HomeMy WebLinkAboutAgreements/Contracts - GRIS (002)/0
A K21-063
MOLINA HEALTHCARE OF WASHINGTON, INC.
PROVIDER SERVICES AGREEMENT
This Provider Services Agreement ("Agreement") is entered by and between Molina Healthcare of Washington,
Inc., a Washington corporation ("Health Plan"), and County of Grant ("Provider"). The purpose of this
Agreement is to make available Covered Services to Members according to the terms and conditions set forth
below.
RECITALS
A. Health Plan arranges for the provision of certain health care services to Members pursuant to contracts
with various government sponsored health programs. Health Plan intends to participate in additional
government sponsored health programs and offer other health products as the opportunities become
available.
S. Health Plan arranges for the provision of certain health care services to Members by entering into
provider service agreements with individual physicians, groups of physicians, individual practice
associations, hospitals, clinics, ancillary health providers, and other health providers.
C. Provider is licensed to render certain health care services and desires to provide such services to Health
Plan's Members in connection with Health Plan's contractual obligations to provide and/or arrange for
Covered Services for Health Plan's Members.
Now, therefore, in consideration of the promises, covenants and warranties stated herein, Health Plan and
Provider agree as follows:
ARTICLE ONE - DEFINITIONS
1.1 Capitalized words or phrases in this Agreement shall have the meaning set forth below.
a. Advance Directive is a Member's written instructions, recognized under state law, relating to the
provision of health care when the Member is not competent to make a health care decision as
determined under state law. Examples of Advance Directives are living wills and durable powers of
attorney for health care.
b. Affiliate means an entity owned or controlled by ,Health Plan or Molina Healthcare, Inc.
C. Agreement means this Provider Services Agreement, all attachments and incorporated documents
or materials.
d. Capitated. Provider is a Provider who receives a monthly premium from Health Plan for each
Member assigned to Provider. Capitated Provider may be responsible for payment of all covered
health services (professional, institutional, pharmacy) incurred by Member.
e. CMS is the Centers for Medicare and Medicaid Services, an administrative agency of the United
States Government, responsible for administering the Medicare program.
f. Claim means an invoice for services rendered to a Member by Provider, submitted in a format
approved by Health Plan and with all service and encounter information required by Health Plan.
g. Clean Claim means a Claim for Covered Services that has no defect, impropriety, lack of any
required substantiating documentation, or particular circumstance requiring special treatment that
prevents timely payment from being made on the Claim.
h. Covered Services mean those health care services that are Medically Necessary, are within the
normal scope of practice and licensure of Provider, and are benefits of the Health Plan product or a
Health Plan affiliate's product which covers the Member. :r=-r_.r �:F: x:��I•�_F.�,v: ,,���,,�„
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2021029_IMC MHWPSA/Revised Sept 2018 $ r ° i ' ` Paged 1 of 27
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i. Downstream Entity means any party that enters into a written arrangement, acceptable to CMS,
with persons or entities involved with the Medicare Advantage, Medicaid, or MMP Products, below
the level of the arrangement between Health Plan (or applicant) and Provider. These written
arrangements continue down to the level of the ultimate provider for health and administrative
services.
j . Emergency Services are Covered Services necessary to evaluate or stabilize the emergent and
acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson
acting reasonably to believe that a health condition exists that requires immediate medical attention,
if failure to provide medical attention would result in serious impairment to bodily functions or
serious dysfunction of a bodily organ or part, or would place the person's health in serious
jeopardy. For Health Plan's Medicaid Members, Emergency Services also includes any services
defined as emergency services under 42 C.F.R. §438.114. Health Plan reserves the right to
investigate certain emergency care Claims to determine if a Claim meets the definition of
Emergency Services. If Health Plan denies a Claim on the basis that a reasonably prudent layperson
would not have believed that an emergency health condition existed, the Member may exercise the
right of appeal under the Grievance Program.
k. Encounter Data means all data captured during the course of a single health care encounter that
specifies: (i) the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or
palliative) pharmaceuticals, medical devices, and equipment associated with a Member receiving
services during the encounter; (ii) the identification of the Member receiving and the provider
providing the health care services during the single encounter; and (iii) a unique and unduplicated
identifier for the single encounter.
Grievance Program means the procedures established by Health Plan to timely address Member
and Provider complaints or grievances.
M. HCA means The Washington State Health Care Authority.
n. Health Benefit Exchange means the Washington health benefit exchange established in RCW
43.71.020, et seq., the Health Benefit Exchange Act.
o. Health Plan means Molina Healthcare of Washington, Inc.
p. HEDIS Studies mean Healthcare Effectiveness Data and Information Set.
q. IPA means Independent Practice Association.
r. Medicaid means the joint federal -state program provided for under Title XIX of the Social Security
Act, as amended.
S. Medicare is the Hospital Insurance Plan (Part A) and the Supplementary Medical Insurance Plan
(Part B) provided under Title XVIII of the Social Security Act, as amended.
t. Medically Necessary means those medical services and supplies which are provided in accordance
with professionally recognized standards of practice which are determined to be: (a) appropriate
and necessary for the symptoms, diagnosis or treatment of the Member's medical condition; (b)
provided for the diagnosis and direct care and treatment of such condition; (c) not furnished
primarily for the convenience of the Member, the Member's family, the treating provider, or other
provider; (d) furnished at the most appropriate level which can be provided consistent with
generally accepted medical standards of care; and (e) consistent with Health Plan policy.
U. Member(s) means a person(s) enrolled in one of Health Plan's benefit products or a Health Plan
affiliate's benefit product and who is eligible to receive Covered Services.
V. Molina Health Benefit Exchange Product means those health benefit programs offered and sold
by Health Plan to individuals or employers who obtain health coverage through the Washington
Health Benefit Exchange.
2021029_IMC MHWPSA/Revised Sept 2018 Page 2 of 27
W. Product means the various health insurance programs offered by Health Plan to Members in which
Provider agrees to be a Participating Provider, identified in the compensation exhibit(s), and which
will include any successors to such Products.
X. Prior Authorization means the requirement that a provider must request, on behalf of a Member
and when required by rule or state and government billing instructions, the state or governments
designee's approval to provide a health care service before the Member receives the health care
service, prescribed drug, device, or drug-related supply.
y. Provider means the person(s) and/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 (42 CFR 438.2). Where Provider is aGroup/IPA or Hospital, Provider means and includes
all constituent physicians, allied health professionals and staff persons who provide health care
services to Members by and/or through the Group/IPA or Hospital. All of said persons are bound by
the terms of this Agreement.
Z. Provider Manual means the compilation of Health Plan policies, procedures, standards and
specimen documents, as may be unilaterally amended or modified from time to time by Health
Plan, that have been compiled by Health Plan for the use and instruction of Provider, and to which
Provider must adhere.
aa. Quality Improvement Program means the policies, procedures and systems developed by Health
Plan for monitoring, assessing and improving the accessibility, quality and continuity of care
provided to Members.
bb. Subcontract means any separate agreement or contract between Health Plan and an individual or
entity ("Subcontractor") to perform all or a portion of the duties and obligations that the Health
Plan is obligated to perform pursuant to Health Plan's contract with the State or CMS.
cc. Subcontractor means an individual or entity that has a contract with the Health Plan that relates
directly or indirectly with the performance of Health Plan's obligations under Health Plan's
contract with the State or CMS.
dd. Utilization Review and Management Program means the policies, procedures and systems
developed by Health Plan for monitoring the utilization of Covered Services by Members,
including but not limited to under -utilization and over -utilization.
ARTICLE TWO - PROVIDER OBLIGATIONS
2.1 Serving as a Panel Provider. Provider shall serve on Health Plan's panel of providers for the products
specified in Exhibit 1. Provider agrees that its practice information may be used in Health Plan's provider
directories, promotional materials, advertising and other informational material made available to the
public and Members. Practice information includes, but is not limited to, name, address, telephone
number, hours of operation, type of practice, and ability to accept new patients. Provider shall promptly
notify Health Plan of any changes in this practice information.
2.2 Standards for Provision of Care.
a. Provision of Covered Services. Provider shall provide Covered Services to Members, within the
scope of Provider's business and practice, in accordance with this Agreement, Health Plan's policies
and procedures, the terms and conditions of the Health Plan product which covers the Member, and
the requirements of any applicable government sponsored program.
b. Standard of Care. Provider shall provide Covered Services to Members at a level of care and
competence that equals or exceeds the generally accepted and professionally recognized standard of
practice at the time of treatment, all applicable rules and/or standards of professional conduct, and any
controlling governmental licensing requirements.
2021029_IN4C MHWPSA/Revised Sept 2018 Page 3 of 27
c. Facilities, Equipment, and Personnel. Provider's facilities, equipment, personnel and administrative
services shall be at a level and quality as necessary to perform Provider's duties and responsibilities
under this Agreement and to meet all applicable legal requirements, including the accessibility
requirements of the Americans with Disabilities Act.
d. Prior Authorization. If Provider determines that it is Medically Necessary to consult or obtain
services from other health professionals that are Medically Necessary, Provider shall obtain the prior
authorization of Health Plan in accordance with Health Plan's Provider Manual unless the situation is
one involving the delivery of Emergency Services. Upon and following such referral, Provider shall
coordinate the provision of such Covered Services to Members and ensure continuity of care.
e. Contracted Providers. Except in the case of Emergency Services or upon prior authorization of
Health Plan, Provider shall use only those health professionals, hospitals, laboratories, skilled nursing
and other facilities and providers which have contracted with Health Plan ("participating providers").
f. Member Eligibility Verification. Provider shall verify eligibility of Members prior to rendering
services.
g. Admissions. Provider shall cooperate with and comply with Health Plan's hospital admission and
prior authorization procedures.
h. Emergency Room Referral. If Provider refers a Member to an emergency room for Covered
Services, Provider shall provide notification to Health Plan within 24 hours of the referral.
Prescriptions. Except with respect to prescriptions and pharmaceuticals ordered for in-patient
hospital services, Provider shall abide by Health Plan's drug formularies and prescription policies,
including those regarding the prescription of generic or lowest cost alternative brand name
pharmaceuticals. Provider shall obtain prior authorization from Health Plan if Provider believes a
generic equivalent or formulary drug should not be dispensed. Provider acknowledges the authority of
Health Plan contracting pharmacists to substitute generics for brand name pharmaceuticals unless
counter indicated on the prescription by the Provider.
j . Subcontract Arrangements. Any subcontract arrangement entered into by Provider for the delivery
of Covered Services to Members shall be in writing and shall bind Provider's subcontractors to the
terms and conditions of this Agreement including, but not limited to, terms relating to licensure,
insurance, and billing of Members for Covered Services.
k. Availability of Services. Provider shall make necessary and appropriate arrangements to ensure the
availability of Covered Services to Members on a twenty-four (24) hours a day, seven (7) days a
week basis, including arrangement to ensure coverage of Member patient visits after hours. Provider
shall meet the applicable standards for timely access to care and services, taking into account the
urgency of the need for the services.
1. Treatment Alternatives. Health Plan encourages open Provider -Member communication regarding
appropriate treatment alternatives. Health Plan promotes open discussion between Provider and
Members regarding Medically Necessary or appropriate patient care, regardless of Covered Services
limitations. Provider is free to communicate any and all treatment options to Members regardless of
benefit coverage limitations.
2.3 Promotional Activities. At the request of Health Plan, Provider shall (1) display Health Plan promotional
materials in its offices and facilities as practical, and (2) shall cooperate with and participate in all
reasonable Health Plan marketing efforts. Provider shall not use Health Plan's name in any advertising or
promotional materials without the prior written permission of Health Plan.
2.4 Nondiscrimination.
a. Enrollment. Provider shall not differentiate or discriminate in providing Covered Services to
Members because of race, color, religion, national origin, ancestry, age, sex, marital status, sexual
orientation, physical, sensory or mental handicap, socioeconomic status, or participation in publicly
financed programs of health care services. Provider shall render Covered Services to Members in the
2021029_IMC MHWPSA/Revised Sept 2018 Page 4 of 27
same location, in the same manner, in accordance with the same standards, and within the same time
availability regardless of payor.
b. Employment. Provider shall not differentiate or discriminate against any employee or applicant for
employment, with respect to their hire, tenure, terms, conditions or privileges of employment, or any
matter directly or indirectly related to employment, because of race, color, religion, national origin,
ancestry, age, sex, height, weight, marital status, physical, sensory or mental disability unrelated to
the individual's ability to perform the duties of the particular job or position.
2.5 Recordkeeping.
a. Maintaining Member Medical Record. Provider shall maintain a medical record for each Member
to whom Provider renders health care services. Provider shall open each Member's medical record
upon the Member's first encounter with Provider. The Member's medical record shall contain all
information required by state and federal law, generally accepted and prevailing professional practice,
applicable government sponsored health programs, and all Health Plan policies and procedures.
Provider shall retain all such records for at least ten (10) years.
b. Confidentiality of Member Health Information. Provider shall comply with all applicable state and
federal laws, Health Plan's policies and procedures, government sponsored program requirements
regarding privacy and confidentiality of Members' health information and medical records, including
mental health records. Provider shall not disclose or use Member names, addresses, social security
numbers, identities, other personal information, treatment modalities, or medical records without
obtaining appropriate authorization to do so. This provision shall not affect or limit Provider's
obligation to make available medical records, encounter data and information concerning Member
care to Health Plan, any authorized state or federal agency, or other Providers of health care upon
authorized referral.
c. HIPAA. To the extent Provider is considered a covered entity under the Health Insurance Portability
and Accountability Act ("HIPAA"), Provider shall comply with all provisions of HIPAA including,
but not limited to, provisions addressing privacy, security, and confidentiality.
d. Delivery of Patient Care Information. Provider shall promptly deliver to Health Plan, upon request
and/or as may be required by state or federal law, Provider's policies and procedures, applicable
government sponsored health programs, Provider's contracts with the government agencies or third
party payers, any information, statistical data, encounter data, or patient treatment information
pertaining to Members served by Provider, including but not limited to, any and all information
requested by Health Plan in conjunction with utilization review and management, grievances, peer
review, HEDIS Studies, Health Plan's Quality Improvement Program, Consumer Assessment of
Health Plans ("CAHPS"), or Claims payment. Health Plan will not pay copying fees when records are
requested for any of the above listed programs. Provider shall further provide direct access to said
patient care information as requested by Health Plan and/or as required by any governmental agency
or any appropriate state and federal authority having jurisdiction over Health Plan.
e. Member Access to Health Information. Provider shall give Health Plan and Members access to
Members' health information including, but not limited to, medical records and billing records, in
accordance with the requirements of state and federal law, applicable government sponsored health
programs, and Health Plan's policies and procedures.
f. National Provider. Identifier ("NPI"). In accordance with applicable statutes and regulations of the
Health Insurance Portability and Accountability Act ("HIPAA") of 1996, Provider will comply with
the Standard Unique Identifier for Health Care Provider regulations promulgated under HIPAA (45
CFR Section 162.402, et seq.) and use only the NPI to identify HIPAA covered health care providers
in standard transactions. Provider will utilize an NPI from the National Plan and Provider
Enumeration System ("NPPES") for itself or for any subpart of the Provider. Provider will make best
efforts to report its NPI and any subparts to Health Plan. Provider will report any changes in its NPI
or subparts to Health Plan within thirty (30) days of the change. Provider will use its NPI to identify
itself on all Claims and encounters (both electronic and paper formats) submitted to Health Plan.
2021029_I 4C MHWPSA/Revised Sept 2018 Page 5 of 27
2.6 Program Participation.
a. Participation in Grievance Program. Provider shall participate in Health Plan's Grievance Program
and shall cooperate with Health Plan in identifying, processing, and promptly resolving all Member
complaints, grievances, or inquiries.
b. Participation in Quality Improvement Program. Provider shall participate in Health Plan's Quality
Improvement Program and shall cooperate with Health Plan in conducting peer review and audits of
care rendered by Provider.
c. Participation in Utilization Review and Management Program. Provider shall participate in and
comply with Health Plan's Utilization Review and Management Program, including all policies and
procedures regarding prior authorizations, and shall cooperate with Health Plan in audits to identify,
confirm, and/or assess utilization levels of Covered Services. If Provider is a medical group or IPA,
Provider shall accept delegation of utilization management responsibilities from Health Plan at Health
Plan's request.
d. Participation in Credentialing. Provider shall participate in Health Plan's credentialing and re-
credentialing process and shall satisfy, throughout the term of this Agreement, all credentialing and
re-credentialing criteria established by the Health Plan. Provider shall immediately notify Health Plan
of any change in the information submitted or relied upon by Provider to achieve credentialed status.
If Provider's credentialed status is revoked, suspended or limited by Health Plan, Health Plan may at
its discretion terminate this Agreement and/or reassign Members to another provider. If Provider is a
medical group or IPA, Provider shall accept delegation of credentialing responsibilities at Health
Plan's request and shall cooperate with Health Plan in establishing and maintaining appropriate
credentialing mechanisms within Provider's organization.
e. Provider Manual. Provider will follow the terms set forth in Health Plan's Provider Manual, which
may be amended from time to time at Health Plan's sole discretion. Provider shall comply and render
Covered Services in accordance with the contents, instructions and procedures set forth in Health
Plan's Provider Manual and any additional operating procedures and policies for Providers which are
communicated to Provider in writing by Health Plan. Provider acknowledges it received Health
Plan's Provider Manual.
f. Government Contracts. Provider acknowledges that Health Plan has entered into contracts with
state and federal agencies for the arrangement of health care services for Members through
government sponsored programs. Provider shall comply with any term or condition of those
government sponsored program contracts that are applicable to the services to be performed under
this Agreement.
g. Health Education/Training. Provider shall participate in and cooperate with Health Plan's Provider
education and training efforts as well as Member education efforts. Provider shall also comply with
all Health Plan health education, cultural and linguistic standards, policies, and procedures, and such
standards, policies, and procedures as may be necessary for Health Plan to comply with its contracts
with employers, the state, or federal government. Provider shall promptly deliver to Provider's
constituent providers, if any, all informational, promotional, educational, or instructional materials
prepared by Health Plan regarding any aspect of providing Covered Services to Members.
h. Supplemental Materials. Health Plan may periodically issue bulletins or other written materials in
order to supplement the Provider Manual or to give additional instruction, guidance, or information
("Supplemental Materials"). Health Plan may issue Supplemental Materials in an electronic format,
which includes, but is not limited to, posting on Health Plan's interactive web -portal, and a physical
copy is available upon request. Supplemental Materials become binding upon Provider as of the
effective date indicated on the Supplemental Materials or, if applicable, the effective date will be
determined in accordance with this Agreement.
i. Health Plan's Electronic Processes and Initiatives. Provider will participate in and comply with
Health Plan's electronic processes and initiatives, including, but not limited to, electronic submission
2021029_IMC MHWPSA/Revised Sept 2018 Page 6 of 27
of prior authorization, access to electronic medical records, electronic claims filing, electronic data
interchange ("EDI"), electronic remittance advice, electronic fund transfers, and registration and use
of Health Plan's interactive web -portal.
2.7 Licensure and Standing.
a. Licensure. Provider warrants and represents that it is appropriately licensed to render health care
services within the scope of Provider's practice, including having and maintaining a current narcotics
number, where appropriate, issued by all proper authorities. Provider shall provide evidence of
licensure to Health Plan upon request. Provider shall maintain its licensure in good standing, free of
disciplinary action, and in unrestricted status throughout the term of this Agreement. Provider shall
immediately notify Health Plan of any change in Provider's licensure status, including any
disciplinary action taken or proposed by any licensing agency responsible for oversight of Provider.
b. Unrestricted Status. Provider represents to its best knowledge, information, and belief, neither it, nor
any of its employees, temporary employees, volunteers, consultants, members of its board of
directors, officers, or contractors (collectively, "Personnel") have been excluded from participation in
the Medicare Program, any state, commonwealth or the District of Columbia's Medicaid Program, or
any other federal health care program (collectively "Federal Health Care Program"). Provider agrees
that it must check the Department of Health and Human Services Office of Inspector General List of
Excluded Individuals and Entities ("LEIE" list), the System for Award Management ("SAM"), any
other list maintained by a state, commonwealth, or federal government and every state,
commonwealth, and the District of Columbia's Medicaid exclusion lists to determine whether
Provider or any of its Personnel have been excluded from participation in any Federal Health Care
Program. These databases must be checked for any new Personnel and thereafter not less than
monthly. Provider will notify Health Plan immediately in writing if Provider determines that Provider
or any of its Personnel are suspended or excluded, or could be suspended or excluded, from any
Federal Health Care Program. Provider agrees that it is subject to 2 CFR Part 376 and will require its
Personnel to agree that they are subject to 2 CFR Part 376. If a governmental agency imposes a
penalty, sanction, or other monetary adjustment or withhold due to Provider's non-compliance with
this provision or any payments were made to Provider while under non-compliance with this
provision, Health Plan may collect the amount by: (i) offsetting from amounts due to Provider; or (ii)
Health Plan may issue a recoupment letter and Provider agrees it will remit funds pursuant to the
terms of the recoupment letter. If required, such offset or recoupment will be done in a manner that is
compliant with laws and government program requirements. This section will survive any
termination.
c. Malpractice and Other Actions. Provider shall give immediate notice to Health Plan of: (a) any
malpractice claim asserted against it by a Member, any payment made by or on behalf of Provider in
settlement or compromise of such a claim, or any payment made by or on behalf of Provider pursuant
to a judgment rendered upon such a claim; (b) any criminal investigations or proceedings against
Provider; (c) any convictions of Provider for crimes involving moral turpitude or felonies; and (d) any
civil claim asserted against Provider that may jeopardize Provider's financial soundness.
d. Staffing Privileges for Providers. Consistent with community standards, every physician Provider
shall have staff privileges with at least one Health Plan contracted hospital as necessary to provide
services to members under this Agreement, and shall authorize each hospital at which he/she
maintains staff privileges to notify Health Plan should any disciplinary or other action of any kind be
initiated against such provider which could result in any suspension, reduction or modification of
his/her hospital privileges.
e. Liability Insurance. Provider shall maintain premises and professional liability insurance in
coverage amounts appropriate for the size and nature of Provider's facility and the nature of
Provider's health care activities. Every physician Provider shall maintain, at a minimum, professional
liability insurance with limits of not less than $1 million per occurrence and $3 million in the
aggregate for the policy year and for each physician comprising Provider. If the coverage is claims
made or reporting, Provider agrees to purchase similar "tail" coverage upon termination of the
2021029_IMC MHWPSA/Revised Sept 2018 Page 7 of 27
Provider's present or subsequent policy. Provider shall deliver copies of such insurance policies to
Health Plan within five (5) business days of a written request by Health Plan.
2.8 Claims Payment.
a. Submitting Claims. Provider shall promptly submit to Health Plan Claims for Covered Services
rendered to Members. All Claims shall be submitted in a form acceptable to and approved by Health
Plan, and shall include any and all medical records pertaining to the Claim if requested by Health
Plan or otherwise required by Health Plan's policies and procedures. Claims. must be submitted by
Provider to Health Plan within three hundred sixty-five (365) days of providing the Covered Services
that are the subject of the Claim. If Health Plan is not the primary payer under coordination of
benefits, Provider must submit Claims to Health Plan within three hundred sixty-five (365) days from
the primary payer's date of payment or date of contest, denial or notice. Except as otherwise provided
by law or provided by government sponsored program requirements, any Claims that are not
submitted by Provider to Health Plan within three hundred sixty-five (365) days from the date of
providing the Covered Service or three hundred sixty-five (365) days from the primary payer's
payment or date of contest, denial or notice shall not be eligible for payment, and Provider hereby
waives any right to payment therefore.
b. Compensation. Health Plan shall pay Provider for Clean Claims for Covered Services provided to
Members, including Emergency Services, in accordance with applicable law and regulations and in
accordance with the compensation schedule set forth in Exhibit 1 and its applicable sub -exhibits.
Provider shall accept such payment, applicable co -payments, deductibles, and coordination of
benefits collections as payment in full for services provided under this Agreement. Provider shall not
balance bill Members for any Covered Services.
c. Co -payment, Deductibles and Co-insurances. Provider is responsible for collection of co-
payments, deductibles and co-insurances, if any, provided for in the Member's Health Plan product.
d. Member Hold Harmless.
i. Provider hereby agrees that in no event, including, but not limited to nonpayment by Health Plan,
Health Plan's insolvency, or breach of this contract will Provider bill, charge, collect a deposit
from, seek compensation, remuneration, or reimbursement from, or have any recourse against a
Member or person acting on their behalf, other than Health Plan, for services provided pursuant
to this Agreement. This provision does not prohibit collection of deductibles, copayments,
coinsurance, and/or payment for noncovered services, which have not otherwise been paid by a
primary or secondary issuer in accordance with regulatory standards for coordination of benefits,
from Members in accordance with the terms of the Member's health plan.
ii. Provider agrees in the event of Health Plan's insolvency to continue to provide the services
promised in this Agreement to Members of Health Plan for the duration of the period for which
premiums on behalf of the Member were paid to Health Plan or until the Member's discharge
from inpatient facilities, whichever time is greater.
iii. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be
construed to modify the rights and benefits contained in the Member's Health Plan.
iv. Provider may not bill the Member for Covered Services except for deductibles, copayments, or
coinsurance where Health Plan denies payments because Provider has failed to comply with the
terms of this Agreement.
v. Provider further agrees i) that the provisions of paragraphs i, ii, iii, iv 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 Health Plan's Members; and ii) that this provision supersedes
any oral or written contrary agreement not existing or hereafter entered into between Provider and
Member or persons acting on their behalf.
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vi. If Provider contracts with other providers or facilities who agree to provide Covered Services to
Members of Health Plan with expectation of receiving payment directly or indirectly from Health
Plan, such providers or facilities must agree to abide by paragraphs i, ii, iii, iv, v, of this section.
e. Coordination of Benefits. Health Plan is a secondary payer in any situation where there is another
payer as primary carrier. Provider shall make reasonable inquiry of Members to learn whether
Member has health insurance or health benefits other than from Health Plan or is entitled to payment
by a third party under any other insurance or plan of any type, and Provider shall immediately notify
Health Plan of said entitlement. In the event that coordination of benefits occurs, Provider shall be
compensated in an amount equal to the allowable Clean Claim less the amount paid by other health
plans, insurance carriers and payers, not to exceed the amount specified in Exhibit 1 and its applicable
sub -exhibits.
£ Offset. In the event that Health Plan determines that a Claim has been overpaid or paid in duplicate,
or that funds were paid which were not provided for under this Agreement, Health Plan may make a
written request for repayment: (1) within twenty-four (24) months after the date that the payment was
made; (2) within thirty (30) months after the date that the payment was made if the request is related
to coordination of benefits with another carrier or entity responsible for payment of the Claim; or (3)
at any time if a third party is found responsible for satisfaction of the Claim as a consequence of
liability imposed by law and Health Plan is unable to recover directly from the third party because the
third party has either already paid or will pay Provider the health care services covered by the Claim.
Provider may contest Health Plan's request in writing by participating in the Claims dispute process
as outlined in Section 2.8g. Overpayment and duplicate payment disputes must be submitted in
writing within thirty (30) days of receipt of request. If itis decided that Health Plan will recover the
contested payment, such refund maybe recovered by way of offset or recoupment from current or
future amounts due Provider after six (6) months have passed from the date Health Plan received
Provider's written notice contesting the repayment. In addition to any other contractual or legal
remedy, if Provider fails to contest Health's Plan's request for a refund in writing within thirty (30)
days of receipt of the request or if Provider contested the request and six (6) months has passed from
the date Provider received Health Plan's refund request, Health Plan may recover the amounts owed
by way of offset or recoupment from current or future amounts due Provider. Nothing in this section
prohibits Provider from choosing at any time to refund to Health Plan any payment previously made
by Health Plan to satisfy a Claim either by way of repayment by Provider or a request that Health
Plan offset or recoup the money from current or future amounts due Provider.
g. Claims Dispute Process. In the event that Provider determines that a Claim has been improperly
denied or underpaid, Provider may make a written request for payment: (1) within twenty-four (24)
months after the date the Claim was denied or payment intended to satisfy the Claim was made; (2)
within thirty (30) months after the date the Claim was denied or payment intended to satisfy the
Claim was made if the request is related to coordination of benefits with another carrier or entity
responsible for payment of the Claim. Provider may not request that payment be made any sooner
than six (6) months after Health Plan's receipt of the request. Any request for review of denied or
underpaid Claims must be submitted to Health Plan in accordance with the requirements stated in this
section and conform to the following instructions:
i. The request must specify why the Provider believes Health Plan owes the payment;
il. In the case of coordination of benefits, the request must include the name and mailing address of
any entity that has disclaimed responsibility for payment;
iii. The request must be addressed to the attention of Health Plan's Provider Services Department;
iv. The request must clearly indicate "Denied Claims Review Request" or "Adjustment Request";
and,
v. The request must include all pertinent information, including, but not limited to, Claim number,
Member identifier, denial letter, supporting medical records, and any new information pertinent
to the request;
vi. Health Plan will render a decision on all disputed Claims within sixty (60) days of receipt of the
Claim;
2021029_IMC MHwPSA/Revised Sept 2018 Page 9 of 27
Should Provider not be satisfied with Health Plan's decision, Provider may proceed to the mediation
steps outlined in Section 5.8.
h. Claims Review and Audit. Provider acknowledges Health Plan's right to review Provider's Claims
prior to payment for appropriateness in accordance with industry standard billing rules, including, but
not limited to, current UB manual and editor, current CPT and HCPCS coding, CMS billing rules,
CMS bundling/unbundling rules, National Correct Coding Initiatives (NCCI) Edits, CMS multiple
procedure billing rules, and FDA definitions and determinations of designated implantable devices
and/or implantable orthopedic devices. Provider acknowledges Health Plan's right to conduct such
review and audit on a line -by-line basis or on such other basis as Health Plan deems appropriate, and
Health Plan's right to exclude inappropriate line items to adjust payment and reimburse Provider at
the revised allowable level. Provider also acknowledges Health Plan's right to conduct utilization
reviews to determine medical necessity and to conduct post -payment billing audits. Provider shall
cooperate with Health Plan's audits of Claims and payments by providing access to requested Claims
information, all supporting medical records, Provider's charging policies, and other related data.
Health Plan shall use established industry claims adjudication and/or clinical practices, state and
federal guidelines, and/or Health Plan's policies and data to determine the appropriateness of the
billing, coding and payment.
i. Payments which are the Responsibility of a Capitated Provider. Provider agrees that if Provider is
or becomes a party to a subcontract or other agreement with another provider contracted with Health
Plan who receives capitation from Health Plan and is responsible for arranging for Covered Services
through subcontract arrangements ("Capitated Provider"), Provider shall look solely to the Capitated
Provider, and not Health Plan, for payment of Covered Services provided to Members that are
covered by Health Plan's agreements with such Capitated Providers.
j. Timely Submission of Encounter Data. Provider understands Health Plan may have certain
contractual reporting obligations that require timely submission of Encounter Data. If a Clean Claim
does not contain the necessary Encounter Data, Provider will submit Encounter Data to Health Plan.
This section will survive any termination.
2.9 Compliance with Applicable Law. Provider shall comply with all applicable state and federal laws
governing the delivery of Covered Services to Members including, but not limited to, Title XIX and Title
XXI of the SSA and Title 42 CFR, Title VI of the Civil Rights Act of 1964; Title IX of the Education
Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975;
the Rehabilitation Act of 1973; the Balanced Budget Act of 1997; the Americans with Disabilities Act,
and Federal Drug and Alcohol Confidentiality Laws in 42 CFR Part 2:
a. Provider acknowledges that this Agreement and all Covered Services rendered pursuant to this
Agreement are subj ect to applicable state licensing statutes and regulations. Accordingly, Provider
shall abide by those provisions set forth in Attachment 2.
b. Provider acknowledges that all Covered Services rendered in conjunction with the state Medicaid
program are subject to the additional provisions set forth in Attachment 3, the effect of which
provisions is limited solely to activities and Covered Services related to the state Medicaid program.
c. For Covered Services rendered to Members enrolled in a Molina Health Benefit Exchange Product,
Medicaid statutes and regulations referenced in this Agreement are inapplicable, and Provider shall
comply with all statutory and regulatory requirements of the Washington Health Benefit Exchange
Act, including the 2012 regular session laws, chapter 87 Affordable Care Act Implementation and
regulations adopted pursuant to RCW 43.71.
2.10 Provider Non -solicitation Obligations. Provider shall not unilaterally assign or transfer patients served
under this Agreement to another medical group, IPA, or provider without the prior written approval of
Health Plan. Nor shall Provider solicit or encourage Members to select another health plan for the primary
purpose of securing financial gain for Provider. Nothing in this provision is intended to limit Provider's
ability to fully inform Members of all available health care treatment options or modalities.
2021029_AW MHWPSA/Revised Sept 2018 Page 10 of 27
2.11 Fraud and Abuse Reporting. Provider shall report to Health Plan's compliance officer all cases of
suspected fraud and/or abuse, as defined in Title 42, of the Code of Federal Regulations, Section 455.2,
where there is reason to believe that an incident of fraud and/or abuse has occurred, by subcontractors,
Members, providers, or employees within ten (10) business days of the date when Provider first becomes
aware of, or is on notice of, such activity. Provider shall establish policies and procedures for identifying,
investigating, and taking appropriate corrective action against fraud and/or abuse in the provision of
health care services under the Medicaid program. Upon the request of Health Plan and/or the State,
Provider shall consult with the appropriate State agency prior to and during the course of any such
investigations.
2.12 Advance Directive. Provider shall document all patient records with respect to the existence of an
Advance Directive in compliance with the Patient Self -Determination Act (Section 4751 of the Omnibus
Reconciliation Act of 1990), as amended, and other appropriate laws.
2.13 Reassignment of Members. Health Plan reserves the right to reassign Members from Provider to another
provider or to limit or deny the assignment or selection of new Members to Provider during any
termination notice period or if Health Plan determines that assignment to Provider poses a threat to the
Members' health and safety. If Provider requests reassignment of a Member, Health Plan, in its sole
discretion, will make the determination regarding reassignment based upon good cause shown by the
Provider. When the Health Plan reassigns Member(s), Provider shall forward copies of the Member's
medical records to the new provider within ten (10) business days of receipt of the Plan's or the
Member's request to transfer the records.
2.14 Confidentiality Each party agrees that the terms set forth in this Agreement are strictly confidential and
neither party shall disclose such terms to any person or entity for purposes other than the administration
of the Agreement without receiving prior written consent of the other party, except as required by law or
government programs.
2.15 Reciprocity Agreements. Provider will cooperate with Affiliates and agrees to ensure reciprocity of
health care services to Affiliate's enrollees. For Affiliate enrollees, Provider will be compensated for
Clean Claims that are determined to be payable in accordance with laws and government program
requirements. If there is not a law or government program requirement governing reimbursement,
Provider will be compensated at the rates set forth in this Agreement. Provider will follow the hold
harmless provisions of this Agreement for Affiliate's enrollees.
ARTICLE THREE - HEALTH PLAN'S OBLIGATIONS
3.1 Compensation. Health Plan shall pay Provider in accordance with the terms and conditions of this
Agreement and the compensation schedule set forth in Exhibit 1 and its applicable sub -exhibits.
3.2 Member Eligibility Determination. Health Plan shall maintain data on Member eligibility and
enrollment. Health Plan shall promptly verify Member eligibility at the request of Provider.
3.3 Prior Authorization Review. Health Plan shall timely respond to requests for prior authorization and/or
determination of Covered Services.
3.4 Medical Necessity Determination. Health Plan's determination with regard to Medically Necessary
services and scope of Covered Services, including determinations of level of care and length of stay
benefits available under the Member's health program shall govern. The primary concern with respect to
all medical determination shall be the interest of the Member.
3.5 Member Services. Health Plan will provide services to Members including, but not limited to, assisting
Members in selecting a primary care physician, processing Member complaints and grievances, informing
Members of the Health Plan's policies and procedures, providing Members with membership cards,
providing Members with information about Health Plan, and providing Members with access to Health
Plan's Provider Directory, updated from time to time, identifying the professional status, specialty, office
address, and telephone number of Health Plan contracted providers.
2021029 IMC MHWPSA/Revised Sept 2018 Page 11 of 27
3.6 Provider Services. Health Plan will maintain a Provider Manual describing Health Plan's policies and
procedures, Covered Services, limitations and exclusions, and coordination of benefits information.
Health Plan will maintain a Provider Services Department available to educate Provider regarding Health
Plan's policies and procedures.
3.7 Medical Director. Health Plan will employ a physician as medical director who shall be responsible for
the management of the scientific, technical, and medical aspects of Health Plan.
ARTICLE FOUR - TERM AND TERMINATION
4.1 Term. This Agreement shall commence on January 1, 2021 and expire December 31, 2021 and shall
continue in effect for one (1) year; it shall automatically renew for successive one (1) year terms unless
and until terminated by either party in accordance with the provisions of this Agreement or in accordance
with applicable state licensing statutes and regulations set forth in Attachment 2 and Attachment 3.
4.2 Termination without Cause. This Agreement may be terminated without cause by either party on at
least one hundred twenty (120) days written notice to the other party.
4.3 Termination with Cause. In the event of a breach of any material provision of this Agreement, the party
claiming the breach will give the other party written notice of termination setting forth the facts
underlying its claim(s) that the other party has breached the Agreement. The party receiving the notice of
termination shall have thirty (30) days from the date of receipt of such notice to remedy or cure the
claimed breach to the satisfaction of the other party. During this thirty (30) -day period, the parties agree
to meet as reasonably necessary and to confer in good faith in an attempt to resolve the claimed breach. If
the party receiving the notice of termination has not remedied or cured the breach within such thirty (30) -
day period, the party who provided the notice of termination shall have the right to immediately terminate
this Agreement.
4.4 Immediate Termination. Notwithstanding any other provision of this Agreement, Health Plan may
immediately terminate this Agreement and transfer Member(s) to another provider by giving notice to
Provider in the event of any of the following:
a. Provider's license or certificate to render health care services is limited, suspended or revoked, or
disciplinary proceedings are commenced against Provider by the state licensing authority;
b. Provider fails to maintain insurance required by this Agreement;
c. Provider loses credentialed status;
d. Provider becomes insolvent or files a petition to declare bankruptcy or for reorganization under the
bankruptcy laws of the United States, or a trustee in bankruptcy or receiver for Provider is appointed
by appropriate authority;
e. If Provider is capitated and Health Plan determines Provider to be financially incapable of bearing
capitation or other applicable risk -sharing compensation methodology;
f. Health Plan determines that Provider's facility and/or equipment is insufficient to render Covered
Services to Members;
g. Provider is excluded from participation in Medicare and state health care programs pursuant to
Section 1128 of the Social Security Act or otherwise is terminated as a provider by any state or
federal health care program;
h. Provider engages in fraud or deception, or knowingly permits fraud or deception by another in
connection with Provider's obligations under this Agreement;
i. Health Plan determines that health care services are not being properly provided, or arranged for, and
that such failure poses a threat to Members' health and safety.
4.5 Termination Notification to Members. Upon receipt of termination by either Health Plan or Provider,
Health Plan will inform affected Members of such termination notice in accordance with the process set
2021029_IMC MHWPSA/Revised Sept 2018 Page 12 of 27
forth in the Provider Manual. Health Plan will make a good faith effort to ensure that such notice is
provided at least thirty (30) days prior to the effective date of the termination or immediately for a
termination for cause that results in less than thirty (30) days' notice to a provider or carrier to all
Members. Members may then be required to select another provider contracted with Health Plan prior to
the effective date of termination of this Agreement.
ARTICLE FIVE - GENERAL PROVISIONS
5.1 Indemnification. Each party shall indemnify and hold harmless the other party and its officers, directors,
shareholders, employees, agents, and representatives from any and all liabilities, losses, damages, claims,
and expenses of any kind, including costs and attorneys' fees, which result from the duties and
obligations of the indemnifying party and/or its officers, directors, shareholders, employees, agents, and
representatives under this Agreement.
5.2 Relationship of the Parties. Nothing contained in this Agreement is intended to create, nor shall it be
construed to create, any relationship between the parties other than that of independent parties contracting
with each other solely for the purpose of effectuating the provisions of this Agreement. This Agreement is
not intended to create a relationship of agency, representation, joint venture, or employment between the
parties. Nothing herein contained shall prevent any of the parties from entering into similar arrangements
with other parties. Each of the parties shall maintain separate and independent management and shall be
responsible for its own operations. Nothing contained in this Agreement is intended to create, nor shall be
construed to create, any right in any third party, including but not limited to Health Plan's Members. Nor
shall any third party have any right to enforce the terms of this Agreement.
5.3 Entire Agreement. This Agreement, together with Attachments, Amendments and incorporated
documents or materials, contains the entire agreement between Health Plan and Provider relating to the
rights granted and obligations imposed by this Agreement. Additionally, as to the Medicaid products
offered by Health Plan, the contract between the Washington Department of Social and Health Services
and the Health Plan shall be the guiding and controlling document when interpreting the terms of this
Agreement. Any prior agreements, promises, negotiations, or representations, either oral or written,
relating to the subj ect matter of this Agreement are of no force or effect.
5.4 Severability. If any term, provision, covenant, or condition of this Agreement is held by a court of
competent jurisdiction to be invalid, void, or unenforceable, the remaining provisions shall remain in full
force and effect and shall in no way be affected, impaired, or invalidated as a result of such decision.
5.5 Notice. All notices required or permitted by this Agreement shall be in writing and may be delivered in
person or may be sent by US Postal Service registered, certified or Express mail, with postage prepaid, or
by Federal Express or other overnight courier that guarantees next day delivery, by electronic mail (e-
mail) or other electronic means of delivery, or by facsimile transmission, and shall be deemed sufficiently
given if served in the manner specified in this Section. The addresses below shall be the particular party's
address for delivery or mailing of notice purposes:
If to Health Plan:
Molina Healthcare of Washington, Inc.
Attention: President
21540 30th Dr SE Ste 400
Bothell, WA 98021
Email: MHWProviderContracting@Molinahealthcare.com
2021029_IMC MHWPSA/Revised Sept 2018 Page 13 of 27
If to Provider:
Attn. Dell Anderson
County of Grant
840 East Plum
Moses Lake, WA 98837
Telephone: (509)765-9239
Email: daanderson@grantcountywa.gov
The parties may change the names and addresses noted above through written notice in compliance with
this Section. Any notice sent by registered or certified mail, return receipt requested, shall be deemed
given on the date of delivery shown on the receipt card, or if no delivery date is shown, the postmark date.
Notices delivered by U.S. Postal Service Express mail, Federal Express or overnight courier that
guarantees next day delivery shall be deemed given twenty-four (24) hours after delivery of the notice to
the United States Postal Service, Federal Express or overnight courier. If any notice is transmitted by
facsimile transmission or similar means, the notice shall be deemed served or delivered upon telephone
confirmation of receipt of the transmission, provided a copy is also delivered via delivery or mail.
5.6 Amendment. Health Plan may, without Provider's consent, immediately amend this Agreement to
maintain consistency and/or compliance with any state or federal law, policy; directive, or government
sponsored program requirement. Health Plan may otherwise amend this Agreement upon sixty (60) days
prior written notice to Provider. If Provider does not deliver to Health Plan a written notice of rejection of
the amendment within that sixty (60) day period, the amendment shall be deemed accepted by and shall
be binding upon Provider. In the event that the amendment is considered a "material amendment" as
defined in RCW 48.3 9.005, Provider shall have the right to rej ect the amendment and such rej ection will
not affect the existing terms of the Agreement.
5.7 Assignment. Provider may not assign, transfer, subcontract or delegate, in whole or in part, any rights,
duties, or obligations under this Agreement without the prior written consent of Health Plan. Subject to
the foregoing, this Agreement is binding upon, and inures to the benefit of the Health Plan and Provider
and their respective successors in interest and assigns. Neither the acquisition of Health Plan nor a change
of its legal name shall be deemed an assignment.
5.8 Dispute Resolution Process.
a. Submission of Non -Claims Payment Related Disputes
i. Provider shall submit any dispute (other than a dispute relating to Claims, which are subject to
Section 2.8(g)) to Health Plan in writing within sixty (60) days of when the issue arises.
ii. Provider shall submit such disputes to the attention of Health Plan's Provider Services
Department.
b. Health Plan Response to Non -Claims Related Disputes
i. Health Plan shall use best efforts to acknowledge by phone, e-mail or other writing, receipt of a
dispute (other than a dispute relating to Claims, which are subj ect to Section 2.8(g)) within seven
(7) business days.
ii. Health Plan's decision regarding disputes shall be communicated within sixty (60) days of Health
Plan's receipt of Provider's written correspondence requesting review. If additional time is
required, Health Plan shall communicate this information to Provider within sixty (60) days.
iii. Health Plan shall use its best efforts to investigate and resolve disputes within sixty (60) days of
Health Plan's receipt of Provider's written correspondence.
c. Nonbinding Mediation. If Provider is dissatisfied with Health Plan's final resolution of a dispute or
if Health Plan fails to grant or reject Provider's request for review of a dispute within thirty (30) days
after it is received, Provider may submit the dispute to nonbinding mediation pursuant to chapter 7.07
RCW. Nonbinding mediation shall not be utilized to adjudicate matters that primarily involve review
2021029_IMC MHWPSA/Revised Sept 2018 Page 14 of 27
of Provider's professional competence or professional conduct, and shall not be available as a
mechanism for appeal of any determinations made as to such matters.
5.9 Corrective Action, Fair Hearing Plan, and Reporting to the State of Washington Medical Quality
Assurance Commission and the NPDB. Provider has a procedural right to appeal in the event that
Health Plan's peer review committee recommends filing a report to the Washington Medical Quality
Assurance Commission and the NPDB. The appeal right, Fair Hearing process, and the requirement to
report to the Washington Medical Quality Assurance Commission and NPDB are described in Health
Plan's Fair Hearing Plan.
5.10 Arbitration. Health Plan and Provider agree, as a condition precedent to the commencement of any civil
action in any court of competent jurisdiction, to submit to arbitration all disputes arising from or related to
this Agreement and the rendition of services to Members pursuant to this Agreement which are not
otherwise resolved pursuant to the processes set forth at Sections 2.8(g) or 5.8; provided, however, that
arbitration shall not be utilized to adjudicate matters that primarily involve review of Provider's
professional competence or professional conduct, and shall not be available as a mechanism for appeal of
any determinations made as to such matters. Arbitration shall proceed according to the rules and
regulations of the American Arbitration Association, then in effect, and shall be conducted in King
County, Washington. The arbitrator shall have no authority to award damages or provide a remedy that
would not be available to such prevailing party in a court of law. Nor shall the arbitrator have the
authority to award punitive damages. The parties recognize that the arbitrator's decision is not binding
and that either party may seek judicial remedies following the arbitration of a dispute. The panel of
arbitrators shall be selected as follows: one arbitrator shall be designated by Health Plan; one arbitrator
shall be designated by Provider; and the third arbitrator shall be selected by the arbitrators designated by
Provider and Health Plan. Health Plan and Provider shall divide and share equally the cost of arbitration.
Each party shall be responsible for its own attorneys' fees.
5.11 Attachments. Each of the Attachments and Exhibits (as selected) and identified below is hereby made a
part of this Agreement:
0 Attachment 1 — Provider Identification Sheet
D Attachment 2 —Required Provisions (Health Care Service Plans)
❑X Attachment 3 —Required Provisions (Health Care Authority)
N Attachment 4 —Medicare Program Requirements -Health Care Services
El Attachment 5 —Indian Health Care Providers MedicaidJCHIP Provisions
F-1 Attachment 6 —Indian Health Care Providers—Qualified Health Plan
❑Exhibit 1-A Compensation Schedule Medicaid (Version 1)
Exhibit 1-A Compensation Schedule Medicaid (Version 2)
❑Exhibit 1-A Compensation Schedule Medicaid (Version 3)
❑Exhibit 1-A Compensation Schedule Medicaid (Version 4)
Exhibit 1-B Compensation Schedule Medicare (Version 1)
DExhibit 1-B Compensation Schedule Medicare (Version 2)
Exhibit 1-C Compensation Schedule Molina Marketplace (Version 1)
El Exhibit 1-C Compensation Schedule Molina Marketplace (Version 2)
Exhibit 1-C Compensation Schedule Molina Marketplace (Version 3)
❑Elchibit 1-C Compensation Schedule Molina Marketplace (Version 4)
❑Exhibit 1-C Compensation Schedule Molina Marketplace (Version 5)
5.12 Conflict with Health Plan Product. Nothing in this Agreement modifies any benefits, terms or
conditions contained in the Member's Health Plan product. In the event of a conflict between this
Agreement and the benefits, terms, and conditions of the Health Plan product, the benefits, terms or
conditions contained in the Member's Health Plan product shall govern.
5.13 Execution in Counterparts and Duplicates. This Agreement may be executed in counterparts, each of
which will be deemed an original, but all of which together will constitute one and the same instrument.
2021029_IMC MHWPSA/Revised Sept 2018 Page 15 of 27
The Parties agree facsimile signatures, pdf signatures, photocopied signatures, electronic signatures, or
signatures scanned and sent via email will have the same effect as original signatures.
5.14 Force Majeure. Neither Party will be liable or deemed to be in default for any delay or failure to perform
any duty under this Agreement resulting directly or indirectly, from acts of God, civil or military
authority, acts of a public enemy, war, accident, fire, explosion, earthquake, flood, strikes by either
Party's employees, or any other similar cause beyond the reasonable control of such Party if it is
determined that such Party: (i) used the efforts a reasonable person would during a force maj eure event to
perform its duties under this Agreement; and (ii) the Party's inability to perform its duties during the force
maj eure event is not due to its failure to take measures to protect itself against the force maj eure event.
5.15 Expenses. Unless otherwise specifically stated in the Agreement, all costs and expenses incurred in
connection with this Agreement will be paid by the Party incurring the cost or expense.
5.16 Adjustments. If a governmental agency imposes a penalty, sanction, or other monetary adjustment or
withhold due to Provider's non-compliance with this Agreement, Health Plan will be able to collect the
amount imposed on or withheld from Health Plan. Health Plan may collect the amount: (i) by offsetting
from amounts due to Provider; or (ii) Health Plan may issue a recoupment letter and Provider will remit
funds pursuant to the terms of the recoupment letter. If required, such offset or recoupment will be done
in a manner that is compliant with Laws and Government Program Requirements. This section will
survive any termination.
5.17 Business Continuity Plan. Provider represents it currently maintains and will continue to maintain a plan
to use during emergency events that adversely impact Provider's staffing and physical and technological
infrastructure. For the purposes of this section, the plan will be referred to as the "Business Continuity
Plan". The Business Continuity Plan will address, at a minimum: (i) processes and resources needed to
ensure continuity and re-establishment of health care services; (ii) data backup and recovery procedures
and fail -over procedures; (iii) how Provider will interact with its business continuity suppliers, if any; and
(iv) alternate service/business locations. Within thirty (30) days following the Effective Date, Provider
will deliver its Business Continuity Plan to Health Plan. Thereafter, Provider will deliver its Business
Continuity Plan to Health Plan on an annual basis and upon any change to the Business Continuity Plan
that is relevant to the Agreement. Provider will test its Business Continuity Plan on an annual basis and
will provide the test results to Health Plan within thirty (30) days upon completion of such test.
5.18 Confidentiality. Any information disclosed by either Party in fulfillment of its obligations under this
Agreement, including, but not limited to, health care information, compensation rates, and the terms of
the Agreement, will be kept confidential. Information provided to Provider, including, but not limited to,
Member lists, QI Program, credentialing criteria, compensation rates, and any other administrative
protocols or procedures of Health Plan, is the proprietary property of Health Plan and will be kept
confidential. Provider will not disclose or release such material to a third party without the written
consent of Health Plan. This section will survive any termination.
5.19 Headings and Construction. The headings in this Agreement are for reference purposes only and are not
considered a part of this Agreement in construing or interpreting its provisions. It is the Parties' desire
that if a provision of this Agreement is determined to be ambiguous, then the rule of construction that
such provision is construed against its drafter will not apply to the interpretation of the ambiguous
provision. The following rules of construction apply to this Agreement: (i) the word "day" means
calendar day unless otherwise specified; (ii) the term "business day" means Monday through Friday,
except federal holidays; (iii) all words used in this Agreement will be construed to be of such gender or
number as circumstances require; (iv) references to specific statutes, regulations, rules or forms, such as
CMS -1500, include subsequent amendments or successors to them; and (v) references to any government
department or agency include any successor departments or agencies.
202102911\4C MHWPSA/Revised Sept 2018 Page 16 of 27
DocuSign Envelope ID: CEDB2471-6789-4024-812B-C9FAD69C65D8
IN WITNE SS WHEREOF, the parties hereto have agreed to and executed this Agreement by their officers
thereunto duly authorized. The individual signing below on behalf of Provider acknowledges, warrants, and
represents that said individual has the authority and proper authorization to execute this Agreement on behalf of
Provider and its constituent providers, if any, and does so freely with the intent to fully bind Provider, and its
constituent providers, if any, to the provisions of this Agreement.
The parties hereby acknowledge that Health Plan's Provider Manual was made available to Provider for review
prior to Provider's decision to enter into this Agreement. Health. Plan's Provider Manual is available at the Health
Plan's website.
County of ant Molina Healthcare of Washington, Inc.
By: ava� 440"t,
e__Docuftned by:
By:
�—U45AMEE44148E...
Its: Cindy Carter, Chair
--------------
late:
---------------- -
Date:
Andrew Nelson
Its: VP Network Managevent
Date.- 5/17/2021
202102911VIC MHWPSA/Revised Sept 2018 Page 17 of 27
IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Agreement by their officers
thereunto duly authorized. The individual signing below on behalf of Provider acknowledges, warrants, and
represents that said individual has the authority and proper authorization to execute this Agreement on behalf of
Provider and its constituent providers, if any, and does so freely with the intent to fully bind Provider, and its
constituent providers, if any, to the provisions of this Agreement.
The parties hereby acknowledge that Health Plan's Provider Manual was made available to Provider for review
prior to Provider's decision to enter into this Agreement. Health Plan's Provider Manual is available at the Health
Plan's website.
County of ant Molina Healthcare of Washington, Inc.
By. By.
Andrew Nelson
Cindy Carter, Chair Its: VP Network Mana
Its: gement
s
i
Date:- Date:
2021029_IMC MHVWPSA/Revised Sept 2018 Page 17 of 27
ATTACHMENT I
Provider Identification Sheet
Mark applicable category(ies) below. For those Providers representing multiple health care professional(s) or
entity(ies), please check all the categories that apply.
❑ Primary Care Provider:
❑ Specialist:
® Group/IPA (a list of constituent members with their License and DEA numbers is attached and incorporated herein)
❑ Hospital:
® Ancillary Provider: Behavioral Health
❑ Other:
Provider Name County of Grant
Billing
Address
840 East Plum
Moses Lake, WA 98837
Telephone No. 509-765-9239
Facsimile No.
Tax I.D. No. 91-6001319
Physical
Address
840 East Plum
Moses Lake, WA 98837
License No.
NPI
NPI Taxonomy Code
DEA No.
Please provide a roster of all locations and/or billing address from which the Provider(s) will submit bills to
Health Plan. Use continuation page(s) if multiple providers under common ownership will submit bills under
more than one TIN.
I, the undersigned, am authorized to and do hereby verify the accuracy 01, he foregoing Provider
information. A A
ProvYdef Si
Cindy Carter, Chair
Si91
tory Name (Pnin ed)
re C(
Signatory Title Printed)
Signature Date
2021029_IMC MHWPSA/Revised Sept 2018 Page 18 of 27
ATTACHMENT I
Provider Identification Sheet
Continuation Page
Use one or more continuation pages as necessary when multiple providers under common ownership (the
Provider is signing on behalf of all of them) are expected to bill Health Plan under more than one TIN.
Provider Name
Billing
Address
Telephone No.
Facsimile No.
Tax I.D. No.
Physical
Address
License No.
NPI
NPI Taxonomy Code
DEA No.
Provider Name
Billing
Address
Telephone No.
Facsimile No.
Tax I.D. No.
Physical
Address
License No.
NPI
NPI Taxonomy Code
DEA No.
Provider Name
Billing
Address
Telephone No.
Facsimile No.
Tax I.D. No.
Physical
Address
License No.
NPI
NPI Taxonomy Code
DEA No.
Provider Name
Billing
Address
Telephone No.
Facsimile No.
Tax I.D. No.
Physical
Address
License No.
NPI
NPI Taxon om Code
DEA No.
2021029_IMC MHWPSA/Revised Sept 2018 Page 19 of 27
ATTACHMENT 2
REQUIRED PROVISIONS
(HEALTH CARE SERVICE PLANS)
The following provisions are required by (i) federal statutes and regulations applicable to Health Plan, or (ii) state
statutes and regulations applicable to health care service plans. These provisions shall be automatically modified
to conform to subsequent amendments to such statutes, regulations, and agreements. Further, any purported
modifications to these provisions inconsistent with such statutes, regulations, and agreements shall be null and
void.
1. Provider hereby agrees that in no event, including, but not limited to nonpayment by Health Plan, Health
Plan's insolvency, or breach of this Agreement shall Provider bill, charge, collect a deposit from, seek
compensation, remuneration, or reimbursement from, or have any recourse against a Member or person
acting on their behalf, other than Health Plan, for services provided pursuant to this Agreement. This
provision shall not prohibit collection of deductibles, co -payments, coinsurance, and/or noncovered
services, which have not otherwise been paid by a primary or secondary carrier in accordance with
regulatory standards for coordination of benefits, from Members in accordance with the terms of the
Member's health program.
2. Provider agrees, in the event of Health Plan's insolvency, to continue to provide the services promised in
this Agreement to Members of Health Plan for the duration of the period for which premiums on behalf of
the Member were paid to Health Plan or until the Member's discharge from inpatient facilities, whichever
time is greater.
3. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be construed to
modify the rights and benefits contained in the Member's health program.
4. Provider may not bill the Member for Covered Services (except for deductibles, co -payments, or
coinsurance) where Health Plan denies payments because Provider has failed to comply with the terms or
conditions of this Agreement.
5. Provider further agrees (i) that the provisions of (1), (2), (3), and (4) of this Attachment shall survive
termination of this Agreement regardless of the cause giving rise to termination and shall be construed to
be for the benefit of Members, and (ii) that this provision supersedes any oral or written contrary
agreement now existing or hereafter entered into between Provider and Members or persons acting on
their behalf.
6. If Provider contracts with other providers or facilities who agree to provide Covered Services to Members
of Health Plan with the expectation of receiving payment directly or indirectly from Health Plan, such
providers or facilities must agree to abide by the provisions of (1), (2), (3), (4), (5), (7), (11) and (12) of
this Attachment.
7. Willfully collecting or attempting to collect an amount from a Member knowing that collection to be in
violation of this Agreement constitutes a class C felony under RCW 48.80.030(5) & (6).
8. Health Plan will provide Provider not less than sixty (60) days' notice of changes that affect Provider's
compensation and that affect health care service delivery unless changes to federal or state law or
regulations make such advance notice impossible, in which case notice shall be provided as soon as
possible. Subject to any termination and continuity of care provisions of the contract, Provider may
terminate the contract without penalty if the Provider does not agree with the changes. No change to this
Agreement maybe made retroactive without the express consent of Provider.
9. Health Plan does not preclude or discourage Provider from informing Members of the care they require,
including various treatment options, and whether in their view such care is consistent with medical
necessity, medical appropriateness, or otherwise covered by the patient's service agreement with Health
Plan. Health Plan will not prohibit, discourage, or penalize Provider if otherwise practicing in compliance
with the law from advocating on behalf of a Member with Health Plan. Members are free to contract at
2021029_IMC MMOSA/Revised Sept 2018 Page 20 of 27
any time to obtain any health care services outside their Health Plan on any terms or conditions the
Members choose. Nothing in this section shall be construed to authorize Provider to bind Health Plan to
pay for any service.
10. Health Plan does not preclude or discourage Member or those paying for their coverage from discussing
the comparative merits of different health carriers with Provider. This prohibition specifically includes
prohibiting or limiting Providers participating in those discussions even if critical of a Health Plan.
11. Provider will make health records available to appropriate state and federal authorities involved in
assessing the quality of care or investigating complaints, grievances, appeals or review of any adverse
benefit determinations of Members subject to applicable state and federal laws related to the
confidentiality of medical or health records. Provider is required to cooperate with audit reviews of
encounter data in relation to the administration of Health Plan risk adjustment and reinsurance programs.
12. Provider shall furnish Covered Services to Members without regard to the Member's enrollment in Health
Plan as a private purchaser of the plan or as a participant in publicly financed programs of health care
services. This requirement does not apply to circumstances when Provider should not render services due
to limitations arising from lack of training, experience, skill, or licensing restrictions.
13. Provider may, in good faith, report to state or federal authorities any act or practice by Health Plan that
jeopardizes Member health or welfare or that may violate state or federal law.
14. Terms and Conditions of Payment
a. For Covered Services provided to Members, Health Plan shall pay Provider, and Provider shall pay
any of its subcontractors, as soon as practical but subject to the following minimum standards
including any applicable federal regulations (i.e. 42 CFR 422.520(b).):
i. Ninety-five (95%) percent of the monthly volume of Clean Claims shall be paid within thirty (30)
days of receipt by Health Plan or Health Plan's agent;
ii. Ninety-five percent (95%) of the monthly volume of all Claims shall be paid or denied within
sixty (60) days of receipt by Health Plan or Health Plan's agent;
iii. Ninety-nine percent (99%) of the monthly volume of Clean Claims shall be paid within ninety
(90) calendar days of receipt, except as agreed to in writing by the parties on a Claim -by -Claim
basis.
b. A Claim is a bill for services, a line item of service or all services for one Member within a bill.
c. The date of receipt of a Claim is the date Health Plan or Health Plan's agent receives either written or
electronic notice of the Claim.
d. The date of payment is the date of the check or other form of payment.
e. Health Plan shall establish a reasonable method for confirming receipt of Claims and responding to
Provider inquiries about Claims.
f. For those State products/programs covered by the Washington Administrative Code (WAC), failure
of Health Plan to abide by the timely Claims payment standards delineated in 14.a above shall result
in a requirement to pay interest on undenied and unpaid Clean Claims as described in WAC 284-170-
431.
g. When Health Plan issues payment in Provider's name and the Member's name, Health Plan shall
make Claim checks payable in the name of the Provider first and the Member second.
h. These standards do not apply to Claims about which there is substantial evidence of fraud or
misrepresentation by Providers, facilities or Members, or instances where Health Plan has not been
granted reasonable access to information under Provider's control.
i. Health Plan and Provider are not required to comply with these terms and conditions of payment if
the failure to comply is occasioned by any act of God, bankruptcy, act of a governmental authority
2021029_IMC MHWPSA/Revised Sept 2018 Page 21 of 27
responding to an act of God or other emergency, or the result of a strike, lockout, or other labor
dispute.
15. Notwithstanding any other provision of this Agreement, Provider is not required to grant Health Plan
access to health information and other similar records unrelated to Members. This provision shall not
limit Health Plan's right to ask for and receive information relating to the ability of Provider or facility to
deliver health care services that meet the accepted standards of medical care prevalent in the community.
16. Notwithstanding any other provision of this Agreement, any access Provider must grant Health Plan to
medical records for audit purposes must be limited to only that necessary to perform the audit.
17. Provider maintains a reciprocal right to audit Health Plan's denials of Provider's Claims when Health
Plan audits Provider's Claims.
18. In the event Provider participates in Health Plan's Medicare Programs, the following provisions shall
apply:
a. Provider shall make all of its "Relevant Records" available for inspection, examination and copying
by all federal and state agencies with regulatory authority over the subject matter of this Agreement.
Provider shall permit such inspection at Provider's place of business and at all reasonable times.
"Relevant Records" shall mean all books and records of Provider related directly or indirectly to the
goods and services furnished under the terms of this Agreement. Provider shall maintain such
Relevant Records for the period of time required by applicable federal and state statutes, but in no
event less than ten (10) years. This provision shall survive termination of the Agreement. (42 CFR
422.504(e)(2), 422.504(e)(3), 422.504(e)(4), and 422.504(i)(2)(ii)).
b. Provider shall comply with the confidentiality and enrollee record accuracy requirements set forth in
42 CFR 422.118. (42 CFR 422.504(a)(13)).
c. Provider agrees that under no circumstance shall a subscriber or enrollee in Health Plan's Medicare
Programs be liable to the Provider for any sums owed by Health Plan to Provider. (42 CFR
422.504(g)(1)(i) and 42 CFR 422.504(i)(3)(i)).
d. If Provider is delegated any of the activities or functions of Health Plan as required in its contract
with CMS, Provider agrees to comply with all applicable contractual provisions in the same manner
as if Provider had executed such contract with CMS directly. The activities or functions delegated to
Provider are set forth in the Agreement. In the event CMS or Health Plan determines, in its sole
discretion, that Provider has not performed the delegated activities or functions satisfactorily, the
delegated activities shall be revoked upon not less than five (5) days prior written notice. The
performance of such delegated activities shall be monitored by Health Plan on an ongoing basis, and
Provider shall cooperate with all reasonable requests made by Health Plan in order to accomplish
such monitoring. If Provider is delegated credentialing activities, Provider's credentialing process will
be reviewed and approved by Health Plan, and such credentialing process will be audited by Health
Plan on an ongoing basis; further, Provider agrees that its credentialing process will comply with all
applicable NCQA standards. (42 CFR 422.504(i)(3)(iii) and 422.504(1)(4)).
e. Provider agrees that any services it performs will be consistent with and comply with Health Plan's
contractual obligations with CMS. (42 CFR 422.504(1)(1) and 422.504(i)(3)(iii)).
£ In the event of termination of this Agreement or Health Plan's insolvency, Provider agrees to comply
with the continuation of benefits provisions included in the Provider Manual. (42 CFR
422.504(g)(2)).
19. Upon termination of this Agreement without cause, Provider will continue to render Covered Services to
Members until the earliest of the following: (1) the date Covered Services being rendered to Member by
Provider are completed or medically appropriate provisions have been made by Health Plan for another
provider to assume responsibility for providing such Covered Services; or (2) sixty (60) days following
notice to the Member of Provider's contract termination. The provision of such Covered Services and the
2021029_IMC MHWPSA/Revised Sept 2018 Page 22 of 27
reimbursement to Provider for such Covered Services shall be subject to all applicable terms of this
Agreement on the same basis as Covered Services provided during the term of this Agreement.
20. Provider will satisfy and be in compliance with all of the requirements in WAC 284-43-0120.
21. Provider will ensure that all of its subcontractors will satisfy and be in compliance with all of the
requirements in WAC 284-43.
2021029_IMC MHWPSAJRevised Sept 2018 Page 23 of 27
ATTACHMENT 3
REQUIRED PROVISIONS
(Health Care Authority)
The following provisions are required by (i) federal statutes and regulations applicable to medical assistance
programs for the indigent, (ii) state statutes and regulations applicable to medical assistance programs for the
indigent, or (iii) contracts and agreements between the Health Plan and the state agencies responsible for
regulating risk-based medical assistance programs for the indigent. These provisions shall be automatically
modified to conform to subsequent amendments to such statutes, regulations, and agreements. Further, any
purported modifications to these provisions inconsistent with such statutes, regulations, and agreements shall be
null and void.
1. Provider shall provide reasonable access to facilities and financial and medical records for duly authorized
representatives of the CMS, HCA, Department of Social & Health Services ("DSHS") or the Department of
Health & Human Services ("DHHS") for audit purposes and immediate access for Medicaid fraud
investigators.
2. Provider shall completely and accurately report encounter data to Health Plan. Provider shall have the
capacity to submit all required data to enable Health Plan to meet the requirements in the Encounter Data
Transaction Guide published by HCA.
3. Provider shall comply with Health Plan's fraud and abuse policies and procedures.
4. Provider shall not assign this Agreement without RCA's written agreement.
5. Provider shall comply with any term or condition of Health Plan's contracts with HCA that is applicable to
the services to be performed by Provider.
6. Provider shall accept payment from the Health Plan as payment in full and shall not request payment from
HCA or any enrollee for Covered Services performed under this Agreement.
7. Provider agrees to hold harmless HCA and its employees, CMS and its employees, and all enrollees served
under the terms of this Agreement in the event of non-payment by Health Plan. Provider further agrees to
indemnify and hold harmless HCA and its employees against all injuries, deaths, losses, damages, claims,
suits, liabilities, judgments, costs and expenses which may in any manner accrue against HCA or its
employees through the intentional misconduct, negligence, or omission of Provider, its agents, officers,
employees or contractors.
8. Provider agrees to comply with the HCA appointment wait time standards. Provider agrees to Health Plan's
regular monitoring of timely access to Provider's services, and agrees to corrective action up to and
including termination for cause in the event that Provider fails to comply with the appointment wait time
standards.
9. Provider shall assure that all sterilizations and hysterectomies performed under this Agreement are in
compliance with 42 CFR 441 Subpart F, and that the Sterilization Consent Form (DSHS 13-364(x)) or its
equivalent is used.
10. Provider shall make reasonable accommodation for enrollees with disabilities, in accord with the Americans
with Disabilities Act, for all Covered Services and shall assure physical and communication barriers shall
not inhibit enrollees with disabilities from obtaining Covered Services.
11. Provider shall comply with all Program Integrity provisions as documented in Health Plan Provider Manual
and as set forth by 42 CFR 43 8.608 and the Health Plan's contracts with HCA.
12. Provider shall comply with Patient Identifying Information from an alcohol or drug abuse "program", as
defined in 42 C.F.R. §2.11, that is federally assisted in the manner described in 42 C.F.R. §2.12(b), then it is
fully bound by the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient
Records, 42 C.F.R. Part 2, with respect to such information and records, including but not limited to the
2021029_MIC MHWPSA/Revised Sept 2018 Page 24 of 27
duty to resist in judicial proceedings any efforts to obtain access to such information or records, other than
as permitted by law.
2021029_IMC MHWPSA/Revised Sept 2018 Page 25 of 27
ATTACHMENT 4
MEDICARE PROGRAM REQUIREMENTS --HEALTH CARE SERVICES
This attachment sets forth applicable laws and government program requirements, or other provisions necessary
to reflect compliance for the Medicare Advantage Product. This attachment will be automatically modified to
conform to subsequent changes to laws or government program requirements. All provisions of the Agreement
not specifically modified by this attachment remain unchanged and will control. In the event of a conflict between
this attachment and any other provision in the Agreement, the provisions in this attachment will control for the
Medicare Advantage Product. Capitalized terms used in this attachment will have the same meaning ascribed to
them in the Agreement unless otherwise set forth in this attachment. Any purported modification or any provision
in this attachment that is inconsistent with a law or government program requirement will not be effective and
will be interpreted in a manner that is consistent with the applicable law and government program requirement.
This attachment only applies to the Medicare Advantage Product.
1.1 Definitions.
a. Completion of Audit means a completion of audit by HHS, the Government Accountability Office, or
their designees of a Medicare Advantage Organization, Medicare Advantage Organization contractor or
Related Entity.
b. Downstream Entity means any party that enters into a written arrangement, acceptable to CMS, with
persons or entities involved with the Medicare Advantage benefit, below the level of the arrangement
between a Medicare Advantage Organization (or applicant) and a First Tier Entity. These written
arrangements continue down to the level of the ultimate provider for health and administrative services.
c. Final Contract Period means the final term of the contract between CMS and the Medicare Advantage
Organization.
d. First Tier Entity means any party that enters into a written arrangement, acceptable to CMS, with a
Medicare Advantage Organization or applicant to provide administrative services or health care
services for a Medicare eligible individual under the Medicare Advantage program.
e. Medicare Advantage Organization means a public or private entity organized and licensed by a State
as a risk -bearing entity (with the exception of provider -sponsored organizations receiving waivers) that
is certified by CMS as meeting the Medicare Advantage contract requirements.
f. Related Entity means any entity that is related to the Medicare Advantage Organization by common
ownership or control and; (i) performs some of the Medicare Advantage Organization's management
functions under contract or delegation; (ii) furnishes services to Medicare enrollees under an oral or
written agreement; or (iii) leases real property or sells materials to the Medicare Advantage
Organization at a cost of more than $2,500 during a contract period.
1.2 Right to Audit. HHS, the Comptroller General, or their designees have the right to audit, evaluate, collect,
and inspect any pertinent information for any particular contract period, including, but not limited to, any
books, contracts, computer or other electronic systems (including medical records and documentation of the
First Tier Entity, Downstream Entity, and Related Entity, through ten (10) years from the final date of the
Final Contract Period of the contract entered into between CMS and the Medicare Advantage Organization
or from the date of completion of any audit, whichever is later.
1.3 Right to Audit Directly from FDR. HHS, the Comptroller General, or their designees have the right to
audit, evaluate, collect, and inspect any records under section 1.2, of this attachment, directly from any First
Tier Entity, Downstream Entity, and Related Entity. For records sub j ect to review under section 1.2, except
in exceptional circumstances, CMS will provide notification to the Medicare Advantage Organization that a
direct request for information has been initiated.
1.4 Confidentiality. Provider will comply with the confidentiality and Member record accuracy requirements,
including: (i) abiding by all laws regarding confidentiality and disclosure of medical records, or other health
and enrollment information; (ii) ensuring that medical information is released only in accordance with
applicable law, or pursuant to court orders or subpoenas; (iii) maintaining the records and information in an
2021029_IMC MHWPSA/Revised Sept 2018 Page 26 of 27
accurate and timely manner; and (iv) ensuring timely access by Members to the records and information
that pertain to them.
1.5 Hold Harmless. Members will not be held liable for payment of any fees that are the legal obligation of the
Medicare Advantage Organization.
1.6 Cost Sharing. For all Members eligible for both Medicare and Medicaid, Members will not be held liable
for Medicare Part A and B cost sharing when the State is responsible for paying such amounts. Providers
will be informed of Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and
Medicaid. Provider may not impose cost-sharing that exceeds the amount of cost-sharing that would be
permitted with respect to the individual under title XIX if the individual were not enrolled in such a plan.
Providers will: (i) accept the Health Plan payment as payment in full; or (ii) bill the appropriate State
source.
1.7 Delegation. Any services or other activity performed in accordance with a contract or written agreement by
Provider or a Downstream Entity of Provider are consistent and comply with the Medicare Advantage
Organization's contractual obligations.
1.8 Prompt Payment. Health Plan will pay Provider for Clean Claims for Covered Services, that are
determined to be payable, in accordance with laws, government program requirements, and this Agreement.
Health Plan will make such payment within sixty (60) days.
1.9 Compliance with Medicare Laws. Provider will comply with all applicable Medicare Laws, regulations,
and CMS instructions.
1.10 Benefit Continuation. Provider agrees to provide for continuation of Member health care benefits: (i) for
all Members, for the duration of the period for which CMS has made payments to Health Plan for Medicare
services; and (ii) for Members who are hospitalized on the date Health Plan's contract with CMS
terminates, or, in the event of insolvency, through discharge
1.11 Accountability. Health Plan may only delegate activities or functions to a First Tier Entity or Downstream
Entity in a manner that is consistent with the requirements set forth in Health Plan's contractual obligations.
1.12 Reporting. Provider agrees to provide relevant data to support Health Plan in complying with the
-requirements set forth in 42 CFR 422.516 and 42 CFR 422.310.
2021029_IMC MHWPSA/Revised Sept 2018 Page 27 of 27
EXHIBIT 1-A
Compensation Schedule - Medicaid (Version 2)
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in
accordance with Health Plan's programs participation, on a fee -for -services basis, at the lesser of; (i) Provider's
allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-
payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any:
Integrated Managed Care ("IMC") Apple Health, IMC Apple Health Adult, IMC Apple Health Blind and
Disabled, IMC Apple Health with Premium (collectively referred to as "IMC"), and Behavioral Health
Services Only ("BHSO"):
Provider agrees to follow Health Plan's IMC Companion Guide, which is intended to supplement the use of the
Health Care Authority ("HCA") Integrated Managed Care Service Encounter Reporting Instructions ("SERI").
Health Plan may unilaterally change or modify the IMC Companion Guide from time to time, as updates are made
to SERI or Health Plan policies and procedures.
Upon written request from Health Plan, Provider shall submit annual independently audited financial statements
to Health Plan based upon Provider's prior fiscal year-end financial statements.
Provider must accurately and separately track Medicaid and Non -Medicaid funds and report the expenditure of these
funds to Health Plan upon its written request.
Reimbursement is inclusive and in accordance with HB 1109 Section 215 (23).
The following language applies to IMC and BHSO services rendered in THE NORTH CENTRAi,
REGIONAL SERVICE AREA.
The terms below pertaining to IMC and BHSO shall be effective January 1, 2021 through December 31, 2021;
thereafter the rates shall automatically renew for successive one (1) year terms, unless otherwise amended upon
mutual agreement of the parties.
Payment shall be made by Health Plan to the Provider as follows:
1. MENTAL HEALTH AND SUBSTANCE USE DISORDER REIMBURSEMENT
1.1 Health Plan shall make known to Provider by written notice, provided no later than the 15th
day of each month, the total North Central Region Medicaid behavioral health premium and
General Funds State ("GF -S") dollars received by Health Plan for the current month. Health
Plan will provide with monthly accounting statement the total membership by county. North
Central Region, for the purpose of this Agreement, is defined as Chelan, Douglas and Grant
Counties and excludes Okanogan County.
1.2 From the total funds received by Health Plan identified above, Health Plan shall create withhold
accounts or apply deductions as follows (each with the fund types comprising them identified):
1.2.1 Health Plan Administrative costs not to exceed 12.8% of Health Plan's dollars received
per section 1.1 above.
1.2.2 Children's Home Society ("CHS") (the amount contracted). These funds will be used
to pay CHS' agreement. Payments to CHS shall not exceed:
a. For outpatient services: Health Plan's proportionate share of the budget
($100,988.00 per month), which is based on the percentage of Apple Health IMC
and BHSO membership in Chelan, Douglas and Grant Counties. Proportionate
share will be assessed on a monthly basis.
1.2.3 Columbia Valley Community Health ("CVCH") (the amount contracted). These funds
will be used to pay CVCH's agreement.
2021029_IMC.CS18 Comp Schedule/2018 Page 1 of 8
a. CVCH is reimbursed Fee -For -Service per encounter hour for outpatient mental
health services. All claims paid for these services will be deducted on a monthly
basis. Payments to CVCH shall not exceed the Health Plan's proportionate share
for this. budget ($60,000 per month), which shall be based on its percentage of
Apple Health IMC and BHSO membership in Chelan, Douglas and Grant Counties.
Proportionate share will be assessed on a monthly basis.
1.2.4 The Center for Drug and Alcohol ("CADT") (the amount contracted). These funds will
be used to pay CADT's agreement.
a. CADT is reimbursed as follows:
i. For outpatient substance use disorder services: Health Plan's proportionate
share (based on Health Plan's Apple Health IMC and BHSO Member
utilization) of the budget ($85,026.00). E.g. 100 IMC/BHSO Members
served during the month; 35 Members are Health Plan's IMC or BHSO
Members, so Health Plan is responsible for 35% of that month's Budget
Amount).
ii. For intensive inpatient residential (including room and board): Health Plan's
proportionate share (based on Health Plan's Apple Health IMC and BHSO
Member utilization) of twelve (12) beds, to be paid at one hundred percent
(100%) of the State of Washington Medicaid Fee -For -Service fee schedule in
effect on the date of service. Vacant bed days will be allocated to Health
Plan, other health plan(s) and the Behavioral Health Administrative Services
Organization (`BH -ASO") based on each party's percentage of utilization for
that month (i.e. if Health Plan utilized 50% of the bed days for the month,
Health Plan will reimburse Provider for 50% of the vacant bed days). Any
utilization above the twelve (12) beds will also be paid via invoice at one
hundred percent (100%) of the State of Washington Medicaid Fee -For -
Service fee schedule in effect on the date of service.
iii. For clinically managed sub -acute withdrawal management beds: Health
Plan's proportionate share (based on Health Plan's Apple Health IMC and
BHSO Member utilization) of 7 beds, to be paid at one hundred percent
(100%) of the State of Washington Medicaid Fee -For -Service fee schedule in
effect on the date of service. Vacant bed days will be allocated to Health
Plan, other health plan(s) and the Behavioral Health Administrative Services
Organization (`BH -ASO") based on each party's percentage of utilization for
that month (i.e. if Health Plan utilized 50% of the bed days for the month,
Health Plan will reimburse Provider for 50% of the vacant bed days). Any
utilization above the 7 beds will also be paid via invoice at one hundred
percent (100%) of the State of Washington Medicaid Fee -For -Service fee
schedule in effect on the date of service.
1.2.5 Incentive Payment (the amount contracted). These funds will be used to pay all
providers' incentive payments per providers' agreements.
1.3 All remaining funds received by Health Plan shall be divided between and paid to Provider and
Catholic Family and Children Services ("CFCS") by the 15th of the month as follows:
1.3.1 All remaining North Central Region Medicaid funds received by Health Plan shall be
divided between Provider and CFCS according to Health Plan's Medicaid eligible IMC
and BHSO population split for Chelan/Douglas and Grant Counties.
1.3.2 From Provider's allocation, the following will be deducted:
a. Effective January 1, 2021 and thereafter: A PMPM will be paid to Beacon for
crisis services to Members in Grant County. Molina will complete periodic
reconciliations on the experience related to the PMPM paid — any excess is paid
back to Molina (and passed on to Provider) and any deficit is due to Beacon (paid
by Provider). If experience indicates the PMPM should be adjusted, Molina will
amend the rate accordingly.
2021029_I1\4C.CS 18 Comp Schedule/2018 Page 2 of 8
b. Paid state hospitalization penalties, behavioral health inpatient and residential
(Effective January 1, 2021: including crisis stabilization/triage) claims for Health
Plan's membership assigned to Grant County. Health Plan will provide Provider
supporting documentation for state hospitalization penalties and behavioral
health inpatient and residential claims paid each month.
C. In accordance with Section 3, Performance Measures below 4% of Provider's
total Medicaid payment will be withheld each month.
1.3.3 From Provider's allocation, the following will be deducted: GF -S funded services
provided to Health Plan's membership assigned to Grant County from out -of -region
providers (i.e. room and board claims for residential mental health/substance use
disorder treatment). All remaining GF -S funds shall be divided between and paid to
Provider and CFCS according to Health Plan's Medicaid eligible IMC and BHSO
population split for Chelan/Douglas and Grant Counties.
1.3.4 Health Plan and Provider agree to work together in good faith to achieve a fair and
reasonable method of addressing costs as a result of Members accessing care outside
their county of residence such that if Provider provides care for Chelan/Douglas County
Members or visa versa, those costs will be fairly adjusted and allocated.
1.4 Variability of costs in any one of these withhold accounts will be addressed as follows:
1.4.1 CHS no overspending will be permitted by the agreement between Health Plan and
CHS.
1.4.2 CVCH no overspending will be permitted by the agreement between Health Plan
and CVCH.
1.4.3 Inpatient behavioral health (inclusive of behavioral health inpatient and residential
claims and state hospitalization penalties) costs for Chelan and Douglas County
Members shall be withheld from CFCS and paid directly by Health Plan.
1.5 Upon execution of this Agreement, Provider shall assume the risk for payment of state hospital
penalties incurred, billed and paid through the termination of the contact. In the event of the
assessment of such state hospital penalty, Provider shall be responsible for the payment of such
penalties that result from state hospital census exceeding Health Plan's allocated proportion of
state hospital beds for Grant County Members for any given month. Upon execution of this
Agreement, Provider shall assume the risk for payment of community hospital claims billed
through the termination of the Agreement. Health Plan shall withhold and pay such state
hospitalization penalties and behavioral health inpatient and residential claims as provided
above.
2. MEDICAID VS. NON -MEDICAID FUNDS
2.1 Provider must accurately and separately track Medicaid and Non -Medicaid funds and report the
expenditure of these funds to Health Plan as required.
3. PERFORMANCE MEASURES
Provider must meet the following performance measures:
3.1 Provider must render a minimum of 11,000 substance use disorder services and 29,200 mental
health services (across all health plans and Behavioral Health Administrative Services
Organization (`BH -ASO") on an annual basis;
3.2 Ensure 99% of encounter data submissions are accepted by Health Plan. Any encounter
submission errors must be corrected and resubmitted;
3.3 Utilization of Evidence Based Practices ("EBP"). At least 30% of youth mental health consumers
receive an EBP as defined in the SERI;
3.4 Maintain a 70% target for Members admitted into treatment within 14 days of first contact as
entered into Provider's EHR; and
3.5 Quality Service Clinical Outcomes. To receive incentive payment for the below measures,
Provider is expected to support collection of information/data. Baseline data will be collected in
year one.
3.5.1 Follow -Up after Hospitalization for Mental Illness ("FUH")
2021029_I1\4C.CS18 Comp Schedule/2018 Page 3 of 8
3.5.2 Antidepressant Medication Management ("AMM")
3.5.3 Penetration Rate for behavioral health services
3.5.4 Engagement of Substance Use Disorder ("SUD") treatment — Percent of adult and
youth SUD outpatient ("OP") and intensive outpatient ("IOP") service episodes where
the member received at least two face-to-face treatment sessions within the 30 days
following "initiation" of SUD treatment during an OP/IOP service episode.
3.6 Achievement of any one of the aforementioned performance measures must result in an incentive
payment of .5% per measure (3.1 through 3.5 above), up to a maximum of 4% of the total award
amount. Total award amount is 4% of Medicaid fund payments each month and will be withheld
monthly.
3.7 Compliance with performance standards must be determined semi-annually with any required
incentive payment being limited to payments received during the six (6) calendar months
preceding the determination.
4. AUDIT
4.1 Provider must obtain an annual independent financial audit or otherwise meet the
requirements prescribed by Federal Office of Management. Provider must submit a copy of
the independent auditor's report to Health Plan within six (6) months of the close of Provider's
fiscal year.
4.2 Provider must submit evidence which documents that the annual audit report has been
reviewed by Provider's governing body.
5. WISE PROGRAM
5.1 Monthly payments for WISe shall be Health Plan's proportionate share of $135,540.00
(calculated based on a 45 Member caseload at $3,012.00 per Member). Health Plan's
proportionate share for this budget shall be based on its percentage of Apple Health IMC and
BHSO Members in the WISe program (e.g. 12 Members out of 45=56%).
5.2 Vacant WISe spots will be allocated to Health Plan, other health plan(s) and the Behavioral
Health Administrative Services Organization (`BH -ASO") based on each party's percentage
of utilization for that month (i.e. if Health Plan utilized 50% of the WISe spots for the month,
Health Plan will reimburse Provider for 50% of the vacant WISe spots).
5.3 Provider must maintain an eighty percent (80%) WISe caseload during the term of the
Agreement. If the WISe caseload is less than 80% for a period of sixty (60) days or more,
Provider will be financially responsible for the per Member shortage.
5.4 Monthly payments will be triggered by the submission of an invoice to Health Plan's Finance
team. Health Plan will issue payment within ten (10) business days of Health Plan's receipt of
a Clean Invoice. Clean Invoice references an invoice that is free of errors and incorrect
information (e.g. ineligible Members).
5.5 Provider will submit encounters for Covered Services rendered by the 10th of the month for
prior month's services.
2021029_IMC.CS18 Comp Schedule/2018 Page 4 of 8
EXHIBIT 1-B
Compensation Schedule - Medicare (Version 1)
Substance Use Disorder:
Health Plan agrees to compensate Provider on a fee-for-service basis for Covered Services provided in accordance
with the Medicare Advantage Product, that are determined by Health Plan to be payable and submitted on a Clean
Claim, less any applicable Member co -payments, deductibles, co-insurance or amounts paid or to be paid by other
liable parties, in any, at the lesser of: (i) Provider's billed charges; or (ii) at an amount equivalent to one hundred
percent (100%) of the Medicare Fee -For -Service Program allowable payment rates (adjusted for place of service
or geography), as of the date of service. The Medicare Fee -For Service Program allowable rate deducts any cost
sharing amounts, including but not limited to co -payments, deductibles, co-insurance, or amount paid or to be
paid by other liable third parties that would have been deducted if the Member were enrolled in the Medicare Fee -
For -Service Program.
2021029_IMC.CS18 Comp Schedule/2018 Page 5 of 8
EXHIBIT 1-B
Compensation Schedule - Medicare (Version 2)
Health Plan agrees to compensate Provider on a fee-for-service basis for Covered Services provided in accordance
with Medicare, that are determined by Health Plan to be payable and submitted on a Clean Claim, less any
applicable Member co -payments, deductibles, co-insurance or amounts paid or to be paid by other liable parties, if
any, at the lesser of; (i) Provider's billed charges or (ii) the amounts set forth below. The Medicare Fee -For
Service Program allowable rate deducts any cost sharing amounts, including but not limited to co -payments,
deductibles, co-insurance, or amount paid or to be paid by other liable third parties that would have been deducted
if the Member were enrolled in the Medicare Fee -For -Service Program.
I. Mental Health:
A. Psychiatrist, Psychologist, Nurse Practitioner:
All Medicare Covered Services shall be paid at an amount equivalent to one hundred percent
(100%) of the Medicare Fee -For Service Program allowable payment rates (adjusted for place of
service or geography) as of the date of service.
B. Clinical Social Worker:
All Medicare Covered Services shall be paid at an amount equivalent to one hundred percent
(100%) of the Medicare Fee -For Service Program allowable payment rates (adjusted for place of
service or geography) as of the date of service.
(Note: Fees are paid at the level of credentialed licensure, not educational attainment.)
2021029_I1\4C.CS18 Comp Schedule/2018 Page 6 of 8
EXHIBIT 1-C
Compensation Schedule - Molina Marketplace (Version 1)
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in
accordance with Health Plan's programs participation, on a fee -for -services basis, at the lesser of; (i) Provider's
allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-
payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any:
Substance Use Disorder:
Covered Services shall be paid at one hundred ten percent (110%) of the State of Washington Medicaid Fee -For -
Service Program fee schedule in effect on the date of service.
If there is no payment rate in the State of Washington Medicaid Fee -For -Service Program fee schedule as of the
date of service, payment shall be at one hundred percent (100%) of the prevailing local and geographically
adjusted Medicare Fee -For -Service Program fee schedule, in effect on the date of service.
If there is no payment rate achieved in the above methodologies, reimbursement shall be paid at fifty percent
(50%) of billed charges.
2021029_IMC.CS18 Comp Schedule/2018 Page 7 of 8
EXHIBIT 1-C
Compensation Schedule - Molina Marketplace (Version 3)
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in
accordance with Health Plan's programs participation, on a fee -for -services basis, at the lesser of; (i) Provider's
allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-
payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any:
I. Mental Health:
A. Psychiatrist:
One hundred thirty-five percent (135%) of the State of Washington Medicaid Fee -For -Service
Program fee schedule in effect on the date of service.
B. Psychologist, Nurse Practitioner:
One hundred ten percent (110%) of the State of Washington Medicaid Fee -For -Service Program
fee schedule in effect on the date of service.
C. Master Level Therapist, Clinical Social Worker:
One hundred ten percent (110%) of the State of Washington Medicaid Fee -For -Service Program
fee schedule in effect on the date of service.
If there is no payment rate in the State of Washington Medicaid Fee -For -Service Program fee schedule in effect on
the date of service, payment shall be at one hundred percent (100%) of the prevailing local and geographically
adjusted Medicare Fee -For -Service Program fee schedule in effect of the date of service.
If there is no payment rate achieved in the above methodologies, reimbursement shall be paid at fifty percent
(50%) of billed charges.
2021029_I1\4C.CS 18 Comp Schedule/2018 Page 8 of 8
Janice Fivnn
From: Kevin J. McCrae
Sent: Wednesday, April 21, 2021 2:38 PM
To:, Linze Greenwalt
Cc: Debra Larson; Janice Flynn
Subject: RE: Agreement between GrIS and Molina
Attachments: 2021029 -IMC -County of Grant - Full Final.pdf; Agreement - 2021-04-14T094907.137.pdf
I do not see any issues with these contracts.
Kevin McCrae
(please note my new e-mail address)
Chief Deputy Prosecuting Attorney (Civil/Appellate Unit),
WSBA #43087
Grant County Prosecutor's Office
P.O. Box 37
35 C Street NW
Ephrata, WA 98823
(509)-754-2011 ext. 3956 (Civil) 3996 (Criminal)
Fax 754-3449
kimccrae@grantcountywa.gov
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reply to this email may be considered a public record and be subject to disclosure upon request. Th a n k yo u.
From: Linze Greenwalt <Igreenwalt@grantcountywa.gov>
Sent: Tuesday., April 20, 20219:15 AM
To: Kevin J. McCrae <kjmccrae@grantcountywa.gov>
Cc: Debra Larson <dlarson@grantcountywa.gov>
Subject: FW: Agreement between GrIS and Molina
Good morning..
Attached are two agreements for Molina Healthcare and Amerigroup. Will you please review these
and let me know if there are any issues? We are hoping to have these on next week's consent
agenda.
Thanks,
Linze Greenwalt
Executive Assistant to Dell Anderson, Executive Director