060 E1060 2259 W/C FULL/REC (E1070), DETACH * * ARMS, SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1065 E1065 2287 W/C POWER ATTACHMENT (E1065) * * ---------------------------------------------------------------------------------------------------------------- E1066 E1066 2247 BATTERY CHARGER (E1066) * * ---------------------------------------------------------------------------------------------------------------- E1069 E1069 2255 BATTERY, DEEP CYCLE (E1069) * * ---------------------------------------------------------------------------------------------------------------- E1070 E1070 2258 W/C FULL/REC (E1060), DETACH * * ARMS, SWING AWAY DET/ ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1083 E1083 2263 W/C HEMI (E1083), FIX ARMS, * * SWING AWAY DETACH ABLE ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1084 E1084 2262 W/C HEMI (E1084), DETACH ARMS, * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1085 E1085 2264 W/C HEMI (E1085), FIX ARMS, * * SWING AWAY DETACH ABLE FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1086 E1086 2261 W/C HEMI (E1086), DETACH ARMS, * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1087 E1087 2265 W/C HI STRENGTH LT-WT (E1087), * * FIX ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1088 E1088 2268 W/C HI STRENGTH LT-WGT (E1088), * * D/ ARMS, S/AWAY ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1089 E1089 2266 W/C HI STRENGTH LT-WGT (E1089), * * FIX ARMS, S/AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1090 E1090 2267 W/C HI STRENGTH LT-WG (E1090), * * DETACH ARMS, S/AWAY D/FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1091 E1091 2321 W/C YOUTH, ANY TYPE (E1091) * * ---------------------------------------------------------------------------------------------------------------- E1092 E1092 2319 W/C WIDE HVY DUTY (E1092), * * DETACH ARMS S/AWAY DETACH ELEVAT LEGS ---------------------------------------------------------------------------------------------------------------- E1093 E1093 2320 W/C WIDE HVY DUTY (E1093), * * DETACH ARMS S/AWAY DETACH FOOTRESTS ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1100 E1100 2296 W/C SEMI-RECLINING (E1100), * * SWING AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1110 E1110 2295 W/C SEMI-RECLINING (E1110), * * DETACH ARMS ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1130 E1130 2303 W/C STANDARD (E1130), FIX OR * * SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1140 E1140 2313 W/C (E1140), DETACH ARMS SWING * * AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1150 E1150 2314 W/C (E1150), DETACH ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2315 W/C (E1160), W/ FIX ARMS, SWING * * AWAY DETACH ELEVAT LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1160 E1160 2396 W/C (E1160), W/FIX ARMS * * REMOVABLE FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1170 E1170 2241 W/C AMPUTEE (E1170), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1171 E1171 2242 W/C AMPUTEE (E1171), FIX ARMS, * * W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1172 E1172 2240 W/C AMPUTEE (E1172), DETACH * * ARMS W/OUT FOOTRESTS OR LEGREST ---------------------------------------------------------------------------------------------------------------- E1180 E1180 2239 W/C AMPUTEE (E1180), DETACH * * ARMS SWING AWAY DETACH FOOTRESTS ---------------------------------------------------------------------------------------------------------------- E1190 E1190 2238 W/C AMPUTEE (E1190), DETACH * * ARMS SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1195 E1195 2273 W/C HVY DUTY (E1195), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1200 E1200 2243 W/C AMPUTEE (E1200), FIX FULL * * LENGTH ARMS, S/AWAY D/FOOTREST ---------------------------------------------------------------------------------------------------------------- E1210 E1210 2281 W/C MOTORIZED (E1210), FIX * * ARMS, S/AWAY DETACH ELEV LEG RESTS ---------------------------------------------------------------------------------------------------------------- E1211 E1211 2279 W/C MOTORIZED (E1211), DETACH * * ARMS, S/AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1212 E1212 2282 W/C MOTORIZED (E1212), FIX * * ARMS, SWING AWAY DETACH FOOT RESTS ---------------------------------------------------------------------------------------------------------------- E1213 E1213 2280 W/C MOTORIZED (E1213), DETACH * * ARMS S/AWAY, DETACH ELEV LEG REST ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2551 W/C CUSTOM (E1220) * ---------------------------------------------------------------------------------------------------------------- E1220 E1220 2579 W/C XXWIDE (E1220) * ---------------------------------------------------------------------------------------------------------------- E1230 E1230 2288 SCOOTER (E1230), THREE OR 4 * * * WHEEL ---------------------------------------------------------------------------------------------------------------- E1240 E1240 2276 W/C LT-WGT (E1240), DETACH ARMS * * SWING AWAY DETACH, ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1250 E1250 2278 W/C LT-WGT (E1250), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1260 E1260 2275 W/C LT-WGT (E1260), DETACH ARMS * * SWING AWAY DETACH FOOTREST ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1270 E1270 2277 W/C LT-WGT (E1270), FIX ARMS, * * SWING AWAY DETACH ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1280 E1280 2270 W/C HVY DUTY (E1280), DETACH * * ARMS ELEV LEGRESTS ---------------------------------------------------------------------------------------------------------------- E1285 E1285 2274 W/C HVY DUTY (E1285), FIX ARMS, * * SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1290 E1290 2271 W/C HVY DUTY (E1290), DETACH * * ARMS SWING AWAY DETACH FOOTREST ---------------------------------------------------------------------------------------------------------------- E1295 E1295 2272 W/C HVY DUTY (E1295), FIX ARMS, * * ELEV LEGREST ---------------------------------------------------------------------------------------------------------------- E1300 DM570 2062 WHIRLPOOL (E1300), PORT * (OVERTUB TYPE) ---------------------------------------------------------------------------------------------------------------- E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT * (BUILT-IN TYPE) ---------------------------------------------------------------------------------------------------------------- E1353 E1353 2381 O2 REGULATOR (E1353) * * ---------------------------------------------------------------------------------------------------------------- E1355 E1355 2384 CYLINDER STAND/RACK (E1355) * * ---------------------------------------------------------------------------------------------------------------- E1372 E1372 2331 IMMERSION EXT HEATER (E1372) * * FOR NEBULIZER ---------------------------------------------------------------------------------------------------------------- E1375 E1375 2334 NEBULIZER PORT (E1375) W/ SMALL * * COMPRESSOR, W/ LIMITED FLOW ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2568 ADAPTER (A9900), AC/DC * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2586 APNEA MONITOR DOWNLOAD (E1399) * * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2552 BATH LIFT (E1399), CUSTOM * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2563 BED WEDGE (E1399), 12" * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2856 BEDROOM EQUIPMENT (E1399), * * CUSTOM ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2525 BREAST PUMP, ELECTRIC (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2581 BREAST PUMP, INSTITUTIONAL * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2580 BREAST PUMP, MANUAL (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2593 COLD THERAPY UNIT, PAD (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2565 COMMODE (E1399), DROP ARM, * HEAVY DUTY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2582 COMPRESSION PUMP BOOT (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2583 COMPRESSION PUMP, FOOT (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2569 CPAP HUMIDIFIER (A9900), HEATED * * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2635 CPAP/BIPAP SUPPLIES (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), * * MISCELLANEOUS ---------------------------------------------------------------------------------------------------------------- E1399 E1220 2584 GERI CHAIR (E1399), THREE * POSITION RECLINING ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6780 HOLTER MONITOR (G0004) * ---------------------------------------------------------------------------------------------------------------- E1399 E0265 2590 HOSP BED (E1399), ELECTRIC, * * XLONG, W/MATTRESS & SIDE RAILS ---------------------------------------------------------------------------------------------------------------- E1399 E0200 2868 LAMP, ULTRAVIOLET (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2588 MONITOR (E1399), VITAL SIGNS * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2529 O2 ANALYZER (A9900) * * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 A9900 2594 O2 CONSERVATION DEVICE (A9900) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6775 OXIMETRY TEST (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2555 PATIENT LIFT, CUSTOM (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2561 PEAK FLOW METER (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4559 PEDIATRIC WALKER (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2567 PNEUMOGRAM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2553 POSITIONING, CUSTOM (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2526 PULSE OXIMETER (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2527 PULSE OXIMETER W/ PROBE (E1399) * * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2562 SHOWER, HAND HELD (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2592 SLEEP STUDY, ADULT (E1399) * ---------------------------------------------------------------------------------------------------------------- E1399 DM590 7483 STIMULATOR (E1399), MUSCLE, LOW * * VOLTAGE OR INTERFERENTIAL ---------------------------------------------------------------------------------------------------------------- E1399 DM570 2855 THERAPY EQUIPMENT, CUSTOM * (E1399) ---------------------------------------------------------------------------------------------------------------- E1399 DM570 6774 THERAPY PERCUSSION, GENERATOR * * ONLY ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7506 W/C, CUSTOM (E1399) MANUAL ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7504 W/C, CUSTOM (E1399) MANUAL * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7507 W/C, CUSTOM (E1399) POWER ADULT * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7505 W/C, CUSTOM (E1399) POWER * * PEDIATRIC ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2564 WALKER (E1399), HEAVY DUTY, * EXTRA WIDE ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2585 WALKER (E1399), HEMI * ---------------------------------------------------------------------------------------------------------------- K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) * ---------------------------------------------------------------------------------------------------------------- K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION * DEVICE (K0539) ---------------------------------------------------------------------------------------------------------------- K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION * DEVICE (K0540) ---------------------------------------------------------------------------------------------------------------- E1400 E1390 2361 O2 CONC (E1390),MANUF SPEC * * MAXFLOWRATE = 2 LTS PER MIN@85% ---------------------------------------------------------------------------------------------------------------- G0015 DM570 6779 CARDIAC EVENT MONITOR (G0015) * ---------------------------------------------------------------------------------------------------------------- K0163 DM590 3713 ERECTION SYSTEM, VACUUM (K0163) * ---------------------------------------------------------------------------------------------------------------- K0183 DM590 2516 CPAP MASK (K0183) * ---------------------------------------------------------------------------------------------------------------- K0184 DM590 2515 NASAL PILLOWS/SEALS (K0184) * REPLACEMENT FOR NASAL APP/ DVC, PAIR ---------------------------------------------------------------------------------------------------------------- K0185 DM590 2514 CPAP HEADGEAR (K0185) * ---------------------------------------------------------------------------------------------------------------- K0186 DM590 2513 CPAP CHIN STRAP (K0186) * ---------------------------------------------------------------------------------------------------------------- K0187 DM590 2512 CPAP TUBING (K0187) * ---------------------------------------------------------------------------------------------------------------- K0188 DM590 2511 CPAP FILTER (A9900), DISPOSABLE * ---------------------------------------------------------------------------------------------------------------- K0189 DM590 2510 CPAP FILTER (A9900), * NON-DISPOSABLE ---------------------------------------------------------------------------------------------------------------- K0268 DM590 2509 CPAP HUMIDIFIER (K0268), COOL * ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- K0413 DM590 6889 MATTRESS (K0413), NONPOWERED, * * EQUIVALENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 7673 MATTRESS (E1399) V-CUE DYNAMIC * * AIR THERAPY ---------------------------------------------------------------------------------------------------------------- A4608 A9900 7621 CATHETER TRACH (A4608) 11CM 1 * SCOOP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7664 COFFLATOR (E1399CF) MANUAL * SECRETION MOBIL DEVICE ---------------------------------------------------------------------------------------------------------------- E0168B A9900 7643 COMMODE (E0168B) HVY DUTY * BEDSIDE CHAIR 251-450 LBS. ---------------------------------------------------------------------------------------------------------------- E0168C A9900 7644 COMMODE (E0168C) HVY DUTY DROP * ARM 451-850 LBS. ---------------------------------------------------------------------------------------------------------------- A6234 HH591 7626 DRESSING <16 SQ IN (A6234) * HYDROCOLLOID DRESSING, EA ---------------------------------------------------------------------------------------------------------------- A6258 HH591 7627 DRESSING >16 SQ IN (A6258) * TRANSPAREN FILM, EA ---------------------------------------------------------------------------------------------------------------- A46203 HH591 7625 DRESSING COMPOSITE <16 SQ IN * (A46203) SELF ADH, EA ---------------------------------------------------------------------------------------------------------------- B9998B DM590 7655 ENT (B9998B) EXT SET Y SITE * F/KANGAROO PUMP ---------------------------------------------------------------------------------------------------------------- B9998C DM590 7656 ENT (B9998C) EXT SET W/ CLAMP * BASIC ---------------------------------------------------------------------------------------------------------------- B9998D DM590 7657 ENT (B9998D) FARRELL GASTRIC * RELIEF VLV ---------------------------------------------------------------------------------------------------------------- B9998E DM590 7658 ENT (B9998E) GASTRO EXT SET * ---------------------------------------------------------------------------------------------------------------- B9998F DM590 7659 ENT (B9998F) GASTRO TUBE ANY * SIZE MIC-KEY OR HIDE A PORT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7620 HUMID-VENT (E1399) ARTIFICIAL * NOSE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7660 IPPB (E1399) UNIV SET UP * W/MANIFOLD NEBULIZER ---------------------------------------------------------------------------------------------------------------- K0105 A9900 7639 IV POLE (K0105) ATTACH F/ W/C * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7641 MECHANICAL SCALE (E1399) * PEDIATRIC/NEONATAL ---------------------------------------------------------------------------------------------------------------- A7008 A9900 7661 NEBULIZER (A7008) KIT PREFILL * W/STR H20 1L BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7663 O2 CONNECTOR (E1399) * SIMS/IRRIGATION NOZZLE BAX ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7615 O2 HUMIDIFIER (E1399) * AQUA+NEONATAL EA HUD ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7623 O2 SWIVEL (E1399) ADAPTER * ANGLED STERILE ---------------------------------------------------------------------------------------------------------------- L8501 A9900 7624 SPEAKING VALVE (L8501) WHITE PAS * ---------------------------------------------------------------------------------------------------------------- A4319 HH591 7629 STERILE WATER (A4319) F/IRRIG * 1L BAX ---------------------------------------------------------------------------------------------------------------- A7001 HH591 7619 SUCTION BOTTLE (A7001) W/LID & * TUBING ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7616 SUCTION FILTER (E1399) BACTERIA * ---------------------------------------------------------------------------------------------------------------- A6265 HH591 7628 TAPE ALL TYPES (A6265) * EXCLUDING MICROFOAM, PER 18 SQ INCHES ---------------------------------------------------------------------------------------------------------------- A4481 A9900 7622 TRACH FILTER (A4481) BACTERIA * ELECTROSTATIC ---------------------------------------------------------------------------------------------------------------- A4623 A9900 7618 TRACH INNER (A4623) CANNULA * ---------------------------------------------------------------------------------------------------------------- A4621 A9900 7617 TRACH TUBE MASK (A4621) COLLAR * OR HOLDER ---------------------------------------------------------------------------------------------------------------- A7010 A9900 7662 TUBING (A7010) AEROSOL * CORRUGATED PER FOOT ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7631 VENT ADAPTER (E1399) MDI HUD * ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7630 VENT BATTERY CHARGER (A9900) * 12V GEL ----------------------------------------------------------------------------------------------------------------
* Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7632 VENT CONNECTOR (E1399) PED OR * ADULT OMNIFLEX DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7633 VENT FILTER (E1399) HYGROBAC S * ELECTOSTATIC MAL ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7634 VENT THERMOMETER (E1399) W/ * ADAPTER ---------------------------------------------------------------------------------------------------------------- K0108 A9900 7638 W/C BRAKE EXTENSION (K0108) TIP * BLK 10/PK ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7635 WALKER BASKET (E1399) VINYL * COATED ---------------------------------------------------------------------------------------------------------------- E0159 A9900 7640 WALKER BRAKE (E0159) ATTACHMENT * ---------------------------------------------------------------------------------------------------------------- E0148 A9900 7636 WALKER HVY DUTY (E0148) FOLDING * X-WIDE ---------------------------------------------------------------------------------------------------------------- E0149 A9900 7637 WALKER HVY DUTY (E0149) W/ * WHEELS ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7645 CPAP (E1399) DC BATTERY ADAPTER * CABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7646 CPAP (E1399) EXHALATION PORT * DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7647 CPAP (E1399) FUSE KIT * INTERNATIONAL A/C ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7648 CPAP (E1399) HUMIDIFIER CHAMBER * KIT DISP ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7649 CPAP (E1399) HUMIDIFIER CHAMBER * REUSABLE ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7650 CPAP (E1399) HUMIDIFIER * MOUNTING TRAY ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7651 CPAP (E1399) INVERTOR AC/DC * ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7652 CPAP (E1399) POWER CORD * F/ARIA-SYNC ---------------------------------------------------------------------------------------------------------------- E1399 A9900 7653 CPAP (E1399) SHELL W/O PRESSURE * TAP ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7566 CPAP CALIBRATION SHELL (A9900) * ---------------------------------------------------------------------------------------------------------------- A9900 DM590 7565 CPAP SHORT TUBING (A9900) * ---------------------------------------------------------------------------------------------------------------- E0601 E0601 7690 VENT, CONTINUOUS POSITIVE * * (E0500) AIRWAY PRESSURE DEVICE ---------------------------------------------------------------------------------------------------------------- E0452 E0452 7691 VENT, BILEVEL INTERMITTENT * * (E0500) ASSIST DEVICE (BIPAP) ---------------------------------------------------------------------------------------------------------------- E0747 DM570 6875 STIMULATOR, OSTEOGENIC, * * ULTRASOUND ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7695 GEL/SILICON GOLD SEAL * * CPAP/BIPAP MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7701 VENT THERAPEUTIC ST BIPAP W/ * * BACKUP RATE (K0533) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7703 O2 SYS HELIOS PORT LIQUID, RENT * * (E1399) ---------------------------------------------------------------------------------------------------------------- HH591 HH591 7704 PUMP, EXT INFUSION, DANA * * DIABECARE, INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, * * INSULIN (E0784) ---------------------------------------------------------------------------------------------------------------- A9900 A9900 7737 CPAP DREAM SEAL INTERFACE FOR * * USE WITH BREEZE MASK (A9900) ---------------------------------------------------------------------------------------------------------------- A7036 DM590 7738 CPAP CHIN STRAP DELUXE (K0186) * * ---------------------------------------------------------------------------------------------------------------- E1340 E1340 7768 W/C REPAIRS - CUSTOM (E1340) * * ----------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances: * Confidential treatment requested ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2731 SHIPPING AND HANDLING FEES * ----------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment: ---------------------------------------------------------------------------------------------------------------- E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) * SERVICE REQUIRING SKILL OF A TECH ---------------------------------------------------------------------------------------------------------------- E1340 E1340 2554 W/C REPAIRS - STANDARD (E1340) * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4552 MISCELLANEOUS SUPPLIES * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 2589 REPAIR (E1399), RESPIRATORY * * EQUIPMENT ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4561 RESPIRATORY SUPPLIES (A4618) * * ---------------------------------------------------------------------------------------------------------------- E1399 E1399 4549 TENS/APNEA SUPPLIES * * ----------------------------------------------------------------------------------------------------------------
NOTES: * * * * * * * Confidential treatment requested