Wisconsin In-Network Transportation Provider Checklist

More documents

Recommendations

Info

obligations under this Agreement, or as otherwise specifically provided forherein. Provider agrees to sign and abide by any subsequent agreementswith respect to confidentiality as may be required by the Health InsurancePortability and Accountability Act (HIPAA) and any similar laws. BothLGTC and the Client shall have unrestricted authority, to the extentpermitted by law, to reproduce, distribute, or use in whole or in part anysubmitted reports, data or materials associated with any services providedby Provider under this Agreement.v. Notices. All written notices required by this Agreement shall be deemeddelivered either on the date of receipt if personally delivered; on the dayfollowing mailing if sent postage prepaid by overnight mail through anationally recognized overnight carrier, or on the third day followingmailing if mailed postage prepaid certified return receipt requested. Suchnotices shall be sent to the following addresses as appropriate, or to suchother addresses as the parties may hereafter designate:to LGTC at:LogistiCare Solutions, LLC1275 Peachtree Street NE, 6 th FloorAtlanta, Georgia 30309Attn: Legal Departmentto Provider at:vi.vii.viii.Amendments. This Agreement (including Exhibits) may be amended onlyby a document in writing duly executed by an authorized representative ofboth parties.Client Amendment. This Agreement is subject to approval by the Client.In the event that the Client at any time requires modifications to thisAgreement, the parties hereto will execute amendments to this Agreementreflecting such modifications. If either party is unwilling to accept anysuch modifications required by the Client, such party may exercise itstermination rights hereunder.Dispute Resolution and Arbitration. If any claim or controversy arisingout of or relating to this Agreement cannot be resolved by the parties inthe normal course of business, each party shall designate a member of itssenior management to meet in an attempt to resolve the dispute. If thedispute cannot be resolved to the satisfaction of the parties in this manner,Wisconsin NET ProgramVersion: March 25 2011Page 22
the dispute shall be referred for binding arbitration in accordance with thecommercial dispute arbitration rules of the American ArbitrationAssociation. Each party shall bear its own costs and expenses and anequal share of the arbitrators' fees and other administrative fees related tothe arbitration. Judgment upon an award in arbitration may be entered inany court of competent jurisdiction, or application may be made to suchcourt for a judicial acceptance of the award and enforcement, as the law ofthe state having jurisdiction may require or allow. The provisions of thisSection shall survive the termination of this Agreement. The arbitrator(s)assigned to the case may construe or interpret but shall not vary or ignorethe terms of this Agreement and shall be bound by controlling law. Thearbitrator(s) shall have no authority to award punitive, exemplary, indirector special damages, except in connection with a statutory claim thatexplicitly provides fur such relief. The provisions of this Section shallsurvive the termination of this Agreement.ix.Severability. If any provision of this Agreement is held invalid by law,rule, order or regulation of any relevant government, or by the finaldetermination of a court of last resort, such invalidity shall not effect (a)the other provisions of this Agreement; (b) the application of suchprovision to any other circumstances other than that with respect to whichthis Agreement was found to be unenforceable, or (c) the validity orenforceability of this Agreement as a whole. The parties hereto agree tonegotiate in good faith to replace any provision found to be unenforceableso that the economic effects of this Agreement for each party remain thesame.x. Waiver. Any delay or omission by either party to exercise any right orremedy under this Agreement shall not be construed to be a waiver of anysuch right or remedy or any other right or remedy hereunder. Except asotherwise explicitly set forth herein, all of the rights of either party underthis Agreement are cumulative and may be exercised separately orconcurrently.xi.Entire Agreement. This Agreement contains the entire agreement of theparties with respect to its subject matter and supersedes all prior oral orwritten agreements or understanding regarding the same subject matter.The parties have not created and do not intend to create by this Agreementany enforceable rights in any third party under this Agreement, including,but without limitation, Members and Vendors. The parties acknowledgeand agree that there are no third party beneficiaries to this Agreement.EXECUTION PAGE FOLLOWSWisconsin NET ProgramVersion: March 25 2011Page 23
Page 1 and 2: Please return all documents to:1275
Page 3 and 4: TRANSPORTATION AGREEMENT(the “Agr
Page 5 and 6: Provider may be withdrawn by LGTC,
Page 7 and 8: ii)iii)iv)scheduled B-Leg pick up t
Page 9 and 10: utilized by Provider.ii) The number
Page 11 and 12: • ADA regulations;• Client Cont
Page 13 and 14: vi)type of vehicle in which it is i
Page 15 and 16: and satisfactorily cleared a nation
Page 17 and 18: ix)a Participant, or in the presenc
Page 19 and 20: iv)Provider warrants that it has no
Page 21 and 22: a) name, date of birth and social s
Page 23: from establishing or maintaining se
Page 27 and 28: EXHIBIT ALIQUIDATED DAMAGESThe Part
Page 29 and 30: Requirement:Provider must perform t
Page 32 and 33: To determine the payment amount LGT
Page 34 and 35: Exhibit B - Execution PageLOGISTICA
Page 36 and 37: scope of the employment or other pr
Page 38 and 39: or created or received by BUSINESS
Page 40 and 41: presenting a preponderance of the e
Page 42 and 43: EXHIBIT EMedicare Advantage Program
Page 44 and 45: information and data necessary for:
Page 46 and 47: e reviewed and approved by Health P
Page 48 and 49: Non-Emergency Medical Transportatio
Page 50 and 51: LOGISTICARE INSURANCE CREDENTIALING
Page 52 and 53: Please describe your hours of opera
Page 54 and 55: Network Development503 Oak Place, S
Page 56 and 57: AFTER HOURS CONTACTINFORMATION SHEE
Page 58 and 59: Form W-9 (Rev. 1-2003) Page 2Exampl
Page 60 and 61: Form W-9 (Rev. 1-2003) Page 4Part I
Page 62 and 63: Dear LogistiCare Transportation Pro
Page 64 and 65: Electronic Data Interchange (EDI) A
Page 66 and 67: Date: __________________________Log
Page 68 and 69: Software User AgreementWHEREAS, Log
Page 70 and 71: III.OWNERSHIPThe Software is protec
Page 72 and 73: X. THIRD PARTY WEBSITESThe Software
Page 74 and 75:
(B) The Content may not be copied,
Page 76 and 77:
this Agreement, or the infringement
Page 78 and 79:
LogistiCare Driver ListLegal name D
show all

Wisconsin In-Network Transportation Provider Checklist

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?