PARTICIPATING PROVIDER AGREEMENT

This Participating Provider Agreement ("Agreement") is entered into this agreement on "Todays Date", by and between The Durango Network, Inc. ("TDN"), a Colorado for-profit corporation, and ("Provider"), a duly licensed provider or an entity employing licensed providers.

RECITALS

WHEREAS, TDN is organized to contract with insurance companies, third-party administrators, and employers to deliver high-quality healthcare services through a network of providers;
WHEREAS, TDN seeks to contract with Provider to deliver professional medical and healthcare services to Subscribers, and Provider agrees to provide such services under the terms herein;
NOW, THEREFORE, in consideration of the mutual covenants, the Parties agree as follows:

I. DEFINITION

Agent: Any individual authorized to act on behalf of the Provider.
Authorization: All necessary licenses, certifications, and registrations.
Clean Claim: A properly completed claim form with accurate information.
Coordination of Benefits: Sequential assignment of payment responsibility among Payors.
Copayments: Required Subscriber payment for a service.
Covered Service: Benefits Subscribers are entitled to under their health plan.
Dependent: Spouse, qualifying child, or medically certified disabled adult child.
Designated Representative: Any party delegated to process claims or administer programs.
Emergency Services: Urgent care required to prevent death or serious harm.
Health Coverage Plan: Any contract, policy, or agreement providing healthcare benefits.
Medically Necessary: Services deemed essential by the Payor.
Non-Covered Services: Services not covered by a Subscriber's plan.
Participating Provider: A duly licensed healthcare provider or facility contracted with TDN.
Payor: Entity paying for healthcare services under agreement with TDN.
TDN Network Services Agreement: Contract between TDN and a Payor.
Provider Services: Healthcare services within Provider's specialty.
Referred Provider: A specialist receiving a referral.
Reimbursement Rates: Rates agreed to between Payor and Provider.
Subscriber: An individual or Dependent enrolled in a Payor's plan.

II. GOVERNING RELATIONSHIP

This Agreement and the TDN Bylaws govern the relationship between Provider and TDN, and obligate Provider to deliver services per applicable TDN Network Services Agreements.

It is further acknowledged that membership in TDN is not limited to Class A or Class B Shareholders. The Board of Directors may designate members at large in accordance with the TDN Bylaws.

All official communications, including notices required under this Agreement or updates to policy or administrative procedures, may be sent and received via email. Email communications shall be considered a valid and acceptable method of official notification.

III. PROVIDER RESPONSIBILITIES

Participation: Participate in applicable Network Services Agreements. Engage in administrative, billing, and credentialing procedures.
Obligations: Comply with TDN bylaws, policies, and regulations. Maintain hospital privileges as required. Cooperate with TDN credentialing and quality assurance.
Participation Conditions: Meet with the Board if requested. Permit verification of credentials and qualifications. Release TDN and cooperating institutions from liability for good-faith evaluations.
Integrated Provider Group: Ensure all employed providers meet participation standards. Notify TDN of changes in group membership within 10 days.
Service Provision: Provide services consistent with community standards. Refuse care only when appropriate. Provide notice before limiting access to new patients.
Referrals: Follow referral and preauthorization procedures as required by Payors.
Continuity of Care: Maintain 24/7 coverage for patients. Ensure covering providers adhere to TDN standards.
Standards of Care: Deliver services per ethical and professional standards. Employ appropriately licensed staff.
Provider/Patient Relationship: Retain independent medical judgment and liability.
Non-Discrimination: Provide services without discrimination.
Licensure: Maintain all necessary licenses and notify TDN of changes.
Representations: Keep application information current.
Insurance: Maintain liability coverage and provide notice of changes. Maintain tail coverage for claims-made policies.
Legal Compliance: Notify TDN of any legal or disciplinary actions.
Grievances: Cooperate in resolving complaints.
Employment Liability: Be solely responsible for employee-related obligations.
Continuing Education: Meet continuing education requirements.
Network Participation Limits: Understand participation may be limited per Payor policies.

IV. NETWORK RESPONSIBILITIES

Marketing: TDN shall actively market network to Payors.
Quality Review: Provider will participate in Payor UR/QA plans.
Liaison: TDN will designate a contact for provider support.

V. ADMINISTRATION

Fees: TDN may assess reasonable dues and fees.
Network Agreements: TDN may enter agreements without prior provider approval.
Coverage Determinations: Payors determine eligibility, copayments, and covered services.
Medical Records: Retain records for 10 years. Allow access for authorized purposes. Comply with TDN privacy policies.
Administrative Updates: TDN shall notify Provider of significant changes.
Noncompliance: May result in corrective action or termination.

VI. COMPENSATION & CLAIMS

Compensation: Provider accepts Payor reimbursement according to payor contracted fee scheduled rate. May not bill Subscribers beyond copayments, coinsurance and deductibles.
Claims: Submit clean claims within 90 days. Follow coding standards and Payor protocols.
Payment Timing: Payments per Payor contracts and state law.
Coordination of Benefits: Assist Payor in COB processes.
Overpayments: Payors may recoup payments per payer contract.
Medicare Compliance: Follow all Medicare requirements.

VII. FINANCIAL LIABILITY

TDN is not liable for Payor or Subscriber nonpayment.

VIII. NAME USAGE

Provider authorizes listing in TDN directories and promotional materials.

IX. TERM & TERMINATION

Term: Agreement is effective upon execution.
Termination: Either party may terminate with 90-day notice. Immediate termination allowed for cause (e.g., license loss, fraud, bankruptcy). Group members may be terminated individually. Provider has no due process rights post-termination.
Post-Termination: Maintain care for 30 days post-termination if needed. Assist with patient transfers.

X. NON EXCLUSIVE ARRANGEMENT

TDN may contract with other providers.
Provider may participate in other networks.
Provider may contract directly with Payors.

XI. REGULATORY COMPLIANCE

Both parties shall comply with applicable laws, including non-discrimination and employment laws.

XII. GENERAL PROVISIONS

Amendments: TDN may amend this Agreement with 30-day notice.
Independent Contractor: Provider is not an employee of TDN.
Anti-Kickback Compliance: No part of this Agreement constitutes unlawful remuneration.
Limitation of Liability: Each party is responsible for its own actions.
Waiver: No waiver unless in writing. Invalid clauses do not void the Agreement.
Governing Law: This Agreement is governed by the laws of Colorado.
Notices: All notices must be delivered to the addresses listed herein.
Assignment: No assignment without written consent. TDN may subcontract.
Entire Agreement: This document is the full agreement. No third-party beneficiaries.
Costs: Each party pays its own legal and administrative costs.

PROVIDER

Full Name:

NPI #:

Entity Members (if applicable):

EXHIBIT A: REIMBURSEMENT RATE

To be entered after agreement with Payor.

EXHIBIT B: CONTRACTING GUIDELINES

TDN shall operate under a Messenger Model. Provider sets minimum fee levels in Exhibit A. TDN may only enter agreements meeting those levels unless otherwise authorized. Reimbursement offers will be shared with Providers for review and consent.

MESSENGER NOTICE AND SIGNATURE AUTHORITY

Practice:

TIN:

Email Contact for Notices

I hereby authorize "Email Contact Name", whose contact information is indicated below, to receive emailed notice for our group in lieu of separate mailings or emails to individual providers in our group.

Email Contact Name:

Email:

Signature Authority for Notices

I hereby grant the following individuals signature authority for response to emailed notices to our group.

Primary Signature Authority:

Title:

Backup Signature Authority:

Title:

THE DURANGO NETWORK WARRANTY

IF YOU RESPOND "YES" TO ANY OF THE FOLLOWING QUESTIONS, PLEASE PROVIDE A WRITTEN EXPLANATION.

1. Have you ever been disciplined by any State Board of Medical Examiners, or by any Professional Conduct Board? Have you ever been reprimanded or fined by any state agency that disciplines physicians or allied health professionals? Has your authorization to practice medicine in any jurisdiction ever been revoked, suspended or subject to probation or conditions or limitations?

Explanation:

2. Have your privileges or membership at any hospital or institution ever been denied, suspended or not renewed or have disciplinary proceedings ever been instituted against you?

Explanation:

3. Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings in any medical organization?

Explanation:

4. Do you have any physical or mental health conditions, treated or untreated, which in any way impairs your ability to practice medicine to the fullest extent of your licensure and qualifications or in any way poses a risk to your patients?

Explanation:

5. Do you have or have you had a chemical dependence/substance abuse or alcohol problem, treated or untreated?

Explanation:

6. Do you have any felony or misdemeanor charges pending other than misdemeanor traffic violations? [

Explanation:

7. Do you have any malpractice suits pending or had any previous judgments? If yes, please state the date the suit was filed, the name and location of the Court, the names of the parties, date and amount of any judgment, and the disposition of the case?

Explanation:

8. Have you ever been or are you currently under investigation, reprimand, censure, suspension or disqualification from a regulatory agency, e.g. Medicare or Medicaid?

Explanation:

9. Has your DEA Certificate ever been suspended, revoked, or otherwise limited?

Explanation:

10. Do you or any member of your family own, have a business interest in or investment as an owner or general partner in any clinical laboratory, diagnostic or testing center, hospital, surgical center, or other business dealing with the provision of ancillary health services, equipment or supplies?

Explanation:

11. To your knowledge, has any information pertaining to you ever been reported to the National Practitioner Data Bank?

Explanation:

12. Have you ever been denied professional liability insurance? Has your policy ever been canceled? Has your professional liability insurer refused to renew your policy or placed any limitations on the scope of your coverage?

Explanation:

APPLICATION & CREDENTIALING INFORMATION

Applying For:

Other (Specify):

PROVIDER INFORMATION

Full Name:

Date of Birth:

Degree:

Board Certified?:

Specialty:

Subspecialty:

CO License #:

Exp. Date:

DEA #:

Exp. Date:

SSN:

CAQH #:

NPI #:

Group NPI #:

Medicare #:

Medicaid #:

Provider Email:

Office Manager/Credentialing Email:

Fax:

MALPRACTICE COVERAGE

Attach File Here: (Max Upload Size: 5mb | File Type: .pdf, .png, .jpeg, .jpg)

Carrier Name:

Address:

Policy #:

Coverage Per Occurrence/Claims Made:

Aggregate Maximum Per Year:

Deductible:

Exp. Date:

PRACTICE / BILLING INFORMATION

Attach W9 Here: (Max Upload Size: 5mb | File Type: .pdf, .png, .jpeg, .jpg)

Name of Corporation:

Tax ID #:

PRIMARY OFFICE

Address:

City:

State:

Zip:

Phone:

Fax:

Hours:

SECONDARY OFFICE

Address:

City:

State:

Zip:

Phone:

Fax:

Hours:

EDUCATION

ALL TIME MUST BE ACCOUNTED FOR FROM COLLEGE/UNIVERSITY TO PRESENT.

Undergraduate University:

Address:

Degree:

Month/Years:

Medical University:

Address:

Degree:

Month/Years:

EXPERIENCE

ALL TIME MUST BE ACCOUNTED FOR FROM COLLEGE/UNIVERSITY TO PRESENT.

Internship:

Address:

Specialty:

Years:

Residency Name:

Program Director:

Specialty:

Years:

Residency Name:

Program Director:

Specialty:

Years:

ECMG Number (Foreign Medical Graduates Only):

If reason for leaving residency was other than successful completion of residency, please explain:

FORMAL FELLOWSHIP OR POST-GRADUATE TRAINING:

Type of Training:

Location:

Date(s):

Program Director:

Type of Training:

Location:

Date(s):

Program Director:

Type of Training:

Location:

Date(s):

Program Director:

Type of Training:

Location:

Date(s):

Program Director:

SPECIALTY BOARD CERTIFICATIONS

Name of Board:

Eligible:

Certified:

Date of Certification:

Date Eligibility Expires:

CURRENT HOSPITAL STAFF PRIVILEGES

Hospital:

Status:

Dates:

Hospital:

Status:

Dates:

Hospital:

Status:

Dates:

PROFESSIONAL MEMBERSHIPS

Medical Societies:

Specialty Societies:

AUTHORIZATION TO RELEASE INFORMATION

AS A PART OF MY APPLICATION FOR PROVIDER PANEL PRIVILEGES IN THE DURANGO NETWORK, I AUTHORIZE ALL:

Hospitals
Insurance Carriers
Schools and Universities
Professional Medical Societies
Professional Review Organizations
Foundations for Medical Care
State and Federal Agencies

To release confidential information about me to The Durango Network and/or Mercy Medical Center and any designated representative for the purpose of validation and evaluation of my application and, if the situation pertains, to notify them of any future status change within 15 days. I understand that all information provided is confidential and shall not be disclosed except as necessary for the purpose described above.

I consent to the release of information for the purpose of evaluation of my professional competence, character, ethics and other qualifications, information concerning my professional liability coverage claims for resolving any doubts about such qualifications, and release from liability and hold harmless any person or entity furnishing such information.

I hereby attest that the information provided in this application process is accurate to the best of my knowledge. I understand that providing false information can be used as grounds for denial of application or termination of my participation.

The undersigned hereby certifies that the above information and attached supplements (if any) are truthful, correct and complete in all respects, and the undersigned further understands that the intentional submission of false or misleading information or the withholding of relevant information are grounds for termination as a participating provider with The Durango Network. The undersigned agrees to notify The Durango Network in writing of any changes in the above information within 15 days.

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Provider Signature:

ELECTRONIC SIGNATURE ACKNOWLEDGMENT & AGREEMENT

By typing your full legal name above, you acknowledge and agree that doing so constitutes your electronic signature and is the legal equivalent of your manual, handwritten signature.

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