PROVIDER REPRESENTATIONS

1.1.          Participant Provider Agreement.  All terms and conditions below apply to that certain Participant Provider Agreement by and between Provider and the ACO (the “Participant Provider Agreement”).  Provider represents and warrants as set forth below in these Provider Representations, and agrees to comply with all terms and conditions of the Participant Provider Agreement and those set forth in these Provider ACO REACH Terms and Conditions.  Capitalized terms used below that are not defined below have the meaning given to them in the Participant Provider Agreement, unless otherwise specified below.

1.2.          Representations.

(a)            Provider represents, warrants, covenants, and agrees that at all times during the Term:

(i)              Provider is a Medicare enrolled provider or supplier.

(ii)            Provider and each Provider Clinician satisfies all eligibility and other criteria for participation set forth in the Care Initiatives Policies and the Participation Agreement.

(iii)          Each Provider Clinician: (A) maintains an unrestricted license to practice his or her profession in each state or commonwealth in which such Provider Clinician provides professional medical services; (B) if a physician, is qualified for and has been granted membership in good standing on the active medical staff of a hospital accredited by the Joint Commission and has appropriate clinical privileges at such hospital (unless the Provider Clinician’s practice is not hospital-based, in which case the Provider Clinician must be Board-eligible in his or her specialty); (C) if appropriate, has current controlled substances registrations issued by the appropriate federal and state governmental agencies, which registrations are not suspended, revoked or restricted in any manner; (D) maintains professional liability insurance with annual limits as may be required by law and ACO policies; (E) will disclose to ACO the existence of any proceeding against him/her which involves any allegation of substandard care or professional misconduct raised against him/her; and (F) will at all times comply with applicable laws, rules and regulations and the ethical standards of his/her applicable professional association.

(iv)          Provider shall maintain services, supplies, and equipment which meet all applicable legal requirements, including accessibility, and which otherwise comply with federal and state law. 

(v)            Provider and each Provider Clinician currently has, and during the term of the Agreement shall maintain, the necessary certification, permits, accreditation, and licensure required by each state or commonwealth in which Provider and Provider Clinician(s) provide professional medical services in, the federal government including CMS, and national accreditation entities for all services furnished under the Participant Provider Agreement.  Upon request, Provider shall provide copies of such information as acceptable to ACO. 

(vi)          Neither Provider nor any Provider Clinician is: (A) involuntarily excluded from participation in any federal health care program (as defined under 42 U.S.C. § 1320a-7b(f)); (B) debarred, suspended or otherwise involuntarily excluded from participating in any other federal or state procurement or non-procurement program or activity; (C) designated a Specially Designated National or Blocked Person by the Office of Foreign Asset Control of the U.S. Department of Treasury; nor (D) a Prohibited Participant (as defined in the Participation Agreement).

(vii)         Neither the execution and the delivery of the Participant Provider Agreement, nor the performance of the arrangements contemplated hereby will:  (A) violate any constitution, statute, regulation, rule, injunction, judgment, order, decree, ruling, charge or other restriction of any government, governmental agency or court to which Provider is subject; or (B) conflict with, result in a breach of, constitute a default under, result in the acceleration of, create in any party the right to accelerate, terminate, modify or cancel, or require any notice or approval or consent under any agreement, contract, lease, license, instrument or other arrangement to which Provider or any Provider Clinician is a party or by which any Provider Clinician is bound or to which the assets or equity of the Provider are subject.

(b)            For purposes of determining eligibility to participate in the ACO REACH Model, Provider shall notify ACO and, if required by the Participation Agreement or CMS policies, Provider also shall notify CMS, promptly: (i) upon Provider’s or any Provider Clinician’s, as applicable, participation in, or termination from, any clinically-integrated managed care contracting network or other accountable care type-organization through which Provider (or any Provider Clinician) participates in shared savings arrangements, other than pursuant to the Participant Provider Agreement, or (ii) upon obtaining knowledge of any facts or circumstances that cause, or through the passage of time would be reasonably likely to cause, any of the representations and warranties of Provider and Provider Clinicians made in the Participant Provider Agreement to be untrue or misleading.

(c)            Provider shall notify ACO within seven (7) days of becoming aware that Provider is under investigation or has been sanctioned by the government or any licensing authority, including, without limitation, the imposition of program exclusion, debarment, civil monetary penalties, corrective action plans, and revocation of Medicare billing privileges.

(d)            Provider has accurately reported to ACO the prior year status of its Provider Clinicians as Eligible Clinicians that use Certified Electronic Health Record Technology (as those terms are defined at 42 C.F.R. § 414.1305) in connection with its application to become a Participant Provider.  Provider has accurately reported to ACO quality review (“QR”) and utilization review (“UR”) and other performance indicators specified by ACO in connection with its application to become a Participant Provider.

Last revised May 30, 2023