MDHIN Provider Participation Agreement

MDHIN Provider Participation Agreement

This Provider Participation Agreement ("Agreement") is entered into by and between MDHIN Corporation ("MDHIN") and the undersigned provider or provider entity including Pharmacy/Pharmacist/Other Provider/Participants ("Provider") as of the Effective Date indicated below.
1. Purpose
This Agreement defines the terms under which Provider will participate in the MDHIN healthcare network, provide eligible services to MDHIN members, and receive compensation in accordance with the attached Exhibit A.
2. Network Participation
Provider agrees to participate as an in-network provider within MDHIN and to render eligible services to members in accordance with the guidelines and reimbursement structure outlined in this Agreement.
3. Scope of Services
Provider shall offer services including but not limited to:
• Primary care (in-person or virtual)
• Pharmacy-based services
• Specialty services such as podiatry and dermatology
• Point-of-care testing (POCT) if available
All services must be within the Provider’s licensure and scope of practice.
4. Compensation
Provider shall be reimbursed on a fee-for-service basis as set forth in Exhibit A – Compensation Schedule. Provider agrees to accept the specified reimbursement as payment in full for the services provided to MDHIN members.
5. Billing and Claims
• Provider shall submit claims using approved codes and modifiers, including codes that may include 99212, 99423 for clinical visits and code 99000 for Point of Care testing (POCT) if applicable. The Approved Providers may use a direct submission (https://www.datawik.com/machform/view.php?id=74179) or their billing/clearinghouse or when available BIN billing.
• For Pharmacy billing, Provider shall also have the option to submit eligible services through MDHIN’s BIN/PCN numbers, using the pseudo-NDCs specified in Exhibit A (Section IV – BIN Billing Service Codes). Claims transmitted via BIN billing shall be adjudicated by MDHIN as payer of record, and must include the appropriate pseudo-NDC, service code, and Visit ID.
• ICD-10 code Z00.00 should be used unless a more specific diagnosis is required.
• Modifier 25 must be used when more than one unit/service is billed in a single encounter.
• Each claim must include a unique Visit ID.
• Providers shall apply acceptable codes approved by MDHIN and as updated by MDHIN
6. Eligibility and Limitations
• Provider shall confirm member eligibility prior to rendering service.
• Reimbursement is subject to the members’ remaining visits and POCT unit allowance (if applicable).
• No reimbursement will be made for claims exceeding these member limits per tier.

Licensure and other Provisions

7. Licensure and Credentialing
Provider affirms they hold current, valid licensure and, if applicable, a CLIA waiver for any POCT services. Provider shall notify MDHIN of any changes in licensure status.
If the Participant is a Pharmacy or Pharmacy Provider, then upon acceptance into the MDHIN network, MDHIN may provide the Participant with access to the Independent Pharmacy Provider Network (IPPN) Software License and Management Agreement (“IPPN Agreement”), which will be transmitted separately for review and optional execution.
The IPPN software enables clinical documentation, patient encounter workflows, and optional collaboration features that may support additional clinical services delivered by the Pharmacy. The IPPN Agreement is not required as a condition of participation in MDHIN, and execution of the IPPN Agreement is at the sole discretion of the Pharmacy Participant.
Participation in MDHIN does not obligate the Participant to utilize the IPPN software, nor does signing this MDHIN Agreement create any financial or contractual obligations related to IPPN. Any decision to license or utilize IPPN services shall be governed exclusively by the terms of the separately provided IPPN Agreement.
8. Term and Termination
This Agreement shall be effective upon execution and shall remain in effect until terminated by either party with thirty (30) days written notice. MDHIN may terminate immediately for cause, including but not limited to fraud, abuse, or licensure issues.
9. Confidentiality
Both parties shall maintain the confidentiality of non-public patient, business, and operational data in accordance with applicable law.
10. Business Associate Agreement (HIPAA Compliance)
Provider acknowledges their role as a Business Associate under HIPAA and agrees to:
• Use or disclose Protected Health Information (PHI) only as permitted under this Agreement or as required by law.
• Implement appropriate safeguards to prevent unauthorized use or disclosure of PHI.
• Report to MDHIN any use or disclosure of PHI not provided for by this Agreement, including security incidents or breaches.
• Ensure that any subcontractors who receive PHI agree to the same restrictions and conditions.
• Make PHI available for access, amendment, and accounting of disclosures as required by HIPAA.
• Cooperate with MDHIN in compliance reviews by the U.S. Department of Health and Human Services (HHS).
• Return or securely destroy all PHI upon termination of this Agreement, where feasible.
This section survives the termination of the Agreement and is governed by HIPAA and the laws of the State of Delaware.
10. General Provisions
• This Agreement shall be governed by the laws of the State of Delaware.
• MDHIN reserves the right to amend or modify this Agreement, including attached exhibits, policies, or compensation schedules. Any such changes will be communicated to Provider in writing with at least thirty (30) days’ notice. Continued participation in the MDHIN network after the effective date of such changes constitutes acceptance.
• Provider agrees to maintain current, unrestricted licensure and, where applicable, a valid CLIA waiver.
• Provider shall notify MDHIN within five (5) business days of any adverse licensure or disciplinary action, board complaint, legal restriction, or exclusion from any federal or state healthcare program.
• MDHIN retains the right to determine accept any Provider and retains the right to determine in which geographic areas or locations its network, services, or reimbursement model shall be available.
• This Agreement may be terminated without cause by either party with thirty (30) days written notice.
• Provider acknowledges that participation in MDHIN does not constitute the provision of insurance and that MDHIN is not an insurance company or health plan. Services rendered and reimbursed under this Agreement are not insurance benefits and do not create an insurer-insured relationship between MDHIN and any participant or member.
• MDHIN may terminate this Agreement immediately for cause, including but not limited to fraud, abuse, failure to maintain licensure, material breach, or jeopardizing patient safety.
• This Agreement shall be governed by the laws of the State of Delaware. Any changes or amendments must be in writing and signed by both parties.

Exhibit A

Exhibit A – Compensation Schedule
I. Reimbursement Structure
Service Type Units Reimbursement
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Pharmacy Direct Primary Care Visit 1 Unit $40 per visit
Provider Direct Primary Care Visit 1 Unit $45 per visit
Specialty Direct Primary Care Visit 1 Unit $45 per visit
Point-of-Care Test (POCT) 1 Unit per test (max 2 per encounter) $15 per test
Per Member Per Month (PMPM) – Only available for Patients Attributed to MD/DO ONLY $2 per member
II. Service Definitions and Conditions
Pharmacy Direct Primary Care Visit: Clinical encounter delivered by a licensed pharmacist. No collaborative agreement required.
Provider Direct Primary Care Visit: Clinical visit by MD, DO, NP, PA, RN, LMSW, LCSW, LSW, LPC, RD/LDN, and LMHC.
Specialty Direct Care Visit: Includes Podiatry, Med Spa and Dermatology.
POCT: Examples include flu, strep, COVID-19, glucose, A1C, lipid panel, urinalysis. Must be CLIA-waived.
III. Billing and Encounter Rules
• Max 2 clinical Units per encounter; up to 2 POCTs may be added.
• POCTs billed with or without a clinical visit.
• Coding by Service Type:
o Provider Direct Primary Care Visit: Use 99212 and 99423 for e-visit.
o Pharmacy Direct Primary Care Visit: Use 99429 (unlisted preventive service or payer-accepted alternative).
o Specialty Direct Primary Care Visit: Use 99499 (unlisted E/M or applicable specialty-specific code).
o Point-of-Care Test (POCT): Use 99000 or other applicable codes.
• ICD-10: Use Z00.00 unless a more specific diagnosis is clinically appropriate.
• Modifier 25 is required when billing more than one unit or service on the same date.
• Each claim must include a unique Visit ID.
• Real-time eligibility check recommended prior to rendering services.
• All Units billed are deducted from member's plan allowance.
IV. BIN Billing Service Codes
Service Code Pseudo-NDC (11-digit) Reimbursement
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Standard Visit VISIT 99999000101 $40 per visit
Follow-up Visit VISIT-FU 99999000201 $40 per visit
Sick Visit VISIT-SICK 99999000301 $40 per visit
Wellness Visit VISIT-WELL 99999000401 $40 per visit
POCT A1C POCT-A1C 99999100101 $15 per test
POCT Lipid POCT-LIPID 99999100201 $15 per test
POCT COVID POCT-COVID 99999100301 $15 per test
POCT Strep POCT-STREP 99999100401 $15 per test
Pharmacogenomic Test* PGX 99999200101 N/A*

*Values for PGx may be adjusted per payer contract or MDHIN fee schedule updates. This is paid to the Lab performing the test and not to the pharmacy or provider ordering the test. The provider or Pharmacy can use a visit as the consultation that would lead to a test order. Also, the PGx test is a one per patient test per lifetime.
**MDHIN may add additional features and services that may be covered within any tier and notification will be made separately to the participating Provider.

Participant Information

Please complete and sign below

Please complete the information below and submit.

ELECTRONIC ACCEPTANCE

By completing and submitting this agreement electronically, the Provider acknowledges and agrees to all terms herein. If additional information is required, it may be submitted upon request. Updates to this agreement may be made from time to time, and email notifications regarding such updates may be sent to the email address listed above.

MDHIN’s acceptance of this Agreement shall be deemed complete upon electronic receipt and subsequent acknowledgement via email. If you have any questions, please contact MDHIN at contact@mdhin.com