Group Network Rules

Group (as defined in the Agreement), Participant (as defined in the Agreement), and Participant Providers (as defined in the Agreement) agree as follows:

  1. Definitions. Capitalized terms used in the Pearl Network Agreement or the Exhibits (“Agreement”) but not defined herein will have the meanings set forth in the Agreement. Where there is a conflict between these Group Network Rules and the Agreement, the Agreement shall control.
    1. “ACO” or “REACH ACO” shall mean the Accountable Care Organization selected by the Centers for Medicare & Medicaid Services (“CMS”) for participation in the ACO REACH Model (hereinafter defined) or MSSP (hereinafter defined). ACO shall be identified in a separate ACO Participant Agreement (hereinafter defined), as applicable.
    2. “ACO Participant Agreement” shall mean the agreement Provider Participant has entered into with ACO, pursuant to which Participant Providers provide Covered Services to Beneficiaries.
    3. “Medicare Shared Savings Program” or “MSSP” shall mean the MSSP Model created by CMS.
    4. “ACO REACH Model” shall mean the ACO REACH Model created by the Center for Medicare and Medicaid Innovation (“CMMI”).
    5. “Beneficiaries” shall mean Medicare beneficiaries who are aligned with ACO under the CMS Agreement.
    6. “CMS” shall mean Centers for Medicare & Medicaid Services.
    7. “CMS Agreement” shall mean the agreement by and between ACO and CMS pursuant to which ACO may participate in the ACO REACH Model or MSSP, which may be amended, supplemented, or re-executed from time to time.
    8. “Covered Services” shall mean those certain medically necessary health care services and items that are covered by Medicare Parts A and/or B provided by Participant Providers to Beneficiaries.
  2. Cooperation with Group Network. Participant covenants and agrees, on behalf of itself and its Participant Providers, to fully and timely cooperate with, participate in, and abide by these Group Network Rules. Participant shall cooperate with the Group Network’s population management activities, including, as applicable, use of Group’s population management software platform, and facilitating Beneficiaries’ engagement. Participant shall also attend such educational sessions and attest to completion of education modules offered by Group pertaining to Group’s care management protocols and the Group Network Rules. More specifically, to be eligible to participate in the Group Network, Participant must:
    1. Timely disclose all Participant legacy TINs, all eligible NPIs, and all addresses for locations billing under participating TINs upon request of Group.
    2. Diligently work with Group to ensure removal from an ACO or any other conflicting Medicare or other CMMI or Medicare Shared Savings Program prior to (a) the withdrawal deadline for those programs, and (b) any termination notification deadlines they may have with their ACO or other applicable CMMI or Medicare Shared Savings Program.
    3. Appoint a designated individual to interface with Group to ensure timely completion of onboarding, actively attend meetings and trainings, provide Group with payment information for remittance of capitation payments (as applicable), participate in Group’s voluntary alignment programs, and otherwise use best efforts to cooperate with Group Network requirements.
  3. Performance and Engagement. Participant shall demonstrate timely commitment to and completion of all performance and engagement goals established by Group as requested by Group and within such reasonable deadlines as Group may from time to time impose, but no later than thirty (30) days of Participant’s receipt of notice of request from Group, unless the Group instructs otherwise (“Performance and Engagement Goals”). Performance and Engagement Goals are as follows:
    1. Participant and its Participant Providers will maintain active efforts to make use of Group’s technology solutions, including but not limited to the Pearl Platform (as defined in the Agreement) during the term of this Agreement.
    2. Complete Group-required annual compliance training within thirty (30) calendar days of notice from Group, or by such a date as indicated so long as Group provides at least thirty (30) calendar days advance notice of any such requirements.
    3. Maintain a strong partnership with Group through attendance to critical workshops, webinars, events, and committee meetings, as requested from time to time. For any such meetings that are required (e.g., any sessions required to maintain compliance with the ACO’s CMS Agreement), Provider agrees to attend.
    4. Utilize Certified Electronic Health Record Technology (“CEHRT”) where required by the CMS Agreement.
    5. Attend and support staff attending Group-sponsored education sessions for which Group may, in its discretion, make reasonable accommodations (e.g., recorded sessions).
    6. Comply with all CMS or other payor reporting requirements as defined and outlined by the CMS Agreement or a given Payor Addendum (as defined in the Agreement).
    7. Collaborate with Group as necessary to allow for care coordination of Beneficiaries, including:
      1. Care plans, including care transitions for Beneficiaries;
      2. Actively managing Beneficiaries with chronic conditions (e.g., COPD/Asthma, CHF, ESRD, DM, HTN);
      3. Identifying and remediating, to the extent possible, avoidable inpatient admissions and readmissions;
      4. Actively managing Beneficiaries that are identified as high risk or high utilizers of services;
      5. Providing or referring Beneficiaries to community resources, as appropriate (e.g., for education, nutrition, or non-urgent transportation);
    8. Ensure after-hours and weekend coverage for Beneficiaries;
    9. Support and participate in all Group quality assurance and quality improvement initiatives;
    10. Support Group’s Voluntary Alignment Activities (as defined in the CMS Agreement) and engage with Group to share Medicare patient data to identify aligned beneficiaries; and
    11. Share payment information in a timely manner as requested by Group, to allow for timely monthly capitation payment
  4. Notice.  In the absence of written direction to the contrary, notice under the Agreement can be provided via email, sent to the address on the signature page of the Agreement. 

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