Letter Of Intent Bcbs Form printable pdf download

HHSC Exclusive Provider Organization RFP

Letter of Intent to Contract

RFP No. 529-08-001

LETTER OF INTENT

This Letter of Intent (LOI) is subject to verification by the Texas Health and Human Services Commission (HHSC).

BCBSTX is proposing to participate in the CHIP and CHIP Perinatal EPO Programs.

This LOI confirms the intent of the undersigned to enter into contract discussions with BCBSTX, for the provision of

services to CHIP EPO members and CHIP Perinatal EPO members enrolled with BCBSTX. Signing this LOI does not

obligate the Health Care Provider, Medical Group or Facility to sign an Amendment to the Managed Care Agreement with

BCBSTX for the provision of services to CHIP EPO members and CHIP Perinatal EPO members.

A contract amendment to your current PPO/POS Managed Care Agreement with BCBSTX will be formalized if BCBSTX

is awarded the contract by HHSC. The reimbursement rate for CHIP EPO network providers is 100% of the then current

year Texas Medicaid Fee Schedule.

Please acknowledge your intent to participate by signing this non-binding LOI and returning it via fax to (877) 726-

4399 or via the enclosed, self-addressed, postage pre-paid envelope by Friday, August 29, 2008. Do not return the

completed LOI to HHSC. An administrator or other verifiable signature authority may sign the LOI. This LOI will apply

to all health care providers operating under the same tax identification number.

This is to warrant, represent and certify to Blue Cross and Blue Shield of Texas, a Division of Health Care Service

Corporation, that I am authorized to execute this LOI on behalf of the tax identification owner (Health Care Provider,

Medical Group, Facility).

_____________________________________________

___________________________________________

Authorized Signature

Printed Name and Title

_____________________________________________

Date

Provider Name:

Business or Group Name (if different):

Business Address:

TIN/FEIN:

__________________________________________________

BCBSTX Signature

M. Shannon Stansbury, Vice President, Network Management

Printed Name and Title

__________________________________________________

Date

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

CHIP LOI form

Letter Of Intent Bcbs Form