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HomeMy WebLinkAboutAgreements/Contracts - Sheriff & JailGRANT COUNTY COMMISSIONERS AGENDA MEETING REQUEST FORM (Must be submitted to the Clerk of the Board by 12:00pm on Thursday) REQUESTING DEPARTMENT:SherlfF'S Office REQUEST SUBMITTED BY:Phillip C. Coats CONTACT PERSON ATTENDING ROUNDTABLE: PII1IIIp C. Coats CONFIDENTIAL INFORMATION: DYES ®NO DATE: 08/04/25 PHONE: eXt. 2021 ®Agreement / Contract ❑AP Vouchers ❑Appointment / Reappointment ❑ARPA Related ❑ Bids / RFPs / Quotes Award ❑ Bid Opening Scheduled ❑ Boards / Committees ❑ Budget ❑Computer Related ❑County Code ❑Emergency Purchase ❑Employee Rel. ❑ Facilities Related ❑ Financial ❑ Funds ❑ Hearing El Invoices / Purchase Orders ❑Grants — Fed/State/County Ell -eases ❑MOA / MOU ❑Minutes ❑Ordinances ❑Out of State Travel El Petty Cash ❑ Policies ❑ Proclamations ❑ Request for Purchase ❑ Resolution El Recommendation ❑Professional Serv/Consultant ❑Support Letter ❑Surplus Req. ❑Tax Levies ❑Thank You's ❑Tax Title Property ❑WSLCB Sheriffs Office is requesting to sign the reimbursement agreement for Molina Healthcare. This is related to the Health Care Authority grant. This will allow the jail to submitt billing to Molina for medical services provided to eligible inmates. If necessary, was this document reviewed by accounting? ❑ YES *1 NO ❑ N/A If necessary, was this document reviewed by legal? *1 YES ❑ NO ❑ N/A DATE OF ACTION: APPROVE: DENIED ABSTAIN D1: D2: D3: DEFERRED OR CONTINUED TO: WITHDRAWN: RECEIVED AUG 0 4 2025 4/23/24 GRANT COUNTY COMMISSIONERS 00 MOLINN 11111111�HEALTHCARE July 21, 2025 County of Grant 35 C Street NW Ephrata, WA 98823 CONFIDENTIAL & PROPRIETARY TRANSMITTED BY EMAIL/FAX TO: Interim Period Reimbursement (Single Case Rate) Agreement Provider County of Grant dba Grant County Sheriff's Office Name: Line of Business: Medicaid Dates of September 2025 through August 2026 OR until such time a Provider Services Service: Agreement is executed between Provider and Molina Healthcare; whichever occurs first. Type of Reentry Initiative Services Services: Dear Provider: This letter is to serve as an interim period reimbursement rate agreement ("Agreement") between Molina Healthcare of Washington, Inc. (Molina Healthcare or Health Plan) and County of Grant dba Grant County Sheriff's Office/ 91-6001319 ("Provider") for the type of services listed above to specific Molina Healthcare members ("Members"). Molina Healthcare shall pay Provider for Covered Reentry Initiative Services that have been authorized by Molina that Provider provides to Molina Members in accordance with applicable law, regulations and the applicable Molina billing and claims policies and procedures, pursuant to the Health Care Authority's ("HCA") rates set forth below. By execution of this Agreement, Provider agrees to accept the rate(s) listed below as payment in full for these services and shall not balance bill the Members for Authorized Covered Services. 1. Reimbursement Rate and Agreements: 1.1 Covered Services shall be paid at 100% of the prevailing local and geographically adjusted State of Washington Medicaid Fee -For -Service Program fee schedule in effect on the date of service. 1.2 This Agreement only covers reimbursement for Covered Reentry Initiative Services. The term "Covered Reentry Initiative Services" refers to Reentry services, as defined by HCA that Heath Plan has authorized and determined are appropriate for the Member. 1.3 Provider shall promptly submit to Health Plan claims ("Claims") for Covered Services rendered to Members. All Claims shall be submitted in a form acceptable to and approved by Health Plan and shall include any and all medical records pertaining to the Claim if requested by Health Plan or otherwise required by Health Plan's policies and procedures. Claims must be submitted by Provider to Health Plan within three hundred sixty-five (365) days of providing the Covered Services that are the subject of the claim. Except as otherwise provided by law or provided by government sponsored program requirements, any Claims that are not submitted by Provider to Health Plan within the timelines stated above shall not be eligible for payment, and Provider hereby waives any right to payment, therefore. MHWCFSCA.062025 Revised June 2025 (MHW) Page 1 of 12 1.4 Claims for Authorized Covered Services will be subject to a review for correct coding. This review includes coding rules outlined in the appropriate Molina Healthcare provider manual ("Provider Manual"), HCA and Centers for Medicare and Medicaid Services ("CMS") guidelines including but not limited to the National Correct Coding Initiative. Claims are also subject to post -claim coding review and audits by Health Plan for coding, fraud, waste and abuse other payment integrity concerns. Provider agrees to provide information and otherwise cooperate in reviews and/or audits by Health Plan, the Health Care Authority, or any other government agency. 1.5 Services must be prior authorized by Molina Healthcare in order to be considered Covered Benefits. Provider must obtain prior authorization for all Members. Health Plan may also conduct concurrent or retrospective reviews at its sole discretion. 1.6 Provider agrees to abide by the terms of Attachment A. Molina Healthcare is not permitted to cover the services if Provider does not agree to this term. 1.7 Provider agrees to cooperate with Molina Healthcare's medical director and utilization review staff by providing information when requested for prior, concurrent and/or retrospective review of patient care, discharge planning, and coordination of needed services. 1.8 If a Member's coverage with Molina Healthcare ends, the specific terms in this Agreement will terminate for that Member on that day as well. 1.9 Claims shall be submitted to Molina Healthcare as directed by HCA: i. At the following address: Molina Healthcare of Washington, Inc., PO Box 22612 Long Beach, CA 90801; or ii. EDI Submission Number: 38336 1.10 Claims and will be subject to terms in Attachment A. 2. Other Terms and Conditions: 2.1 Standards for Provision of Care. a. Provision of Covered Services. Provider shall provide Covered Services to Members, within the scope of Provider's business and practice, in accordance with this Agreement, Health Plan's policies and procedures, the terms and conditions of the Health Plan Product which covers the Member, and the requirements of any applicable government. sponsored program. b. Standard of Care. Provider shall provide Covered Services to Members at a level of care and competence that equals or exceeds the generally accepted and professionally recognized standard of practice at the time of treatment, all applicable rules and/or standards of professional conduct, and any controlling governmental licensing requirements. c. Facilities, Equipment, and Personnel. Provider's facilities, equipment, personnel and administrative services shall be at a level and quality as necessary to perform Provider's duties and responsibilities under this Agreement and to meet all applicable legal requirements, including the accessibility requirements of the Americans with Disabilities Act. d. Member Eligibility Verification. Provider shall verify eligibility of Members for coverage by Health Plan under the Apple Health Medicaid program prior to rendering services. 2.2 Compliance with Applicable Law. Provider shall comply with all applicable state and federal laws ("Laws") governing the delivery of Covered Services to Members or other aspects of its operations including, but not limited to ACA Section 1557m Title VI of the Civil Rights Act of 1964; ; the Age Discrimination Act of 1975; the Section 504 of the Rehabilitation Act of 1973; the Balanced Budget Act of 1997; the Americans with Disabilities Act, and Federal Drug and Alcohol Confidentiality Laws in 42 CFR Part 2, and the EPSDT requirements of the Medicaid Act at 42 U.S.C. § 1396a(a)(43) and 1396d(r). MHWCFSCA.062025 Revised June 2025 (MHW) Page 2 of 12 2.3 Recordkeeping. a. Confidentiality of Member Health Information. Provider shall comply with all Laws, Health Plan's policies and procedures, and government sponsored program requirements regarding privacy and confidentiality of Members' health information and medical records, including mental health records. Provider shall not disclose or use Member names, addresses, social security numbers, identities, other personal information, treatment modalities, or medical records without obtaining appropriate authorization to do so. This provision shall not affect or limit Provider's obligation to make available medical records, encounter data and information concerning Member care to Health Plan, any authorized state or federal agency, or other Providers of health care upon authorized referral. b. HIPAA. To the extent Provider is considered a covered entity under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), Provider shall comply with all provisions of HIPAA including, but not limited to, provisions addressing privacy, security, and confidentiality. c. Delivery of Patient Care Information. Provider shall promptly deliver to Health Plan, upon request and/or as may be required by Laws, Health Plan's policies and procedures, applicable government sponsored health programs, Health Plan's contracts with the government agencies or third party payers, any information, statistical data, encounter data, or patient treatment information pertaining to Members served by Provider, including but not limited to, any and all information requested by Health Plan in conjunction with utilization review and management, grievances, peer review, HEDIS Studies, Health Plan's quality improvement program, Consumer Assessment of Health Plans ("CAHPS"), or Claims payment. Health Plan will not pay copying fees when records are requested for any of the above listed programs. Provider shall further provide direct access to said patient care information as requested by Health Plan and/or as required by any governmental agency or any appropriate state and federal authority having jurisdiction over Health Plan. d. Member Access to Health Information. Provider shall give Health Plan and Members access to Members' health information including, but not limited to, medical records and billing records, in accordance with Laws, applicable government sponsored health programs, and Health Plan's policies and procedures. 2.4 Program Participation. a. Participation in Grievance Program. Provider shall participate in Health Plan's Member grievance program and shall cooperate with Health Plan in identifying, processing, and promptly resolving all Member complaints, grievances, or inquiries. b. Provider Manual. Provider will follow the terms set forth in Health Plan's Provider Manual, which may be amended from time to time at Health Plan's sole discretion. Provider shall comply and render Covered Services in accordance with the contents, instructions and procedures set forth in Health Plan's Provider Manual and any additional operating procedures and policies for Providers which are communicated to Provider in writing by Health Plan. Provider acknowledges it received Health Plan's Provider Manual. c. Government Contracts. Provider acknowledges that Health Plan has entered into contracts with state and federal agencies for the arrangement of health care services for Members through government sponsored programs. Provider shall comply with any term or condition of those government sponsored program contracts that are applicable to the services to be performed under this Agreement. d. Supplemental Materials. Health Plan may periodically issue bulletins or other written materials in order to supplement the Provider Manual or to give additional instruction, guidance, or information ("Supplemental Materials"). Health Plan may issue Supplemental Materials in an electronic format, which includes, but is not limited to, posting on Health Plan's interactive web -portal, with a physical copy available upon request. Supplemental Materials become binding upon Provider as of MHWCFSCA.062025 Revised June 2025 (MHW) Page 3 of 12 the Effective Date indicated on the Supplemental Materials or, if applicable, the Effective Date will be determined in accordance with this Agreement. 2.5 Licensure and Standing. a. Licensure. Provider warrants and represents that it is appropriately licensed to render health care services within the scope of Provider's practice, including having and maintaining a current narcotics number, where appropriate, issued by all proper authorities. Provider shall provide evidence of licensure to Health Plan upon request. Provider shall maintain its licensure in good standing, free of disciplinary action, and in unrestricted status throughout the term of this Agreement. Provider shall immediately notify Health Plan of any change in Provider's licensure status, including any disciplinary action taken or proposed by any licensing agency responsible for oversight of Provider. b. Unrestricted Status. Provider represents to its best knowledge, information, and belief, neither it, nor any of its owners, employees, temporary employees, volunteers, consultants, members of its board of directors, officers, or contractors (collectively, "Personnel") have been excluded from participation in the Medicare Program, any state, commonwealth or the District of Columbia's Medicaid Program, or any other federal health care program (collectively "Federal Health Care Program"). Provider agrees that it must check the Department of Health and Human Services Office of Inspector General List of Excluded Individuals and Entities, the System for Award Management, any other list maintained by a state, commonwealth, or federal government and every state, commonwealth, and the District of Columbia's Medicaid exclusion lists to determine whether Provider or any of its Personnel have been excluded from participation in any Federal Health Care Program. These databases must be checked for any new Personnel and thereafter not less than monthly. Provider will notify Health Plan immediately in writing if Provider determines that Provider or any of its Personnel are suspended or excluded, or could be suspended or excluded, from any Federal Health Care Program. Provider agrees that it is subject to 2 CFR Part 376 and will require its Personnel to agree that they are subject to 2 CFR Part 376. If a governmental agency imposes a penalty, sanction, or other monetary adjustment or withhold due to Provider's non- compliance with this provision or any payments were made to Provider while under non- compliance with this provision, Health Plan may collect the amount by: (i) offsetting from amounts due to Provider; or (ii) issuing a recoupment letter to Provider. If required, such offset or recoupment will be done in a manner that is compliant with Laws and Government Program Requirements. This section will survive any termination. c. Malpractice and Other Actions. Provider shall give immediate notice to Health Plan of: (a) any malpractice claim asserted against it by a Member, any payment made by or on behalf of Provider in settlement or compromise of such a claim, or any payment made by or on behalf of Provider pursuant to a judgment rendered upon such a claim; (b) any criminal investigations or proceedings against Provider; (c) any convictions of Provider for crimes involving moral turpitude or felonies; and (d) any civil claim asserted against Provider that may jeopardize Provider's financial soundness. 2.6 Member Hold Harmless. a. Provider hereby agrees that in no event, including, but not limited to nonpayment by Health Plan, Health Plan's insolvency, or breach of this contract will Provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a Member or person acting on their behalf, other than Health Plan, for services provided pursuant to this Agreement. This provision does not prohibit collection of deductibles, copayments, coinsurance, and/or payment for noncovered services, which have not otherwise been paid by a primary or secondary issuer in accordance with regulatory standards for coordination of benefits, from Members in accordance with the terms of the Member's health plan. 2.7 Offset. In the event that Health Plan determines that a Claim has been overpaid or paid in duplicate, or that funds were paid which were not provided for under this Agreement, Health Plan may make a MHWCFSCA.062025 Revised June 2025 (MHW) Page 4 of 12 written request for repayment: (1) within twenty-four (24) months after the date that the payment was made; (2) within thirty (30) months after the date that the payment was made if the request is related to coordination of benefits with another carrier or entity responsible for payment of the Claim; or (3) at any time, if required by law or if a third party is found responsible for satisfaction of the Claim as a consequence of liability imposed by law and Health Plan is unable to recover directly from the third party because the third party has either already paid or will pay Provider the health care services covered by the Claim. Provider may contest Health Plan's request in writing by participating in the Claims dispute process as outlined in Section 2.8.Overpayment and duplicate payment disputes must be submitted in writing within thirty (30) days of receipt of request. If it is decided that Health Plan will recover the contested payment, such refund maybe recovered by any means permitted by this Agreement or by law, or by way of offset or recoupment from current or future amounts due Provider after six (6) months have passed from the date Health Plan received Provider's written notice contesting the repayment. In addition to any other contractual or legal remedy, if Provider fails to contest Health's Plan's request for a refund in writing within thirty (30) days of receipt of the request or if Provider contested the request and six (6) months has passed from the date Provider received Health Plan's refund request, Health Plan may recover the amounts owed by way of offset or recoupment from current or future amounts due Provider. As a material condition to Health Plan's obligations under this Agreement, Provider agrees that the offset and recoupment rights set forth herein shall be deemed to be and to constitute rights of offset and recoupment authorized in state and federal law or in equity to the maximum extent legally permissible, and that such rights shall not be subject to any requirement of prior or other approval from any court or other governmental authority that may now or hereafter have jurisdiction over Health Plan and/or Provider. Nothing in this section prohibits Provider from choosing at any time to refund to Health Plan any payment previously made by Health Plan to satisfy a Claim either by way of repayment by Provider or a request that Health Plan offset or recoup the money from current or future amounts due Provider. 2.8 Claims Dispute Process. In the event that Provider determines that a Claim has been improperly denied or underpaid, Provider may make a written request for payment ("Provider Claims Dispute"): (1) within twenty-four (24) months after the date the Claim was denied or payment intended to satisfy the Claim was made; (2) within thirty (30) months after the date the Claim was deniedor payment intended to satisfy the Claim was made if the request is related to coordination of benefits with another carrier or entity responsible for payment of the Claim. Provider may not request that payment be made any sooner than six (6) months after Health Plan's receipt of the request. A Provider Claims Dispute submission shall comply with the Provider Dispute Resolution Process stated in the Provider Manual. Health Plan shall consider and make a decision on each Provider Dispute based on the procedures which are described in the Provider Manual. If a Provider is dissatisfied with the result of a Provider Dispute, it may file a request for Non -Binding Mediation as provided in Section 2.18.c, below. 2.9 Term. This Agreement shall have a one year term, commencing on the date this Agreement is fully executed. Health Plan and Provider agree to meet and confer in good faith to enter into a standard provider agreement to succeed the term of this Agreement. 2.10 Termination without Cause. This Agreement may be terminated without cause by either party on at least ninety (90) days written notice to the other party. 2.11 Termination with Cause. In the event of a breach of any material provision of this Agreement, the party claiming the breach will give the other party written notice of termination setting forth the facts underlying its claim(s) that the other party has breached the Agreement. The party receiving the notice of termination shall have thirty (30) days from the date of receipt of such notice to remedy or cure the claimed breach to the satisfaction of the other party. During this thirty (30) day period, the parties agree to meet as reasonably necessary and to confer in good faith in an attempt to resolve the claimed breach. If the party receiving the notice of termination has not remedied or cured the breach within such thirty (30) day period, the party who provided the notice of termination shall have the right to immediately terminate this Agreement. MHWCFSCA.062025 Revised June 2025 (MHW) Page 5 of 12 2.12 Immediate Termination. Notwithstanding any other provision of this Agreement, Health Plan may immediately terminate this Agreement and transfer Member(s) to another provider by giving notice to Provider in the event of any of the following: a. Provider's "license or certificate to render health care services is limited, suspended or revoked, or disciplinary proceedings are commenced against Provider by the state licensing authority; b. Health Plan determines that Provider's facility and/or equipment is insufficient to render Covered Services to Members; c. Provider is excluded from participation in Medicare and/or any state health care program t or otherwise is terminated as a provider by any state or federal health care program; d. Provider engages in fraud or deception, or knowingly permits fraud or deception by another in connection with Provider's obligations under this Agreement; or e. Health Plan determines that health care services are not being properly provided, or arranged for, and that such failure poses a threat to Members' health and safety. 2.13 Termination Notification to Members. Upon receipt of termination by either Health Plan or Provider, Health Plan will inform affected Members of such termination notice in accordance with the process set forth in the Provider Manual. Health Plan will make a good faith effort to ensure that such notice is provided at least thirty (30) days prior to the effective date of the termination or immediately for a termination for cause that results in less than thirty (30) days' notice to all Members. Members may then be required to select another provider contracted with Health Plan prior to the effective date of termination of this Agreement. 2.14 Indemnification. Each party shall indemnify and hold harmless the other party and its officers, directors, shareholders, employees, agents, and representatives from any and all liabilities, losses, damages, claims, and expenses of any kind, including costs and attorneys' fees, which result from the duties and obligations of the indemnifying party and/or its officers, directors, shareholders, employees, agents, and representatives under this Agreement. 2.15 Entire Agreement. This Agreement, together with Attachments, Exhibits, Amendments and incorporated documents or materials, contains the entire agreement between Health Plan and Provider relating to the rights granted and obligations imposed by this Agreement. Additionally, as to the Medicaid products offered by Health Plan, the contract between HCA and the Health Plan shall be the guiding and controlling document when interpreting the terms of this Agreement. Any prior agreements, promises, negotiations, or representations, either oral or written, relating to the subject matter of this Agreement are of no force or effect. 2.16 Amendments. a'. Regulatory Amendments. Health Plan may, without Provider's consent, immediately amend this Agreement to maintain consistency and/or compliance with any state or federal law, policy, directive, or government sponsored program requirement. b. Non -Regulatory Amendments. Notwithstanding the Regulatory Amendments section, Health Plan may otherwise amend this Agreement upon sixty (60) days prior written notice to Provider. If Provider does not deliver to Health Plan a written notice of rejection of the amendment within that sixty (60) day period, the amendment shall be deemed accepted by and shall be binding upon Provider. In the event that the amendment is considered a "material amendment" as defined in RCW 48.3 9.005, Provider shall have the right to rej ect the amendment and such rej ection will not affect the existing terms of the Agreement. 2.17 Assignment. Provider may not assign, transfer, subcontract or delegate, in whole or in part, any rights, duties, or obligations under this Agreement without the prior written consent of Health Plan. Subject to the foregoing, this Agreement is binding upon, and inures to the benefit of the Health Plan and Provider and their respective successors in interest and assigns. Neither the acquisition of Health Plan nor a change of its legal name shall be deemed an assignment. MHWCFSCA.062025 Revised June 2025 (MHW) Page 6 of 12 2.18 Dispute Resolution Process. a. Submission of Non -Claims Payment Related Disputes i. Provider shall submit any dispute (other than a dispute relating to Claims Payment, which are subject to Section 2.8 to Health Plan in writing within sixty (60) days of when the issue arises. ii. Provider shall submit such disputes to the attention of Health Plan's Provider Services Department. b. Health Plan Response to Non -Claims Payment Related Disputes Health Plan shall use best efforts to acknowledge by phone, e-mail or other writing, receipt of a dispute (other than a dispute relating to Claims, which are subject to Section 2.8 within seven (7) business days. ii. Health Plan's decision regarding disputes shall be communicated within sixty (60) days of Health Plan's receipt of Provider's written correspondence requesting review. If additional time is required, Health Plan shall communicate this information to Provider within sixty (60) days. iii. Health Plan shall use its best efforts to investigate and resolve disputes within sixty (60) days of Health Plan's receipt of Provider's written correspondence. c. Nonbinding Mediation. If Provider is dissatisfied with Health Plan's final resolution of a dispute or if Health Plan fails to grant or reject Provider's request for review of a dispute within thirty (30) days after it is received, Provider may submit the dispute to nonbinding mediation pursuant to RCW Title 7, Chapter 7.07. Nonbinding mediation shall not be utilized to adjudicate matters that primarily involve review of Provider's professional competence or professional conduct and shall not be available as a mechanism for appeal of any determinations made as to such matters. d. Nonbinding Arbitration. Health Plan and Provider agree, as a condition precedent to the commencement of any civil action in any court of competent jurisdiction, to submit to arbitration all disputes arising from or related to this Agreement and the rendition of services to Members pursuant to this Agreement which are not otherwise resolved pursuant to the processes set forth at Sections 2.8 or 2.18; provided, however, that arbitration shall not be utilized to adjudicate matters that primarily involve review of Provider's professional competence or professional conduct, and shall not be available as a mechanism for appeal of any determinations made as to such matters. Arbitration shall proceed according to the rules and regulations of JAMS Optional Arbitration Appeal Procedure, then in effect, and shall be conducted in King County, Washington. The arbitrator shall have no authority to award damages or provide a remedy that would not be available to such prevailing party in a court of law. Nor shall the arbitrator have the authority to award punitive damages. The parties recognize that the arbitrator's decision is not binding and that either party may seek judicial remedies following the arbitration of a dispute. The panel of arbitrators shall be selected as follows: one arbitrator shall be designated by Health Plan; one arbitrator shall be designated by Provider; and the third arbitrator shall be selected by the arbitrators designated by Provider and Health Plan. Health Plan and Provider shall divide and share equally the cost of the arbitrator. Each party shall be responsible for its own attorneys' fees and costs. MHWCFSCA.062025 Revised June 2025 (MHW) Page 7 of 12 In consideration of the promises, covenants, and warranties stated, the Parties agree as set forth in this Agreement. The Authorized Representative acknowledges, warrants, and represents that the Authorized Representative has the authority and authorization to act on behalf of its party. The Authorized Representative further acknowledges he/she received and reviewed this Agreement in its entirety. The Authorized Representative for each party executes this Agreement with the intent to bind the Parties in accordance with this Agreement. County of Grant dba Grant County Sheriffs Office Molina Healthcare of Washington, Inc. 0 Its: Date: 0 Dhyan Lal Its: VP, Network Management & Ops Date: MHWCFSCA.062025 Revised June 2025 (MHW) Page 8 of 12 ATTACHMENT A REQUIRED PROVISIONS This attachment sets forth applicable State Laws or other provisions necessary to reflect compliance with State Laws. This attachment will be automatically modified to conform to subsequent changes to Law. All provisions of the Agreement not specifically modified by this attachment remain unchanged and will control. In the event of a conflict between this attachment and any other provision in the Agreement, the provisions in this attachment will control. Capitalized terms used in this attachment will have the same meaning ascribed to them in the Agreement unless otherwise set forth in this attachment. Any purported modification or any provision in this attachment that is inconsistent with Law will not be effective and will be interpreted in a manner that is consistent with the applicable Law. For the avoidance of doubt, this attachment does not apply to the Medicare Product or the Medicare -Medicaid Product to the extent such Products are preempted by Federal Law. 1. Provider hereby agrees that in no event, including, but not limited to nonpayment by Health Plan, Health Plan's insolvency, or breach of this Agreement shall Provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a Member or person acting on their behalf, other than Health Plan, for services provided pursuant to this Agreement. This provision shall not prohibit collection of deductibles, co -payments, coinsurance, and/or noncovered services, which have not otherwise been paid by a primary or secondary carrier in accordance with regulatory standards for coordination of benefits, from Members in accordance with the terms of the Member's health program. 2. Provider agrees, in the event of Health Plan's insolvency, to continue to provide the services promised in this Agreement to Members of Health Plan for the duration of the period for which premiums on behalf of the Member were paid to Health Plan or until the Member's discharge from inpatient facilities, whichever time is greater. 3. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be construed to modify the rights and benefits contained in the Member's health program. 4. Provider may not bill the Member for Covered Services (except for deductibles, co -payments, or coinsurance) where Health Plan denies payments because Provider has failed to comply with the terms or conditions of this Agreement. 5. Provider further agrees (i) that the provisions of (1), (2), (3), and (4) of this Attachment shall survive termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of Members, and (ii) that this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and Members or persons acting on their behalf. 6. If Provider contracts with other providers or facilities who agree to provide Covered Services to Members of Health Plan with the expectation of receiving payment directly or indirectly from Health Plan, such providers or facilities must agree to abide by the provisions of (1), (2), (3), (4), (5), (7), (11) and (12) of this Attachment. 7. Willfully collecting or attempting to collect an amount from a Member knowing that collection to be in violation of this Agreement constitutes a class C. felony under RCW 48.80.030 (5) & (6). 8. Health Plan will provide Provider not less than sixty (60) days' notice of changes that affect Provider's compensation and that affect health care service delivery unless changes to federal or state law or regulations make such advance notice impossible, in which case notice shall be provided as soon as possible. Subject to any termination and continuity of care provisions of the contract, Provider may terminate the contract without penalty if the Provider does not agree with the changes. No change to this Agreement may be made retroactive without the express consent of Provider. 9. Health Plan does not preclude or discourage Provider from informing Members of the care they require, including various treatment options, and whether in their view such care is consistent with medical necessity, medical appropriateness, or otherwise covered by the patient's service agreement with Health MHWCFSCA.062025 Revised June 2025 (MHW) Page 9 of 12 Plan. Health Plan will not prohibit, discourage, or penalize Provider if otherwise practicing in compliance with the law from advocating on behalf of a Member with Health Plan. Members are free to contract at any time to obtain any health care services outside their Health Plan on any terms or conditions the Members choose. Nothing in this section shall be construed to authorize Provider to bind Health Plan to pay for any service. 10. Health Plan does not preclude or discourage Member or those paying for their coverage from discussing the comparative merits of different health carriers with Provider. This prohibition specifically includes prohibiting or limiting Providers participating in those discussions even if critical of a Health Plan. 11. Provider will make health records available to appropriate state and federal authorities involved in assessing the quality of care or investigating complaints, grievances, appeals or review of any adverse benefit determinations of Members subject to applicable state and federal laws related to the confidentiality of medical or health records. Provider is required to cooperate with audit reviews of encounter data in relation to the administration of Health Plan risk adjustment and reinsurance programs. 12. Provider shall furnish Covered Services to Members without regard to the Member's enrollment in Health Plan as a private purchaser of the plan or as a participant in publicly financed programs of health care services. This requirement does not apply to circumstances when Provider should not render services due to limitations arising from lack of training, experience, skill, or licensing restrictions. 13. Provider may, in good faith, report to state or federal authorities any act or practice by Health Plan that jeopardizes Member health or welfare or that may violate state or federal law. 14. Terms and Conditions of Payment a. For Covered Services provided to Members, Health Plan shall pay Provider, and Provider shall pay any of its subcontractors, as soon as practical but subject to the following minimum standards including any applicable federal regulations (i.e. 42 CFR 422.520(b)): i. Ninety-five (95%) percent of the monthly volume of Clean Claims shall be paid within thirty (30) days of receipt by Health Plan or Health Plan's agent; ii. Ninety-five percent (95%) of the monthly volume of all Claims shall be paid or denied within sixty (60) days of receipt by Health Plan or Health Plan's agent; iii. Ninety-nine percent (99%) of the monthly volume of Clean Claims shall be paid within ninety (90) calendar days of receipt, except as agreed to in writing by the parties on a Claim -by -Claim basis. b. A Claim is a bill for services, a line item of service or all services for one Member within a bill. c. The date of receipt of a Claim is the date Health Plan or Health Plan's agent receives either written or electronic notice of the Claim. d. The date of payment is the date of the check or other form of payment. e. Health Plan shall establish a reasonable method for confirming receipt of Claims and responding to Provider inquiries about Claims. f. For those State products/programs covered by the Washington Administrative Code (WAC), failure of Health Plan to abide by the timely Claims payment standards delineated in WAC 284-170-431(2) shall result in a requirement to pay interest on undenied and unpaid Clean Claims more than sixty-one days old until Health Plan meets the standards under that subsection. Interest shall be assessed at the rate of one percent per month and shall be calculated monthly as simple interest prorated for any portion of a month. Health Plan shall add the interest payable to the amount of the unpaid claim without the necessity of Provider submitting an additional claim. g. When Health Plan issues payment in Provider's name and the Member's name, Health Plan shall make Claim checks payable in the name of the Provider first and the Member second. MHWCFSCA.062025 Revised June 2025 (MHW) Page 10 of 12 h. These standards do not apply to Claims about which there is substantial evidence of fraud or misrepresentation by Providers, facilities or Members, or instances where Health Plan has not been granted reasonable access to information under Provider's control. Health Plan and Provider are not required to comply with these terms and conditions of payment if the failure to comply is occasioned by any act of God, bankruptcy, act of a governmental authority responding to an act of God or other emergency, or the result of a strike, lockout, or other labor dispute. 15. Notwithstanding any other provision of this Agreement, Provider is not required to grant Health Plan access to health information and other similar records unrelated to Members. This provision shall not limit Health Plan's right to ask for and receive information relating to the ability of Provider or facility to deliver health care services that meet the accepted standards of medical care prevalent in the community. 16. Notwithstanding any other provision of this Agreement, any access Provider must grant Health Plan to medical records for audit purposes must be limited to only that necessary to perform the audit. 17. Provider maintains a reciprocal right to audit Health Plan's denials of Provider's Claims when Health Plan audits Provider's Claims. 18. In the event Provider participates in Health Plan's Medicare Programs, the following provisions shall apply: a. Provider shall make all of its "Relevant Records" available for inspection, examination and copying by all federal and state agencies with regulatory authority over the subject matter of this Agreement. Provider shall permit such inspection at Provider's place of business and at all reasonable times. "Relevant Records" shall mean all books and records of Provider related directly or indirectly to the goods and services furnished under the terms of this Agreement. Provider shall maintain such Relevant Records for the period of time required by applicable federal and state statutes, but in no event less than ten (10) years. This provision shall survive termination of the Agreement. (42 CFR 422.504(e)(2), 422.504(e)(3), 422.504(e)(4), and 422.504(i)(2)(ii)). b. Provider shall comply with the confidentiality and enrollee record accuracy requirements set forth in 42 CFR 422.118. (42 CFR 422.504(a)(13)). c. Provider agrees that under no circumstance shall a subscriber or enrollee in Health Plan's Medicare Programs be liable to the Provider for any sums owed by Health Plan to Provider. (42 CFR 422.504(g)(1)(i) and 42 CFR 422.504(i)(3)(i)). d. If Provider is delegated any of the activities or functions of Health Plan as required in its contract with CMS, Provider agrees to comply with all applicable contractual provisions in the same manner as if Provider had executed such contract with CMS directly. The activities or functions delegated to Provider are set forth in the Agreement. In the event CMS or Health Plan determines, in its sole discretion, that Provider has not performed the delegated activities or functions satisfactorily, the delegated activities shall be revoked upon not less than five (5) days prior written notice. The performance of such delegated activities shall be monitored by Health Plan on an ongoing basis, and Provider shall cooperate with all reasonable requests made by Health Plan in order to accomplish such monitoring. If Provider is delegated credentialing activities, Provider's credentialing process will be reviewed and approved by Health Plan, and such credentialing process will be audited by Health Plan on an ongoing basis; further, Provider agrees that its credentialing process will comply with all applicable NCQA standards. (42 CFR 422.504(i)(3)(iii) and 422.504(i)(4)). e. Provider agrees that any services it performs will be consistent with and comply with Health Plan's contractual obligations with CMS. (42 CFR 422.504(i)(1) and 422.504(i)(3)(iii)). £ In the event of termination of this Agreement or Health Plan's insolvency, Provider agrees to comply with the continuation of benefits provisions included in the Provider Manual. (42 CFR 422.504(g)(2)). MHWCFSCA.062025 Revised June 2025 (MHW) Page 11 of 12 19. Upon termination of this Agreement without cause, Provider will continue to render Covered Services to Members until the earliest of the following: (1) the date Covered Services being rendered to Member by Provider are completed or medically appropriate provisions have been made by Health Plan for another provider to assume responsibility for providing such Covered Services; or (2) sixty (60) days following notice to the Member of Provider's contract termination. The provision of such Covered Services and the reimbursement to Provider for such Covered Services shall be subject to all applicable terms of this Agreement on the same basis as Covered Services provided during the term of this Agreement. 20. Provider will satisfy and be in compliance with all of the requirements in WAC 284-170-421(5). 21. Provider will ensure that all of its subcontractors will satisfy and be incompliance with all of the requirements in WAC 284-170-421(5). 22. Telemedicine Services. i. Pursuant to RCW 48.43.735(8) and its implementing regulations, if Provider intends to bill a Member or Health Plan for an audio -only telemedicine service, Provider must obtain Member consent for the billing in advance of service being delivered. ii. Beginning January 1, 2023, Provider must have an established relationship with the Member to be eligible for reimbursement for audio -only telemedicine (RCW 48.43.735). iii. "Established Relationship" means the provider providing audio -only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and: (i) For health care services included in the essential health benefits category of mental health and substance use disorder services, including behavioral health treatment: (A) The covered person has had, within the past three years, at least one in -person appointment, or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio -only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48� or 48.46 RCW as the provider providing audio - only telemedicine; or (B) The covered person was referred to the provider providing audio -only telemedicine by another provider who has had, within the past three years, at least one in -person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio -only telemedicine; (ii) For any other health care service: (A) The covered person has had, within the past two years, at least one in -person appointment, or, until January 1, 2024, at least one real-time interactive appointment using both audio and video technology, with the provider providing audio -only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48� or 48.4+6 RCW as the provider providing audio -only telemedicine; or (B) The covered person was referred to the provider providing audio -only telemedicine by another provider who has had, within the past two years, at least one in -person appointment, or, until January 1, 2024, at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio -only telemedicine; 23. Drug Utilization Review. Health Plan maintains documented drug utilization management criteria to align with RCW 48.43.420 and WAC 284-43-2020(2) and can be found on Health Plan's website, https://www.molinamarketplace.com/marketplace/wa/en-us/Providers/Dl-u -.List. MHWCFSCA.062025 Revised June 2025 (MHW) Page 12 of 12