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Agreements/Contracts - Sheriff & Jail
GRANT COUNTY COMMISSIONERS AGENDA MEETING REQUEST FORM (Must be submitted to the Clerk of the Board by 12:00pm on Thursday) REQUESTING DEPARTMENT: Sheriffs Office REQUEST SUBMITTED BY: Phillip C. Coats CONTACT PERSON ATTENDING ROUNDTABLE: Phillip C. Coats CONFIDENTIAL INFORMATION: ❑YES ®NO DATE: 04/17/26 PHONE:2021 DAgreement / Contract ❑AP Vouchers ❑Appointment / Reappointment ❑ARPA Related ❑ Bids / RFPs / Quotes Award ❑ Bid Opening Scheduled ❑ Boards / Committees ❑ Budget El Computer Related ❑County Code ❑Emergency Purchase El Employee Rel. ❑ Facilities Related ❑ Financial ❑ Funds ❑ Hearing ❑Invoices / Purchase Orders ❑Grants — Fed/State/County ❑Leases ❑MOA / MOU El 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 Phillip Coats is requesting to sign the contract with United Health Care in order to secure this medical group as a participant in the Health Care Authority 1115 Waiver. This agreement will allow us to bill for medical services provided inside the jail clinic. If necessary, was this document reviewed by accounting? ❑ YES 0 NO ❑ N/A If necessary, was this document reviewed by legal? M YES ❑ NO ❑ N/A DATE OF ACTION: � 2� APPROVE: DENIED ABSTAIN D1: 6 D2: DEFERRED OR CONTINUED TO: WITHDRAWN: 4/23/24 Medical Group Contract - Grant County SO Date: 0 U N 7 v. zo, 0 ca: Uj SEA co o,...• • �= ._ VIA x§ NGTO)Vk ATTEST: Caitlin E. kk5'n'ell Clerk of the Board APPROV A -10 FORM: 7, V7 T, or R. Bevi6r, WSBA #47989 rant County Prosecutor's Office Civil Deputy Prosecuting Attorney Date: BOARD OF COUNTY COMMISSIONERS GRANT COUNTY, WASHINGTON Kevin R. Burgod'ss, Chair �x�c�.S{� Rob Jones, Vice -Chair Cindy Carthr, Member INTRODUCTION Our agreement consists of this contract, the appendices, and the additional materials we reference in the attached Appendix 1. Guiding principles We strive to operate in accordance with the following principles: • We want to work together with America's best physicians to improve the health care experience of our customers. ■ We respect and support the physician/patient relationship while adhering fairly to the contract for benefits we provide our customers. ■ Whether a particular treatment is covered under a benefit contract should not determine if the treatment is provided. Physicians and health care professionals should provide the care they believe is necessary regardless of coverage. • You should discuss treatment options with patients regardless of coverage. We encourage that communication. ■ Physicians should describe any factors that could affect their ability to render appropriate care. Matters such as professional training, financial incentives, availability constraints, religious or philosophical beliefs, and similar matters are all things that a physician should consider discussing with a patient. We encourage these communications. We urge full disclosure. ■ Fairness and efficiency ficiency will govern the ways in which we administer our products. We will make our determinations promptly. Our commitments to our customers will be clear. We will honor our agreements. When it comes to coverage determinations, the language of the benefit contract will take precedence. Next steps Please read this agreement. If you have questions, write to or call: UnitedHealthcare Attn: Network Market VP MN103 6022 Blue Circle Drive Minnetonka, MN 55343 (866) 574-6088 You can visit our website at www.unitedhealthcareonline.com (UnitedHealthcare Online°) for additional details on items described in the agreement. If the agreement is acceptable to you, please sign both of the enclosed copies of the contract, and send both copies to the address above. UHC1SMGA.02.24.WA_Grant Parties bound to confidentiality under Section'About data and confidentiality' -1- MEDICAL GROUP CONTRACT This agreement is entered into by and between UnitedHealthcare Insurance Company, UnitedHealthcare of Washington, Inc., and PacifiCare Life and Health Insurance Company ("Carrier", "we", Ccour(s)", "us") contracting on behalf of itself individually and you for certain products and services we offer our customers, all of which we describe in the attached Appendix 2. This agreement applies to you and to your professional staff (the physicians and other professionals who are your employees, or your independent contractors providing services to your patients, and who are subject to credentialing by us) and the services you provide at the locations in the attached Appendix 4. When this agreement refers to "you", it also refers to your professional staff. Your professional staff is bound to the same requirements of this agreement as you are. You represent to us that you have the authority to bind your professional staff to this agreement. With your signature, you confirm you understand the contract, the appendices, and the items referenced in Appendix 1. UnitedHealthcare Insurance Company Medical Group: Grant County Address: Address: 35 C St Nw Ephrata WA, 98823 Attn: Network Market VP MN103 6022 Blue Circle Drive Minnetonka, MN 55343 {Outreach Blame} Signature: Signature: Print Print Name: Name: Title: Title: Date: Date: PacifiCare Life and Health Insurance Company Medical Group: Grant County Address: Address: 35 C St Nw Ephrata WA, 98823 Attn: Network Market VP MN103 6022 Blue Circle Drive Minnetonka., MN 55343 Signature: Signature: Print Print Name: Name: Title: Title: Date: Date: UHC1SMGA.02.24.WA,.-Grant Parties bound to confidentiality under Section 'About data and confidentiality' -2- UnitedHealthcare of Washington, Inc. Address: Attn: Network Market VP MN103 6022 Blue Circle Drive Minnetonka, MN 55343 Signature: Print Name: Title: Date: Medical Group: Grant County Address: 35 C St Nw Ephrata WA, 98823 Signature: Print Name: Title: Date: For office use only: Deal Number: 83342695 Month, day and year in which agreement is first effective: What you will do You need to be credentialed in accordance with our Credentialing Plan, as referenced in Appendix 1, for the duration of this agreement. You must notify us in a timely manner about certain services you provide in accordance with our Administrative Guide so that we can provide our customers with the services we have committed to provide. If you do not so notify us about these services, you will not be reimbursed for the services, and you may not charge our customer. Within one year of the effective date of this agreement, you must conduct business with us entirely on an electronic basis to the extent that we are able to conduct business electronically (described in the Administrative Guide), including but not limited to determining whether your patient is currently a customer, verifying the customer's benefit, and submitting your claim. We will communicate enhancements in UnitedHealthcare Online® functionality as they become available and will make information available to you as to which products are supported by UnitedHealthcare Online. You must submit your claims within 90 days of the date of service. After we receive your claim, if we request additional information in order to process your claim, you must submit this additional information within 90 days of our request. If your claim or the additional information is not submitted within these timeframes, you will not be reimbursed for the services, and you may not charge our customer. You will submit claims only for services performed by you or your staff. Pass through billing is not payable under this agreement and may not be billed to our customer. For laboratory services, you will only be reimbursed for the services that you are certified through the Clinical Laboratory Improvement Amendments (CLIA) to perform, and you must not bill our customers for laboratory services for which you are not certified. You will submit claims that supply all applicable information. These claims are complete claims. Further information about complete claims is provided in our Administrative Guide. UHC1SMGA.02.24.WA_Grant Parties bound to confidentiality under Section'About data and confidentiality' -3- If you disagree with our payment determination on a claim, you may submit an appeal as described in our Administrative Guide. You will not charge our customers anything for the services you provide, if those services are covered services under their benefit contract, but the applicable co -pay, coinsurance or deductible amount. If the services you provide are denied or otherwise not paid due to your failure to notify us, to file a timely claim, to submit a complete claim, to respond to our request for information, or based on our reimbursement policies and methodologies, you may not charge our customer. If the services you provide are denied for reason of not being medically necessary, you may not charge our customer unless our customer has, with knowledge of our determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. If the services you provide are not covered under our customer's benefit contract, you may, of course, bill our customer directly. You will not require a customer to pay a "membership fee" or other fee in order to access you for covered services (except for co -payments, coinsurance and/or deductibles provided for under the customer's benefit contract) and will not discriminate against any customer based on the failure to pay such a fee. You will cooperate with our reasonable requests to provide information that we need. We may need this information to perform our obligations under this agreement, under our programs and agreements with our customers, or as required by regulatory or accreditation agencies. You will refer customers only to other network physicians and providers, except as permitted under our customer's benefit contract, or as otherwise authorized by us or the participating entity. What we will do We or the other applicable participating entity will promptly adjudicate and pay your complete claim for services covered by our customer's benefit contract. If you submit claims that are not complete, ■ You may be asked for additional information so that your claim may be adjudicated; or • Your claim may be denied and you will be notified of the denial and the reason for it; or ■ We may in our discretion attempt to complete the claim and have it paid by us or the other applicable participating entity based on the information that you gave in addition to the information we have. If governing law requires us to pay interest or another penalty for a failure to pay your complete claim for covered services within a certain time frame, we will follow those requirements. The interest or other penalty required by law will be the only additional obligation for not satisfying in a timely manner a payment obligation to you. In addition, if we completed a claim of yours that was not complete, there shall be no interest or other late payment obligation to you even if we subsequently adjust the payment amount based on additional information that you provide. The applicable participating entity will reimburse you for the services you deliver that our customer's benefit contract covers. The amount you receive will be based on the lesser of your billed charges or our fee schedule, which is described at Appendix 1 and is subject to the reimbursement (coding) policies and methodologies of us and the participating entities. Our reimbursement policies and methodologies are updated periodically and will be made available to you online or upon request. To request a copy of our reimbursement policies and methodologies, write to UnitedHealthcare, Attn: Network Market VP MN1031 6022 Blue Circle Drive, Minnetonka, MN 55343. Your reimbursement is also subject to our rules concerning retroactive eligibility, subrogation and coordination of benefits (as described in the Administrative Guide). We recognize CPT reporting guidelines as developed by the American Medical Association, as well as ICD diagnostic codes and hospital -based revenue codes. Following these guidelines does not imply a right to reimbursement for all services as coded or reported. UHC1SMGA.02.24.WA_Grant Parties bound to confidentiality under Section 'About data and confidentiality' -4- Ordinarily, fee amounts listed in the Payment Appendix(ices) are based upon primary fee sources. We reserve the right to use gap -fill fee sources where primary fee sources are not available. We routinely update our fee schedule in response to additions, deletions and changes to CPT codes by the American Medical Association, price changes for immunizations and. injectable medications, and in response to similar changes (additions and revisions) to other service coding and reporting conventions that are widely used in the health care industry, such as those maintained by the Centers for Medicare and Medicaid Services (for example, HCPCS). Ordinarily, our fee schedule is updated using similar methodologies for similar services. We will not generally attempt to communicate routine maintenance of this nature and will generally implement updates within 90 days from the date of publication. We will give you 90 days written or electronic notice of non -routine fee schedule changes which will substantially alter the overall methodology or reimbursement level of the fee schedule. In the event such changes will reduce your overall reimbursement under this Agreement, you may terminate this Agreement by giving 60 days written notice to us, provided that the notice is given by you within 60 days after the notice of the fee schedule change. If either of us believes that a claim has not been paid correctly, either of us may seek correction of the payment within a 12-month period following the date the claim was paid, except that overpayments as a result of abusive or fraudulent billing practices may be pursued by us beyond the 12-month time frame mentioned above. In the event of an overpayment, we will correct these errors by adjusting future claim payment and/or by billing you for the amount of the overpayment. Your professional staff and practice locations You represent to us that all of the members of your professional staff, as of the date you executed this agreement, are listed in Appendix 3. All of the members of your professional staff will participate in our network through this agreement, except in cases in which one of your professional staff is not accepted for participation or is removed from participation under our credentialing program, or removed from participation by us immediately due to that professional being sanctioned by any governmental agency or authority (including Medicare or Medicaid), or having lost a license to provide all or some of the professional services under this agreement, or no longer having hospital admitting privileges in any participating hospital. Your professional staff will cooperate with our credentialing program. If a new professional joins your professional staff, you will give us 60 days notice and provide the information included in Appendix 3. You will assure that the new professional will promptly submit a credentialing application to us (unless the new professional is already credentialed with us) and cooperate with our credentialing program. You will assure that a member of your professional staff who has not been approved or is not in good standing under our credentialing program will not provide covered services to our customers. In the event that professional does provide covered services, you will not bill us, our customer, or anyone acting on our customer's behalf for the service, and you will assure that the professional also does not bill for the service. If a professional leaves your professional staff, you will notify us within ten business days after you become aware that the professional will leave. The notice will include the date that the professional will depart from your professional staff. If you know the future contact information for the professional and whether the professional will continue to practice after leaving your professional staff, you will make reasonable commercial efforts to include that information in the notice and will provide that information to us if we request it. UHC/SMGA.02.24.WA—Grant Parties bound to confidentiality under Section 'About data and confidentiality' -5- This agreement applies to your practice locations identified in Appendix 4. If you begin providing services at other locations (either by opening such locations yourself, or by acquiring, merging or coming under common ownership and control with an existing provider of services that was not already under contract with us or a company under common ownership to participate in a network of health care providers), those additional locations will become subject to this agreement 30 days after we receive notice from you. If you acquire or are acquired by, merged with, or otherwise become affiliated with another provider of health care services that is already under contract with us or a company under common ownership to participate in a network of health care providers, this agreement and the other agreement will each remain in effect and will continue to apply as they did prior to the acquisition, merger or affiliation, unless otherwise agreed to in writing by all parties to those agreements. If you decide to transf er some or all of your assets to another entity, and the result of the transfer would be that all or some 'of the services subject to this agreement would be rendered by the other entity rather than by you, you must first request that we approve an assignment of this agreement as it relates to those services and the other entity must agree to assume this agreement. How long our agreement lasts; how it gets amended; and how it can en Assuming you are credentialed by us, and we execute this agreement, you will receive a copy from us with the effective date noted below the signature block. It continues until one of us terminates it. We can amend this agreement or any of the appendices on 90 days' written or electronic notice by sending you a copy of the amendment. Your signature is not required to make the amendment effective. However, if you do not wish to continue your participation with our network as changed by an amendment that is not required by law or regulation but that includes a material adverse change to this agreement, then you may terminate this agreement on 60 days' written notice to us so long as you send this termination notice within 30 days of your receipt of the amendment. In addition, this agreement has an initial term of 3 years, and it will automatically renew after the initial term for renewal terms of one year each. Either you or we can terminate this agreement, effective at the end of the initial term or effective at the end of any renewal term, by providing at least 90 days' prior written notice. Either you or we can terminate this agreement at any time if the other party has materially breached this agreement, by providing 60 days' written notice, except that if the breach is cured before our agreement ends, the agreement will continue. Either of us can immediately terminate this agreement if the other becomes insolvent or has bankruptcy proceedings initiated. Finally, we can immediately terminate this agreement if any governmental agency or authority (including Medicare or Medicaid) sanctions you. We both agree that termination notices under this agreement must be sent by certified mail, return receipt requested, to UnitedHealthcare, Attn: Network Market VP MN103, 6022 Blue Circle Drive, Minnetonka, MN 55343, or to the post office address you provided us. We both will treat termination notices as "received" on the third business day after they are sent. About data and confidentiality We agree that your medical records do not belong to us. You agree the information contained in the claims you submit is ours. We both will protect the confidentiality of our customers' information in accordance with applicable state and federal laws, rules, and regulations. UHC/SMGA.02.24.WA_Grant Parties bound to confidentiality under Section 'About data and confidentiality' -6- We are both prohibited from disclosing to third parties any fee schedule or rate information. There are three exceptions: ■ You can disclose to our customer information relating to our payment methodology for a service the customer is considering (e.g., global fee, fee for service), but not specific rates (unless for purposes of benefit administration). ■ We and the participating entities may use this information to administer our customers' benefit contracts and to pay your claims. We also may permit access to information by auditors and other consultants who need the information to perform their duties, subject to a confidentiality agreement. We both may produce this information in response to a court order, subpoena or regulatory requirement to do so, provided that we use reasonable efforts to seek to maintain confidential treatment for the information, or to a third party for an appropriate business purpose, provided that the disclosure is pursuant to a confidentiality agreement and the recipient of the disclosure is not a competitor of either of us. What if we do not agree We will resolve all disputes between us by following the dispute procedures set out in our Administrative Guide. If either of us wishes to pursue the dispute beyond those procedures, they will submit the dispute to binding arbitration in accordance with the Commercial Dispute Procedures of the American Arbitration Association (see http://www.adr.ory,) within one year. We both expressly intend that any dispute between us be resolved on an individual basis so that no other dispute with any third party(ies) may be consolidated or joined with our dispute. We both agree that any arbitration ruling by an arbitrator allowing class action arbitration or requiring consolidated arbitration involving any third party(ies) would be contrary to our intent and would require immediate judicial review of such ruling. The arbitrator will not vary the terms of this agreement and will be bound by governing law. We both acknowledge that this agreement involves interstate commerce, and is governed by the Federal Arbitration Act, 9 U.S.C. § 1 et seq. The arbitrator will not have the authority to award punitive or exemplary damages against either of us, except in connection with a statutory claim that explicitly provides for such relief. Arbitration will be conducted in King County, WA. If a court allows any litigation of a dispute to go forward, we both waive rights to a trial by jury with respect to that litigation, and the judge will be the finder of fact. Any provision of this agreement that is invalid or unenforceable shall not affect the validity or enforceability of the remaining provisions of this agreement or the validity or enforceability of the offending provision in any other situation or in any other jurisdiction. This section. of the agreement shall survive and govern any termination of this agreement. What is our relationship to one another You are an independent contractor. This means we do not have an employer -employee, principal -agent, partnership, joint venture, or similar arrangement. It also means that you make independent health care treatment decisions. We do not. We do not reserve any right to control those treatment decisions. It further means that each of us is responsible for the costs, damages, claims, and liabilities that result from our own acts. You will look to the applicable participating entity for reimbursement for the products and services under our agreement. This means that we are not financially responsible for claims payment for groups that are self -funded or that are not under common ownership with us. UHC/SMGA.02.24.WA_Grant Parties bound to confidentiality under Section 'About data and confidentiality' -7- We may assign this agreement to any entity that is under common ownership with us at the time of the assignment. This is it This contract, the appendices and the items referenced in the attached Appendix 1, constitute our entire understanding. It replaces any other agreements or understandings with regard to the same subject matter — oral or written — that you have with us. Federal law and the applicable law of the jurisdiction where you provide health care services govern our agreement. Such laws and the rules and regulations promulgated under them, when they are applicable, control and supersede our agreement. In the event of any inconsistent or contrary language between the Regulatory Appendix (when it applies) and any other part of our agreement, including but not limited to appendices, amendments and exhibits, the Regulatory Appendix will control. UHCISMGA. 02.24. WA —Grant Parties bound to confidentiality under Section 'About data and confidentiality' -8- Appendix 1 We include as part of our agreement the following additional materials that bind you and us: Appendix 2 Definitions, Products and Services. This appendix sets forth definitions for our "customer" and "participating entities" as well as lists the type of benefit contracts offered to our customers. Payment Fee Information Documents Include: Fee Specifications Document, Fee Appendix(ices) Schedule Sample, and Additional Information About Your Fee Schedule. Further information about the fee schedule (such as additional fee samples) can be requested by writing to UnitedHealthcare, Market VP MN101-D003., 9700 Healthcare Lane, Minnetonka, MN 55343. Appendix 3 This document provides information about the members of your professional staff. Appendix 4 This document provides information about your practice locations. State In some instances, states add requirements to our agreement that are set forth in Regulatory this appendix. Requirements Appendix Medicare (This appendix applies only if you are in our Medicare network.) Regulatory Your participation in our network for customers with Medicare benefit Requirements contracts is subject to additional Medicare requirements set forth in this Appendix appendix. Medicaid (This appendix applies only if you are in our Medicaid network.) Regulatory Your participation in our network for customers with Medicaid benefit Requirements contracts is subject to additional Medicaid requirements set forth in this Appendix appendix. Administrative We have enclosed a copy of our Administrative Guide. This guide is available Guide to you to review prior to contracting and governs the mechanics of our relationship. Our Administrative Guide may be viewed by going to www.unitedhealthcareonline.com. Unless a longer period is required as set out in any Regulatory Requirements Appendix to this agreement or by applicable law, we may make changes to the Administrative Guide upon 30 days electronic or written notice to you. For services rendered to customers enrolled in certain benefit contracts that may be included under this agreement, you will be subject to additional requirements described in or made available to you through one or more additional provider manuals ("Additional Manuals"). When the agreement refers to the Administrative Guide, it is also referring to the Additional Manuals. The Additional Manuals will be made available to you on a designated website or upon request. In the event of any conflict between this Medical Group Contract or the "UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide" or other UnitedHealthcare administrative protocols and payment policies, and any Additional Manual, in connection with any matter pertaining to customers UHCISMGA. 02.24. WA —Grant Parties bound to confidentiality under Section 'About data and confidentiality' -9- enrolled in the benefit contracts to which the Additional Manual applies, that Additional Manual will govern, unless applicable statutes and regulations dictate otherwise. Notwithstanding the prior sentence, in the event of a conflict between a provision of this agreement and a provision of an Additional Manual, this agreement will govern with regard to those benefit contracts regulated by Washington law to which that Additional Manual applies. We may make changes to the protocols and payment policies subject to this provision in accordance with the provisions of the agreement relating to protocol and payment policy changes. The benefit contracts or names of entities under common ownership with us, names of the Additional Manuals, and name of the website to view and download the Additional Manuals, when applicable, are set forth in the table below. We will notify you of any changes in the location of the Additional Manuals. You may request a copy of the Additional Manual. Type of Benefit Description of Website Contract Applicable Additional Manual No Additional Manuals Apply Credentialing To review our credentialing plan, visit www.unitedhealthcareonline.com. This Plan plan requires your professional staff to be covered by malpractice insurance in amounts with carriers and on terms and conditions that are customary for physicians like them in your community. To request access to, or a copy of, our credentialing plan, write to UnitedHealthcare, Market VP MN101-D003, 9700 Healthcare Lane, Minnetonka., MN 55343. UHCISMGA. 02.24. WA —Grant Parties bound to confidentiality under Section 'About data and confidentiality' -10- Appendix 2 Definitions,, Products and Services 1. Customer. Individuals who are enrolled in benefit contracts insured or administered by us or any participating entity are included in our use of the phrase "customer" in this agreement. 2. Participating entities. Participating entities have access to our agreement. A participating entity is an entity obligated to a customer to provide reimbursement for covered services under the customer's benefit contract and authorized by us to access your services under our agreement. 3. Products and services• a) We may include you in networks where your patients are enrolled in benefit contracts of the types generally described below: Washington Medicaid and CHIP Benefit Contracts. b) However, this agreement does not apply to the following: Capitation arrangements for Medicare Advantage Benefit Contracts. (See below for definition of capitation arrangements.) - Capitation arrangements other than for Medicare Advantage Benefit Contracts. (See below for definition of capitation arrangements.) - Unite dHealthcare Community Plan Medicare Advantage Benefit Contracts. - Workers' compensation benefit contracts. - Washington Other Governmental Benefit Contracts. - Benefit contracts for Medicare Select. - Medicaid and CHIP Benefit Contracts for states other than Washington. - TRICARE Benefit Contracts. - Unite dHealthcare Medicare Solutions Medicare Advantage Benefit Contracts. - I -SNP Medicare Advantage Benefit Contracts. - Washington Benefit Contracts for the Uninsured. - Benefit contracts where individuals are offered a network of participating physicians and other health care professionals and must select a primary care physician. Such benefit contracts may or may not include an out -of -network benefit. Benefit contracts where individuals are offered a network of participating physicians and other health care providers but are not required to select a primary care physician. Such benefit contract may or may not include and out -of -network benefit. Benefit contracts where individuals are not offered a network of participating physicians and other health care professionals from which they may receive covered services. This agreement does not supersede any existing agreements between the parties and their affiliates that are not identified above in section 3a of this Appendix. Additionally, this UHCISMGA. 02.24. WA —Grant Parties bound to confidentiality under Section 'About data and confidentiality' -11- agreement does not prevent the parties or their affiliates from entering into such agreements in the future. 4. Appendix 2 Definitions: Note- Certain benefit contracts defined below are defined with reference to specific identifiers on the customer identification card. Those benefit contracts may adopt a different identification card identifier in the future, and this Appendix will continue to apply to those benefit contracts; if that happens, we will provide you with information regarding the new customer identification cards. CAPITATION ARRANGEMENTS: A. Capitation arrangements are when all of the following apply: (i) You (directly or through an IPA or other provider organization, in which you participate) are part of a network for one of our affiliates; and (ii) As part of that network, you arrange directly with our affiliate, or an IPA, or another medical group or other 'provider organization, for certain designated services to be provided to members who are assigned to you or to the IPA or the other medical group or other provider organization (as the case may be) and who are covered under benefit contracts; and under which either: (a) You are capitated or otherwise have financial responsibility; or (b) You are paid on a fee for service basis directly by the IPA, other medical group or other provider organization that has financial responsibility for the service, at a rate you have agreed upon with the IPA or other medical group or other provider organization; and (iii) You provide those designated services to one of those assigned members. In such cases, the obligation for payment will be primarily that of the IPA, medical group or other provider organization that has financial responsibility for the service, and not ours or our affiliate's. It is not a capitation arrangement when: (1) Another medical group or an IPA or other provider organization is not affiliated with you, and is capitated by Carrier for designated covered services rendered to assigned customers covered by a benefit contract issued by Carrier; and (2) You provide those designated covered services to one of those assigned customers, without having a contract or other arrangement with the other medical group or the IPA or other provider organization for the terms under which those designated covered services are provided. In such cases, this agreement will apply and the medical group or IPA or other provider organization that has responsibility for the covered service will be considered the participating entity. COMMERCIAL: B. UnitedHealthcare Navigate Benefit Contracts means benefit contracts for which the customer selects or is assigned a primary care physician to manage the customer's health care needs and referrals to network specialists, and that are marketed under one of the following names: UHCISMGA. 02.24. WA —Grant Parties bound to confidentiality under Section 'About data and confidentiality' -12- - UnitedHealthcare Navigate; - UnitedHealthcare Navigate Balanced; - UnitedHealthcare Navigate Plus; - another name Carrier may develop in the future that also includes the word "Navigate". In the event Carrier discontinues using the brand name "Navigate" for this portfolio of benefit contracts at some time in the future and adopts a different name for these benefit contracts, Carrier will give written notice to you of that name change, and this definition will continue to apply to benefit contracts marketed under that new name in the same way as it previously did to benefit contracts marketed under names that included the word "Navigate". MEDICARE: C. Medicare Advantage Benefit Contracts means benefit contracts sponsored, issued or administered by a Medicare Advantage organization as part of: (i) the Medicare Advantage program under Title XVIII, Part C of the Social Security Act, or (ii) the Medicare Advantage program together with the Prescription Drug program under Title XVIII, Part C and Part D. respectively, of the Social Security Act, as those program names may change from time to time. D. I -SNP Medicare Advantage Benefit Contracts means UnitedHealthcare Medicare Solutions Medicare Advantage Benefit Contracts that (A) are specialized Medicare Advantage plans for special needs individuals (as that term is defined in 42 CFR 422.2) and (B) exclusively enroll special needs individuals who are institutionalized (as that term is defined in 42 CFR 422.2) as indicated by a reference to "Nursing Home" or "Nursing Care" on the face of the valid identification card of any customer eligible for and enrolled in those benefit contracts. E. UnitedHealthcare Medicare Solutions Medicare Advantage Benefit Contracts means Medicare Advantage Benefit Contracts that are offered through the UnitedHealthcare Medicare Solutions business unit. Those benefit contracts will include a reference to "Medicare Solutions" on the back of the valid identification card of any customer eligible for and enrolled in those benefit contracts. F. UnitedHealthcare Community Plan Medicare Advantage Benefit Contracts means Medicare Advantage Benefit Contracts offered through the UnitedHealthcare Community Plan business unit. Those Benefit Contracts will include a reference to "Medicare Community Plan." MEDICAID AND OTHER STATE PROGRAMS: G. Medicaid Benefit Contracts means benefit contracts that offer coverage to beneficiaries of a program authorized by Title XIX of the federal Social Security Act, and jointly financed by the federal and state governments and administered by the state. H. Children's Health Insurance Program ("CHIP") Benefit Contracts are benefit contracts under the program authorized by Title XXI of the federal Social Security Act that are jointly financed by the federal and state governments and administered by the state. I. Washington Medicaid and CHIP Benefit Contracts means Washington Medicaid Benefit Contracts and Washington CHIP Benefit Contracts that have references to UHC/SMGA.02.24.WA Grant Parties bound to confidentiality under Section'About data and confidentiality' -13- "UnitedHealthcare Community Plan" on the identification card of any customer eligible for and enrolled in that benefit contract. J. Washington Benefit Contracts for the Uninsured means benefit contracts that have a reference to "Basic Health" on the identification card of any customer eligible for and enrolled in that benefit contract. K. Other Governmental Benefit Contracts are benefit contracts that are funded wholly or substantially by a state or district government or a subdivision of a state (such as a city or county), but excluding benefit contracts for (1) employees of a state government or a subdivision of a state and their dependents, and (2) for students at a public university, college or school. However, Washington Medicaid Benefit Contracts, Washington CHIP Benefit Contracts and Washington Benefit Contracts for the Uninsured are not "Other Governmental Benefit Contracts." UHC/SMGA.02.24.WA—Grant Parties bound to confidentiality under Section'About data and confidentiality' -14- Appendix 3 Your Professional Staff Appendix 3 PHYSICIAN ROSTER UHCISMGA. 02.24. WA —Grant Parties bound to confidentiality under Section 'About data and confidentiality' -15- Appendix 4 Your Practice Locations Medical Group attests that this Appendix identifies all services and locations covered under this Agreement. 1WEIR-®r 0, _0-0, HIM F'sommom, in 0 F-"V;l WE 0, aw , W-0-1 I � wom - ffl-- wm� �, - W—M, Practice Name Grant County Street Address PO BOX 37 City EPHRATA State WA Tax ID Number (TIN) 916001319 National Provider ID (NPI) Zip 98823 1750268736 PRACTICE LOCATIONS (complete one for each service location) Primary Practice Location Address: Address: 35 C ST NW City: EPHRATA State: WA Zip: 98823 Tel #: (509) 754-2011 Fax #: (509) 754-6064 Billing Address: Address: PO BOX 37 City: EPHRATA State: WA Zip: 98823 Tel #: (509) 754-2011 Fax #: (509) 754-6064 Additional Service Location Address: Address: 35 C ST NW City: EPHRATA State: WA Zip: 98823 Tel #: (509) 754-2011 Fax #: (509) 754-6064 Billing Address: Address: PO BOX 37 City: EPHRATA State: WA Zip: 98823 Tel #: (509) 754-2011 Fax #: (509) 754-6064 Mailing Address: Address: City: State: Zip: Tel #: Fax #: UHC1SMGA.02.24.WA,.-Grant Parties bound to confidentiality under Section 'About data and confidentiality' -16- Payment Appendix Washington Medicaid and CHIP Applicability This Appendix applies to covered services rendered by you to customers covered under the following types of benefit contracts, as described in the agreement: Washington Medicaid and CHIP Benefit Contracts. SECTION 1 Payment for Covered Services 1.1 Payment. Your contract rates for covered services are 100% of the amounts as published in the Washington Medicaid fee schedule by the applicable state agency. This fee schedule is the "primary fee source" for contract rates. The actual payment amount is also subject to matters described in this agreement, such as the payment policies. For certain CPT codes, we may use a higher amount than the contract rate described above. If we do pay a higher amount, then at a future date we may revert to the contract rate described above. In these circumstances, we will not attempt to collect as overpayments amounts paid higher than the contract rate. In the event that a specific dollar amount is not published in a fee source, then the contract rate for covered services will be priced at 40% of eligible charges. Eligible charges are Customary Charges for covered services. If an applicable state or federal program is available to provide items or payment directly to you for specific covered services for customers subject to this Appendix that would otherwise be payable under this Appendix, the applicable program will apply and not this Appendix. (For example, the Vaccines For Children program currently provides vaccines free of charge, and therefore no amount will be payable under this Appendix for vaccines within the Vaccines For Children program. However, the administration of such vaccine is payable under this Appendix, because payment is not provided to professionals under the Vaccines For Children program for vaccine administration.) The contract rates established by this appendix are all-inclusive, including without limitation any applicable taxes, for all covered services provided to the customer. Unless specifically indicated otherwise, amounts listed in this fee schedule represent global fees and may be subject to reductions based on appropriate modifiers (for example, professional and technical modifiers). Any co -payment, deductible or coinsurance that the customer is responsible to pay under the customer's benefit contract will be subtracted from the listed amount in determining the amount to be paid by us. This information is subject to the confidentiality provisions of this agreement. 1.2 Routine Maintenance. We routinely update this fee schedule in response to changes published by the primary fee source, such as fee amount changes. We will use reasonable commercial efforts to implement the fee schedule changes in its systems within 90 days after final publication and make them effective in our system on the effective date of the change by the primary fee source. However, claims already processed prior to the change being implemented by us will not be reprocessed unless otherwise required by law. We also routinely update this fee schedule in response to coding changes as described in this agreement. When implementing coding updates, we will apply the same percentages as set forth above in section 1.1 and the then current value of the published code to determine the contract rate. We will use reasonable commercial efforts to implement such changes within 90 days from the date of publication. However, claims already processed prior to the change being implemented by us will not be reprocessed unless otherwise required by law. CS_SMGA PAYAPX WA03.13_GR_02_2026 Parties bound to confidentiality under Section 'About data and confidentiality' -17- 1.3 Medicaid Agency Payment Changes. If the Medicaid agency changes the manner in which it reimburses or changes the Medicaid primary fee source such that we are required to make significant programming or platform changes in order to implement the Medicaid agency changes, we will make commercially reasonable efforts to implement the Medicaid agency changes, within a reasonable time frame, from the date the change is published in the Medicaid agency's official correspondence to us or is otherwise formally communicated by the Medicaid agency to us. You agree that, in such case, you will accept the current payment as set forth in this Appendix, until such a time as we can implement the Medicaid agency change. At such time as we are able to implement the change, we will communicate the change and the effective date of the change via a copy of a new payment appendix. From that effective date forward, the contract rate will be calculated based on the new Medicaid agency payment. If we are unable, through commercially reasonable efforts, to incorporate the Medicaid agency payment changes in their entirety, we will so notify you within 90 days from the date the change is published in the Medicaid agency's official correspondence to us, or otherwise formally communicated by the Medicaid agency. The parties will then negotiate in good faith for a period of up to 90 days to amend the agreement to replace this Appendix with a new Appendix and stated effective date for the new contract rates. If the parties have not reached an agreement upon such art amendment within the aforementioned 90 day period, either party may terminate this Appendix upon 60 days prior written notice to the other party. CS_SMGA PAYAPX WA03.13_GR_02_2026 Parties bound to confidentiality under Section'About data and confidentiality' -18- Washington Regulatory Requirements Appendix In addition to our understandings in the agreement between you and us, there are certain additional items which Washington laws and regulations require us to include in our contract. This Washington Regulatory Requirements Appendix (the "Appendix") sets forth those items and is made part of the agreement between you and us. These requirements apply to products or services sponsored by participating entities or issued or administered by, or accessed through us to the extent they are regulated under Washington laws and for which Washington laws control. The requirements in this Appendix, however, do not apply to the extent they are preempted by the Medicare Modernization Act or other applicable law. We each agree to be bound by the terms and conditions contained in this appendix. In the event of a conflict or inconsistency between this appendix and any term or condition contained in the agreement between you and us, this appendix shall control except with regard to benefit contracts outside the scope of this appendix. For the purpose of this appendix, "enrollee," "enrolled participant," or "member" shall mean customers who are enrolled in products or services insured or administered by us or any participating entity. This appendix will be deemed to be updated to incorporate any changes to the laws and regulations referenced herein, including any changes to definitions referenced herein, effective as of the date of such changes. 1. The following provision is added as bullet -point number 7 and does not replace section "Guiding Principles" of the agreement: Communication. We each agree that nothing in this agreement in any way precludes or discourages you from informing patients 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 benefit contract with us. We shall not prohibit, discourage, or penalize you otherwise practicing in compliance with the law from advocating on behalf of a member. We do not preclude or discourage patients or those paying for their coverage from discussing the comparative merits of different health carriers with their providers, including you. This prohibition specifically includes prohibiting providers participating in those discussions even if critical of a carrier, including us. 2. The following provisions are added to the end of the section and do not replace section "What you will do" of the agreement: A. Enrolled Participant Protection Provision. You hereby agree that in no event, including, but not limited to nonpayment by us or a participating entity, or our insolvency or breach of this agreement, shall you bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against an enrolled participant or person acting on their behalf, other than us, for services provided pursuant to this agreement. This provision does not prohibit collection of copayments, coinsurance, deductibles and/or payment for non -covered services, which have not otherwise been paid by a primary or secondary carrier in accordance with regulatory standards for coordination of benefits, from enrolled participants in accordance with the terms of the enrolled participant's benefit contract. You agree, in the event of our or a participating entity's insolvency, to continue to provide the services promised in this agreement to enrolled participants for the duration of the period for which premiums on behalf of the enrolled participant were paid or until the enrolled participant's discharge from inpatient facilities, whichever time is greater. Notwithstanding any other provision of this agreement, nothing in this agreement shall be construed to modify the rights and benefits contained in the enrolled participant's benefit contract. You may not bill the enrolled participant for covered health services (except for copayments, coinsurance and/or deductibles) where we or a participating entity deny payments because you have failed to comply UHC/SMGA.REGAPX.09.24. YVA with the terms or conditions of this agreement. You further agree (a) that the provisions of this section shall survive termination of this agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the enrolled participants and (b) that this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between you and enrolled participants or persons acting on their behalf. If you contract with other health care providers who agree to provide covered health services to enrolled participants with the expectation of receiving payment directly or indirectly from us or a participating entity, such providers must also agree to abide by this section. B. Collection of Amounts from ]Enrollees. If you willfully collect or attempt to collect an amount from an enrollee knowing that collection to be in violation of this agreement, such collection or attempts to collect will constitute a class C felony under Washington Statutes. C. Continuation of Covered Health Services after Termination. In the event the agreement between you and us is terminated and in the event you are a primary care physician and you are rendering covered health services to enrolled participants, you agree to continue providing such covered health services pursuant to the terms and conditions of this addendum and this agreement (a) for at least sixty (60) days following termination; and (b) in the case of group benefit plans, until the end of the next open enrollment period. D. Subcontractors. You shall ensure that providers and facilities subcontracting with you comply with the applicable requirements set forth in this agreement and the Washington Administrative Code. E. Equal Treatment of Enrolled Participants. You and we each agree to treat all enrolled participants equally, regardless of whether the enrolled participant's enrollment is through a private purchaser or a publicly funded program such as Medicare or Medicaid. F. Audit of Billing Records. To the extent the agreement between you and us allows us the right to audit your billing records, you shall have the right to audit our denial of your claims under the same terms and conditions that the agreement sets forth for our audit of your billing records. G. Administrative Protocols, Policies and Programs. Pursuant to WAC § 284-170-421, we shall notify you of your responsibilities with respect to our applicable administrative protocols, policies and programs, including but not limited to payment terms, utilization management, quality assessment and improvement programs, credentialing, grievance, appeal and adverse benefit determination procedures, data reporting requirements, pharmacy benefit substitution process, confidentiality requirements and any applicable federal or state requirements. You shall comply with the Carrier's protocols, policies and programs. You hereby acknowledge that you have been given the opportunity prior to contracting to access the Carrier's Administrative Guide at no cost to you by way of Carrier's website or by hardcopy upon request to the Carrier. Therefore, you have had the opportunity to learn of your responsibilities under the Administrative Guide. The Administrative Guide describes, among other things, administrative and operational protocols and procedures, such as claims submission, and clinical submission requirements. Documents, protocols, procedures, and other administrative policies and programs referenced in the agreement between you and us shall be available for review by you prior to contracting and thereafter for changes, amendments, supplements and replacements. You must be given reasonable notice of not less than sixty days of changes that affect your 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 agreement between you and us, you may terminate that agreement without penalty if you do not agree with the changes. No change to that agreement may be made retroactive without your express written consent. UI ISMGA.REGARY 09.24. FVA H. Participating Entities. Participating entities as defined in paragraph 2 of Appendix 2 of the agreement have access to our agreement. I. Prescription Drug Exception Process. Our process to request exceptions to our drug utilization management process can be found at www.UHCProvider.com. J. Customer Consent for Telemedicine. Patient consent is required for telemedicine services prior to rendering such services. Failure to obtain consent could result in disciplinary action pursuant to RCW 48.43.735. In addition, audio only telemedicine services may only be billed when provided to established patients. "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) 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 48.44 or 48.46 RCW as the provider providing audio -only telemedicine; or (ii) 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. 3. The following provision replaces, in its entirety, paragraph 8 of section "What you will do" of the agreement: Denial of Claims for Not Following Protocols, Not Filing Timely, or Lack of Medical Necessity. You will not charge our customers anything for the services you provide, if those services are covered services under their benefit contract, but the applicable co -pay, coinsurance, payments for non -Covered Services or deductible amount. If the services you provide are denied or otherwise not paid, or an administrative sanction is imposed, due to your failure to notify us, to file a timely claim, to submit a complete claim, to respond to our request for information, or based on our reimbursement policies and methodologies, you may not charge our customer. If the services you provide are denied for reason of not being medically necessary, you may not charge our customer unless our customer has, with knowledge of our determination of a lack of medical necessity, agreed in writing to be responsible for payment of those charges. If the services you provide are not covered under our customer's benefit contract, you may, of course, bill our customer directly. You will not require a customer to pay a "membership fee" or other fee in order to access you for covered services (except for co -payments, coinsurance and/or deductibles provided for under the customer's benefit contract) and will not discriminate against any customer based on the failure to pay such a fee. 4. The following provisions are added to the end of the section and do not replace section "What we will do" of the agreement: A. Prompt Payment of Claims. For claims governed by Washington law, we or the participating entity, as applicable, shall pay or deny claims in accordance with the claims payment standards contained in WAC 284-170-431 which are set forth below. UHC/SMGA.REGAPX.09.24. TVA (a) (i) For covered health care services provided to enrolled participants, we or the participating entity shall pay you as soon as practical but subject to the following minimum standards: (A) Ninety-five percent of the monthly volume of clean claims shall be paid within thirty days of receipt by us or our agent; and (B) Ninety-five percent of the monthly volume of all claims shall be paid or denied within sixty days of receipt by us or our agent, except as agreed to in writing by the parties on a claim - by -claim basis. (ii) The receipt date of a claim is the date we or our agent receives either written or electronic notice of the claim. (iii) We shall establish a reasonable method for confirming receipt of claims and responding to your inquiries about claims. (iv) If we or the participating entity fails to pay claims within the standard established under subsection (a) of this section, we or the participating entity shall pay interest on undenied and unpaid clean claims more than sixty-one days old until the standard under subsection (a) of this section is met. 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. Interest shall be added payable to the amount of the unpaid claim without the necessity of you submitting an additional claim. Any interest paid under this section shall not be applied to an enrolled participant's deductible, copayment, coinsurance, or any similar obligation of the enrolled participant. (v) When payment is issued in both your name and the enrolled participant's name, claim checks shall be made payable in your name first and the enrolled participant second. (b) For purposes of this section, "clean claim" means a claim that has no defect or impropriety, including any lack of any required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payments from being made on the claim under this section. (c) Denial of a claim must be communicated to you and must include the specific reason why the claim was denied. If the denial is based upon medical necessity or similar grounds, then we, upon your request, must also promptly disclose the supporting basis for the decision. (d) We shall be responsible for ensuring that any person acting on our behalf or at our direction or acting pursuant to our standards or requirements complies with these billing and claim payment standards. (e) These standards do not apply to claims about which there is substantial evidence of fraud or misrepresentation by you or enrolled participants, or instances where we have not been granted reasonable access to information under your control. (f) You and we are not required to comply with this section 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. B. Payment of Claims Involving Coordination of Benefits. We or the participating entity shall not unreasonably delay payment of a claim by reason of the application of a coordination of benefits provision. Payment of a claim involving the application of a coordination of benefit provision shall be made 30 days after receipt of the claim. When payment of a claim is necessarily delayed for reasons other than the application of a coordination of benefits provision, investigation of other plan coverage shall be conducted concurrently, so as to create no fiirther delay in the ultimate payment of benefits. If we or the participating entity is required by the above stated time limit to make payment as the primary plan, and we or the UHC/SMGA. REGAPX. 09.24. YVA participating entity is not the primary plan, we or the participating entity may exercise its rights of recovery under the agreement between you and us to recover any excess payments made thereby. C. Enrolled Participants Contracting Outside the Health Care Plan. Notwithstanding any other provision of law, we, when subject to the jurisdiction of the state of Washington as a health carrier, may not prohibit, directly or indirectly, enrolled participants from freely contracting at any time to obtain any health care services outside the health care plan on any terms or conditions enrolled participant chooses. Nothing in this section shall be construed to bind us for any services delivered outside the health plan. D. Retrospective Denial. In the event we offer a health care plan that is governed by RCW 48.43.525 or WAC 284-43-2000(4), we will comply with the applicable retrospective claim denial requirements as set forth in RCW 48.43.525 and WAC 284-43-2000(4). E. Refunds and Additional Payment. Additionally, in the event we offer a health care plan that is governed by RCW 48.43, and only if you are a "health care provider" as that term is defined in RCW 48.43.005. (a) Our Requests for a Refund. Except in cases of fraud or as otherwise provided in this section and RCW 48.43.600, All requests for refunds must be made by us in writing within twenty-four (24) months after the date that the payment was made; (ii) Requests for refunds that relate to coordination of benefits must be made within thirty (30) months after the date that the payment was made; and (iii) We may not request a contested refund to be paid any sooner than six (6) months after receipt of the request. Requests for refunds must specify why we believe you owe the refund. Requests for a refund that involve coordination of benefits must include the name and mailing address of the entity that has primary responsibility for payment of the claim. If you do not contest the request in writing to us within thirty (30) days of its receipt, the request is deemed accepted and the refund must be paid. We may at any time request a refund from you of a payment previously made to satisfy a claim if: (A) a third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law, such as tort liability; and (B) we are unable to recover directly from the third party because the third party has either already paid or will pay you for the health services covered by the claim. (b) Your Requests for Additional Payment. Except in cases of fraud or as otherwise provided in this section and RCW 48.43.605, All requests by you for additional payment to satisfy a claim must be made in writing within twenty-four (24) months after the date that the claim was denied or initial payment intended to satisfy the claim was made; (ii) Requests for additional payments to satisfy claims that relate to coordination of benefits must be made within thirty (30) months after the date that the payment was made; and (iii) you may not request a contested refund to be paid any sooner than six (6) months after receipt of the request. Requests for additional payments must specify why you believe we or the participating entity owes the additional payment. Requests for additional payment that involve coordination of benefits must include the name and mailing address of the entity that has disclaimed responsibility for payment of the claim. 5. The following provisions are added to the end of the section and do not replace section "How long our agreement lasts; how it gets amended; and how it can end" of the agreement: A. Termination. We each agree to provide written notice to each other in the form and for the length of time as provided in the Agreement, but in no case less than sixty (60) days, before terminating the agreement between you and us and this appendix without cause. Pursuant to WAC 284-170-421, in the event the agreement is terminated for any reason, we or the participating entity must make a good faith effort to ensure written notice is provided no later than 30 calendar days prior to the effective date of the UHC/SMGA.REGAPX. 09.24. TVA termination, or immediately for a terminations for cause that results in less than thirty (30) calendar days' notice of termination to you, to members who (1) are seen by you as a primary care physician, (2) are seen on a regular basis by a specialist, or (3) have a standing referral to you. B. Minimum Notice Required for Amendments Subject to This Appendix. You must be given reasonable notice of not less than sixty days of material changes that affect compensation and 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. However, you may reject a material amendment as specifically defined in RCW 48.3 9.005 without terminating the Agreement. Your rejection of the material amendment will not affect the terms of the Agreement. Carrier will provide at least 30 days' notice of any other regulatory amendment, unless a shorter notice is necessary in order to accomplish compliance. 6. The following provisions are added to the end of the section and do not replace section "About data and confidentiality" of the agreement: A. Confidentiality. We each agree to comply with all applicable state and federal laws regarding the confidentiality of medical information relating to members. B. Access to ]Enrolled Participant Health Records. You shall be required to make enrolled participants' 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 from enrolled participants subject to applicable state and federal laws related to the confidentiality of medical or health records. You are required to cooperate with audit reviews of encounter data in relation to the administration of health plan risk adjustment and reinsurance programs. 7. The following provision replaces, in its entirety, the section "What if we do not agree" of the agreement: A. What if We Do Not Agree. We will work with you in good faith to resolve any and all disputes between us (hereinafter referred to as "Disputes") including but not limited to all questions of the existence, validity, scope or termination of the Agreement or any term thereof. If the Dispute pertains to a matter which is generally administered by our procedures, such as a credentialing or quality improvement plan, the policies and procedures set forth in that plan must be fully exhausted by you before you may invoke any rights to dispute resolution under this provision. If the parties are unable to resolve any such Dispute within 60 days following the date one party sent written notice of the Dispute to the other party, and if either party wishes to pursue the Dispute, it shall thereafter be submitted to nonbinding mediation in accordance with the Commercial Dispute Procedures of the American Arbitration Association, as they may be amended from time to time (see http://www.adr.org). Further, we shall provide reasonable means that allow you, if aggrieved by actions of ours, to be heard after you submit a written request to us. If we fail to grant or reject a request within thirty days after it has been made, you may proceed as if the complaint had been rejected; except that in the case of a billing dispute that has been timely -made by you, we shall render a decision within sixty days of receipt of your complaint. A complaint that has been rejected by us or any dispute we have with you relating to the terms of this Agreement may be submitted to nonbinding mediation. Any mediation proceeding under this Agreement shall be conducted in King County, WA. The mediator may construe or interpret but shall not vary or ignore the terms of this Agreement and shall be bound by UIIC/SMGA.REGARY O9.24. TVA controlling law. The parties acknowledge that because this Agreement affects interstate commerce the Federal Arbitration Act applies. If the parties are unable to resolve a Dispute through nonbinding mediation, and if either party wishes to pursue the Dispute, such party may commence litigation proceedings. In the event that any portion of this provision or any part of this Agreement is deemed to be unlawful, invalid or unenforceable, such unlawfulness, invalidity or unenforceability shall not serve to invalidate any other part of this provision or agreement. In the event a party wishes to terminate this agreement based on an assertion of uncured material breach, and the other party disputes whether grounds for such a termination exist, while such Dispute remains pending, the termination for breach will not take effect. This provision governs any dispute between the parties arising before or after execution of this agreement, and shall survive any termination of this agreement. 8. The following provision replaces, in its entirety, the section "Appendix 1" of the agreement: Appendix 1 We include as part of our agreement Appendix 2, Payment Appendix(ices), Appendix 3, Appendix 4, State Regulatory Requirements Appendix, Medicare Regulatory Requirements Appendix, and Medicaid Regulatory Requirements Appendix: Appendix 2 Definitions, Products and Services. This appendix sets forth definitions for our "customer" and "participating entities" as well as lists the type of benefit contracts offered to our customers. Payment Fee Information Documents Include: Fee Specifications Document, Fee Schedule Appendix(ices) Sample, and Additional Information About Your Fee Schedule. Further information about the fee schedule (such as additional fee samples) can be requested by writing to UnitedHealthcare, Market VP MN 101-1)003, 9700 Health Care Lane, Minnetonka, MN 55343. Appendix 3 Professional Staff: This document provides information about the members of your professional staff. Appendix 4 Locations. This document provides information about your office, billing, and mailing locations. Please remember that, as described on page 2, this agreement applies to all of your locations even if you do not list all of your current locations or if you add a location in the future. State In some instances, states add requirements to our agreement that are set forth in this Regulatory appendix. Requirements Appendix Medicare (This appendix applies only if you are in our Medicare network.) Regulatory Your participation in our network for customers with Medicare benefit Requirements contracts is subject to additional Medicare requirements set forth in this Appendix appendix. UHC/SMGA.REGAPX.09.24. YVA Medicaid (This appendix applies only if you are in our Medicaid network.) Regulatory your participation in our network for customers with Medicaid benefit contracts g y Requirements � is subject to additional Medicaid requirements set forth in this appendix. Appendix Administrative Additionally, we have provided access to our Administrative Guide and Guide Credentialing Plan. Our Administrative Guide may be viewed by going to www.uhcprovider.com. Unless a longer period is required as set out in any Regulatory Requirements Appendix to this agreement or by applicable law, we may make changes to the Administrative Guide upon 30 days electronic or written notice to you. For services rendered to customers enrolled in certain benefit contracts that may be included under this agreement, you will be subject to additional requirements described in or made available to you through one or more additional provider manuals ("Additional Manuals"). When the agreement refers to the Administrative Guide, it is also referring to the Additional Manuals. The Additional Manuals will be made available to you on a designated website or upon request. In the event of any conflict between the "UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide" or other UnitedHealthcare administrative protocols and payment policies, and any Additional Manual, in connection with any matter pertaining to customers enrolled in the benefit contracts to which the Additional Manual applies, that Additional Manual will govern, unless applicable statutes and regulations dictate otherwise. We may make changes to the protocols and payment policies sub j ect to this provision in accordance with the provisions of the agreement relating to protocol and payment policy changes. The benefit contracts or names of entities under common ownership with us, names of the Additional Manuals, and name of the website to view and download the Additional Manuals, when applicable, are set forth in the table below. We will notify you of any changes in the location of the Additional Manuals. You may request a copy of the Additional Manual. Applies? (y/N) Type of Benefit Contract Description of Applicable Additional Manual Website No Additional Manuals Apply Benefit contracts, other than UnitedHealthcare West Non- www.iihcprovider.com Medicaid, CHIP and Benefit Capitated Supplement to the Contracts for the Uninsured, UnitedHealthcare Physician, issued or administered by Health Care Professional, UnitedHealthcare of Facility and Ancillary Provider Washington, Inc. and Administrative Guide or PacifiCare Life and Health UnitedHealthcare West Insurance Company Ca itated Administrative Guide UHC/SMGA.REG APX.09.24. PVA Washington Medicaid, CHIP UnitedHealthcare Community www.uhccommunityplan.com and Benefit Contracts for the Plan Physician, Health Care Uninsured Professional, Facility and Ancillary Administrative Guide Credentialing To review our credentialing plan, visit www.uhcprovider.com Plan This plan requires you to carry malpractice insurance in amounts with carriers and on terms and conditions that are customary for physicians like you in your community. To request access to, or a copy of, our credentialing plan, write to UnitedHealthcare Credentialing Plan 2023-2025 (uhcprovider.com). UHC/SMGA.REGAPX. 09.24. YVA WASHINGTON STATE PROGRAMS REGULATORY REQUIREMENTS APPENDIX PROVIDER THIS WASHINGTON STATE PROGRAMS REGULATORY REQUIREMENTS APPENDIX (this "Appendix") supplements and is made part of the provider agreement (the "Agreement") between UnitedHealthcare of Washington, Inc. (referred to in this Appendix as "Carrier") and the party named in the Agreement ("Provider"). SECTION I APPLICABILITY The requirements of this Appendix apply to "State Program" (as defined below) benefit plans sponsored, issued or administered by Carrier, including the State's Apple Health and related programs, and Washington Benefit Plans for the Uninsured, as governed by the State's designated regulatory agencies. In the event of a conflict between this Appendix and other appendices or any provision of the Agreement, the provisions of this Appendix shall control except with regard to benefit plans outside the scope of this Appendix or unless otherwise required by law. In the event Carrier is required to amend or supplement this Appendix as required or requested by the State to comply with federal or State regulatory requirements, Provider agrees that Carrier shall be permitted to unilaterally initiate such additions, deletions or modifications. SECTION 2 DEFINITIONS Unless otherwise defined in this Appendix, all capitalized terms shall be as defined in the Agreement. For purposes of this Appendix, the following terms shall have the meanings set forth below; provided, however, in the event any definition set forth in this Appendix or the Agreement is inconsistent with any definitions under the applicable State Program, the definitions shall have the meaning set forth under the applicable State Program. 2.1 Administrative Functions): Any obligation of Carrier under a State Contract other than the direct provision of Covered Services to Covered Persons. Administrative Functions include, but are not limited to, utilization/medical management, claims processing, Covered Person grievances and appeals, and the provision of data or information necessary to fulfill any of Carrier's obligations under a State Contract. 2.2 Claim: A bill for services, a line item of service or all services for one Covered Person within a bill. 2.3 Clean Claim: A Claim that can be processed without obtaining additional information from the provider of the service or from a third party. 2.4 Covered Person: An individual who is currently enrolled with Carrier for the provision of services under a State Program. A Covered Person may also be referred to as an Enrollee, Member or Customer under the Agreement. UHC/STATE PROGRAMS REGAPX. WA. 02.25_GR 2026 2.5 Contracted Services: Covered Services that are to be provided under the terms of the State Contract. 2.6 Covered Services: Health care services that HCA determines are covered for Covered Persons, 2.7 HCA: Washington State Health Care Authority, any division, section, office, unit or other entity of HCA, or any of the officers or other officials lawfully representing HCA. 2.8 Primary Care Provider or PCP: A participating provider who has the responsibility for supervising, coordinating, and providing primary health care to Enrollees, initiating referrals for specialist care, and maintaining the continuity of Enrollee care. PCPs include, but are not limited to Pediatricians, Family Practitioners, General Practitioners, Internists, Naturopathic physicians, medical residents (under the supervision of a teaching physician), Physician Assistants (under the supervision of a physician), or Advanced Registered Nurse Practitioners (ARNP), as designated by the Contractor. The definition of PCP is inclusive of primary care physician as it is used in 42 C.F.R. § 43 8.2. All Federal requirements applicable to primary care physicians will also be applicable to primary care providers as the term is used in this Contract. 2.9 Provider: Any individual or entity engaged in the delivery of services, or ordering or referring for those services, and is legally authorized to do so by the State in which it delivers the services. 2.10 State: The State of Washington or its designated regulatory agencies. 2.11 State Contract: Carrier's contract with the HCA for the purpose of providing and paying for Covered Services to Covered Persons enrolled in one or more State Programs. 2.12 State Program(s): The State of Washington Apple Health, Apple Health for Kids, Integrated Managed Care or other similar program(s) where Carrier provides services to Washington residents through a contract with the State. For purposes of this Appendix, State Program may referto the State agency(ies) responsible for administering the applicable State Program. SECTION 3 PROVIDER REQUIREMENTS The State Programs, through contractual requirements and federal and State statutes and regulations, requires the Agreement to contain certain conditions that Carrier and Provider agree to undertake, which include the following: 3.1 Definitions Related to the Provision of Covered Services. Provider shall follow the State Contract's requirements for the provision of Covered Services. Provider's decisions affecting the delivery of acute or chronic care services to Covered Persons shall be made on an individualized basis and in accordance with the following definitions: i) Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: i) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; ii) serious impairment to bodily functions; or iii) serious dysfunction of any bodily organ or part. UHC/STATE PROGRAMS REGAPX. WA. 02.25 GR 2026 Emergency Services: Inpatient and outpatient contracted services furnished by a provider qualified to furnish the services needed to evaluate or stabilize an Emergency Medical Condition. iii) Medically Necessary or Medical Necessity: Services that are "Medically Necessary" as defined in WAC 182-500-0070. In addition, Medically Necessary services shall include services related to a Covered Person's ability to achieve age -appropriate growth and development. 3.2 Medicaid Eligibility. Provider must be enrolled with the State as a Medicaid or CHIP provider, as applicable to participate in Carrier's Medicaid or CHIP network. Upon notification from the State that Provider's enrollment has been denied or terminated, Carrier must terminate Provider immediately and will notify affected Covered Persons that Provider is no longer participating in the network. Carrier will exclude from its network any provider who is on the State's exclusion list or has been terminated or suspended from the Medicare, Medicaid or CHIP program in any state. 3.3 Primary Care Provider (PCP) Requirements. Providers who are PCPs shall comply with the PCP requirements of the State Contract, as set forth in the applicable provider manuals, protocols, policies and procedures that Carrier has provided or delivered to Provider. 3.4 .Accessibility Standards. Provider shall provide for timely access for Covered Person appointments in accordance with the appointment availability and wait time standard requirements established under the State Contract, as further described in the applicable provider manual. Provider also agrees to report accurately the information required for the Carrier's provider directory and any changes thereto. Carrier shall regularly monitor Provider's compliance with timely access and wait time standards and Provider shall implement appropriate corrective action in the event Provider fails to comply with the appointment wait time requirements under the State Contract. 3.5 Hours of Operation. Provider shall offer hours of operation that are no less than the hours of operation offered to commercial beneficiaries or comparable to Medicaid fee -for -service if Provider serves only Medicaid beneficiaries. As applicable, Provider will make Covered Services available 24 hours a day, 7 days a week when medically necessary. 3.6 Hold Harmless. Except for any applicable cost -sharing requirements under the State Contract, Provider shall accept payment from Carrier as payment in full and shall not request payment from the HCA or any Covered Person for Covered Services provided pursuant to the Agreement and the State Contract. Provider shall hold the State, HCA and its employees, the U.S. Department of Health and Human Services (DHHS) and Covered Persons harmless in the event that Carrier cannot or will not pay for such Covered Services. In accordance with 42 CFR Section 447.15, as may be amended from time to time, the Covered Person is not liable to Provider for any services for which Carrier is liable and as specified under the State's relevant health insurance or managed care statutes, rules or administrative agency guidance. Provider shall not require any copayment or cost sharing for Covered Services provided under the Agreement unless expressly permitted under the State Contract. Provider shall also be prohibited from charging Covered Persons for missed appointments if such practice is prohibited under the State Contract or applicable law. Neither the State, the HCA nor Covered Persons shall be in any manner liable for the debts and obligations of Carrier and Linder no circumstances shall Carrier, or any providers used to deliver services covered Linder the terms of the State Contract, charge Covered Persons for Covered Services. UHC/STATE PROGRAMS REGAPX. WA. 02.25_GR 2026 Pursuant to Washington Administrative Code (WAC) 182-502-0160, if the medical assistance services are not Covered Services, prior to providing the services, Provider shall inform the Covered Person of the non -covered service and have the Covered Person acknowledge the information. If the Covered Person still requests the service, Provider shall obtain such acknowledgment in writing prior to rendering the service and report to Carrier any instances where a Covered Person is charged for the types of services identified under WAC 182-502- 0160. Carrier will determine whether a Covered Person was charged for Covered Services inappropriately and may recover such payment as applicable. This provision shall survive any termination of the Agreement, including breach of the Agreement due to insolvency. 3.7 Indemnification. To the extent applicable to Provider in performance of the Agreement, Provider shall indemnify, defend and hold the HCA and its employees harmless from and against all injuries, deaths, losses, damages, claims, suits, liabilities, judgments., costs and expenses, including court costs and attorney fees, to the extent proximately caused by any negligent act or other intentional misconduct or omission of Provider, its agents, officers, employees or contractors arising from the Agreement. The HCA may waive this requirement for public entities if Provider is a state agency or sub -unit as defined by the State or a public health entity with statutory immunity. This clause shall survive the termination of the Agreement for any reason, including breach due to insolvency. 3.8 Provider Selection. To the extent applicable to Provider in performance of the Agreement, Provider shall comply with 42 CFR 43 8.214, as may be amended from time to time, which includes, but is not limited to the selection and retention of providers, credentialing and recredentialing requirements and nondiscrimination. If Carrier delegates credentialing to Provider, Carrier will provide monitoring and oversight and Provider shall ensure that all licensed medical professionals are credentialed in accordance with Carrier's and the State Contract's credentialing requirements. 3.9 Restrictions on Referrals. Provider shall not make inappropriate referrals for designated health services to health care entities with which Provider or a member of Provider's family has a financial relationship, pursuant to federal anti -kickback and physician self -referral laws that prohibit such referrals. 3.10 Subcontracts. Provider shall perform those services and reports to be provided as set forth in the Agreement, and may subcontract services only if permitted by Carrier in writing. If Provider subcontracts or delegates any functions of the Agreement, in accordance with the terms of the Agreement, the subcontract or delegation must be in writing and include all of the requirements of this Appendix, applicable requirements of the State Contract and applicable laws and regulations. Provider further agrees to promptly amend its agreements with such subcontractors, in the manner requested by Carrier, to meet any additional State Program requirements that may apply to the services. UHUSTATE PROGRAMS REGAPX. WA. 02.25 GR 2026 3.11 Records Retention. As required under State or federal law or the State Contract, Provider shall maintain an adequate record keeping system for recording services, charges, dates and all other commonly accepted information elements for services rendered pursuant to the State Contract. All financial records shall follow generally accepted accounting principles. Medical records and supporting management systems shall include all pertinent information related to the medical management of each Covered Person. Other records shall be maintained as necessary to clearly reflect all actions taken by Provider related to services provided under the State Contract. Provider shall retain all records, including but not limited to grievance and appeal records and any other records related to data, information, and documentations for a period of not less than 10 years from the close of the Agreement, or such other period as required by law. If records are under review or audit, they must be retained for a minimum of 10 years following resolution of such action. Prior approval for the disposition of records must be requested and approved by Carrier if the Agreement is continuous. 3.12 Records Access. Provider acknowledges and agrees that the State, the U.S. Department of Health and Human Services and other authorized federal and state personnel shall have complete access to all records pertaining to services provided to Covered Persons. Provider shall provide immediate access to facilities, records and supportive materials pertinent to the State Contract for State or Federal fraud investigators. 3.13 Government Audit; Investigations. Provider acknowledges and agrees that the State and the U.S. Department of Health and Human Services or their authorized representatives shall have the right to inspect or otherwise evaluate the quality, appropriateness, and timeliness of services provided under the terms of the State Contract and any other applicable rules. There shall be no restrictions on the right of the State or federal government to conduct whatever inspections and audits are necessary to assure quality, appropriateness or timeliness of services provided pursuant to the State Contract and the reasonableness of their costs. Moreover, Provider agrees to permit the State, including HCA, MFCD and state auditor, and federal agencies, including but not limited to: CMS, Government Accountability Office, Office of the Inspector General, Office of Management and Budget, the Office of the Inspector General, the Comptroller General, and their designees, to access, inspect and audit any records or documents of Provider, and shall permit inspection of the premises, physical facilities, and equipment where Medicaid -related activities or work is conducted, at any time. Provider shall forthwith produce all records, documents, or other data requested as part of such inspection, review, audit, investigation, monitoring or evaluation. If the requesting agency asks for copies of records, documents, or other data, Provider shall make copies of records and shall deliver them to the requester, within 30 calendar days of request, or any shorter timeframe as authorized by law or court order. Copies of records and documents shall be made at no cost to the requesting agency. (42 C.F.R. § 455.21(a)(2); 42 C.F.R. § 431.107(b)(2)). The right for the parties named above to audit, access and inspect under this Provision exists for 10 years from the final date of the contract period or from the date of completion of any audit, whichever is later, or any other timeframe authorized by law. 3.14 Privacy; Confidentiality. Provider understands that the use and disclosure of information concerning Covered Persons is restricted to purposes directly connected with the administration of the State Program and shall maintain the confidentiality of Covered Person's information and records as required by the State Contract and in federal and State law including, but not limited to, all applicable privacy, security and Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), Public Law 104-191, and associated implementing regulations, including but not limited to 45 CFR Parts 160, 162, 164, as applicable and as may be amended from time to time, and shall safeguard information about UHC/STATE PROGRAMS REGAPX. W,4. 02.25_GR 2026 Covered Persons in accordance with applicable federal and State privacy laws and rules including but not limited to 42 CFR §438.224, 42 CFR Part 2, and 42 CFR Part 431, Subpart F; 42 CFR Part 434 and 42 CFR 438.6 (if applicable), as may be amended from time to time. Access to member identifying information shall be limited by Provider to persons or agencies that require the information in order to perform their duties in accordance with this Agreement, including the U.S. Department of Health and Human Services (HHS), the HCA and other individuals or entities as may be required. (See 42 CFR §431.300, et seq. and 45 CFR Parts 160 and 164.) Any other party shall be granted access to confidential information only after complying with the requirements of state and federal laws, including but not limited to HIPAA, and regulations pertaining to such access. Provider is responsible for knowing and understanding the confidentiality laws listed above as well as any other applicable laws. Nothing herein shall prohibit the disclosure of information in summary, statistical or other form that does not identify particular individuals, provided that de- identification of protected health information is performed in compliance with the HIPAA Privacy Rule. Federal and State Medicaid regulations, and some other f e d e r a 1 and State laws and regulations, including but not limited to those listed above, are often more stringent than the HIPAA regulations. Provider shall notify Carrier and the HCA of any breach of confidential information related to Covered Persons within the time period required by applicable federal and State laws and regulations following actual knowledge of a breach, including any use or disclosure of confidential information, any breach of unsecured PHI, and any Security Incident (as defined in HIPAA regulations) and provide Carrier and the HCA with an investigation report within the time period required by applicable federal and State laws and regulations following the discovery. Provider shall work with Carrier and the HCA to ensure that the breach has been mitigated and reporting requirements, if any, complied with. 3.15 Compliance with Law. Provider shall comply with all applicable federal and State laws and regulations, including but not limited to the following to the extent applicable to Provider in performance of the Agreement: i) Title XIX and Title XXI of the Social Security Act; ii) Title VI of the Civil Rights Act of 1964; iii) Title IX of the Education Amendments of 1972, regarding any education programs and activities; iv) The Age Discrimination Act of 1975; v) The Rehabilitation Act of 1973; vi) The Budget Deficit Reduction Act of 2005; vii) Individuals with Disabilities Education Act (IDEA) of 1975, with respect to early intervention services; viii) The False Claims Act; ix) The Health Insurance Portability and Accountability Act (HIPAA); x) The American Recovery and Reinvestment Act (ARRA); xi) The Patient Protection and Affordable Care Act (PPACA or ACA); xii) The Health Care and Education Reconciliation Act; xiii) Chapter 70.02 RCW and the Washington State Patient Bill of Rights, including, but not limited to, the administrative and financial responsibility for independent reviews; xiv) All federal and State professional and facility licensing and accreditation requirements/standards that apply to the services Provider performs pursuant to the Agreement, including but not limited to: UHUSTATE PROGRAMS REGAPX. WA. 02.25 6 a) All applicable standards, orders or requirements issued under Section 306 of the Clean Water Act (33 USC 1368), Executive Order 11738, and Environmental Protection Agency (EPA) regulations (40 CFR Part 15), which prohibit the use of facilities included on the EPA List of violating Facilities. Any violations must be reported to the HCA, DHHS, and the EPA; b) Any applicable mandatory standards and policies relating to energy efficiency that are contained in the State Energy Conservation Plan, issued in compliance with the Federal Energy Policy and Conservation Act. c) Those specified for laboratory services in the clinical Laboratory Improvement Amendments (CLIA); d) Those specified in Title 18 RCW for professional licensing; e) Industrial Insurance — Title 51 RCW; f) Reporting of abuse as required by RCW 26.44.03 0; g) Federal Drug and Alcohol Confidentiality Laws in 42 CFR Part 2; h) Equal Opportunity in Employment (EEO) provisions, including but not limited to compliance with E.O. 11246, "Equal Employment Opportunity," as amended by E.O. 11375, "Amending Executive Order 11246 Relating to Equal Employment Opportunity," and as supplemented by regulations at 41 CFR part 60, "Office of Federal Contract Compliance Programs, Equal Employment Opportunity, Department of Labor." i) The Copeland Anti -]Kickback Act; D The Davis -Bacon Act, k) The Byrd anti -Lobbying Amendment; 1) All federal and State nondiscrimination laws and regulations; m) The American with Disabilities Act (ADA). Provider shall make reasonable accommodation for Covered Persons with disabilities in accord with the ADA for all Covered Services and shall assure physical and communication barriers do not inhibit Covered Persons with disabilities from obtaining Covered Services; n) Any other requirements associated with the receipt of federal funds. xv) Applicable State and federal rules and regulations as set forth in the State Contract, including, but not limited to, the applicable requirements of 42 U.S.C. § 1396a(a)(43), 42 U.S.C. § 1396d(r), and 42 C.F.R. § 438.3(1), CFR 438.6(i), and 438.230(c)(2). xvi) Chapter 70.02 RCW and the Washington State Patient Bill of Rights, including, but not limited to, the administrative and financial responsibility for independent reviews. 3.16 Physician Incentive Plans. In the event Provider participates in a physician incentive plan ("PIP") under the Agreement, Provider agrees that such PIPs must comply with 42 CFR 417.479, 42 CFR 43 8.6(h), 42 CFR 422.208, and 42 CFR 422.210, as may be amended from time to time. Neither Carrier nor Provider may snake a specific payment directly or indirectly under a PIP to a physician or physician group as an inducement to reduce or limit Medically Necessary services furnished to an individual Covered Person. PIPs must not contain provisions that provide incentives, monetary or otherwise, for the withholding of Medically Necessary care. 3.17 Lobbying. Provider agrees to comply with the following requirements related to lobbying: i) Prohibition on Use of Federal Funds for Lobbying: By signing the Agreement, Provider certifies to the best of Provider's knowledge and belief, pursuant to 31 U.S.C. Section 1352 and 45 CFR Part 93, as may be amended from time to time, that no federally appropriated funds have been paid or will be paid to any person by or on Provider's behalf UHC/STATE PROGRAMS REGAPE WA. 02.25_GR 2026 for the purpose of influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the award of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. ii) Disclosure Form to Report Lobbying: If any funds other than federally appropriated funds have been paid or will be paid to any person for the purpose of influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the award of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment or modification of any federal contract, grant, loan, or cooperative agreement and the value of this Agreement exceeds $100,000, Provider shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. 3.18 Conflict of Interest. Provider shall cooperate with Carrier's policies and procedures related to detecting and preventing conflicts of interest in accordance with federal laws for parties involved in public contracting. 3.19 Excluded Individuals and Entities. By signing the Agreement, Provider certifies to the best of Provider's knowledge and belief that neither it nor any of its principals, nor any providers, subcontractors or consultants with whom Provider contracts and who are providing items or services that are significant and material to Provider's obligations under the Agreement is: i) excluded from participation in federal health care programs under either Section 1128 or section 1128A of the Social Security Act; or ii) debarred, suspended or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in nonprocurement activities under regulations issued under Executive Order no. 12549 or under guidelines implementing Executive Order No. 12549; or an affiliate, as defined in the Federal Acquisition Regulation, of such a person. Provider is obligated to screen. its employees and contractors initially and on an ongoing monthly basis to determine whether any of them have been excluded from participation in Medicare, Medicaid, CHIP, or any Federal Health Care Programs (as defined in Section 112813(f) of the Social Security Act). Provider shall not employ or contract with an individual or entity that has been excluded. Provider shall immediately report to Carrier any exclusion information discovered. Provider acknowledges and agrees that civil monetary penalties may be imposed against Provider if he or she employs or enters into contracts with excluded individuals or entities to provide items or Covered Services. Provider can search the HHS-OIG website, at no cost, by the names of any individuals or entities. The databases are called LEIE and EPLS and can be accessed at http://www.oi�hhs.gov/fraud/exclusions.asp. Carrier will terminate the Agreement immediately and exclude from its network any provider who has been excluded from the Medicare, Medicaid or CHIP program in any state. Carrier may also terminate the Agreement if Provider or Provider's owners, agents, or managing employees are found to be excluded on a State or federal exclusion list. UHUSTATE PROGRAMS REGAPX. WA. 02. 25 GR 2026 3.20 Disclosure. Provider must be screened and enrolled into the State's Medicaid or CHIP program, as applicable and submit disclosure to HCA on ownership and control, significant business transactions, and persons convicted of crimes, including any required criminal background checks, in accordance with 42 CFR Part 455 Subparts B and E. Provider shall not give employees, volunteers, and/or subcontractor staff access to children and/or vulnerable adults until a criminal history background check is performed and a positive result is reported. Provider must submit information related to ownership and control of subcontractors or wholly owned suppliers within thirty-five (3 5) calendar days of a request for such information in accordance with 42 CFR 455.105. Additionally, Provider must cooperate with HCA for submission of fingerprints upon a request from HCA or CMS in accordance with 42 CFR 455.434. If Provider fails to submit such information or fingerprints in a form and manner to be determined by HCA or CMS within thirty (30) calendar days when requested by HCA or CMS, the Carrier must terminate or deny enrollment to Provider. 3.21 Cultural Competency and Access. Provider shall participate in Carrier's and the State's efforts to promote the delivery of services in a culturally competent manner to all Covered Persons, including those with limited English proficiency, physical and mental disabilities, and diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity, and shall provide interpreter services in a Covered Person's primary language and for the hearing impaired for all appointments and emergency services. Provider shall provide information to Covered Persons regarding treatment options and alternatives, as well as information on complaints and appeals, in a manner appropriate to the Covered Person's condition and ability to understand. Provider shall provider physical access, reasonable accommodations, and accessible equipment for Covered Persons with physical or mental disabilities. United shall support and provide resources to Provider to comply with the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care to all Covered Persons. Provider shall provide physical access, reasonable accommodations, and accessible equipment for Covered Persons with physical or mental disabilities. 3.22 Marketing. Provider agrees to comply with the prohibition against direct and/or indirect door- to- door, telephonic, or other cold -call marketing of enrollment. As required Linder State or federal law and the State Contract, any marketing materials developed and distributed by Provider as related to the performance of the Agreement must be developed at the sixth grade reading level and submitted to Carrier to submit to the State Program for prior approval. 3.23 Fraud, waste and Abuse Prevention. Provider shall cooperate fully with Carrier's policies and procedures designed to protect program integrity and prevent and detect potential or suspected fraud, waste, and abuse in the administration and delivery of services under the State contract and shall cooperate and assist the State Program and any other State or federal agency charged with the duty of preventing, identifying, investigating, sanctioning or prosecuting suspected fraud, waste, and abuse in state and/or federal health care programs. Provider shall immediately refer credible allegations of fraud to HCA and the Medicaid Fraud Control Division (MFCD) as required in the State Contract. In accordance with Carrier's policies and the Deficit Reduction Act of 2005 (DRA), Provider shall have written policies for its employees, contractors or agents that: (a) provide detailed information about the federal False Claims Act (established under sections 3729 through 3733 of title 31, UHC/STATE PROGRAMS REGAPX. WA. 02.25_GR 2026 United States Code), including, if such Provider receives annual payments under the State Program of at least $5,000,000, Provider must establish certain minimum written policies and information communicated through an employee handbook relating to the Federal False Claims Act in accordance with 42 CFR §438.600; (b) cite administrative remedies for false claims and statements (established under chapter 38 of title 31, United States Code) and whistleblower protections under federal and state laws; (c) reference state laws pertaining to civil or criminal penalties for false claims and statements; and (d) with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in federal health care programs (as defined in section 1128B(f)), include as part of such written policies, detailed provisions regarding Provider's policies and procedures for detecting and preventing fraud, waste, and abuse. Provider agrees to train its staff on the aforesaid policies and procedures. 3.24 Compliance with Medicaid Laws and Regulations. Provider agrees to abide by the Medicaid laws, regulations and program instructions to the extent applicable to Provider in Provider's performance of the Agreement. Provider understands that payment of a Claim by Carrier or the HCA is conditioned upon the Claim and the underlying transaction complying with such laws, regulations, and program instructions (including, but not limited to, federal requirements on fraud, waste and abuse, disclosure, debarment, termination and exclusion screening), and is conditioned on the Provider's compliance with all applicable conditions of participation in Medicaid. Provider understands and agrees that each Claim the Provider submits to Carrier constitutes a certification that the Provider has complied with all applicable Medicaid laws, regulations and program instructions in connection with such Claims and the services provided therein. Provider's payment of a claim will be denied if Provider is terminated or excluded from participation in federal health care programs. Provider's payment of a Claim may be temporarily suspended if Carrier provides notice that a credible allegation of fraud exists and there is a pending investigation. Carrier performs coding edit procedures based primarily on National Correct Coding Initiative (NCCI) policies and other nationally recognized and validated policies. Provider agrees that it will provide medical records to Carrier upon its request in order to determine appropriateness of coding. Claims payments may be temporarily suspended or adjusted if the Provider bills a claim with a code that does not match the service provided. Provider may dispute any temporarily suspended or adjusted payment consistent with the terms of the Agreement. 3.25 Claims Information. Provider shall promptly submit to Carrier information needed to make payment. Provider must submit a Clean Claim no more than twelve (12) months after the calendar month in which the Covered Service is performed. Provider shall identify third party liability coverage, including Medicare and other insurance, and if applicable seek such third party liability payment before submitting Claims to Carrier. 3.26 Data; Reports. Provider shall cooperate with and release to Carrier any information necessary for Carrier to perform its obligations under the State Contract to the extent applicable to Provider in performance of the Agreement, including the timely submission of reports and information required by Carrier. Such reports shall include child health check-up reporting, if applicable, as well as complete and accurate encounter data in accordance with the requirements of Carrier and the State Contract. Data and reports must be provided within the timeframes specified and in a form that meets Carrier and State requirements. By submitting data to Carrier, Provider represents to Carrier that the data is accurate, and upon Carrier's request Provider shall certify in writing, that the data is accurate, complete, and truthfitl, based on Provider's best knowledge, information and belief. 3.27 Insurance Requirements. As applicable, Provider shall secure and maintain during the term of the Agreement insurance appropriate to the services to be performed under the Agreement. If Provider UHUSTATE PROGRAMS REGAPX. WA. 02.25 GR 2026 10 is a home health agency, Provider shall comply with the surety bond requirements in accordance with 42 CFR 441.16. Upon request, Provider shall make available to Carrier copies of its Certificate(s) of Insurance. 3.28 Licensure. Provider represents that it is currently licensed and/or certified under applicable State and federal statutes and regulations and by the appropriate State licensing body or standard- setting agency, as applicable. Provider represents that it is in compliance with all applicable State and federal statutory and regulatory requirements of the State Program and that it is eligible to participate in the State Program. Provider represents that it does not have a State Program provider agreement with HCA that is terminated, suspended, denied, or not renewed as a result of any action of the HCA, CMS, HHS, or the MFCD of the State's Attorney General. Provider shall maintain at all times throughout the term of the Agreement all necessary licenses, certifications, registrations and permits as are required to provide the health care services and/or other related activities delegated to Provider by Carrier under the Agreement. If at any time during the term of the Agreement, Provider is not properly licensed as described in this Section, Provider shall discontinue providing services to Covered Persons. 3.29 Quality; Utilization Management. Pursuant to any applicable provider manuals and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Carrier's quality assessment, performance improvement and utilization review and management activities, which shall be tailored to the nature and type of services subcontracted. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Carrier or as required under the State Contract to ensure quality control for the health care provided, including but not limited to the accessibility of Medically Necessary health care, and Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Carrier or Provider. Provider shall adhere to the quality assurance and utilization review standards of the State Programs and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care. 3.30 Continuity of Care. Provider shall cooperate with Carrier to provide newly enrolled Covered Persons with continuity of treatment, including coordination of care to the extent required under law or required to ensure that ongoing care is not disrupted or interrupted. Provider shall also coordinate with Carrier to ensure continuity of treatment in the event Provider's participation with Carrier terminates during the course of a Covered Person's treatment by Provider. 3.31 Informed Consent; Information for Covered Persons. To the extent applicable to Provider in performance of the Agreement, Provider shall obtain informed consent prior to treatment, or from persons authorized to consent on behalf of a Covered Person as described in RCW 7.70.065. Providers that are hospitals, nursing facilities, home health agencies, hospices, or organizations responsible for providing personal care, as well as PCPs that contract with any of the above entities, shall comply with federal and State law (WAC 182-501-0125 and 42 CFR 43 8.6(m)) and Carrier's policies regarding advance directives for adult Covered Persons. Provider shall also comply with the provisions of the Natural Death Act (RCW 70.122), and when appropriate, inform Covered Persons of their right to make anatomical gifts (RCW 68.50.540). 3.32 Special Health Care Needs. As applicable, Provider shall identify Covered Persons with special health care needs in the course of contact, or a Covered Person initiated health care visit, and report such identification to Carrier. UHC/STATE PROGRAMS REGAPX. WA. 02.25_GR 2026 11 3.33 Termination. In the event of termination of the Agreement, Provider shall promptly supply to Carrier all information necessary for the reimbursement of any outstanding Medicaid claims. 3.34 Health Information Systems. Provider shall maintain a health information system that complies with the requirements of 42 CFR 438.242 and provides the information necessary to meet Provider's obligations under the Agreement and this Appendix. 3.35 Clinical Laboratory Improvements Act (CLIA) certification or waiver. As applicable, if Provider performs any laboratory tests on human specimens for the purpose of diagnosis and/or treatment, Provider agrees to acquire and maintain the appropriate CLIA certification or waiver for the type of laboratory testing performed. Provider further agrees to provide a copy of the certification if requested by Carrier. A State authorized license or permit that meets the CLIA requirements may be substituted for the CLIA certificate pursuant to State law. Medicare and Medicaid programs require the applicable CLIA certification or waiver for the type of services performed as a condition of payment. Provider must include the appropriate CLIA certificate or waiver number on claims submitted for payment for laboratory services. 3.36 Encounter Data. Provider agrees to cooperate with Carrier to comply with Carrier's obligation to prepare timely encounter data submissions, reports, and clinical information including, without limitation, child and adolescent health check-up reporting, EPSDT encounters, and cancer screening encounters, as applicable, and such other reporting regarding Covered Services as may be required under the State Contract. Encounter data must be accurate and include all services furnished to a Covered Person, including capitated provider's data and rendering provider information. Encounter data must be provided within the timeframes specified and in a form that meets Carrier and State requirements. By submitting encounter data to Carrier, Provider represents to Carrier that the data is accurate, and upon Carrier's request Provider shall certify in writing, that the data is accurate, complete, and truthful, based on Provider's best knowledge, information and belief. 3.37 Health Records. Provider agrees to cooperate with Carrier to maintain and share a health record of all services provided to a Covered Person, as appropriate and in accordance with applicable laws, regulations and professional standards. UHUSTATE PROGRAMS REGAPE WA. 02.25GR2026 12 3.38 Non -Discrimination. Provider will not discriminate against Covered Persons on the basis of race, color, national origin, sex, sexual orientation, gender identity, or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, or national origin, sex, sexual orientation gender identity, or disability. i) Provider shall not discriminate on the bases enumerated in RCW 49.60.530(3); Title VII of the Civil Rights Act, 42 U.S.C. §12101 et seq.; and the Americans with Disabilities Act of 1990 (ADA), 42 U.S.C. § 12101 et seq., and 28 C.F.R. Part 35. ii) Provider shall give written notice of this nondiscrimination requirement to any labor organizations with which Provider has a collective bargaining or other agreement. iii) Obligation to Cooperate. Provider shall cooperate and comply with any Washington state agency or federal agency investigation regarding any allegation that Provider has engaged in prohibited discrimination. iv) Suspension and Termination. United or HCA may suspend Provider upon written notice from United HCA of a failure to participate in and cooperate with any state or federal agency investigation into alleged prohibited discrimination. v) Any such suspension will remain in place until United HCA determines that Provider is cooperating with the investigating agency. vi) If Provider is determined by United or HCA to have engaged in discrimination under any of the provisions identified in this Section, United HCA may terminate the Agreement in whole or in part, and Provider may be referred for debarment as provided in RCW 39.26.200. United or HCA, in its sole discretion, may give Provider a reasonable time in which to cure the noncompliance, including implementing conditions consistent with any court order or settlement agreement. vii) Damages. In the event of contract termination or suspension for engaging in discrimination, Provider shall be liable for damages as authorized by law. viii) Any such damages are distinct from any penalties imposed under chapter 49.60 RCW or other applicable law. ix) Nothing in this Section shall preclude United or HCA from requiring a Corrective Action Plan or imposing sanctions or liquidated damages. 3.39 Advance Directives. When applicable, Provider shall comply with the advance directives requirements for hospitals, nursing facilities, providers of home and health care and personal care services, hospices, and HMOs as specified in 42 CFR Part 49, subpart I, 42 CFR § 417.436(d), 42 CFR § 422.128, and 42 CFR 438.3(i). In addition, as applicable, Provider must comply with Chapter 71.32 RCW (Mental Health Advance Directives). 3.40 Termination. In the event of termination of the Agreement, Provider shall promptly supply to Carrier all information necessary for the reimbursement of any outstanding Medicaid claims. 3.41 Overpayment. Provider shall report to Carrier when it has received an overpayment and will UHC/STATE PROGRAMS REGAPX. WA. 02.25 GR 2026 13 return the overpayment to the Carrier within 60 calendar days after the date on which the overpayment was identified. Provider will notify Carrier in writing of the reason for the overpayment. 3.42 Electronic Visit Verification (EVV). Provider shall cooperate with State requirements for electronic visit verification for personal care services and home health services, as applicable. 3.43 Bi-Directional Behavioral and Physical Health Integration. Outpatient behavioral health and primary care practices shall use reasonable efforts to complete the Washington Integrated Care Assessment (WA-ICA) as defined by the Clinical Integration Assessment Workgroup. Outpatient behavioral health and primary care practices shall use reasonable efforts to complete the WA-ICA in July of each year, consistent with the implementation schedule defined by the Clinical Integration Assessment Workgroup. SECTION 4 ADDITIONAL REQUIREMENTS FOR DELEGATED ADMINISTRATIVE FUNCTIONS 4.1 This Section applies to those Providers to whom Carrier has delegated an Administrative Function. Provider shall perform those delegated Administrative Functions set forth in the Agreement through an exhibit or otherwise. Any changes or modifications to the Administrative Functions shall be agreed to in writing by the parties. 4.2 Prior to delegation, Carrier shall perform an evaluation of Provider's ability to successfully perform and meet the requirements of the State Contract for any delegated Administrative Function. 4.3 Provider agrees to cooperate with Carrier's requirements for delegation of Administrative Functions, including but not limited to ongoing monitoring and an annual evaluation for the purpose of determining Provider's compliance with requirements related to the delegated Administrative Functions. As a result of such monitoring activities, Carrier shall identify to Provider any deficiencies or areas for improvement mandated under the applicable State Contract and Provider shall take appropriate corrective action. 4.4 If Provider is at financial risk, Provider shall comply with, and maintain throughout the term of the Agreement, the solvency requirements established by Carrier from time to time. Carrier shall monitor Provider's compliance with such solvency requirements. 4.5 Provider shall maintain records necessary to adequately document the performance of delegated Administrative Functions and shall release to Carrier any data or information necessary for Carrier to perform its reporting obligations under the State Contract. 4.6 In addition to its termination rights under the Agreement, Carrier shall have the right to revoke any delegated Administrative Functions Carrier delegates to Provider under the Agreement or impose other sanctions consistent with the applicable State Contract if in Carrier's reasonable judgment Provider's performance of a delegated Administrative Function is inadequate. UHUSTATE PROGRAMS REGAPX. WA. 02.25 GR 2026 14 SECTION 5 CARRIER REQUIREMENTS 5.1 Prompt Payment. Carrier shall pay Provider pursuant to the State Contract, applicable State law and regulations, including the timeliness of payment standards specified in applicable state law, noted in the Agreement and the timeliness of payment standards specified for Medicaid fee- for- service in Section 1902(a)(37)(A) of the Social Security Act and 42 CFR 447.46, 42 CFR 447.45(d)(2), 42 CFR 447.45(d)(3), 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), as maybe amended from time to time. To be compliant with both payment standards, Carrier shall pay 95 percent of Clean Claims within thirty (30) calendar days of receipt, 95 percent of all Claims within sixty (60) calendar days of receipt and 99 percent of Clean Claims within ninety (90) calendar days of receipt; provided, however, that Carrier and Provider may agree to a different payment requirement in writing on an individual Claim. If a third party liability exists, payment of Claims shall be determined in accordance with federal and/or State third party liability law and the terms of the State Contract. Unless Carrier otherwise requests assistance from Provider, Carrier will be responsible for third party collections in accordance with the terms of the State Contract. 5.2 No Incentives to Limit Medically Necessary Services. Carrier shall not structure compensation provided to individuals or entities that conduct utilization management and concurrent review activities so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary services to any Covered Person. 5.3 Provider Discrimination Prohibition. In accordance with 42 CFR 43 8.12 and 43 8.214(c), Carrier shall not discriminate with respect to the participation, reimbursement or indemnification of a provider who is acting within the scope of such provider's license or certification under applicable State law, solely on the basis of such license or certification. Further, Carrier shall not discriminate with respect to the participation, reimbursement or indemnification of any provider who serves high -risk Covered Persons or specializes in conditions requiring costly treatments. This provision shall not be construed as prohibiting Carrier from limiting a provider's participation to the extent necessary to meet the needs of Covered Persons. This provision also is not intended and shall not interfere with measures established by Carrier that are designed to maintain quality of care practice standards and control costs. 5.4 Communications with Covered Persons. Carrier shall not prohibit or otherwise restrict Provider, when acting within the lawful scope of practice, from advising or advocating on behalf of a Covered Person for the following: i} The Covered Person's health status, medical care, or treatment options, including any alternative treatment that may be self-administered; ii) Any information the Covered Person needs in order to decide among all relevant treatment options; iii) The risks, benefits, and consequences of treatment or non -treatment; or iv) The Covered Person's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. UHC/STATE PROGRAMS REGAPX. WA. 02.25_GR 2026 15 Carrier also shall not prohibit a Provider from advocating on behalf of a Covered Person in any grievance system, utilization review process, or individual authorization process to obtain necessary health care services. 5.5 Grievance & Appeals. Carrier will supply Provider with information regarding Carrier's grievance and appeals system, including: (a) the toll -free numbers to file oral grievances and appeals; (b) the availability of assistance in filing a grievance or appeal; (c) a Covered Person's rights to request continuation of benefits during an appeal or hearing and, if Carrier's action is upheld, the Covered Person's responsibility to pay for the cost of the benefits received for the first 60 calendar days after the appeal or hearing request was received; (d) a Covered Person's right to file grievances and appeals and the requirements and timeframes for filing, to include the availability of review by an IRO; and (e) a Covered Person's right to a hearing, how to obtain a hearing, and representation rules at a hearing. 5.6 Termination, Revocation and Sanctions. In addition to Carrier's termination rights under the Agreement, Carrier shall have the right to revoke any functions or activities Carrier delegates to Provider under the Agreement or impose other sanctions consistent with the State Contract if in HCA's or Carrier's reasonable judgment Provider's performance under the Agreement is inadequate. Carrier shall also have the right to suspend, deny, refuse to renew or terminate Provider in accordance with the terms of the State Contract and applicable law and regulation. The administrative guide located at www.uhcprovider.com describes applicable provider policies and procedures, including specific criteria for termination pursuant to this provision. SECTION 6 OTHER REQUIREMENTS 6.1 Compliance with State Contract. All tasks performed under the Agreement shall be performed in accordance with the requirements of the State Contract, as set forth in this Appendix, applicable provider manuals, and protocols, policies and procedures that Carrier has provided or delivered to Provider. The applicable provisions of the State Contract are incorporated into the Agreement by reference. Nothing in the Agreement relieves Carrier of its responsibility under the State Contract. If any provision of the Agreement is in conflict with provisions of the State Contract as it relates to the State Programs, the terms of the State Contract shall control and the terms of the Agreement in conflict with those of the State Contract will be considered waived. Carrier agrees to comply with the State Contract provisions relating to providing a reasonably accessible on-line location of policies and procedures. For this purpose, the administrative guide and other information is located at www.uhcprovider.com. 6.2 Monitoring. Carrier shall perform ongoing monitoring (announced or unannounced) of services rendered by Provider under the Agreement and shall perform periodic formal reviews of Provider at least every three (3) years and according to any other schedule established by the State, consistent with industry standards or State managed care organization laws and regulations or requirements under the State Contract. As a result of such monitoring activities, Carrier shall identify to Provider any deficiencies or areas for improvement mandated under the State Contract and Provider and Carrier shall take appropriate corrective action. Provider shall comply with any corrective action plan initiated by Carrier and/or required by the State Program. In addition, Provider shall monitor and report the quality of services delivered under the Agreement and initiate a plan of correction where necessary to improve quality of care, in accordance with that level of care which is UHC/STATE PROGRAMS REGAPX. WA. 02.2 5GR 2026 16 recognized as acceptable professional practice in the respective community in which Carrier and Provider practice and/or the performance standards established under the State Contract. 6.3 Delegation. The parties agree that, prior to execution of the Agreement, Carrier evaluated Provider's ability to perform any duties delegated to Provider under the Agreement. Any delegated duties and reporting responsibilities shall be reduced to writing and set forth in the Agreement or other written delegation agreement or addendum between the parties. In addition to Carrier's termination rights under the Agreement, Carrier shall have the right to revoke any functions or activities Carrier delegates to Provider under the Agreement or impose other sanctions consistent with the State Contract if in Carrier's reasonable judgment Provider's performance under the Agreement is inadequate. Carrier shall also have the right to suspend, deny, refuse to renew or terminate Provider in accordance with the terms of the State Contract and applicable law and regulation. 6.4 Assignment. No assignment of the Agreement shall take effect without the written agreement of the HCA. 6.5 Termination Notice. Notwithstanding the termination provisions set forth in the Agreement, Provider and Carrier shall provide at least ninety (90) days advance notice to the other party of intent to terminate the Agreement without cause. Such notice shall be in accordance with the terms of the Agreement. 6.6 Health Care Acquired/Preventable Conditions. Carrier and Provider acknowledge and agree that Carrier is prohibited from making payments to Provider for the provision of medical assistance for health care -acquired conditions and other provider -preventable conditions as may be identified by HCA. As a condition of payment, Provider shall identify and report to Carrier any provider preventable conditions in accordance with 42 CFR § 434.6(a)(12), 42 CFR §438, including but not limited to § 438.3, and § 447.26. 6.7 C.S.A. v. Bellevue School District No. 405, 32 Wash. App. 2d 544, 557 P.3d 268 (Div. 1 2024), review denied, 4 Wash. 3d 1019, 566 P.3d 92 (2025) (trial court erroneously dismissed student's PRA complaint alleging failure to produce school surveillance video); Freedom Foundation v. Gregoire, 178 Wash. 2d 686, 310 P.3d 1252 (2013). "`Public record' includes any writing containing information relating to the conduct of government or the performance of any governmental or proprietary function prepared, owned, used, or retained by any state or local agency regardless of physical form or characteristics." RCW 42.56.010(2). The PRA requires that "[e] ach agency, in accordance with published rules, shall make available for public inspection and copying all public records, unless the record falls within the specific exemptions of ... this chapter, or other statute which exempts or prohibits disclosure of specific information or records." RCW 42.56.070; O'Neill v. City of Shoreline, 170 Wash. 2d 138, 240 P.3d 1149, 38 Media L. Rep. (BNA) 2345 (2010). UHC/STATE PROGRAMS REGAPX. WA. 02.25_GR 2026 17 Amendment to the Medical Group Contract This Amendment (this "Amendment") is to the Medical Group Contract, effective as of 04/01/2026 (the "Agreement"), between UnitedHealthcare Insurance Company, UnitedHealthcare of Washington, Inc., UnitedHealthcare of Oregon, Inc. and PacifiCare Health and Life Insurance Company, each contracting individually (each, "United"), and Grant County ("Practitioner"). Unless otherwise provided herein, this Amendment is effective on the first day of the calendar month that begins at least 90 days after the day you receive this Amendment (the "Amendment Effective Date"). The parties agree to modify the Agreement as follows: 1. The capitalized terms used in this Amendment, but not otherwise defined, will have the meanings ascribed to them in the Agreement. If UnitedHealthcare of Oregon, Inc. is not listed as a party to the Agreement, the definition of "United" is revised to include "UnitedHealthcare of Oregon, Inc." and UnitedHealthcare of Oregon, Inc. is added as a party to the Agreement. 2. United's process to request exceptions to United's drug utilization process can be found at www.U-fICProvider.com. 3. Appendix 2 attached to the Agreement is hereby deleted and replaced by the Appendix 2 attached to this Amendment. 4. Prior to rendering telemedicine services Practitioner will obtain the Customer's prior consent. Failure to obtain consent could result in disciplinary action against Practitioner. 5. In accordance with the Agreement, United may amend the Agreement to remain complaint with regulatory requirements by sending Practitioner a copy of the Amendment 90 days prior to the Amendment's effective date. Practitioner's signature is not required to make the Amendment effective. 6. Except as expressly provided in this Amendment, the terms and conditions of the Agreement remain in full force and effect. If the provisions of this Amendment conflicts with the provisions of the Agreement,, the terms and conditions of this Amendment control. UnitedHealthcare Insurance Company, Grant County UnitedHealthcare of Washington, Inc., UnitedHealthcare of Oregon, Inc. and PacifiCare Health and Life In ran, e Company, each individually Signature: TIN:916001319 Print Name: Scott Williams Title: VP, Network Management Date: 2-15-2026 NEXUSDOCTelm.ed. Uni.Simple. 09.21. WA —Grant UnitedHealthcare Confidential & Proprietary Appendix 2 Benefit Plan Descriptions Section 1. United may allow Payers to access Practitioner services under this Agreement for the Benefit Plan types described in each line item below, unless otherwise specified in section 2 of this Appendix 2: F-1 Benefit Plans where Customers are offered a network of participating providers and must select a primary physician, who in some cases must approve any care provided by other health care providers. Such Benefit Plans may or may not include an out-of-networl,-, benefit. F-1 Benefit Plans where Customers are offered a network of participating providers but are not required to select a primary physician. Such Benefit Plans may or may not include an out -of -network benefit. ❑ Benefit Plans where Customers are not offered a network of participating providers from which they may receive Covered Services. ❑ Medicare Advantage Benefit Plans. F-1 Benefit Plans for Medicare Select FX_1 Washington Medicaid and CHIP Benefit Plans. F-1. Additional Network Benefit Plans. As used here Additional Network Benefit Plans means commercial narrow network Benefit Plan types in which Facility does not participate, as described in section 2 of this Appendix 2, but that provide for an additional network of providers for outpatient emergency services, inpatient services following an emergency admission, urgent care services and services pre -approved by United. Additional Network Benefit Plan types will be identified by the notation "W500" on the Customer's ID card. United may modify this ID card notation in the ftiture and will provide Practitioner with the -updated information. Section 2. Notwithstanding the above section I of this Appendix 2, this Agreement will not apply to the Benefit Plan types described in the following line items: ® Benefit Plans where Customers are not offered a network of participating providers from which they may receive Covered Services. FX_1 Medicare Advantage Benefit Plans. 0 Capitation Arrangements F-1 Washington Medicaid and CHIP Benefit Plans. F Washington Medicaid and CHIP Benefit Plans for Blind and Disabled. FX� Medicaid and CHIP Benefit Plans other than those separately addressed in this Appendix 2 0 Medicare and Medicaid Enrollees (MME) Benefit Plans. 2 NEXUSDOCTelmed. Uni.Siniple. 09.21. WA —Grant UnitedHealthcare Confidential & Proprietaty 0 Benefit Plans for workers' compensation benefit programs. 0 Benefit Plans for Medicare Select. 0 Medicare Advantage Private Fee -For -Service Benefit Plans and Medicare Advantage Medical Savings Account Benefit Plans. FX� Other Governmental Benefit Plans. FX UnitedHealthcare Navigate Benefit Plans. As used here, UnitedHealthcare Navigate Benefit Plans means commercial narrow network Benefit Plans for which the Customer selects or is assigned a primary care physician to manage the Customer's health care needs and referrals to network specialists, and that are marketed under a name that includes the word "Navigate". References to "UnitedHealthcare Navigate" also apply to any brand name adopted by United in the future to supplement and/or replace "UnitedHealthcare Navigate". F UnitedHealthcare Core Benefit Plans. As used here, UnitedHealthcare Core Benefit Plans means commercial narrow network Benefit Plans marketed under a name that includes the word "Core". References to "UnitedHealthcare Core" also apply to any brand name adopted by United in the future to supplement and/or replace "UnitedHealthcare Core". N UnitedHealthcare Charter Benefit Plans. As used here, UnitedHealthcare Charter Benefit Plans means commercial narrow network Benefit Plans for which the Customer selects or is assigned a primary care physician to manage the Customer's health care needs and referrals to network. specialists, and that are marketed under a name that includes the word "Charter". References to "UnitedHealthcare Charter" also apply to any brand name adopted by United in the future to supplement and/or replace "UnitedHealthcare Charter". 0 UnitedHealthcare Doctors Plan Benefit Plans. As used here, UnitedHealthcare Doctors Plan Benefit Plans means conunercial narrow network Benefit Plans for which the Customer selects or is assigned a primary care physician to manage the Customer's health care needs and referrals to network specialists, and that are marketed under a name that includes the word "Doctors". References to "UnitedHealthcare Doctors" also apply to any brand name adopted by United in the future to supplement and/or replace "UnitedHealthcare Doctors." N UnitedHealthcare NexusACO Benefit Plans. As used here, UnitedHealthcare NexLIsACO Benefit Plans means commercial tiered Benefit Plans for which the Customer selects or is assigned a primary care physician to manage the Customer's health care needs and that are marketed under a name that includes the word "ACO". References to "UnitedHealthcare NexusACO" also apply to any brand name adopted by United in the future to supplement and/or replace "UnitedHealthcare NexusACO." Note: Excluding certain Benefit Plans or programs from this Agreement sloes not preclude the parties or their affiliates from having or entering into a separate agreement providing for Practitioner participation in a network for such Benefit Plans or programs. NEXUSDOCTelmed. Uni.Simple.09.21. WA —Grant UnitedHealthcare Confidential & Proprietary Section 3. Definitions: Note: United may adopt a different name for a particular Benefit Plan, and/or may modify information referenced in the definitions in this Appendix 2 regarding Customer identification cards. If that happens, section 1 or section 2 of this Appendix 2 will continue to apply to those Benefit Plans as it did previously, and United will provide Practitioner with the updated information. Additionally, United may revise the definitions in this Appendix 2 to reflect changes in the names or roles of United's business -units, provided that doing so does not change Practitioner participation status in Benefit Plans impacted by that change, and further provided that United provides Practitioner with the -updated information. MEDICARE: Medicare Advantage Benefit Plans means Benefit Plans sponsored, issued or administered by a Medicare Advantage organization as part of: i) the Medicare Advantage program under Title XVIII, Part C of the Social Security Act, or ii) the Medicare Advantage program together with the Prescription Drug program under Title XVIIL Part C and Part D, respectively, of the Social Security Act, as those program names may change from time to time. I Medicare and Medicaid Enrollees (MME) Benefit Plan means the CMS sponsored Financial Alignment Demonstration Plan providing integrated care benefits for individuals eligible for both the state Medicaid program and the Medicare program (Parts A, B, C and D). At such time as this Benefit Plan is no longer a demonstration project and is fully implemented in the state, this definition will be interpreted to refer to the frilly implemented plan. MEDICAID, CHIP AND OTHER STATE PROGRAMS: Medicaid Benefit Plans Means Benefit Plans that offer coverage to beneficiaries of a program that is authorized by Title XIX of the federal Social Security Act, and jointly financed by the federal and state governments and administered by the state. Children's Health Insurance Program ("CHIP") Benefit Plans means Benefit Plans under the program authorized by Title XXI of the federal Social Security Act that is jointly financed by the federal and state governi-nents and administered by the state. Washington Medicaid and CHIP Benefit Plans means Medicaid Benefit Plans issued in Washington that include a reference to "UnitedHealthcare Community Plan" on the Valid identification card of any Customer eligible for and enrolled in that Benefit Plan. Washington Benefit Plans for the Uninsured means Benefit Plans issued in Washington under the Basic Health program. Such Benefit Plans will include a reference to "UnitedHealthcare Community Plan" and "Basic Health" on the valid identification card of any Customer eligible for and enrolled in that Benefit Plan. Other Governmental Benefit Plans means Benefit Plans that are funded wholly or substantially by a state or district government or a subdivision of a state (such as a city or county), but do not include Benefit Plans for: i) employees of a state government or a subdivision of a state and their dependents; ii) students at a public university, college or school; iii) employer -based coverage of private sector employees, even if the employer receives a government subsidy to help fund the coverage, 4 NEXUSDOCTelmed. Uni. Simple. 09.21. WA —Grant UnitedHealthcare Confidential & Proprietary iv) Medicaid beneficiaries; v) Children's Health Insurance Program (CHIP) beneficiaries; and vi) Medicare and Medicaid Enrollees (MME). "Capitation arrangements" are when all of the following apply: i) Practitioner is part of a network for United; and ii) As part of that network, Practitioner arranges directly with United, or with a Practitioner, an IPA, a hospital or other provider organization for certain designated services to be provided to members covered by United's Benefit Plans who are assigned to that Practitioner, IPA, hospital or other provider organization and under which either: a) Practitioner (directly by United or through another entity) is capitated or otherwise has financial responsibility; or b) Practitioner is paid on a fee -for -service basis directly by the Practitioner, IPA, or hospital which has financial responsibility for the service, at a rate agreed upon by Practitioner and that Practitioner, IPA or hospital; and iii) Practitioner provides those designated services to one of those assigned members. In such cases, the obligation for payment will be primarily that of the Practitioner, IPA, hospital or other provider organization that has financial responsibility for the service, and not that of United. It is not a capitation arrangement when: 1) A Practitioner, IPA, hospital or other provider organization is not affiliated with Practitioner, and is capitated by United for designated Covered Services rendered to assigned Customers covered by a Benefit Plan issued by United; and 2) Practitioners provide those designated Covered Services to one of those assigned Customers, without having a contract or other arrangement with the Practitioner, IPA, hospital or other provider organization for the terms under which those designated Covered Services are provided. In such cases, this Agreement will apply and the Practitioner, IPA, hospital or other provider organization that has financial responsibility for the Covered Service will be considered the Payer. NEXUSDOCTelmed. Uni.Simple.09.21. WA —Grant UnitedHealthcare Confidential & Proprietary APPENDIX COMMERCIAL NETWORKS DISCLOSURE ADDENDUM This Networks Disclosure Addendum is required by the Washington Office of the Insurance Commissioner and added to Appendix 2 of this Agreement. All references in the Agreement to "Appendix 2" include this Networks Disclosure Addendum. Practitioner participates in the following commercial network(s) that support the commercial Benefit Plans listed in Appendix 2 of the Agreement: Commercial Networks: 7 NexusACO and NexusACO with Standard SelectRx F-1 Charter and Charter with Standard SelectRx 7 Choice and Choice with Standard SelectRx El Core and Core with Standard SelectRx El Doctors Plan and Doctors Plan with Standard SelectRx F-1 Navigate and Navigate with Standard SelectRx El Options and Options with Standard SelectRx 7 SignatureValue and SignatureValue with Standard SelectRx F-1 Select and Select with Standard SelectRx Government Program Networks: N Washington Medicaid F-1 Medicare Advantage United may amend the list of networks in which Provider participates with 60 days' prior written notice. United will include in such notice the payment appendix or appendices to which any new networks will apply. Tiered Provider Networks For purposes of this section, "Tiered Provider Network" means a network that identifies and groups physicians, healthcare professionals, ancillary providers and facilities into specific groups to which different provider reimbursement, Customer cost -sharing, or provider access requirements, or any combination thereof, apply as a means to manage cost, utilization, quality, or to otherwise incentivize Customer or provider behavior. United will not use a Tiered Provider Network to limit access to certain categories of providers or facilities. United will disclose to Customers at the time of enrollment the cost difference and the basis for United's placement of providers in one tier or another. United will provide notice to any affected providers of proposed changes to the tier criteria 60 days before implementing. The notice will explain the methodology and data, if any, used for particular providers and include information on provider appeal rights. United will make its physician cost profile available to providers under a Tiered Provider Network, including the written criteria by which the provider's performance is measured. 1. Select and Select with Standard SelectRx. The Select Tiered Provider Network only groups primary care professionals ("PCPs") into tiers. The tier with the lowest cost sharing will include PCPs in medical practices which meet all of the following criteria: a) Medical practices with at least 1 participating provider who is a PCP. A PCP is a medical doctor or doctor of osteopathy who is credentialed with United in one of the following primary specialties: general medicine, pediatrics, internal medicine, family practice, obstetrics and gynecology, or adolescent medicine; 6 NEXUSDOCTelmed. Uni. Simple. 09.21. WA —Grant UnitedHealthcare Confidential & Proprietary b) Medical practices which are not owned/employed by a hospital or hospital system or if owned by a hospital or hospital system, the hospital or hospital system and medical practice have agreed to payment appendices specific to the Select Tiered Provider Network; c) The majority of physicians within the medical practice provide Covered Services in the Select service area; and d) Medical practices which have 1,000 or more Customers attributed to its PCPs, directly or through a contractual relationship with a. medical practice to which at least 1,000 Customers are attributed (e.g. an affiliate). Customers are attributed by United annually based on a plurality of claims to a PCP. All other participating providers, including facilities, are not tiered. 2. NexusACO and NexusACO with Standard SelectRx. The NexusACO Tiered Provider Network groups into tiers the following provider types: hospital, primary care professionals and specialists. Other provider types are not tiered. The tier with the lowest cost sharing will include providers which meet all the criteria in one of the following criteria sets: C~ri teri a ',q et 1 a) The provider has entered into an agreement with an organization (all "Accountable Care Organization" or "ACO") to participate in accountable care incentive programs and that ACO has entered into an ACO Agreement with United or has executed a letter of intent to enter such arrangement within 6 months of the date of the letter of intent. b) The ACO Agreement includes specific criteria related to NexusACO Customers and quality and efficiency requirements or has executed a letter of intent to enter such arrangement within 6 months of the date of the letter of intent. Criteria a �,et The provider is a physician who has been designated as a Premium Care Physician as part of the UnitedHealth Premium program by meeting both quality and cost efficiency criteria. Information about the UnitedHealth Premium program can be found at www.UHCProvider.com. Criterin qet I The provider has agreed to a NexusACO specific payment appendix or has executed a letter of intent to enter such arrangement within 6 months of the date of the letter of intent. 7 NEMSDOCTelmed. Uni.Simple.09.21. WA —Grant UnitedHealthcar"e Confidential & Proprietary Amendment to the Medical Group Participation Agreement - Grant County SO Date: /w 7-�t 0 U NT y %�,�. % 0 0%'Z;0P' ZLZ co: S 04" 0'-0 ow00 § vlli,;•NGTOA ATTEST: TF6or R. Bevier' , WSBA#47 Prant County Prosecutor's Office Civil Deputy Prosecuting Attorney Date: BOARD OF COUNTY COMMISSIONERS GRANT COUNTY, WASHINGTON Kevin R. BurgAs, Chair Rob Jones, Vice -Chair A Cindy Cart , Member Amendment to the Medical Group Participation Agreement This amendment (this "Amendment") is to the Medical Group Participation Agreement, effective as of 05/01 /2026 (the "Agreement"), between UnitedHealthcare Insurance Company, UnitedHealthcare of Washington, Inc., and UnitedHealthcare of Oregon, Inc. ("United") contracting on behalf of each entity individually (collectively, "United") and Western Medical Resources. ("Medical Group"). This Amendment is effective on 05/01/2026 (the "Amendment Effective Date"). The parties agree to modify the Agreement as follows: 1. The capitalized terms used in this Amendment, but not otherwise defined, will have the meanings ascribed to them in the Agreement. 2. Appendix 4 to the Agreement is deleted in its entirety and replaced with the Appendix 4 attached hereto. 3. Medical Group represents that it has provided United with a Medical Group Professional Roster that includes all of the following data elements for each Professional: Any previous Professional Roster attached to the Agreement is deleted in its entirety. - Name of Professional (first name, middle initial, last name) - Degree (MD, DO, NP, PA, other) - Gender (M/F) - Provider Specialty(ies) (primary, secondary, additional specialties) - Operates as and willing to be listed/assigned as a Primary Care Professional "PCP" (Y/N) - State License Number Medicaid ID Number - NPI Number Foreign Language(s) - Admitting Hospital(s) If any data element is not applicable to a specific Medical Group Professional, Medical Group will indicate "not applicable" in the appropriate field. Acceptable formats include in writing, electronically in Excel, ANSI, or text (comma delineated) formats. 4. The attached "Behavioral Health Services and Payment Addendum" is hereby added to the Agreement as Attachment 1. All other provisions of the Agreement shall remain in full force and effect. In the event of a conflict between the terms of the Agreement and this Amendment, the Amendment will control. Gen.Amd.SMGA.BH. WA. 06.25 - 1 - UnitedHealthcare Confidential and Proprietary UnitedHealthcare Insurance Company, as signed by its authorized representative Signature: Print Name: Title: Date: UnitedHealthcare of Washington, Inc., as signed by its authorized representative Signature: Print Name: Title: Date: Grant County, as signed by its authorized representative Signature: Print Name: Title: Date: TIN: Grant County, as signed by its authorized representative Signature: Print Name: Title: Date: TIN: Unite Mealthcare of Oregon, Inc., as signed Grant County, as signed by its authorized by its authorized representative representative Signature: Signature-. Print Name: Print Name: Title: Title: Date: Date: TIN: Gen.Amd.SMGA.BH. WA. 06. 5 - ? - UnitedHealtheare Confidential and Pr°op•ietary Appendix 4 Medical Group Service Locations Medical Group attests that this Appendix identifies all services and locations covered under this Agreement. IMPORTANT NOTE: Medical Group acknowledges its obligation pursuant to the agreement to promptly report any change in Medical Group's name or Taxpayer Identification Number. Failure to do so may result in denial of claims or incorrect payment. ILL _ : ING D:R�S Identify only if a common name and address appears on all Medical Group service location bills that utilize the Medical Group's Taxpayer Identification Number(s) under the Agreement. Practice Name:_Grant County Street Address 35 C St NW City_ Ephrata _State WA_ Zip_ 98823 Taxpayer Identification Number(s) (TIN) 916001319 National Provider 1D (NPI): 1750268736 Service Location Billing Address for the Service Location (if different from above) .:Medical Grou " Name Medical Grou Name Grant County Grant County Street Address Street Address 35 C St NW 35 C St NW Ci Cit Ephrata Ephrata 'State and Zi :Code State and Z Code WA 98823 WA 98823 Phone Number '; Phone Number 509-754-2011 509-754-2011 `.TIN (If di event from above) National Provider ID'(NPI) ADDITIONAL MEDICAL GROUP LOCATIONS List BOTH the Service Location and the Billing Address for the Service Location Service Location Billing Address for the Service Location (if different from above) Gen.Amd.SMGA.BH. WA. 06.25 - 3 - UnitedHealthcare Confidential and Proprietary Phone Number Phone Number-. TIN:(jf drf e fer nt-froM above) National, Provi,der',ID (NPI) Gen.,4mdSMG,4.BH. WA. 06.25 - 4 - Un. itedHealth care Confidential and Proprietary v_..✓..i�.�..ii_. i_...:.s__ -"i.._ ..>....s�.,-,i _."....,i, i.-".. n... -,:. i. �ri-�":> ...�.i.....,�. ,..iW::.._i,�. �"//ii�ia ,a �:�.:�/. it Rsi ....�i .�/_G ,_..irii �iii _iii.Ci_iii...: .. ,..r _.._..._„-�_a..ii_.v. _.„�-_.__,. . �_:.... _.� .. _."_"_ __�_>... _, ,, �. ___�_. _... [dentify only if a common name and address appears on all Medical Group service location bills [hat utilize the Medical Group's Taxpayer Identification Numbers) under the Agreement. Practice Name:_Grant County Street Address 35 C St NW City_ Ephrata _State WA Zip_ 98823 Taxpayer Identification Number(s) (TIN) 916001319 National Provider Ill (NPI): 1750268736 Service Location Billing Address for the Service Location (if different from above) Medical GroupName Medical Group Name Grant County Grant Count Street Address` Street Address 35 C St NW 35 C St NW Cit Ci Ephrata Ephrata State and Zi '.Code Stateand Zi Code WA 98823 WA 98823 Phone Number Phone Number 509-754-2011 509-754-2011 :TIN `If di ferent rom above). National Provider ID (NPI) ADDITIONAL MEDICAL GROUP LOCATIONS FOR le H/SUD SERVICES ONLY List BOTH the Service Location and the Billing Address for the Service Location Service Location Billing Address for the Service Location (if different from above) 'Medical Groups Name Medical Group Name Street Address. Street Address � National Provider ID (NPI) � Medical Group Name I Medical Grouia Name Street Address Street Address Gen.Amd.SMGA.BH. WA.06.25 - 5 - UnitedHealthcare Confidential and Proprietary Gen.Amd.SMGA.BH. WA-06.25 - 6 - UnitedHealth care Confidential and Proprietary BEHAVIORAL HEALTH SERVICES AND PAYMENT ADDENDUM WASHINGTON MEDICAID AND CHIP BENEFIT PLANS This Behavioral Health Services and Payment Addendum (this "Addendum") sets forth the terms and conditions under which Medical Group will participate in one or more behavioral health networks to provide Covered MH/SUD Services (as defined below) to Customers enrolled in Washington Medicaid and CHIP Benefit Plans. This Addendum applies to the Washington Medicaid network. In the event of a conflict between the terms and conditions in this Addendum and the terms of the Agreement, including all other addenda, appendices and attachinents, the terms in this Addendum will control Medical Group's provision of Covered MH/SUD Services, except that the terms of any regulatory requirements appendix will control over any conflicting terms of this Addendum, as applicable. This Addendum does not apply to Covered Services other than Covered MH/SUD Services. ARTICLE 1 Definitions Unless otherwise defined in this Article 1, capitalized terms used in this Addendum have the meanings assigned to them in the Agreement. For purposes of this Addendum, the following definitions will apply: CMHC: A Community Mental Health Center. CMHC Provider: An employee of a CMHC who provides MH/SUD Services, but is not a CMHC Supervising Provider. CMHC Supervising Provider: A psychiatrist, psychologist, social worker, family or other therapist duly - licensed and qualified in the state in which MH/SUD Services are provided to Customers who practices as an employee of CMHC and has been approved as a CMHC Supervising Provider in writing by United. Covered MH/SUD Services: MH/SUD Services that are (i) Covered Services under a Benefit Plan (ii) provided at a Service Location listed in Appendix 4 of the Agreement as providing MH/SUD Services, and (iii) which are set forth in one or more Behavioral Health Service Payment Appendices attached to this Addendum. Emergency Care for Mental Health Condition: Covered MH/SUD Services provided for an individual, that, if not provided, would likely result in the need for crisis intervention or hospital evaluation due to concerns of potential danger to self, others, or grave disability according to chapter 71.05 RCW. Facility -based Provider: A health care professional, who is employed by or under contract or supervision to render MH/SUD Services to Customers. Facility -based Providers include, but are not limited to, emergency room physicians, pathologists, radiologists, anesthesiologists, certified registered nurse anesthetists ("CRNAs"), and intensivists. Facility Participating Provider: A health care professional, facility, or other organization that has a written Facility Participating Provider Agreement in effect with United, directly or through another entity, to provide MH/SUD Services to Customers. Group: Group -based Provider, and Group Participating Provider. Gen.Amd.SMGA.BH. WA. 06.25 - 7 - Un itedHealth care Confidential and Proprietary Group -based Provider: A health care professional, psychiatrist, psychologist, therapist or other behavioral health professional who is employed by or under contract or supervision by Group to render MH/SUD Services to Customers. Group Participating Provider: An entity, organization, group, partnership or affiliation however categorized, consisting of health care professionals, facilities, psychiatrists, psychologists, therapists or other behavioral health professionals that is duly -licensed or certified to provided MH/SUD Services wltll'111 the state such MH/SUD Services are provided, and who has a written Group Participating Provider Agreement in effect with United, directly or through another entity, to provide MH/SUD Services to Customers. Mental Health and Substance Use Disorder Services ("MH/SUD Services"): Health care services, treatment or supplies that are used to treat a mental health or substance abuse illness, condition or disease, MH/SUD Payment Policies: For purposes of this Addendum, MH/SUD Payment Policies are Payment Policies or other guidelines adopted by United for calculating payment of claims for Covered MH/SUD Services provided by Medical Group (including claims from Medical Group under this Addendum). The MH/SUD Payment Policies operate in conjunction with the specific reimbursement rates and terms set forth in the applicable Behavioral Health Services Payment Appendix to this Agreement. Like other Payment Policies, the MH/SUD Payment Policies may change from time to time as discussed in -the Payment of Claims provision of the Agreement. MH/SUD Protocols: For purposes of this Addendum only, MH/SUD Protocols are Protocols limited to those programs and administrative procedures adopted by United or a Payer to be followed Medical Group in providing Covered MH/SUD Services and doing business with United and PaVe_rs under this Addendum. These MH/SUD Protocols may include, among other things, credentialing and recredentialing processes, utilization management and care management processes, quality improvement, peer review, Customer grievance or concurrent review. The MH/SUD Protocols may change from time to time as described in the Agreement and this Addendum. MH/SUD Provider Manual: Those provisions of an administrative guide that apply to Covered MH/SUD Services will be made available to Medical Group online, WWW.UHCProvider.com, or upon request. Any changes to the manual will be made consistent with the terms of the Agreement. ARTICLE 2 MH/SUD Services 2.1 Provision of MH/SUD Services. Medical Group hereby acknowledges and agrees to cooperate and comply with all of the ten-ns and conditions of this Addendum and the Agreement as a participating provider for the provision of Covered MH/SUD Services to Customers as designated by United or Payer. At the request of a Payer, Medical Group may not be authorized to provide Covered MH/SUD Services for some or all of Payer's Customers. Medical Group will otherwise accept Customers as new patients on the same basis as Group is accepting -non-Customers as new patients without regard to race, religion, gender, color, national origin, age or physical or mental health status, or on any other basis deemed unlawful under federal, state or local law. At all times, Medical Group will require any employed or subcontracted MH/SUD providers to comply with the terms and conditions of this Addendum, all MH/SUD Protocols and MH/SUD Payment Policies, as may be set forth in the MH/SUD Provider Manual and the requirements of all applicable laws and regulations. Gen.Amd.SMGA.BH. WA.06.25 - 8 - UnitedHealth care Confidential and Proprietary 2.2 Cooperation with MH/SUD Provider Manual, MH/SUD Protocols, MH/SUD Payment Policies. Medical Group will be bound by, accept, strictly comply with, and cooperate with applicable MH/SUD Protocols and applicable MH/SUD Payment Policies, as may be set forth in the MH/SUD Provider Manual. The MH/SUD Protocols and MH/SUD Payment Policies will be made available to Medical Group online or upon request. Some or all MH/SUD Protocols and MH/SUHD Payment Policies also may be disseminated in the MH/SUD Provider Manual or in other communications. Currently, the MH/SUD Protocols and MH/SUD Payment Policies may be found at www.UHCProvider.com. United will notify Medical Group of Medical Group's failure to comply with the applicable MH/SUD Protocols or applicable MH/SUD Payment Policies may result in loss of or reduction of payment or reimbursement to Medical Group or the imposition of other corrective action by United To the extent that the provisions of the MH/SUD Provider Manual differ from this Addendum or the Agreement, the terms and conditions of the Agreement and this Addendum govern. For purposes of Covered MH/SUD Services, the MH/SUD Protocols and the MH/SUD Payment Policies control and supersede all other Protocols, Payment Policies or administrative manuals or guides, with the exception of Additional Manuals, if applicable as described in the Agreement. 2.3 Continuity of Care; Referral to Other Health Professionals. Medical Group will furnish Covered MH/SUD Services, providing continuity of care and ready referral of Customers to other participating providers as may be appropriate and consistent with the standards of care in the community. As appropriate, Medical Group will coordinate and exchange Customer data with Customer's primary care provider ("PCP"), to properly accomplish person -centered, integrated care. If a Customer requires additional services or evaluation, including Emergency Care for Mental Health Condition, Medical Group agrees to refer Customer to Customer's PCP or another participating provider in accordance with the terms and conditions of Customer's Benefit Plan. Medical Group will refer Customers requiring Emergency Care for Mental Health Condition to the "9-1-1" emergency response system. 2.4 Payment of Services. All payments obligated by Payer will be paid to Medical Group in accordance with the terms of the applicable Behavioral Health Services Payment Appendix to this Addendum and in accordance with applicable MH/SUD Payment Policies. Medical Group agrees to continue to provide MH/SUD Services to Customers who have exhausted his/her covered benefits under the Benefit Plan and agrees not to collect or charge more than the contracted rate for those MH/SUD Services. Medical Group may bill the Customer directly for those NIH/SUD Services for which there is no longer any coverage under the Benefit Plan, provided the Medical Group obtained the Customer's prior written consent. Each party agrees to defend, indemnify and hold the other party harmless for any claims, damages, actions, or judgments arising from any employee or contractor related to the provision of MH/SUD Services to Customers. ARTICLE 3 MH/SUD Submission of Claims. Medical Group will submit claims for Covered MH/SUD Services to United in a manner and format prescribed by United. [Medical Group agrees that claims received by United after the relevant time period(s) set forth in the Agreement may be rejected for payment, at United's and/or Payer's sole discretion. Gen.Amd.SMGA.BH. WA.06.25 - 9 - Un itedHealth care Confidential and PYoprietaq ARTICLE 4 Alcohol and Drug Abuse Patient Records Medical Group acknowledges that in receiving, storing, processing or otherwise dealing with information from United or Payer about Customers, it is fully bound by the provisions of the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as amended (the "Confidentiality to Kegulations ); an Medical Group agrees that it will resist in judicial p1vVCculI.Lgs ally GL1V1� VULaul t. information pertaining to patients otherwise than as expressly provided for in the Confidentiality Regulations. ARTICLE 5 Miscellaneous 5.1 Survival. Upon termination of the Agreement or this Addendum, the provisions herein, which contemplate performance or observance subsequent to termination, will survive and remain of frill force and effect between the parties. 5.2 Entire Agreement. On the Effective Date, this Agreement and this Addendum will supersede and replace any existing provider agreements between the parties related to the provision of Covered MH/SUD Services for Benefit Plans to which this Addendum applies as described in the preamble, including any agreements between Medical Group and United or a United Affiliate including United Behavioral Health. This Agreement, together with any and all attachments, addenda, appendices, as may be amended or modified from time to time, whether contemporaneous or subsequently made, are hereby incorporated herein by reference, and constitutes the entire agreement between the parties in regard to its subject matter. Gen.Amd.SMGA.BH. WA.06.25 -10 - Un itedHealth care Confidential and Proprietaq --INTERACTIVE COMPLEXITYINTERACTIVE COMPLEXITY (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE) ADDITION TO THE CODE•.PRIMARY PROCEDURE) Yii-- • '11 • PSYCHIATRIC • •1 •• •• 1 ® 1 1 -- DIAGNOSTIC • EVALUATION• Psychotherapy,Psychotherapy, 45 minutes with patient 1® - Psychotherapy, Psychotherapy, 45 minutes with patient when • with an evaluation and management service, add • Psychotherapy, 45 minutes with patient when performod with an evaluation and management service, add on 1 1 •' 1 1 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service, add on Psychotherapy, 45 minutes with patient when performed with an evaluation and management service, add on �=Ihiill"'Ifith nqticit w1hixerforiacd withan evaluation and manaaenwnt ad UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONAL REIMBURSEMENT SCHEDULE Multiple -Family Group Psychotherapy Multiple -Family Group Psychotherapy Multiple -Family Group Psychotherapy r���- t I r ■�■ 1 Group Psychotherapy Groupmultiple-Family Group Psychotherapy • •� ©� �� ... ...... ... .. � t , Group Psychotherapy (Other Than, Multiple -Family Group) 0 �-11 up Psychotherapy (Other Than, Multiple -Family Group) r�-Group(Other Narcosynthesis, Psychiatric IN arcosyn thesis, Psychiatric Dx & Therapeutic Purposes Not Priced Therapeutic repetitive transcranial magnetic stimulation treatment: planning 1 1 Therapeutic repetitive transcranial magnetic stimulation treatment; planning Therapeutic repetitive transcranial magnetic stimulation treatment; planning Therapeutic repetitive transcranial magnetic stimulation treatment; delivery and management, per session -- . : r - 1 1 . • - .. MM �herapeutic repetitive transcranial magnetic stimulation treatment; delivery and management, per session 0 �, ®■■�z■ His �WTHIERAPIEILITIC REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (TIVIS) TREATMENT; SUBSEQUENT MOTOR THRESHOLD RIE- •1: , -- (W/Monitoring); Single Seizure • • •r - Electroconvuls_ive Therapy (W/Monitoring); Single Seizure --Prep, Report, PsychiatricPatientPrep, I t r Prep, Report, Psychdatric Patient -pati Report, Psychiatric ent -Prep, 1 ,.• .� Prep, Report, Psychiatric Patient Developmental Testing; Limited, W/Interpretation & Report, Per Hr Developmental Testing; Limited, W/Interpretation & Report, Per Hr Developmental Testing; Limited, W/Interpretation & Report, Per Hr Developmental Testing; Limited, W/Interpretation & Report, Per Hr Developmental Testing; Limited, W/Interpretation & Report, Per Fir . ., Developmental Testing; Limited, W/Interpretation & Report, Per Hr executive functions by standardized 1 1 • , t t executive functions by standardized Developmenta I I est adirliru stration (inc I ud ing assessment o f fi ne arl or gross motor, language, co gniti ve leve 1, socia 1, memory and/or Developmental test admimstration (including assessment of fine and/or gross, motor, language, cognitive level, social. memory and/or executive functions by standardized ®_- rexe cutive functionsI 1 1 Developmental test administration (including assessment of fineand'or gross motor. language. cognitive level. social. memory and/or exe cutive fianction., by standardized executive functions by standardized executive functions by standardized memory, planning and problem solving, and v Neurobehavioral status exam (clinical assessment ofthinking, reirsoning andjudgment, [eg, acquired knowledge. attention, language, memory, planning and problem sohing, and N, Not Priced ,memory, planning and problem solving, and v ®_-Njeurobc�haviural status exam (clinical assessment ufthinking, reasoning and judgment. feg, memory, planning and problem sohing, and v acquired language,Not Priced Not Priced planning and problem solving, and v Not Priced memory,memory, ,1 1 . :1 Not Priced tir; Not Price ®�_ UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONALSCHEDULE ..... - - — - - — Neurcibehavioral language, memory, planning and problem solving, - - - - -- - — ---- — — — - - - -- m-ml planning and problem solving, . • ' —_'memory, planning and problem solving, —iiiij memory, planning and problem solving, • • memorl, planning and problem solving, ®®_mem.• ® • • It =,PER STANDARDIZED INSTRUMENT BRIEF EMOTIONAL/BEHAVIORAL ASSESSMENT (EG, DEPRESSION INVENTORY, ADHD SCALE), WITH SCORING AND DOCUMENTATION, PER STANDARDIZED INSTRUMENT PER STAN DARDIZED INSTRUMENT PER STANDARDIZED INSTRUMENT —_ 71111mmilgillinterpretation of standardized test interpretation of standardized ®—_rl Psychological testing evaluation services by physician or other qualified health care professional, including integration of pati nt data, interpretation of standardized test interpretation of standardized test Psychological testing evaluation services by phys�cian or other qualified health care professional, including integration of patient data, interpretation of standardized test Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test ®—_ • • • interpretation of standardized test for ='interpretation intperation of patient data of standardized test interpretation of standardized test P sycho I o gi ca I I esting c%,a I tia t i on scr,6c es by p by si ci a ii or o their qi ta I i tied heal th care pro fessiona 1, inc I rid i ng ini i i on of pa I ient da ta, interpretation ofsandardized test Psychological testing evaluation services by physician or other qualified licalthcareprotessional. including integration of patient data. interpretation ofslaridardized test I Psychological testing evaluation services by physician or other qualified health care professional, including integration of'patient data, interpretation of standardized test Neuropsychological testing evaluationservices bv physician or other qualified health care professional, includilig integrationol7patieut Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration oftiatient data, • • . �—data, • • , �—Neurupsychological testing evaluation set -vices by physician or other qualified health care professiunal, including integration ofpatient �data. • • .. �— Neurcipsychologicai testing evaluation services by physician or other qualified health care professional. Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardize —_ Neur•, •atient data, interpretation of standardize • • Neuropsychological testing evaluation services by physician or other qualified health care professional, including integrat patient data, interpretation of standardize Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of ®_•Neurcipsychological at�ientdata, interpretation of standardize Neurcipsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardize l_.. Neur®. .. sychological testing evaluation services by physician or other qualified health care professional, including integration of . •. . testingNeu ro psychological evaluation services by physician or other qualified health care professional, including integrati n of • of Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes Psychological or neuropsychological test administration and scoring by physician other qualified health care professional, two or more tests, any method; first 30 minutes Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes Psychological or neurcipsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes Psychological orhealth care professional, two or more tests, any method; first 30 minutes is I • • Psychological or neu ro psychological test administration and scoring by physician or other qualified health care professional, .. more tests, any method; first 30 minutes • • • Psychological or neurcipsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes Psychological or neurcipsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method; first 30 minutes 1 • • tests. any triethod each additional 30 ®_— Psychological or neuropychologicial test ach �andl —scoring by phylicianorother qualified health care professional. two or more tests, any method each additional 30 tests, any method each additional 30 psychological or neuropsychological test administration and scoring by pliyqcian or other qualified health care professional. two or more tests, any tilethod each additional .3 0 ®�— psychological.. i i ��- `'�. ��_ , �.._ UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONALSCHEDULE Psychotherapy with patient and/or family member (each additional 15 minutes) it addition to -� ®� .. ®� ..it addition toFa i Psychotherapy without Patient (initial 30 minutes) .. Family Psychotherapy without Patient (initial 30 minutes) 'Family Psychotherapy without Patient (initial 30 minutes) Family without patient present, face to face (initial 30 minutes) Familywithout patient present, face to face (initial 30 minutes) Family without patient present, face to face (initial 30 minutes) Family without patient present, face to face (initial 30 minutes) Family without patient present, face to face (initial 30 minutes) Family without patient present, face to face (initial 30 minutes) Family without patient present, face to face (initial 30 minutes) Family without patient present, face to face (initial 30 minutes) Family Psychotherapy without Patient (each additional 15 minutes) Family Psychotherapy without Patient (each additional 15 minutes) Family Psychotherapy without Patient (each additional 15 minutes) Family Psychotherapy without Patient (each additional 15 minutes) :Familywithout patient present,face to face (each additional 15 minutes) Family without patient present, face to face (each additional 15 minutes) 173111ily WilhOUt patient present, face to face (each additional 15 minutes) Farruily without patient presexit. face to fjce�difional 15 minutes) Family without patient present, face to face (each additional 15 minutes) Family without patient present, face to face (each additional 15 minutes) 7amily without patient present, face to face (each additional 15 �minutes) ... Family without patient present, face to face (each additional 15 minutes) Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcu taneous or Intramuscular Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcutaneous or Intramuscular Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcutaneous or Intramuscular Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcutaneous or Intramuscular Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcutaneous or Intramuscular Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcutaneous or Intramuscular Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcutaneous or Intramuscular Therapeutic, Prophylactic, or Diagnostic Injection (Specify Substance or Drug); Subcutaneous or Intramuscular ®-_ Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physiciaris 6 ®-_ Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the • . . ®-_professional,Behavior identification assessment, administered by a physician or other qualified health care • administered. -Behavior identification assessment, physicians ®-_ Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-t -face with one patie I I ®-__professional, face-to-face with one patie ------- face-to-face with one patie protocol,professional, Group adaptive behavior treatment by :health care professional, face-to-face �. protocol,Group adaptive behavior treatment by health care professional, face-to-face Group adaptive behavior by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face Group adaptive behavior treatment by protocol, administered by tZhZicliMnunder the direction of a physician or other qualified health care professional, face-to-face Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face Group a protocol, a by technician tinder the direction ofa physicilnorotherclualified UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONAL• New patient outpatient visit, total time 15-29 minutes New patient outpatient visit, total time 15-29 minutes �New patient outpatient visit, total time 15-29 minutes New patient outpatient visit, tota I time 15-29 minutes New patient outpatient visit, total time 15-29 minutes New patient outpatient � isit, total time 3044 minut es New patient outpatient visit, total time 3044 minutes �New patient Outpatient ViSit, total time 3044 rninute, New patient outpatient visit, total time 30-44 millutc.q Ne w patient outpatient visit, total time 30-44 minutes New patient outpatient visit, total time 30-44 minutes New patient outpatient visit, total time 30-44 m in utes New patient outpatient visit, total time 30-44 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 45-59 minutes New patient outpatient visit, total time 60-74 minutes New patient outpatient visit, total time 60-74 minutes New patient outpatient visit, total time 60-74 minutes New patient outpatient visit, total time 60-74 minutes New patient outpatient visit, total time �0-74 minutes --New patient outpatient visit, total time •' -. New patient outpatient visit, total time 60-74 minutes •' �� New patient outpatient visit, total time 60-74 minutes -�Established patient outpatient visit, minimal presenting problemEstablished patient outpatient visit, minimal presenting problem -�Established patient outpatient visit, minimal presenting problem Established patient outpatient visit, minimal presenting problem Established patient outpatient visit, minimal presenting problem Established patient outpatient visit, minimal presenting problem Established patient outpatient visit, minimal presenting problem Established patient outpatient visit, minimal presenting problem Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 10-19 minutes shed patient outpatient visit, total time- 10-19 minutes Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 10-19 minutes Established patient outpatient visit, total time 20-29 minutes Established patient outpatient visit, total time 20-29 minutes UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONAL REIMBURSEMENT SCHEDULE -S.bscqmrit - Hosp Care 2+ Key Components: Expand Prob FocLLq Int Hx�Expand Prob ExamI Dec Mod Complex Subsequent Hosp Care 2+ Key Cotinponents:Expand Prob Focus Lot Hx;Expand Prob Exarn;-Med Dec Mod Complex Subsequent Hosp Care-2+ Key Components: Detailed IntervI Hx: Detailed Exam:Med Decision High Complex Subsequent Hosp Care 2+ Key Components: Detailed Interd Hx: Detailed Exarri Decision High Complex Subsequent Hosp Care 2+ Key Components: Detailed Inter-0 Hx-- Detailed ExamNed Decision High Complex Subsequent Hosp Care 2� Key Coirponcrits: Detailed Iri Hx: Detailed Exani;Med Decision High Complex Subsequent Hosp Care 2- Key Components: Detailed IrI Hx� Detailed ExamNed Decision High Complex Subsequent Hosp Care 2+ Key Components: Detailed Intervi Hx; Detailed Exam;Med Decision H igh Complex O1 1" • 1 D• • Dec• 1' •1 • • Decision Obsv/lnpt Hosp Care 3 Key Components: Comprehensive Comprehensive Exam; Med Decision Mod Complex ,Obsv/lnpt Hosp Care 3 Key Components: Comprehensive Hx; Comprehensive Exam; Med Decision High Compix Obsv/Inpt Hosp Care 3 Key Components: Comprehensive Hx; Comprehensive Exam; Med Decision High CompIx ®_- Hospital Discharge 1. 1 MinNot 1. 1' Priced Hospital Discharge Day Management; Up To 30 Min Hospital Discharge Day Management; Up To 30 Min Hospital Discharge Day Management; Up To 30 Min Hospital Discharge Day Management; Up To 30 Min OS Discharge 1 I Min Discharge Day Management, > 30 Min Hospital Discharge Day Management; > 30 Min Hospital Discharge Day Management; > 30 Min ot Priced Hospital Discharge Day Management; > 30 Min Office Consultation, 3 Key Components: Expand Prob Focus Rx�Expand Prob Focus Exam.;Sirffivd Med Decisn Office Consultation, 3 Key Coniponents:Expand Prob Focus Hx�Expand Prob Focus Exan6irtAviJ Mud Decisn Office Consultation. 3 Key Components: Expand Prob Focus Hx:Expand Prob Focus Exain;Strt-fWd Med Decisn office Consultation. 3 Key Components:Expand Prob Focus Hx�Expaiid Prob Focus Exja0trtAvd Med Decim Office Consultation, 3 Key Componcrits: Detailcd Hx: Detailed Exam Med Decision Low Complexity Office Consultation, 3 Key Components: Detailed Hx, Detailed Exam; Med Decision Low Complexity :Office Consultation, 3 Key Components: Detailed Hx; Detailed Exam; Med Decision Low Complexity Office Consultation, 3 Key Components: Detailed Hx; Detailed Exam; Med Decision Low Complexity !Office Consultation, 3 Key Components: Detailed Hx; DetailedExam; Med Decision •• Low •III •11 OfficeHospital `• Decision Mod Complex/ • It Office Consultation, 3 Key Components:Comprehensive Hx; Comprehensive Exam; I Decision Mod Complex Office Consultation, 3 Key Components:Comprehensive Hx; Comprehensive Exam; Med Decision Mod Complex Office Consultation, 3 Key Components: Comprehensive Hx;Comprehensive Exanri Decision High Complex Office Consultation, 3 Key Components: Comprehensive Hx;Comprehensive Exam;Med Decision High Complex --Office 3 Key Components: Comprehensive• •1 Decision High Complex1 1 1 1 • I II --� r• •1• • --Office Co In • • Decls ion H igh Co mplex ® 1 1 • • • 1 1 Initial Inpt Consult, 3 Key Components: Expand Prob Focus Hx;Expand Prob Focus Exam;Strtfwd med Decis ®--Initial that Consult,• •• 'rob • Med Decis1 1 •' '1 • 'I --Initial that Consult,• • •r • • 'd Decis • �� Anitial Inpt Consult, 3 Key Components: Expand Prob Focus Hx; Expand Prob Focus Exam;Strtfwd I Decis Initial Inpt Consult, 3 Key Components: Detailed Hx; Detailed Exam; Med Decision Low Complex Initial Inpt Consult, 3 Key Components: Detailed Hx; Detailed Exam; I Decision Low Complex ®__initial Inpt Consult, 3 Key Components: I Detailed • Decision Low Complex1 1 •. UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONALSCHEDULE Initial Inpt Consult, 3 Key Components: Detailed Hx; Detailed Exam; Med Decision Low Complex ------- -- - Initial Inpt Consult, 3 Key Components: r- .- . Decision Initial Inpt Consult, 3 Key Components: Detailed Hx; Detailed Exam; Med Decision Low Complex Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam; Med Decision Mod Complex Ir Init al Inpt Consult, 3 Key Components;Comprehensive Hx;Comprehensive Exam; Med Decision Mod Complex !Initial Inpt Consult, 3 Key Components:Comprehensive Hx; Comprehensive Exam; Med Decision Mod Complex Initial Inpt Consult, 3 Key Components: Corn prehensive Hx;Comprehensive Exam; Med Decision Mod Complex Mums Ma. ilLer-Tiun tal.-MIN11 Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam; Med Decision Mod Complex Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam; Med Decision Mod Complex Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam;Med Decision High Complex Not Priced Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam;Med Decision High Complex 'Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam;Med Decision High Complex Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam;Med Decision High Complex Not Priced Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exam;Med Decision High Complex Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exarri Decision High Complex Initial Inpt Consult, 3 Key Components:Comprehensive Hx;Comprehensive Exarri Decision High Complex Not Priced Emergency Dept Visit, 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Emergency Dept Visit, 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Emergency Dept Visit, 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Emergency Dept Visit, 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision 'Emergency Dept Visit, 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Emergency Dept Visit, 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Emergency Dept Visit,3 Key Corn ponents: Expa nd Prob Focus Hx; Expand Prob Focus Exam; Med Dec Low CompIx Not Priced Emergency Dept Visit,3 Key Components:Expand Prob Focus Hx;Expand Prob Focus Exam;Med Dec Low CompIx Emergency Dept Visit,3 Key Corn ponents:Expa nd Prob Focus Hx; Expand Prob Focus Exam; Med Dec Low CompIx . , Emergency Dept Visit,3 Key Components:Expand Prob Focus Hx;Expand Prob Focus Exam;Med Dec Mod Compix Emergency Dept Visit,3 Key Components:Expand Prob Focus Hx;Expand Prob Focus Exam;Med Dec Mod Complx Emergency Dept Visit,3 Key Components: Expa nd Prob Focus Hx; Expand Prob Focus Exa m; Med Dec Mod Complx Emergency Dept Visit,3 Key Components:Expa nd Prob Focus Hx; Expand Prob Focus Exam; Med Dec Mod CompIx 'ER visit, 3 key components: detailed DX; exam; med decision mod complexity; counseling and/or coord of high severity presenting problem but no sig2ificant threat to life/funct ER visit, 3 key components: detailed DX; exam; med decision mod complexity; counseling and/or coord of high severity presenting problem but no si'nificant threat to life/funct ® _... ER visit, 3 key components: detailed i ® _ .. complexity; counseling and/or coord of high severity presenting problem to ® ri exam;complexity; UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONAL REIMBURSEMENT SCHEDULE nursing facility care, detailed/comp history; detailed/comp exam; decision making straightforward/low complexity Initial Initial nursing facility care, per day, comp history; comp exam; and medical decision making of moderate complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of moderate complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of moderate complexity Initial nursingfacility care, per day, comp history; comp exam; and medical decision making of moderate complexity Fill -r.4 a, n mmm! K-111-AZLTUM Initial nursing facility care, per day, comp history; comp exam; and medical decision making of moderate complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of moderate complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of moderate complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of moderate complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of high complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of high complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of high complexity Not Priced i itial nursing facility care, per day, comp history; comp exam; and medical decision making of high complexity Initial nursing facility care, per day, comp history; comp exa m; and medical decision making of high complexity Initial nursing facility care, perday,comp history; comp exam; and medical decision makingofhigh complexity Initial nursing facility care, per day, comp history; comp exam; and medical decision making of high complexity Ini tial nursing facility care, per day, comp history; comp exam; and medical decision making of high complexity ;Subsequent nursing facility care, per day, 2 of: problem focus history; problem focus exam; straightfwd decision making Subsequent nursing facility care, per day, 2 of; problem focus history; problem focus exam; straightfwd decision making Subsequent nursing facility care, per day, 2 of: problem focus history; problem focus exam; straightfwd decision making Subsequent nursing facility care, per day, 2 of: problem focus history, problem focus exam; straightfwd decision making Subsequent nursing facility care, per day, 2 of: problem focus history; problem focus exam; straightfwd decision making �Subsequent nursing facility care, per day, 2 of: problem focus history; problem focus exam; straightfwd decision making Subsequent nursing facility care, per day, 2 of: problem focu hisjor7- —probiem focus exam; straightfwd decision making Subsequent nursing facility care, per day, 2 of: problem focus history; problem focus exam; straightfwd decision making Subsequent nursing facility care, per day, 2 of: problem focus history; problem focus exam; straightfwd decision making S ubsequent nUrsi ng fac i I ily care, per day, 2 of, expdd prob] em focus lix; expdd problem Focus exam� low deui sion ma k ing Not Priced libseqUent nursing facility care. per day, 2 of-. expdd problem fOCLL% EX� expdd problem focus exam; low decision making, Subsequent nursing facility care, per day, 2 of expdd problem Ifocus lix; expdd problem focus cxaiix low decision making SlAbsequent nursing facility care, per day, 2 of: expdd problem focus hx; expdd problem focus exam; low decision making zlmflffl� a Subsequent nursing facility care, per day, 2 of: expdd problem focus hx; expdd problem focus exam; low decision making Subsequent nursing facility care, per day, 2 of: expdd problem focus hx; expdd problem focus exam; low decision making Subsequent nursing facility care, per day, 2 of: detailed history; detailed exam; moderate medical decision making Subsequent nursing facility care, per day, 2 of: detailed history; detailed exam; moderate medical decision making Subsequent nursing facility care, per day, 2 of: detailed history; detailed exam; moderate medical decision making Subsequent nursing facility care, per day, 2 of: detailed history; detailed exam; moderate medical decision making Subsequent nursing facility care, per day, 2 of: detailed history; detailed exam; moderate medical decision making ... Subsequent nursing facility care, per day, 2 of� detailed history; detailed exam; moderate medical decision making Subsequent nursing facility care, per day, 2 of: detailed history; detailed exam; moderate medical decision making Not Priced Subsequent nursing facility care, per day 2 of: detailed history; detailed exam; moderate medical decision making Not Priced �Subsequent nursing facility care, per day, 2 of: detailed history; detail exam; moderate medical decision making Sub sequent nursing facility care, per day, 2 of: detailed history; detailed exam; moderate medical decision making Subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical decision making of high complexity Subsequent nursing facility care, per day, 2 of: comp history: comp exam; medical decision making of high complexity Subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical decision making of high complexity :Subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical decision making of high complexity Subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical decision making of high complexity Subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical decision making of high complexity ... subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical ecision making of high complexity !Subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical decision making of high complexity Subsequent nursing facility care, per day, 2 of: comp history; comp exam; medical decision making of high complexity Subsequent nursing facility care, per day, 2 of: comp history: comp exam; medical decision making of high complexity UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONALSCHEDULE Nursing Facility Discharge Day Management; 30 Min Or < Not Priced Nursing Facility Discharge Day Management; 30 Min Or < Nursing Facility Discharge Day Management; 30 Min Or < Nursing Facility Discharge Day Management; 30 Min Or < Nursing Facility Discharge Day Management; 30 Min Or < Nu sing Facility Discharge Day Management; > 30 Min Nursing Facility Discharge Day Management; > 30 Min Nu sing Facility Discharge Day Management; > 30 Min Not Priced Not Priced Domiciliary/rest home visit, new patient, problem focus history; problem focus exam; straightforward decision making 711 Domiciliary/rest home visit, new patient, problem focus history; problem focus exam; straightforward decision making Domiciliary/rest home visit, new patient, problem focus history; problem focus exam; straightforward decision making Dom !cilia ry/rest home visit, new patient, expdd problem focus history; expdd problem focus exam; low decision making Dom i cilia ry/rest home visit, new patient, expdd problem focus history; expdd problem focus exam; low decision making Domiciliary/rest home visit, new patient, expdd problem focus history; expdd problem focus exam; low decision making Domiciliary/rest home visit, new patient, detailed history; detailed exam; decision making of moderate complexity Not Priced Domiciliary/rest home visit, new patient, detailed history; detailed exam; decision making of moderate complexity �Dom—lcl h—o—m—evisit, new patient, detailed history; detailed exam; decision making of moderate complexity 1 Domiciliary/rest home visit, new patient, detailed history; detailed exam; decision making of moderate complexity Domiciliary/rest home visit, new patient, camp history; camp exam; decision making of moderate complexity 11:1111 Mil Domiciliary/rcst home viqt, new patient, camp history; comp exani; decision making ofmodcrate complexity Domiciliary/rest home visit, new patient. camp history. camp exam; decision making ofmoderate complexity 1 Domiciliary/rest home visit, new patient, camp history; camp exam; decision making of high complexity Not Priced I Domiciliary/rest home visit, new patient, camp history, camp exam; decision making of high complexity Domiciliary/rest home visit, new patient, camp history; camp exam; decision making of high complexity Domiciliary/rest home visit, est patient, 2 of: problem focus history; problem focus exam; stfwd medical decision making Domiciliary/rest home visit, est patient, 2 of; problem focus history; problem focus exam; stfwd medical decision making Domiciliary/rest home visit, est patient, 2 of: problem focus history; problem focus exam; stfwd medical decision making Not Priced 7 1 1 Domiciliary/rest home visit, est patient, 2 of; expdd history; expdd exam; low decision making Domiciliary/rest home visit, est patient, 2 of: expdd history; expdd exam; low decision making Domiciliary/rest home visit, est patient, 2 of: expdd history; expdd exam; low decision making Domiciliary/rest home visit, est patient, 2 of: expdd history; expdd exam; low decision making M ��MiDom — iciliary/rest home visit, est patient, 2 of! detailed history; detailed exam; mod decision making Domiciliary/rest home visit, est patient, 2 of: detailed history; detailed exam; mod decision making Domiciliary/rest home visit, est patient, 2 of: detailed history; detailed exam; mod decision making Domiciliary/rest home visit, est patient, 2 of: detailed history; detailed exam; mod decision making Domiciliary/rest home visit, est patient, 2 of: camp history; camp exam; mod to high decision making Do iciliary/rest home visit, est patient, 2 of: camp history; camp exam; mod to high decision making Not Priced DomiciliarV/rest home visit, est patient, 2 of: camp history; camp exam; m ad high decision making to . . Domiciliary/rest home visit, est patient, 2 of: camp history; camp exam; mod to high decision making i Home Visit New Pt 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtwd Med Decision Home Visit New Pt 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Home Visit New Pt 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Not Priced • ,- ■■ Home Visit New Pt 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision Home Visit New Pt 3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision a I Home Visit New Pt-3 Key Components: Prob Focus Hx; Prob Focus Exam; Strtfwd Med Decision I �-Home Visit New Pt 3 Key Components: Prob Focus. . Decision �-I •. Home Visit New Pt 3 Key Components:Expand Prob Focus Hx;Expand Prob Focus Exam; Med Decn Low Complex ��� Decn Low Complex UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONALSCHEDULE UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON•• THE UNINSURED BEHAVIORAL HEALTH PROFESSIONALSCHEDULE Home Visit Est Pt 2+ Key Components: Comprehensive Hx; Comprehensive Exam; Mod/High Complexity Home Visit Est Pt 2+ Key Components: Comprehensive Hx; Comprehensive Exam; Mod)�High Complexity Home Visit Est Pt 2+ Key Components: Comprehensive Hx; Comprehensive Exam; Mod/High Complexity Home Visit Est Pt 2+ Key Components: Comprehensive Hx; Comprehensive Exam; Mod/High Complexity Ph sician Standby Service, W/Prolonged Physician Attendance, Each 30 Min Not Priced Medical Team Conference, Face -To -Face with Patient and/or Family, 30 Min or More, Participation by Nonphysician Medical Team Conference, Face -To -Face with Patient and/or Family, 30 Min or More, Participation by Nonphysician Medical Team Conference, Face -To -Face with Patient and/or Family, 30 Min or More, Participation by Nonphysician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Physician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Physician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Physician 'Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Physician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Physician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Physician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Nonphysician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Nonphysician Medical Team Conference, Patient and/or Family Not Present, 30 Min or More; Participation by Nonphysician ,Physician Supervision, Patient, Home Health Agency; 30+ Min Physician Supervision, Patient, Home Health Agency; 30+ Min :Physician Supervision, Hospice Patient; 30+ Min Physician Supervision, Hospice Patient; 30+ Min Physician Supervision, Nursing Facility Patient; 30+ Min Physician Supervision, Nursing Facility Patient; 30+ Min Not Priced Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; Infant < I Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; Infant < 1 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; Infant < 1 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; Infant < 1 Yr �Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; Infant < 1 Yr :Initial Comprehensive Preventive Medicine E&MW/Hx/Exam, New Pt; 1-4Yr Initial Comprehensive Preventive Medicine E&MW/Hx/Exam, NewPt; 1-4Yr Tn'iiial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 1-4 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 1-4 Yr Not Priced Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 1-4 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 5-11 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 5-1 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 5-11 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 5-11 Yr Not Priced 177fial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 5-11 Yr Not Priced Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 5-11 Yr Initial Comprehensive Preventive Medicine E&M-W--/Hx/Exam, New Pt; 12-17 Yr initial Comprehensive Preventive Medicine E& M W/Hx/Exam, New Pt; 12-17 Yr initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 12-17 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 18-39 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 18-39 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 18-39 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 18-39 Yr Initial Comprehensive Preventive Medicine E&M W/Hx/Exam, New Pt; 1 8-39 Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; Infant < 1 Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; Infant < I Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; Infant < I Yr !Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; Infant < I Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; Infant < 1 Yr Not Priced iodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; Infant < I Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; 1-4 Yr UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONAL REIMBURSEMENT SCHEDULE Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; 1-4 Yr ---------- - ffm 7-3: F3 0 1 LVITI; 171 [x F1 0 1 zi a 'A a�illlllllllllll Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; 1-4 Yr Periodic Comprehensive Preventive medicine E&M W/Hx/Exam, Est Pt; 1-4 Yr Not Priced Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; 1-4 Yr Periodic Comprehensive Preventive Medicine E&M W/Chx/Exam, Est Pt; 5-11 Yr Periodic Comprehensive Preventive Medicine E&M W/Chx/Exam, Est Pt; 5-11 Yr Pericidic Comprehensive Preventive Medicine E&M WChx/Exam. Est Pt� 5-11 Yr Pericidic Comprehensive Preventive Medicine F&M WiChx/Exam. Est Pt: 5-11 Yr Not Priced Periodic Comprehensive Prn,entive Medicine E&M W/Chx/Exani. Est P t: 5-1 1 Yr Periodic Comprehensive Prevent ive Medicine E& M w6=7mt 5--11 Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam. Est Pt, 12-17 Yr Periodic Comprehensive Preventive Medicine E&NI W144x'Exam, Est Pt; 12-17 Yr Periodic Compreheusive Preventive Medicine E&M WHxExarrL Est Pt; 12-17 Yr Periodic Curnprehersivc Preventive Medicine E&NI W/Hx/Exam, Est Pt� 1.2-17 Yr Periodic Comprehensive Preventive Medicine E&NIT W/Hx/Exani. Est Pt� 12-17 Yr P riodic Comprehensive Preventive Medicine E&M WIlIx/Exatill Est Pt; 18-39 Yr Periodic Cornpreherl Preventive Medicine E&.\4 W/HxiExarrL Est Pt; 18-39 Yr Periodic Cumpreliensive Preventive Medicine E&M W/Hx/Exam, Est Pl 18-39 Yr Not Priced Pel Comprehensive Preventive Medicine E&M W/14-(/Exam. Est Pt� 18-39 Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; 18-39 Yr Periodic Comprehensive Preventive Medicine E&M W/Hx/Exam, Est Pt; 18-39 Yr Preventive Medicine Counseling, Indiv; 15 Min Preventive Medicine Counseling, Indiv; 15 Min Not Priced Preventive Medicine Counseling, Indiv; 15 Min Preventive Medicine Counseling, Indiv; 15 Min Smoking and Tobacco Use Cessation Counseling Visit; Intensive, Greater than 10 Minutes Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; 15 to 30 Minutes ;Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; 15 to 30 Minutes Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; 15 to 30 Minutes ,Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; 15 to 30 Minutes lAlcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; 15 to 30 Minutes Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; Greater than 30 Minutes Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; Greater than 30 Minutes lcohol and/or Substance Abuse Structured Screening, and Brief intervention (SBI) Services: Greater than 30 Minutes Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; Greater than 30 Minutes lcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI) Services; Greater than 30 Minutes Alcohol and/or Substance Abuse Structured Screening, and Brief Intervention (SBI� Services: Greater than 30 Minutes .. - . . - . - 111111111 1 i I Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond t he required time of t service Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact b yond the required time of the primary service Prolonged inpatient or observation evaluation and management sel time with or without direct patient contact bey required time of the primary service miclephone Evaluation and Management Service Provided by a Physician; S-10 Minutes of Medical Discussion Not Priced Telephone Evaluation and Management Service Provided by a Physician; 5-10 Minutes of Medical Discussion M� 5111VITIMP-M. Telephone Evaluation and Management Service Provided by a Physician; 5-10 Minutes of Medical Discussion 'Telephone Evaluation and Management Service Provided by a P icial 5-10 Minutes of Medical Discussion Telephone Evaluation and Management Sel Provided by a Physician; 5-10 Minutes of Medical Discussion Te I eplione Eva I tiat ion and Mana gement Se rvii ce P rovid ed by a P hysic inn; 11 -20 Nhnut es o IF Medi ca I Di scussion Telephone Evaluation and Management SeiMce Provided by a Physician. I 1 -.10 Minutes o(Medical Discussion Telephone Evaluation and Management Service Provided by a Physician. 11 -20,10trutes ofMedical Discussion Tel ephone Eva I uat ion and Management Service Prov ided by a Physician; 11 -20 M i nutes of Medical Discussion Telephone Evaluation and Management Service Provided by a Physician; 11-20 Minutes of Medical Discussion :Telephone Evaluation and Management Service Provided by a Physician; 11-20 Minutes of Medical Discussion le —phone Evaluation and Management Service Provided by a Physician; 21-30 Minutes of Medical Discussion Not Priced 99443 Telephone Evaluation and Management Service Provided by a Physician; 21-30 Minutes of Medical Discussion 0-20/IP 43.79 Not Priced Not Priced 43.79 Ucohol And/Or Drug Asqc.v, Alcohol And/Or Drug Assess UNITED HEALTHCARE WASHINGTON MEDICAID r WASHINGTON BENEFIT PLANS FOR THE UNINSUREDBEHAVIORAL •• •SCHEDULE Behavioral Health Counseling &Therapy lie ach 15 minutes) .•.• �- Behavioral Health Counseling& Therapy (each 15 minutes) .r�• --Alcohol And/Or. . . • And/Or Drug Services ...• ®-,Alcohol And/orDrug ServicesAlcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services ... • . And/or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol Ani Drug Senlices Alcohol Andior Drug Sen.-ices Alcohol Andi Drug Semces :Alcohol And/Or Drug Services Alcohol Anil Drug Smices Alcohol And,,Or Drug Services Alcohol And/Ot Drug Services lcohol Anil Drug Services Alcohol AnciOr Dnig Services -Alcohol AndiOr Drug Services Alcohol And, Or Drug Semice, Behavioral health; short-term residential (nonhospital residential treatment program). without room and board. per diem Behavioral heatft short-term residential (nonhospital residential treatment program), without room and board, per them Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per them Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per them Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per them Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per them Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per them Behavioral health; short-term residential (nonhospital residential treatm ent program), without room and board, per them ������Wcohol And/Or Drug Services ..-• AlcoholAlcohol Drug Services ..-Alcohol And/OrDrug Services UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONALSCHEDULE Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And, Or Dr-ug Services -AJcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or Drug Services Alcohol And/Or. And/Or Drug Sen,ices ,Alcohol And/Or Drug Services Alcohol And/Or Drug Services And/OrAlcohol Alcohol Drug Services Alcohol And,'Or Drug Sen,ices Alcohol And/Or Drug Training n' hol And/Or Drug Training Alcohol And/Or Drug Outreach Alcohol And/Or Drug Outreach ������Alcohol And/Or Drug Outreach Alcohol And/Or Drug Outreach Alcohol And/Or Drug Ou treach Alcohol And/Or Drug Preventi �W'Alcohol And/Or Drug Preventi Or .. �■ Alcohol And/Or Drug Preventi Alcohol And/Or Drug Preventi Alcohol And/Or Drug Preventi ��:Alcohol And/Or Drug Preventi icohol And/Or Preventi ., •Drug mmw ��IAIcohol And/Or Drug Preventi Alcohol And/Or Drug Hotline ,, , �� Drug Hotline �������Alcohol And/Or Drug Hotline ��'Alcohol And/Or Drug Hotline It Mental Health Assessment, By Non -Physician . , „■� .. . Mental Health Service Plan Development� ■ , R .._ UNITED HEALTHCARE WASHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEALTH PROFESSIONAL REIMBURSEMENT SCHEDULE T2007 Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2) hour increments 0-20/01' 8.66 8.66 8.66 8.66 T2007 Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2) hour increments 21-999/IP 8.66 8.66 8.66 8.66 T2007 Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2) hour increments 21-999/OP 8.66 8.66 8.66 8.66 T2038 Community transition, waiver; per service 0-20/I1) 30.12 30.12 30.12 30A2 T2038 Community transition, waiver; per service 0-20/OP 30.12 30.12 30.12 30.12 T2038 Community transition, waiver; per service 21-999/IP 30.12 30.12 30.12 30.12 T2038 Community transition, waiver; per service 21-999/013 30.12 30.12 30.12 30.12 00001 CDC 2019 Novel Coronavirus (2019-nCoV) Real -Time RT-PCR Diagnostic Panel 0-20/IP 34.87 Not Priced Not Priced 34.87 00001 CDC 2019 Novel Coronavirus (2019-nCoV) Real -Time RT-PCR Diagnostic Panel 0-20/OP 34.87 Not Priced Not Priced 34.87 00001 CDC 2019 Novel Coronavirus (2019-nCoV) Real -Time RT-PCR Diagnostic Panel 21-999/IP 34.87 Not Priced Not Priced 34.87 00001 CDC 2019 Novel Coronavirus (2019-nCoV) Real -Time RT-PCR Diagnostic Panel 21-999/OP 34.87 Not Priced Not Priced 34.87 00002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all 0-20/IP 49.81 Not Priced Not Priced 49.81 00002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique. multiple types or subtypes (includes all 0-20/OP 49.81 Not Priced Not Priced 49.81 00002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all 21-999/IP 49.81 Not Priced Not Priced 49.81 00002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all 21-999/OP 49.81 Not Priced Not Priced 49.81 1) The listing of a service or CPT code above does not guarantee that it will be covered under every account -specific plan. To be reimbursable, a service provided to a beneficiary must be a covered benefit under the beneficiary's benefit plan. Lesser of logic applies. All reimbursements are less patient responsibility and represent the total allowable reimbursement, including patient responsibility, for all pre -authorized services only. Patient responsibility represents the applicable co -payment, coinsurance, and/or deductible, and is determined by type of insurance and/or benefit plan. Reimbursement: There will be reimbursement for the transmission fee at the originating site + MH services provided based upon rates above. There will be no facility fee reimbursement for the distant site. Claim and encounter submission is based upon the Washington Health Care Authority published IMC Service Encounter Reporting Instructions (SERI) and/or state published billing guidelines. Modifiers HA - Child/Adolescent Program HD- Pregnant and Parenting Women HF - Susbtance Abuse Program HV- funded State addiction UC- State defined 52- Reduced Services 53- Discontinued Procedure H9- Court ordered HE- Mental health HH- MH/SA integrated HT- Multi -disciplinary team HW- Funded by state mental health agency HZ- Funded by criminal justice account U5- Medicaid level of care 5, as defined by each state US -Medicaid level of Bare 8, as defined by each state U9- Medicaid level of care 9, as defined by each state UA- Medicaid level of care 10, as defined by each state UI3- Medicaid level of care 11, as defined by each state UD- Medicaid level of care 13, as defined by each state