Settlement Agreement - Attorney General - State of California

e. Where tests (such as certain panels) that are ordered by a
single Test Order Code are billed to Medi-Cal under more than one CPT code, the Reporting
Business Unit will also report an allocation of the total applicable Test Bill Code price to each
included CPT code in proportion to Medi-Cal’s then applicable maximum reimbursement rates,
resulting in multiple “Allocated CPT Code Prices” for that Test Bill Code price. Provided that
all of the requirements in this Section III.C.5.e are met, and subject to the exceptions in Section
III.K of this Settlement Agreement, California will not make any claim against or seek
withholding from a Quest Releasee under Section 51501(a), or seek any discretionary suspension
or exclusion of a Quest Releasee under Section 51501(a), on the ground that an Allocated CPT
Code Price that was charged before November 1, 2013 for a test performed on or before that date
was lower than a price that was charged to Medi-Cal, unless the price charged to Medi-Cal was
for a test ordered under the same Test Order Code. The requirements are that:
(i) The same Test Order Codes are offered to the
ordering provider regardless of whether or not payment is sought from Medi-Cal, and no attempt
is made to influence the ordering of a test in order to avoid comparing charges to Medi-Cal with
charges to other purchasers; and
(ii) the Reporting Business Units have otherwise
complied with the reporting requirements set forth in this Settlement Agreement.
f. The name, address, telephone number, and e-mail address
of a contact at Quest with knowledge of the circumstances of the relevant laboratory tests.
g. To the extent Quest believes the identity of the purchaser
does not reveal them, the facts, if any, upon which Quest contends that it was not required to
charge Medi-Cal at least as low a price as the Lower Price Purchaser (“Justifications”).
California agrees that if Quest fails to include a particular Justification, Quest does not waive its
right to assert that Justification at a later point.
6. For insurance companies and other similar commercial third-party
payors whose reimbursement rates are determined in accordance with a contract with Quest
(“Commercial Third Party Payors”), each Reporting Business Unit shall list, in each Exception
Report, the top ten (10) such Commercial Third Party Payors (determined by revenue to the
Reporting Business Unit during the Reporting Period) that have reimbursed on a Fee-for-Service
basis for Potentially Reportable Tests. For each such Commercial Third Party Payor, the
Reporting Business Unit shall provide, in each Exception Report, the contracted rates in effect
for the Reporting Period by CPT code which the Reporting Business Unit has in its possession or
can obtain from the Commercial Third Party Payor after a good faith effort.
7. Each Exception Report shall also include, in a separate section, a
listing by customer of all capitated contracts between the Reporting Business Unit filing the
Exception Report and any entity with which it has such a capitated contract, together with a
description of the essential pricing terms of the contract.
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