Three Penn Plaza East. Newark, NJ HorizonBlue.com

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1 Three Penn Plaza East Newark, NJ HorizonBlue.com January 2, 2015 <<Name>> <<Address1>> <<Address2>> <<City, State ZIP>> <<Attention>> Dear Participating Ancillary Provider: Horizon Blue Cross Blue Shield of New Jersey is amending our Ancillary Services Provider Agreement. Please review the enclosed Amendment that will modify your current Agreement with Horizon BCBSNJ. The new language in the Amendment is formatted in a bold font. The Amendment adds new language that allows for the collection of member cost-sharing amounts that fall outside traditional cost-sharing (i.e., deductible, coinsurance or copayment) definitions for certain services provided to members enrolled in certain plans. The Amendment also addresses electronic communications. To ensure all our future communications, including those sent by or fax, are received, we encourage you to regularly review and update your practice demographic information so we have your most current and complete practice information, including addresses and fax numbers. To update practice demographic information, please contact your Network Specialist. If you accept the terms of the Amendment: There is no need to respond to us or to return signed copies. The terms of the Amendment will be effective on April 15, Please retain the Amendment in your records. If you object to the terms of the Amendment: You may seek to terminate your Agreement(s) by responding in writing to Horizon BCBSNJ within 30 days of delivery of this notice of Amendment. Termination letters may be faxed to or mailed to: Horizon BCBSNJ Provider Files Dept. Three Penn Plaza East, PP-14C Newark, NJ If you have questions about the Amendment, please call Physician Services at or contact your Network Specialist. Sincerely, James F. Albano Vice President Network Management and Horizon Healthcare Innovations Encl CMC D (1114) An Independent Licensee of the Blue Cross and Blue Shield Association.

2 AMENDMENT TO THE ANCILLARY SERVICES PROVIDER AGREEMENT WITH HORIZON HEALTHCARE SERVICES, INC. THIS is an Amendment to your Ancillary Services Provider Agreement (as amended, hereafter together with the amendments referred to as "Agreement") with Horizon Healthcare Services, Inc., dba Horizon Blue Cross Blue Shield of New Jersey ("Horizon") and will be effective ninety (90) days after the date of receipt of this Amendment (the Effective Date ). Any conflict in the terms of the Agreement and the Amendment shall be governed by the terms of this Amendment. WHEREAS, You are a participating provider in Horizon's networks; and WHEREAS, Horizon desires to amend the Agreement to reflect various changes to the Agreement; NOW, THEREFORE, the Parties agree to amend the Agreement as follows: 1. The following shall replace the first sentence of Section 3.7-Compliance with Company Requirements, Policies, and Procedures, of the Agreement: Provider agrees to provide Covered Services in conformity with and to cooperate and comply with the requirements, policies, procedures and protocols established by and acceptable to Company, or its designee, including, but not limited to, Quality Improvement/Risk Management, Utilization Management, provider audit and risk adjustment programs, claim edit and processing procedures, and the Company's complaint, grievance and appeal process. 2. The following shall replace the first paragraph of Section Hold Harmless, of the Agreement: Provider hereby agrees that in no event, including, but not limited to non-payment, Company s insolvency or breach of this Agreement, or refusal to pay for services or supplies deemed by it not to be Medically Necessary and Appropriate Covered Services, and regardless of whether or not Provider believes Provider's compensation is made in accordance with the reimbursement provisions of this Agreement or is otherwise inadequate, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Covered Persons or persons other than Company acting on their behalf for Provider Services. This provision shall not prohibit collection of Copayments, Coinsurance and Deductibles made in accordance with the terms of the agreements between Company and its subscribers/enrollees, or other amounts associated with exclusions or limitations Ancillary RBB and Notice Amendment

3 contained in the Covered Person's Health Benefit Plan (see Section 6.3 below); provided, however, that Provider shall not bill Covered Persons for services or supplies for which Company provides benefits. 3. The following shall replace the first paragraph of Section 6.1- Payment to Provider, of the Agreement: The basis of payment to Provider, for Medically Necessary and Appropriate Covered Services, for which the Company has provided Precertification and which Provider has provided to Covered Persons in accordance with the terms and conditions of this Agreement during the term of this Agreement, shall be set forth in Appendix B of this Agreement which is attached hereto. The Payment Rate shall be limited to the amounts referred to in Appendix B, less Copayments, Coinsurance and Deductibles as provided in the applicable Health Benefit Plan, or other amounts associated with exclusions or limitations contained in the Covered Person's Health Benefit Plan (See Section 6.3 below), and subject to all terms, exclusions and limitations of such Plan as well as Company s claims adjudication policies, and less amounts received or receivable from sources through subrogation (to the extent not otherwise prohibited by the New Jersey collateral source rule, where applicable) and workers' compensation provisions or other sources, as may be allowed by the applicable Health Benefit Plan, and subject to Coordination of Benefits and Horizon s claim payment policies. Claims shall be paid, contested or denied in accordance with the applicable statutes and regulations regarding prompt payment, investigation and settlement of claims. To the extent required by applicable law, Provider shall be paid interest on claims not paid within the time period provided by applicable law (unless an exception applies). However, Provider acknowledges and agrees that payment may be denied for claims submitted after one hundred and eighty (180) days from the date of service; such period shall not begin to run until Provider receives notification of the primary payor's responsibility if Company is the secondary payor. Ancillary RBB and Notice Amendment

4 4. The sentence in Section 6.2- Claims and Billing, of the Agreement that reads: With regard to Covered Services, Provider shall be entitled to collect from Covered Persons an amount not to exceed any Copayments, Coinsurance or Deductibles. is amended to read: With regard to Covered Services, Provider shall be entitled to collect from Covered Persons an amount not to exceed any Copayments, Coinsurance or Deductibles, or other amounts associated with exclusions or limitations contained in the Covered Person s Health Benefit Plan (see Section 6.3 below). 5. The following shall replace Section Notices, of the Agreement: For purposes of this Agreement notices shall become effective on the day of receipt, counting the day of actual receipt of the notice as the first day of notice. Notice required to be given pursuant to this Agreement by Provider to Horizon shall be in writing and shall be sent by United States mail, certified, return receipt requested, postage prepaid, or via Federal Express or other similar professional overnight courier to: Ancillary Contracting Department Horizon Healthcare Services, Inc. 3 Penn Plaza East, PP-14N Newark, New Jersey and Corporate Secretary Horizon Healthcare Services, Inc. 3 Penn Plaza East, PP-16D Newark, New Jersey Ancillary RBB and Notice Amendment

5 Notice required to be given pursuant to this Agreement by Horizon to Provider shall be sent either: (1) via the Company website, (2) electronically via or fax mail, or (3) sent by United States mail, certified, return receipt requested, postage prepaid, via Federal Express or other similar professional overnight courier to: Provider: Address: Your mailing address on file with Horizon Your on file with Horizon Fax: Your fax number on file with Horizon or such other address as the Parties shall designate in writing. 6. Except as provided herein, the Agreement shall remain unmodified and in full force and effect. NOW, THEREFORE, effective on the date written below, your Agreement shall be amended to reflect the foregoing. HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY By: James F. Albano Vice President, Network Management and Horizon Healthcare Innovations Effective Date: April 15, 2015 Ancillary RBB and Notice Amendment