HomeMy WebLinkAboutAgreements/Contracts - GRISK 19-042
RECEIVED APR 08 IN 4( s
AMENDMENT NUMBER FOUR
PARTICIPATING PROVIDER AGREEMENT
This Amendment Number Four ("Amendment") is entered into as of March 7, 2019 by and between Coordinated
Care of Washington, Inc. ("Health Plan") and County of Grant dba Grant Integrated Services ("Provider"),
collectively referred to herein as the "Parties".
WHEREAS, Health Plan and Provider have previously entered into a Participating Provider Agreement (the
"Agreement") effective as of January 1, 2018 (defined in the Agreement as the "Effective Date"); and
WHEREAS, the Parties desire to amend the Agreement;
NOW THEREFORE, in consideration of the promises and mutual covenants herein contained, the Parties agree as
follows:
1. Section 2.5 of Exhibit A-3 shall be deleted from the Agreement in its entirety and replaced with the
following:
"2.5 Term. The term of this exhibit shall be in accordance with Article V 1 l section 7.1 "
2. Section 2.5 of Exhibit A-12 shall be deleted from the Agreement in its entirety and replaced with the
following:
"2.5 Term. The term of this exhibit shall be in accordance with Article VI I section 7.1."
3. All other terms and conditions of the Agreement and any amendments thereto, if any, shall remain in full
force and effect. If the terms of this Amendment conflict with any of the terms of the Agreement, the terms
of this Amendment shall prevail.
IN WITNESS WHEREOF, the Parties hereto have executed and delivered this
Amendment as of the date first set forth above.
HEALTH PLAN: PROVIDER:
County of Grant dba Grant Integrated
Coordinated Care of Washington, Inc. Services
Authorized Signatur
Printf : so
Tille:President & CEO
Date:
Authorized Signature
Printed Name:
1 Lm Taylor
Title: SOCC Chair
Date: S/1 lb 110(
ECM #; 425548 Tax 1D Number: 91-6001319
State Medicaid Number: 1981109
1.$, "Covered Person" means any individual entitled to receive Covered Services pursuant to the terms
of a Coverage Agreement.
1.9. "Covered Services" means those services and items for which benefits are available and payable
under the applicable Coverage Agreement and which are determined, if applicable, to be Medically Necessary
tinder the applicable Coverage Agreement.
1.10. `'Health Plan" means either CCC or CCW with respect to each Product covered by this Agreement,
as specified in accordance with Schedule 13 to this Agreement or the applicable Product Attachment.
1.11. "Medically Necessary'' or "Medical Necessity" shall have the meaning defined in the applicable
Coverage Agreement and applicable Regulatory Requirements.
1.:12. "Participatin Provider" means, with respect to a particular Product, any physician, hospital,
ancillary, or other health care provider that has contracted, directly or indirectly, with Health Plan to provide
Covered Services to Covered Persons, that has been approved for participation by Company, and thatisdesignated
by Company as a `'participating provider" in such Product.
1.13. "_Pavor" means the entity (including Company where applicable) that hears direct financial
responsibility for paying from its own funds, without reimbursement from another entity, the cost of Covered
Services rendered to Covered Persons under a Coverage Agreement and, if such entity is not Company, such entity
contracts, directly or indirectly, with Company for the provision of certain administrative or other services with
respect to such Coverage Agreement.
1.14. 'Payor Contract'' means the contract with a Payor, pursuant to which Company furnishes
administrative services or other services in support of the Coverage Agreements entered into, issued or agreed to by
a Payor, which services may include access to one or more of Company's provider networks or vendor
arrangements, except those excluded by Health Plan. The term "Payor Contract" includes Company's or other
Payor's contract with a governmental authority (also referred to herein as a "Governmental Contract') tinder which
Company or Payor arranges for the provision of Covered Services to Covered Persons.
"Product" means any program or health benefit arrangement designated as a "product" by Health
Plan (e.g., Health Plan Product, Medicaid Product, PPO Product, Payor -specific Product, etc.) that is now or
hereafter offered by or available from or through Company (and includes the Coverage Agreements that access, or.
are issued or entered into in connection with such product, except those excluded by Health Plan).
1.16, "Product Attachment" means an Attachment setting forth requirements, terms and conditions
specific or applicable to one or more Products, including certain provisions that must be included in a provider
agreement under the Regulatory Requirements, which may be alternatives to, or in addition to, the requirements,
terms and conditions set forth in this Agreement.
1.17. `°Rei=ulatory Requirerrzetits"means all applicable federal and state statutes, regulations, regulatory
guidance, judicial or administrative rulings, requirements of Governmental Contracts and standards and
requirements of any accrediting or certifying organization, including, but not limited to, the requirements set forth
in a Product Attachment.
1.1$. "State" is defined as the state of Washington.
ARTICLE It—PRODUCTS AND SERVICES
2.1. Contracted Providers. `Provider shall, and shall cause each Contracted Provider, to comply with
and abide by the agreements, representations, warranties, acknowledgements, certifications, terns and conditions of
this Agreement (including the provisions of Schedule A that are applicable to Provider, a Contracted Provider, or
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their services, and any other Attachments) and fulfill all of the duties, responsibilities and obligations imposed on
Provider and Contracted Providers under this Agreement (including each Attachment).
2.2. Products and Attachments. Subject to the other provisions of this Agreement, Provider and each
Contracted Provider is subject to and bound by all Attachments designated on Schedule B of this Agreement, and
may be identified as a Participating Provider in each Product identified in a Product Attachment designated on
Schedule..B of this Agreement.
2.2.1. Provider shall, at all times during the term of this Agreement, °require each of its
Contracted Providers to, subject to Company's approval, participate as Participating Providers in each Product
identified in a Product, Attachment that is designated on Schedule B of this Agreement or added to this agreement
in accordance with Section 2.2 hereof.
2.2.2. A Contracted Provider may only identify itself as a Participating Provider for those
Products in which the Contracted Provider actually participates as provided in this Agreement. Provider
acknowledges that Company or Payor may have, develop or contract to develop various Products or provider
networks that have a variety of provider panels, program components and other requirements. No Company or
Payor warrants or guarantees that any Contracted Provider: (i) will participate in all or a minimum number of
provider panels, (ii) will be utilized by a minimum number of Covered Persons, or (iii) will indefinitely remain a
Participating Provider or member of the provider panel for a particular network or Product.
2.2.3. Attached hereto as Schedule Cis the initial list of the Contracted Providers as of the
Effective Date. Provider shall provide Health Plan on a quarterly basis or more often upon request with a complete
and accurate list containing the names, office telephone numbers, addresses, tax identification numbers, hospital
affiliations, specialties and board status (if applicable), languages spoken, whether Contracted Provider is accepting
new patients, State license number, and National Provider Identifier of Contracted Providers and such other
information as mutually agreed upon by the Parties, and shall provide Health Plan with a list of modifications to
such list at least thirty (30) days prior to the effective date of such changes. Provider shall provide such lists in a
Ynanner and format mutually acceptable to the Parties.
2.2.4. Provider may add new providers to this Agreement as Contracted Providers. In such case,
Provider shall provide written notice to Health Plan of the prospective addition(s) and shall use best efforts to
provide such notice at least sixty (60) days in advance of such addition. Provider shall maintain written agreements
with each of its Contracted Providers (other than Provider) that require Contracted Providers to comply with the
terns and conditions of this Agreement and that address and comply with the Regulatory Requirements.
2.2.3, IF Company desires to add an additional Product, Company or Payor, as applicable, will
provide at least sixty (60) days' prior written notice (electronic or paper) thereof to Provider, along with the
applicable Product Attachment and the new Compensation Schedule, if any. Contracted Providers will not be
designated as Participating Providers in such additional Product until Provider agrees to participate in such
additional Product by giving Company or Payor, as applicable, written notice of its decision to participate in
accordance with the process specified in the notice to Provider. If Provider grives timely notice of agreement to
participate in an additional Product, then each Contracted Provider shall be a Participating Provider in such
additional Product on the terms and conditions set forth in this Ag=reement and the applicable Product Attachment.
2.3. Covered Services. Each Contracted Provider shall provide Covered Services described or
referenced in the applicable Product Attachment(s) to Covered Persons in those Products in which the Contracted
:Provider is a Participating Provider in accordance with this Agreement. Each Contracted Provider shall provide
Covered Services to Covered Persons with the same degree of care and skillas customarily provided to patients
who are not Covered Persons, within the scope of the Contracted Provider's license and in accordance with
generally accepted standards of the Contracted Provider's practice and business and in accordance with the
provisions of this Agreement and Regulatory Requirements.
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2.41 Policies and Procedures. Provider warrants that Provider and Contracted Providers shall at all
times cooperate and comply with applicable administrative requirements, policies, pro -rains and procedures of
Company and Payor, which may include, but are not limited to, the following: credentialing criteria and
requirements; confidentiality and notification requirements; medical management programs; claims and billing,
quality assessment and improvement, utilization review and management, disease management, case management,
on-site reviews, referral and prior authorization, and grievance and appeal procedures; coordination of benefits and
third party liability policies; carve -out and third party vendor programs; and data reporting requirements. The
failure to comply with such policies and procedures could result in a denial or reduction of payment to the Provider
or Contracted Provider or a denial or reduction of the Covered Person's benefits. Such policies and procedures do
not in any way affect or remove the obligation of Contracted Providers to render care. Health Plan shall make the
applicable policies available to Provider and Contracted Providers prior to contracting and throughout the term of
the Agreement upon reasonable request via one or more designated websites or alternative means. Company shall
notify Provider at least sixty (60) days in advance of changes in administrative policies and procedures that affect
Provider's compensation or health care service delivery unless changes to federal or State law or regulations make
such advance notice impossible, in which case notice w-iIl be provided as soon as possible. Such notice may be
given by Health Plan through an update to information available to Provider online, or any other written method
(electronic or paper). Provider shall notify Contracted Providers of such changes.
2.5. Credentialins Criteria. Provider and each Contracted Provider shalt complete Company's and/or
Payor's credentialing and/or recredentialing process as required by Company's and/or Payor's credentialing
policies, and shall at all times during the term of this Agreement meet all of Company's and/or Payor's
credentialing criteria. Provider and each Contracted Provider represents, warrants and agrees: (a) that it is
currently, and for the duration of this Agreement shall remain: (i) in compliance with all applicable Regulatory
Requirements, including licensing laws; (ii) if applicable, accredited by The Joint Commission or the American
Osteopathic Association; and (iii) a Medicare -certified provider under the federal Medicare program and a
Medicaid participating provider under applicable federal and State laws; and (b) that all Contracted Providers and
all employees and contractors thereof will perform their duties in accordance with all Regulatory Requirements, as
well as applicable national, State and local standards of professional ethics and practice. No Contracted Provider
shall provide Covered Services to Covered Persons or identify itself as a Participating Provider unless and until the
Contracted Provider has been notified, in writing, by Company that such Contracted Provider has successfully
completed Company's credentialing process.
2.6. Eligibility Determinations. Provider or Contracted Provider shall timely verify whether an
individual seeking Covered Services is a Covered Person. Company or Payor, as applicable, will make available to
Provider and Contracted Providers a method whereby Provider and Contracted Providers can obtain, in a timely
manner, general information about eligibility and coverage. Company or Payor, as applicable, does not guarantee
that persons identified as Covered Persons are eligible for benefits or that all services or supplies are Covered
Services. If Company, Payor or its delegate determines that an individual was not a Covered Person at the tithe,
services were rendered, such services shall not be eligible for payment under this Agreement, except to the extent
such services were expressly authorized by Company or Payor. For retrospective review, eligibility determinations
will be made solely on the medical information available to the Contracted Provider at the time the health service
was provided. Such retrospective review will be completed within thirty (30) calendar days of receipt of the
necessary information. In addition, Company will use reasonable efforts to include or contractually require Payors
to clearly display Company's name, logo or mailing address (or other identifier(s) designated from time to time by
Company) on each membership card.
2.7. Referral and Preauthorization Procedures. Provider and Contracted Providers shall comply with
referral and preauthorization procedures adopted by Company and/or Payor, as applicable, prior to referring a
Covered Person to any individual, institutional or ancillary health care provider. Unless otherwise expressly
authorized in writing by Company or Payor, Provider and Contracted Providers shall refer Covered Persons only to
Participating Providers to provide the Covered Service for which the Covered Person is referred. Except as
required by applicable law, failure of Provider and Contracted Providers to follow such procedures may result in
denial of payment for unauthorized treatment. Preauthorization is not required prior to provision of Covered
Services in the event of an emergency.
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2.8. Treatment Decisions. No Company or Payor is liable for, not will it exercise control over, the
manner or method by which a Contracted Provider provides items or services under this Agreement. Provider and
Contracted Providers understand that determinations of Company or Payor that certain items or services are not
Covered Services or have not been provided or billed in accordance with the requirements of this Agreement are
administrative decisions only. Such decisions do not absolve the Contracted Provider of its responsibility to
exercise independent judgment in treatment decisions relating to Covered Persons. Nothing in this Agreement (i) is
intended to interfere with Contracted Provider's relationship with Covered Persons, or (ii) prohibits or restricts a
Contracted Provider from disclosing to any Covered Person any information that the Contracted Provider deems
appropriate regarding health care quality, medical treatment decisions or alternatives.
2.9. Carve -Out Vendors. Provider acknowledges that Company may, during the term of this
Agreement, carve -out certain Covered Services from its general provider contracts, including this Agreement, for
one or more Products as Company deerns necessary or appropriate. Provider and Contracted Providers shall
cooperate with and, when medically appropriate, utilize all third party vendors designated by Company for diose
Covered Services identified by Company from time to time for a particular Product.
2.10, Dis�aragernent Prohibition. Provider, each Contracted Provider and the officers of Company shall
not disparage the other during the term of this Agreement or in connection with any expiration,. termination or non-
renewal of this Agreement Neither Provider nor Contracted Provider shall interfere with Company's direct or
indirect contractual relationships including, but not limited to, those with Covered Persons or other Participating
Providers. Nothing in this Agreement should be construed as limiting the ability of Health Pian, Company,
Provider or a Contracted Provider to inform Covered Persons that this Agreement has been terminated or otherwise
expired or, with respect to Provider, to promote Provider to the general public, or to limit Contracted Providers
from participating in discussions with apatient or someone paying for thein coverage regarding the comparative
merits of different health carriers, even if critical of a carrier, or to post information regarding other health plans
consistent with Provider's usual procedures, provided that no such promotion or advertisement is specifically
directed at one or more Covered Persons. In addition, nothing in this provision should be construed as limiting
Company's ability to use and disclose information_ and data obtained from or about Provider or Contracted
Provider, including this Agreement, to the extent determined reasonably necessary or appropriate by Company in
connection with its efforts to comply with Regulatory Requirements and to communicate with regulatory
authorities.
2.11. Nondiscrimination. Provider and each Contracted Provider will provide Covered Services to
Covered Persons without discrimination on account of race, seat, sexual orientation, age, color, religion, national
origin, place of residence, health status, type of Payor, source of payment (e.g., Medicaid generally or a State -
specific health care program), physical or mental disability or veteran status, and will ensure that its facilities are
accessible as required by Title Ill of the Americans With Disabilities Act of 1991. This requirement does not
require a Contracted Provider to render services that are not appropriate for the provider to render due to limitations
arising from lack of training, experience, skill, or licensing restrictions. Provider and Contracted Providers
recognize that, as a governmental contractor, Company or Payor may be subject to various federal laws, executive
orders and regulations regarding equal opportunity and affirmative action, which also may be applicable to
subcontractors, and :Provider and each Contracted Provider agree to comply with such requirements as described in
any applicable Attachment.
2.12. Notice of Certain Events. Provider shall give written notice to Health Plan of (i) any event of
which notice must be given to a licensing or accreditation agency or board; (ii) any change in the status of
Provider's or a Contracted Provider's license; (iii) termination, suspension, exclusion or voluntary withdrawal of
Provider or a Contracted Provider from any state or federal health care program, including but not limited to
Medicaid; or (iv) any settlements or judgments in connection with a lawsuit or claim filed or asserted against
Provider ora Contracted Provider alleging, professional malpractice involving a Covered Person. In any instance
described in subsection (i)4iii) above, Provider must notify Health Plan or Payor in writing within ten (10) days,
and in any instance described in subsection (iv) above, Provider must notify Health Plan or Payor in writing within
thirty (30) clays, from the date it first obtains knowledge of the pending of the same.
WA PPA County of Grant dba Grant Inte4grated 11.02/2017 342323 - Public Page 5 of 20
2.13.. Use of Name. Provider and each Contracted Provider hereby authorizes each Company or Payor to
use their respective names, telephone numbers, addresses, specialties, certifications, hospital affiliations (if any),
and other descriptive characteristics o.ftheir facilities, practices and services for the purpose of identifying the
Contracted Providers as "Participating Providers" in the applicable Products. Provider and Contracted Providers
may only use the name of the applicable Company or Payor for purposes of identifying the Products in which they
participate, and may not use the registered trademark or service mark of Company or Payor without prior written
consent.
2.14, C'ornpliance with Regulat M. Requirements. Provider, each Contracted Provider and Company
agree to carry out their respective obligations under this Agreement in accordance with all applicable Regulatory
Requirements, including, but not limited to, Chapter 284-43 of the Washington Administrative Code, the Health
Insurance Portability and Accountability Act, the Health Information Technology for Economic and Clinical Health
(HITECH) Act, and federal chug and alcohol confidentiality laws in 42 C.F.R. Part 2, each as amended, including
any regulations promulgated thereunder. If, due to Provider's or Contracted Provider's noncompliance with
applicable Regulatory Requirements or this Agreement, sanctions or penalties are imposed on Company, Company
may, to its sole discretion, offset such amounts against any amounts due Provider or Contracted Providers from any
Company or require Provider or the Contracted Provider to reimburse Company for such amounts. If Pro,6der
subcontracts any services under this Agreement, then Provider is responsible for ensuring that its written
agreements with such subcontractors contain all applicable Regulatory Requirements and that its subcontractors
comply with such requirements.
2,15. Program IntezritvRequired Disclosures. Provider agrees to ftimish to Health Plan complete and
accurate information necessary to permit Health Plan to comply with the collection of disclosures requirements
specified in 42 C.F_R. Part 455 Subpart 8 or any other applicable State or federal requirements, within such time
period as is necessary to permit Health Plan to comply with such requirements. Such requirements include but are
not limited to: (i) 42 C.F.R. §455.105, relating to (a) the ownership of any subcontractor with whom Provider has
had business transactions totaling more than $25,000 during the 12 -month period ending on the date of the request
and (b) any significant business transaction between Provider and any wholly owned supplier or subcontractor
during the five (5) year period ending on the date of the request; (ii) 42 C.F.R. §455.104, relating to individuals or
entities with. an ownership or controlling interest in Provider; and (iii) 42 G.F.R. §455.106, relating to individuals
with an ownership or controlling interest in Provider, or who are managing employees of Provider, who have been
convicted of a crime
ARTICLE III - CLAIINIS SUBYUSSION, PROCESSING, AND COMPENSATION
3.1. Claims or Encounter {data Submission. Contracted Providers shall submit to Payor or its delegate
claims for payment for Covered Services rendered to Covered Persons. Contracted Provider shall submit encounter
data to Payor or its delegate in a timely Fashion, which must contain statistical and descriptive medical and patient
data and identifying information. Payor or its delegate reserves the right to deny payment to the Contracted
Provider if the Contracted Provider fails to submit claims for payment or encounter data in accordance with the
applicable policies and procedures.
3.2. Compensation, The compensation for Covered Services provided to a Covered Person
("Compensation Amount") will be the appropriate amount under the applicable Compensation Schedule in effect
on the date of service for the Product in which the Covered Person participates. Subi ect to the terms of this
ApTyeement, Provider and Contracted Providers shall accept the Compensation Amount as payment in full for the
provision of Covered Services, Subject to the terms of this Agreement, Payor shall pay or arrange for payment of
each Clean Claim received from a Contracted Provider for Covered Services provided to a Covered Person in
accordance with the applicable Compensation Amount less any applicable copayments, cost-sharing or other
amounts that are the Covered Person's financial responsibility under the applicable Coverage Agreement..
3.3. Financial Incentives. The Parties acknowledge and agree that nothing in this Agreement shall be
construed to create any financial incentive for Provider or a Contracted Provider to withhold Covered Services.
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3.4, Holt- Harmless.
3.4.1 Provider and each Contracted Provider agree that in no event, including; but not limited to
tion-pay mentby a Payor, a Payor's insolvency, or breach of this Agreement, shall Provider ora Contracted
Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any
recourse against a Covered Person or person acting oil the Covered Persons behalf, outer than Payor, for Covered
Services provided under this :Agreement. This provision shall not prohibit collection of any applicable copayments,
cost-sharing or other amorous, which have not otherwise been paid by a primary or secondary carrier in accordance
with regulatory ;standards for coordination of benefits, that are the Covered Person's financial responsibility under
the applicable Coverage Agreement.
3.4.2 Provider and each Contracted Provider agree, in the event of .Payor's;insolvency, to
continue to provide the services promised in the Coverage Agreement to Covered Parsons for the duration of the
period for which premiums on behalf of the Covered Persons were paid to Provider or Contracted Provider or until
the Covered Person's discharge from inpatient facilities, whichever time is greater,
3.4.3 Notwithstanding any other. provision of this Agreement, nothing in this Agreement shall be
construed to modify the rights and benefits contained in the Covered Person's Coverage Agreement.
3.4.4 Provider and each Contracted Provider may not bill Covered Persons for Covered Services
(except for deductibles, copayments, or coinsurance) where Payor denies payment because Provider or a Contracted
Provider has failed to comply with the terms or conditions of this Agreement.
3.4.5 Provider and each Contracted Provider further agree (i) that the provisions of 3.4.1, 3.4.2,
3.4.3, 3.4.44 and 3.4.5 of this Section 3.4 shall survive termination of this Agreement regardless of the cause giving
rise to termination and shall be construed to be for the benefit of Covered Persons, and (ii) that these provisions
supersede any oral or written contrary agreement now existing or hereafter entered into between Contracted
Provider and Covered Persons or persons acting on their behalf.
3.4.6 If Provider or Contracted Provider contracts with other providers or facilities who agree to
provide Covered Services to Covered Persons with the expectation of receiving payment directly or indirectly from
Payor, such providers or facilities must agree to abide by the provisions of Subsections 3.4.1 through 3.4.7.
3.4.7 Provider acknowledges that willfully collecting or attempting to collect payment from a
Covered Person, knowing that collection to be in violation of this Section 3.4, constitutes a class C felony under
RCW 44.50.030(5).
3.5. Terms and Conditions of Payment.
3.5.1 Payor shall pay Provider and each Contracted Provider for Covered Services in accordance
with the applicable Compensation Schedule as soon as practical but subject to the following minimum standards:
(a) Ninety-five percent (95%) of the monthly volume of Clean Claims shall be paid within thirty (30) days of
receipt by Payor; (b) Ninety-five percent (95%) of the monthly volume of all claims shall be paid or denied within
sixty (60) days of receipt by .Payor, except as agreed to in writing by the Parties on a claim -by -claim basis. The
date of receipt of claim is the date the Payor or its agent receives either written or electronic notice of the claim,
Payor shall utilize a reasonable method for confirming receipt of claims and responding to Provider or Contracted
Provider inquiries thereof.
3.5.2 Failure to pay claims within these minimum standards will result in interest payments on
undenied and unpaid Clean Claims more than sixty-one (6 1) days old until Payor meets the standards in this
Section 3.5. Interest shall be assessed at the rate of one percent (1%) per month, and shall be calculated monthly as
simple interest prorated for any portion of a month. Payor shall add the interest payable to the amount of the
unpaid claim without the necessity of the Provider or Contracted Provider submitting an additional claim. Any
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interest paid under this Section shall not be applied by the Payor to a Covered Person's deductible, copayment,
coinsurance, or any similar obligation of the Covered Person.
3.5.3 When Payor issues payment in Provider or Contracted Provider and Covered Person
names, Payor shall make claim checks payable in the name of Provider or Contracted Provider first and Covered
Person second.
3.5.4 Churn denials shall be communicated to Provider or Contracted Provider and shall include
the specific reason why the claim was denied. If the denial is based upon Medical Necessity or similar grounds,
then Payor upon request of Provider or Contracted Provider must also promptly disclose the supporting basis for the
decision.
3.5.5 Payor shall be responsible for ensuring that any person acting on behalf of or at the
direction of Payor or acting pursuant to Payor standards or requirements complies with these billing and claim
payment standards.
3.5.6 The standards in this Section 3.5 do not apply in the following circumstances: to claims
about which there is substantial evidence of fraud or misrepresentation by Provider, Contracted Providers or
Covered Persons; in instances where Payor or Company has not been granted reasonable access to information
under Contracted Providers control; or if the failure to comply is occasioned by any act of God, bankruptcy, act of
a governmental authority responding to an act of God or other emergency, or the result of a strike, lockout, or other
labor dispute.
3.6. Recovery Rights - Payor. Payor or its delegate shall have the right to immediately offset or recoup
any and all amounts owed by Provider or a Contracted Provider to Payor or Company against amounts owed by the
Payor or Company to the Provider or Contracted Provider. Provider and Contracted Providers agree that all
recoupment and any offset rights under this Agreement will constitute rights of recoupment authorized under State
or federal law and that such rights will not be subject to any requirement of prior or other approval from any court
or other government authority that may now have or hereafter have jurisdiction over Provider or a Contracted
Provider. Notwithstanding the foregoing, except in the case of fraud, a Payor may not request (a) a refund of a
payment previously made to satisfy a claim unless Payor does so in writing within twenty-four (24) months (or
within thirty (30) months for reasons related to coordination of benefits) in accordance with RCW 48.43.600 or (b)
payment of a contested refund sooner that six (6) months after receipt of the request. This sectiones not applicable
to subrogation claims.
3.7. Recovery Rights - Provider. Except in the case of fraud, Provider or a Contracted Provider may
not request payment from Company or Payor to satisfy a claim unless it does so in writing within twenty-four (24)
months after the date the claim was denied or payment intended to satisfy the claim was made. In the case of
coordination of benefits, Provider or a Contracted Provider must request from Company or Payor within thirty (30)
months after original payment was made any additional balances owed. Additional payment cannot be requested
any sooner than six (6) months after request is trade. This section is not applicable to subrogation claims.
ARTICLE IV — RECORDS AND INSPECTIONS
4.1. Records. Each Contracted Provider shall maintain medical, financial and administrative records
related to items or services provided to Covered Persons, including but not limited to a complete and accurate
permanent medical record for each such Covered Person, in such form and detail as are required by applicable
Regulatory Requirements and consistent with generally accepted medical standards. Such records shall be
maintained for a minimum of five (5) years after final payment is made under this Agreement. However, when an
audit, litigation, or other action involving records is initiated prior to the end of said period, records shall be
maintained for a minimum of five (5) years following resolution of such action. Medical records must support
claims submitted to Company for payment in accordance with accepted standards for claims coding as interpreted
and applied by the Payor and regulatory authorities.
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4.2. Access. Provider and each Contracted Provider shall provide access to their respective books and
records to each of the following, including any delegate or duly authorized agent thereof, subject to applicable
Regulatory Requirements: (i) Company and Payor, during regular business hours and upon prior notice; (ii)
appropriate State and federal authorities, to the extent such access is necessary to comply with Regulatory
Requirements; and (iii) accreditation organizations. Access to health information and other similar records by
Company or Payor shall be limited to records related to Covered Persons. Access to medical records for audit
purposes must be limited to only that necessary to perform the audit. Provider and each Contracted Provider shall
provide copies of such records at no expense to any of the foregoing that may make such request. Each Contracted
Provider also shall obtain any authorization or consent that may be required from a Covered Person in order to
release medical records and information to Company or Payor or any of their delegates. Provider and each
Contracted Provider shall cooperate in and allow on-site inspections of its, his or her facilities and records by any
Company, Payor, their delegates, any authorized government officials, and accreditation organizations. Provider
and each Contracted Provider shall compile information necessary for the expeditious completion of such on-site
inspection in a timely manner. Contracted Providers may audit or examine Company or Payor's books and records
of account related to transactions between Company or Payor and Contracted Provider during non -nal business
hours and upon reasonable prior notice.
4.3. Record Transfer. Subject to applicable Regulatory Requirements, each Contracted Provider shall
cooperate in the timely transfer of Covered Persons' medical records to any other health care provider, at no charge
and when required by Company.
ARTICLE V — INSURANCE AND INDEMMFICATION
5.1. Insurance. During the term of this Agreement and for any applicable continuation period as set
forth in Section 7.3 of this Agreement, Provider and each Contracted Provider shall maintain policies of general and
professional liability insurance and other insurance necessary to insure Provider and such Contracted Provider,
respectively; their respective employees; and any other person providing services hereunder on behalf of Provider
or such Contracted Provider, as applicable, against any claim(s) of personal injuries or death alleged to have been
caused or caused by their perfonnance under this Agreement. Such insurance shall include, but not be limited to,
any "tail" or prior acts coverage necessary to avoid any gap in coverage. Insurance shall be through a licensed
carrier acceptable to Health Plan, and in a minimum amount of one million dollars ($1,000,000) per occurrence,
and three million dollars ($3,000,000) in the aggregate unless a lesser amount is accepted by Health Plan or where
State law mandates otherwise. Provider and each Contracted Provider will provide Health Plan with at least fifteen
(15) days' prior written notice of cancellation, non -renewal, lapse, or adverse material modification of such
coverage. Upon Health Plan's request, Provider and each Contracted Provider will furnish Health Plan with
evidence of such insurance.
5.2. Indemnification by Provider and Contracted Provider. Provider and each Contracted Provider shall
indemnify and hold harmless (and at Health Plan's request defend) Company and Payor and all of their respective
officers, directors, agents and employees from and against any and all third party claims for any Loss, damages,
liability, costs, or expenses (including reasonable attorney's fees) judgments or obligations arising from or relating
to any negligence, wrongful act or omission, or breach of this Agreement by Provider, a Contracted Provider, or
any of their respective officers, directors, agents or employees.
5.3, Indemnification by Health Plan. Health Plan agrees to indemnify and hold harmless (and at
Providers request defend) Provider, Contracted Providers, and their officers, directors, agents and employees from
and against any and all third party claims for any loss, damages, liability, costs, or expenses (including reasonable
attorney's fees), judgments, or obligations arising from or relating to any negligence, wrongful act or omission or
breach of this Agreennent by Company or its directors, officers, agents or employee.
ARTICLE VI — DISPUTE RESOLUTION
6.1. Infornial Dispute Resolution. Any dispute between Provider and/or a Contracted Provider, as
applicable (the "Provider Party"), and Health Plan and/or Company, as applicable (including any Company acting
WA PPA County of Grant dba Grant Integrated 1110212017 — 342323 - Public Page 9 of 20
as Payor) (the "Administrator Party"), with respect to or involving the performance under, termination of, or
interpretation of this Agreement, or any other claim or cause of action hereunder, whether sounding in tort, contract
or under statute (a "Dispute") shall first be addressed by exhausting the applicable policies and procedures
pertaining to claims payment, credentialing, utilization management, or other programs. Company or Payor must
render a decision on a Provider or Contracted Provider complaint within a reasonable time for the type of dispute.
In the case of billing disputes, Company or Payor must render a decision within sixty (60) days of a complaint. If,
at the conclusion of these applicable procedures, the matter is not resolved to the satisfaction of the Provider Party
and the Administrator Party, or if there are no such policies, then the Provider Party and the Administrator Party
agree that they will engage in a period of good faith negotiations between their designated representatives who have
authority to settle the Dispute, which negotiations may be initiated by either the Provider Party or the Administrator
Party upon written request to the other, provided such request takes place within one year of the date on which the
requesting party first had, or reasonably should have had, knowledge of the event(s) giving rise to the Dispute. If
the matter has not been resolved within sixty (60) days of such request, either the Provider Party or the
Administrator Party may initiate arbitration pursuant to Section 6.2 below by providing a written request to the
other party. The other parry may, but is not required to, consent to such binding arbitration process.
6.2. Arbitration. If mutually agreed upon by the Provider Party and the Administrator Party, either of
the Provider Party and the Administrator Party wishing to pursue the Dispute as provided in Section 6..1 may submit
it to binding arbitration conducted in accordance with the Comanercial Arbitration Rules of the American
Arbitration Association ("AAA"). in no event may any arbitration be initiated more than one (1) year following, as
applicable, the end of the sixty (60) day negotiation period set forth in Section 6. 1, or the date of notice of
termination. Arbitration proceedings shall be conducted by an arbitrator chosen from the National Healthcare Panel
at a mutually agreed upon location within the State. The arbitrator shall not award any punitive or exemplary
damages of any kind, shall not vary or ignore the provisions of this Agreement, and shall be bound by controlling
law. Each of the Provider Party and the Administrator Party shall bear its own costs and attorneys' fees related to
the arbitration except that the AAA's Administrative Fees, all Arbitrator Compensation and travel and other
expenses, and all costs of any proof produced at the direct request of the arbitrator shall be borne equally by the
applicable parties, and the arbitrator shall not have the authority to order otherwise. The existence of a Dispute or
arbitration proceeding shall not in and of itself constitute cause for termination of this Agreement. Except as
hereafter provided, during an arbitration proceeding, each of the Provider Party and the Administrator Party shall
continue to perform its obligations under this Agreement pending the decision of the arbitrator. Nothing herein
shall bar either the Provider Party or the Administrator Party from seeking emergency injunctive relief to preclude
any actual or perceived breach of this Agreement. Judgment on the award rendered may be entered in any court
having jurisdiction thereof: Nothing contained in this Article VI shall limit a Party's right to terminate this
Agreement with or without cause in accordance with Section 7.2. Nothing herein shall be construed to require
alternative dispute resolution to the exclusion of judicial remedies.
ARTICLE "I — T1a R 1+I AND TU, MINA.TION
7,1, Term. This Agreement is effective as of the EffectiveDate, acid will remain in effect for an initial
term (".Initial Term") of one (1) years, after which it will automatically renew for successive terms of one (1) year
each (each a "Renewal Term"), unless this Agreement is sooner terminated as provided in this Agreement or either
Party gives the other Party written notice of non -renewal of this Agreement not less than one hundred eighty (130)
days prior to the end of the then -current term.
7.2. Termination. This Agreement, or the participation of Provider or a Contracted Provider as a
Participating :Provider in one or more Products, may be tenninated or suspended as set forth below.
7.2.1. U2on Notice. This Agreement may be terminated by either Party giving the other Party at
least one hundred eighty (ISO) days' prior written notice of such termination.
7.2.2. With Cause. This Agreement, or the participation of any Contracted Provider as a
Participating Provider in one or more Products under this Agreement, may be terminated by either Party giving at
least ninety (90) days' prior written notice of termination to the other Party if such other Party (or the applicable
WA PPA County of Grant dba Grant Integrated 11,'02!2017 -- 342323 - Public Page 10 of 20
Contracted Provider) is in breach of any /material term or condition of this Agreement and such other Party (or the
Contracted Provider) fails to cure the breach within the sixty (60) day period immediately following the giving of
written notice of such breach. Any notice given pursuant to this Section 7.2.2 must describe the specific breach. In
tide case of a termination of a Contracted Provider, Provider shall immediately notify the affected Contracted
Provider of such termination.
7.2.3. Suspension of Participation. Unless expressly prohibited by applicable Regulatory
Requirements, Health Plan has the right to immediately suspend or terminate the participation of a Contracted
Provider in any or all Products by giving written/ notice thereof to Provider when Health Plan determines that (i)
based upon available information, the continued participation of the Contracted Provider appears to constitute an
immediate threat or risk to the health, safety or welfare of Covered Persons, or (ii) the Contracted Provider's fraud,
malfeasance or non-compliance with Regulatory Requirements is reasonably suspected. Provider shall immediately
notify the affected Contracted Provider of such suspension. During such suspension, the Contracted Provider shall,
as directed by Health Plan, discontinue the provision of all or a particular Covered Service to Covered Persons.
During the term of any suspension, the Contracted Provider shalt notify Covered Persons that his or her status as a
Participating Provider has been suspended. Such suspension will continue until the Contracted Provider's
participation is reinstated or terminated.
7.2.4. lnsolvencv. This Agreement may be terminated immediately by a Party giving written
notice thereof to the other Party if the other Party is insolvent or has bankruptcy proceedings initiated against it.
7.2.5. CredentiaiinQ. The status of a Contracted Provider as a Participating Provider in one or
more Products may be terminated immediately by Health Plan giving written notice thereof to Provider if the
Contracted Provider fails to adhere to Health Plan's credentialing criteria, including, but not limited to, if the
Contracted Provider (i) loses, relinquishes, or has materially affected its license to provide Covered Services in the
State, (ii) fails to comply with the insurance requirements set forth in this Agreement; or (iii) is convicted of a
criminal offense related to involvement in any state or federal health care program or been terminated,
suspended, barred, voluntarily withdrawn as part of a settlement agreement, or otherwise excluded from any state or
federal health care program. Provider shall immediately notify the affected Contracted Provider of such
termination.
7.3. Effect of Termination. After the effective date of termination of this Agreement or a Contracted
Provider's participation in a Product, this .Agreement shall remain in effect for purposes of those obligations and
rights arising prior to the effective date of termination. Upon such a termination, each affected Contracted Provider
(including.Provider, if applicable) shall (i) continue to provide Covered Services to Covered Persons in the
applicable Product(s) during the longer of the ninety (90) day period following the date of such termination or such
other period as may be required under any Regulatory Requirements, and, if requested by Company, each affected
Contracted Provider (including Provider, if applicable) shall continue to provide, as a Participating Provider,
Covered Services to Covered Persons until such Covered Persons are assigned or transferred to another
Participating. Provider in the applicable Product(s), and (ii) continue to comply with and abide by all of the
applicable terms and conditions of this Agreement, including, but not limited to, Section 3.4 (Hold Harmless)
hereof, in connection with the .provision of such Covered Services during such continuation period. During such
continuation period, each affected Contracted Provider (including Provider, if applicable) will be compensated in
accordance with this Agreement and shall accept such compensation as payment in full. Company shall make a
food faith effort to provide written notice of termination within fifteen (15) working days of receipt or issuance of a
notice of termination to all Covered Persons who are patients seen on a regular basis by each affected Contracted
Provider that is terminated, regardless of the cause for termination. The Contracted Provider will inform any
Covered Person that seeks the Contracted Provider's services that this Agreement has been terminated.
7.4. Survival of Obligations.. All provisions hereof that by their nature are to be performed or complied
with following the expiration or termination of this Agreement, including without limitation Sections 2.8, 2.10, 3.2,
3.4, 3.5, 3.6, 3.7, 4.2, 4.3, 5.1, 5.2, 5. 3, 7.3, and 7.4 and Article VIII, survive the expiration or tennination of this
Agreement.
SVA PPA County of Grant dba Grant lnteg,•ated 11/02/2017 — 342323 - Public Page 11 of 20
ARTICLE VIII - MISCELLANEOUS
8.1. Relationship of Parties. The relationship between or among Health Plan, Company, Provider, and
any Contracted Provider hereunder is that of independent contractors. None of the provisions of this Agreement
will be construed as creating any agency, partnership, joint venture, employee -employer, or other relationship.
8.2. Conflicts Between Certain Documents. If there is any conflict between this Agreement avid any
policy or procedure of Company, this Agreement will control. In the event of any conflict between this Agreement
and any Product Attachment, the Product Attachment will control as to such Product.
8.3. Assignment. This Agreement is intended to secure the services of and be personal to Provider and
may not be assigned, sublet, delegated or transferred by Provider without Health Plan's prior written consent.
Health Plan shall have the right, exercisable in its sole discretion, to assign or transfer all or any portion of its rights
or to delegate all or any portion of its interests under this Agreement or any Attachment to an Affiliate, successor of
Health Plan, or purchaser of the assets or stock of Health Plan, or the line of business or business unit primarily
responsible for carrying out.Health Pians obligations under this Agreement.
8.4. Headines. The headings of the sections of this Agreement are inserted merely for the purpose of
convenience and do not limit, define, or extend the specific terms of the section so designated.
8,5. Governing Law. The interpretation of this Agreement and the rights and obligations of Health Plan
Company, Provider and any Contracted Providers hereunder will be governed by and construed in accordance
with applicable federal and State laws.
8.6. Third Party Beneficiary. This Agreement is entered into by the Parties signing it for their benefit,
as well as, in the case of Health Plan, the benefit of Company, and in the case of Provider, the benefit of each
Contracted Provider. Except as specifically provided in Section 3.4 hereof, no Covered Person or third party, other
than Company, will be considered a third party beneficiary of this Agreement.
8.7. Amendment. Except as otherwise provided in this Agreement, this Agreement may be amended
only by written agreement of duly authorized representatives of the Parties.
8.7.1. Health Plan may amend this Agreement by giving Provider written notice of the
amendment to the extent such amendment is deemed necessary or appropriate by Health Plan to comply with any
Regulatory Requirements. Any such amendment will be deemed accepted by Provider upon the giving of such
notice.
8.7.2. Health Plan may amend this Agreement by giving Provider written notice (electronic or
paper) of the proposed amendment. Unless Provider notifies Health Plan in writing of its objection to such
amendment during the thirty (30) day period following the giving of such notice by Health Plan, Provider shall be
deemed to have accepted the amendment. If Provider objects to any proposed amendment to either the base
agreement or any Attachment, Health Plan may exclude one or more of the Contracted Providers from being
Participating Providers in the applicable Product (or any component program of, or Coverage Agreement in
connection with, such Product).
8.7.3. Notwithstanding the above, Health Plan will give Provider at least sixty (60) days' prior
tivritten notice of any amendment or new Attachment involving changes that affect health care service delivery or
compensation, unless changes to federal or State law or regulations make such advance notice impossible, in which
case notice shall he provided as soon as possible. In such case, if Provider notifies Flealth Plan in writing of its
objection to such amendment within thirty (30) days following the giving of such notice by Health Plan, such
amendment or new Attachment shall not go into effect as to Provider; health Plan may on sixty (60) days' notice
terminate this Agreement or the participation of Provider and Contracted Providers in the Products affected by the
proposed amendment for any component program of such Products). No change to this Agreement will be made
retroactive without the express consent of Provider.
WA PPA County of Grant dba Grant Integrated 11/02/2017 — 342323 - Public Page 12 of 20
8.8. Entire Agreement. All prior or concurrent agreements, promises, negotiations or representations
either oral or written, between Health Plan and Provider relating to a subject matter of this Agreement, which are
not expressly set forth in this Agreement, are of no force or effect.
8.9. Severability. The invalidity or unenforceability of any terms or provisions hereof will in no way
affect the validity or enforceability of any other terms or provisions.
8.10. Waiver. The waiver by either Party of the violation of any provision or obligation of this
Agreement will not constitute the waiver of any subsequent violation of the same or other provision or obligation.
8.11. Notices. Except as otherwise provided in this Agreement, any notice required or permitted to be
given hereunder is deemed to have been given when such written notice has been personally delivered or deposited
in the United States mail, postage paid, or delivered by a service that provides written receipt of delivery, addressed
as follows:
To Health Plan at. To Provider at:
Attn: President Attn: &Xx +'%
Coordinated Care Corporation County of Grant dba Grant integrated Services
1145 Broadway, Suite 300 840 E Plum St
Tacoma, WA 98402 Moses Lake, WA 98037
or to such other address as such Party may designate in writing. Notwithstanding the previous sentence, Health
Plan may provide notices by electronic mail, through its provider newsletter or on its provider website.
8.12. force Nlajeure. Neither Party shall be liable or deemed to be in default for any delay or failure to
perform any act under this Agreement resulting, directly or indirectly, from acts of God, civil or military authority,
acts of public enemy, war, accidents, tares, explosions, earthquake, flood, strikes or other work stoppages by either
Partys employees, or any other similar cause beyond the reasonable control of such Party.
8.13. Proprietary Information. Each Party is prohibited from, and shall prohibit its Affiliates and
Contracted Providers from, disclosing to a third party the substance of this Agreement, or any information of a
confidential nature acquired from the other Party (or Affiliate or Contracted Provider thereof) during the course of
this Agreement, except to agents of such Party as necessary for such Party's performance tinder this Agreement, or
as required by a Pavor Contract or applicable Regulatory Requirements. Provider acknowledges and agrees that all
information relating to Company's programs, policies, protocols and procedures is proprietary information and
Provider shall not disclose such information to any person or entity without Health Plan's express written consent.
8.14. Authority. The individuals whose signatures are set forth below represent and warrant that they are
duly empowered to execute this Agreement. Provider represents and warrants that it has all legal authority to
contract on behalf of and to bind all Contracted Providers to the terms of the Agreement with Health Plan.
[Signature Pagze Below]
WA PPA County of Grant dba Grant Inte_rated i 1/02/2017 — 342323 - Public Page 13 of 20
IN WITNESS WHERE F, the Parties hereto have executed this Agreement, including all Product Attachments
noted on Schedule B, effective as of the date set forth beneath their respective signatures.
HEALTH PLAN:
Coordinated Care Corporation
Authorized Signature:
Print Name:
Title:
Signature Bate:
Coordinated Care of Washington, Inc.
Authorized Signature:
Print Name:
Title:
Signature Date:
To be completed by Health Plan only:
Effective Date:
PROVIDER:
County of Grant dba Grant Integrated Services
(Legibly Print Name of P er)
Authorized Signature.
Print Name: RiJruivtjevgns
Title k..l
Signature Date:
Tax Identification Number: 91-6001319
State Medicaid Number: 1981109
L%'r\ PPA County of Grant dba Grant Integrated 11/0212017 —' 42323 Public Page 14 of 20
PARTICIPATING PROVIDER AGREEMENT
SCHEDULE A
CONTRACTED PROVIDEI"PECIFIC PROVISIONS
Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A.
Applicable sections are indicated by a checked box where appropriate..
U I Hospitals. If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions
apply.
l 24 Hour Coverage. Each Hospital shall be available to provide Covered Services to
Covered Persons twenty-four (24) hours per day, seven (7) days per week.
1.2 Emergency Care. Each Hospital shall provide Emergency Care (as hereafter defined) in
accordance with Regulatory Requirements. The Contracted Provider shall notify Company's medical management
department of any emergency room admissions by electronic file sent within twenty -four (24) hours or by the next
business day of such admission. "Emergency Care'' (or derivative thereof) has, as to each particular Product, the
meaning set forth in the applicable Coverage Agreement or Product Attachment. If there is no definition in such
documents, "Emergency Care" means inpatient and/or outpatient Covered Services furnished by a qualified
provider that are needed to evaluate or stabilize an Emergency Medical Condition. "Emergency Medical
Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result in the following: (i) placing the health of the individual
(or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (ii) serious
impairment to bodily functions; or (iii) serious dysfunction of any bodily organ or part.
1.3 Staff Privileges. Each Hospital shall assist in granting staff privileges or other appropriate
access to Company's Participating Providers who are qualified medical or osteopathic physicians, provided they
meet the reasonable standards of practice and credentialing standards established by the Hospital's medical staff
and bylaws, rules, and regulations.
1.4 Discharge Planning. Each Hospital agrees to cooperate with Company'ssystem for the
coordinated discharge planning of Covered Persons, including the planning of any necessary continuing care.
1.5 Credentialing Criteria. Each Hospital shall (a) currently, and for the duration of this
Agreement, remain accredited by the Joint Commission or American Osteopathic Association, as applicable; and
(b) ensure that all employees of Hospital perform their duties in accordance with all applicable local, State and
federal licensing requirements and standards of professional ethics and practice.
Fx�W 2 Practitioners. If Provider or Contracted Provider is a physician or other health care practitioner
(including physician extenders) ("Practitioner"), the following provisions apply,
2.1 Contracted Professional Qualifications. At all times during the term of this Agreement,
Practitioner shall, as applicable, maintain medical staff membership and admitting privileges with at least one
hospital that is a Participating Provider ("Participating Hospital-) with respect to each Product in which the
Practitioner participates. Upon Company's request, Practitioner shall furnish evidence of the foregoing to
Company. If Practitioner does not Have such admitting privileges, Provider or the Practitioner shall provide
Company with a written statement from another Participating Provider who has such admitting privileges, in good
standing, certifying that such individual agrees to assume responsibility for providing inpatient Covered Services to
Covered Persons who are patients of the applicable Practitioner.
SVA PPA County of Grant dba Grant Integrated 11/02/2017 - 342323 Public Page 15 of 20
2.2 Acceptance of New Patients. To the extent that Practitioner is accepting new patients, such
Practitioner must also accept new patients who are Covered Persons with respect to the Products in which such
Practitioner participates. Practitioner shall notify Company in writing forty-five (45) days prior to such
.Practitioner's decision to no longer accept Covered Persons with respect to a particular Product. In no event will an
established patient of anyractitioner be considered a new patient.
23 Preferred Drug List/Drug Formulary. If applicable to the Covered Person's coverage,
.Practitioners shall use commercially reasonable efforts, when medically appropriate under the circumstances, to
comply with formulary or preferred drug list when prescribing medications for Covered Persons.
, t 3 Ancillary Providers. If Provider or Contracted Provider is an ancillary provider (including but not
limited to a chemical dependency services provider, residential treatment facility/BH agency, home health agency,
durable medical equipment provider, sleep center, pharmacy, ambulatory surgery center, nursing facility, laboratory
or urgent care center)(' :Ancillary Provider") the following provisions apply.
3_I Acceptance of New Patients. To the extent that Ancillary Provider is accepting new
patients, such Ancillary Provider must also accept new patients who are Covered Persons with respect to the
Products in which such Ancillary Provider participates. Ancillary Provider shall notify Company in writing forty-
five (45) days prior to such Ancillary Provider's decision to no longer accept Covered Persons with respect to a
particular Product.. In no event will an established patient of any Ancillary Provider be considered a new patient.
4 EQHC. if Provider or a Contracted Provider is a federally qualified health center ("FQHC"), the
following provision applies.
4.1 FQHC Insurance. To the extent FQHC's employees are deemed to be federal employees
qualified for protection under the Federal Tort Claims Act ("FTCA") and Health Plan has been provided with
documentation of such status issued by the U.S. Department of Health and Human Services (such status to be
referred to as "FICA Coverage"), Section 5.1 of this Agreement will not apply to those Contracted Providers with
FTCA Coverage. FQHC shall provide evidence of such FICA Coverage to Health Plan at any time upon request.
FQHC shall promptly notify Health Plan if, any time during the term of this Agreement, any Contracted Provider is
no longer eligible for, or if FQHC becomes aware of any fact. or circumstance that would jeopardize, FTCA
Coverage. Section 5.1 of this Agreement will apply to a Contracted Provider immediately upon such Contracted
Provider's loss of FTCA Coverage for any reason.
SVA :PPA County of Grant dba Grant Integrated 11/02/2017 — 342323 - Public Page 16 of 20
PARTICIPATING PROVIDER AGREEMENT
SCHEDULE B
PRODucr PARTICIPATION
Provider and Contracted Providers will be subject to and bound by the Attachments' marked below, and designated
as a "Participating Provider' in the Products narked below as of the date of successful completion of credentialing
in accordance with this Agreement.
List of Product Attachments:
A: Medicaid
Exhibit A- I
Medicaid Product Attachment
Exhibit A-2
Medicaid Hosp. Comp. Sched.
Exhibit A-3
Medicaid Pract. Comp. Sched.
Exhibit A-4
Medicaid Vision Comp. Sched.
Exhibit A-5
Medicaid SNF Comp. Sched.
Exhibit A-6
Medicaid Ancillary Comp. Sched.
Exhibit A-7
Medicaid Critical Access Hosp. Comp. Sched.
Exhibit A-8
Medicaid Ancillary — DME Comp. Sched.
Exhibit A-9
Medicaid LTC and Rehab. Comp. Sched.
Exhibit A-10
Medicaid Ancillary—Dialysis Comp. Sched.
Exhibit A -i I
Medicaid Ancillary— ASG Comp. Sched.
Exhibit A-12
Medicaid Ancillary BH Comp. Sched.
[Reserved for future Exhibits]
Medicare Product Attachment
Plan
Exhibit B-3.2
Exhibit B-2.1
MAiNt k -PD Hospital Comp. Sched.
Exhibit B-2:2
MA/MA-PD Practitioner Comp. Sched.
Exhibit B-2.3
MAMA -PD Vision Comp. Sched.
Exhibit B-2.4
MA/MA-PD Critical Access Hosp. Comp. Sched.
Exhibit B-2.5
MAMA -PD Facility - LTC, Rehab., SNF Camp. Sched.
Exhibit B-2.6
MA/M.A-PD Ancillary - Amb., HH, Hospice, Lala.
DSNP Ancillary - ASC Comp. Sclied.
Comp. Sched.
Exhibit B-2.7
MAMA -PD Ancillary - ASC Comp, Schen!.
Exhibit B-2.8
M.AlMA-PD Ancillary - Dialysis Comp. Sched.
Exhibit B-2.9
MAMA -PD Ancillary - DME Comp. Sched.
[Reserved for future Exliibits]
Exhibit B-3.1
DSNP Hospital Comp. Sched,
Exhibit B-3.2
DSNP Practitioner Comp. Sched.
Exhibit B-3.3
DSNP Vision Comp. Sched.
Exhibit B-3.4
DSNP Critical Access Hosp. Comp. Sched.
Exhibit B-3.5
DSNP Facility - LTC, Rehab., SNF Comp. Sched.
Exhibit B-3.6
DSNP Ancillary - Amb., HH, Hospice, Lab. Comp.
Sched.
Exhibit B-3.7
DSNP Ancillary - ASC Comp. Sclied.
Exhibit B-3.8
DSNP Ancillary - Dialysis Comp. Sched.
Exhibit B-3.9
DSNP Ancillary - DME Comp. Sched.
WA PPA County of Grant dba Grant Integrated 11/02/2017 — 342323 - Public Page 17 of 20
[Reserved for future Exhibits]
C: Conimercial-Exchange
Exhibit C-0
CE Product Attachment
Exhibit C-1
CE Hosp. Comp. Sched.
Exhibit C-2
CE Pract. Conip. Sched.
Exhibit C-3
CE Vision Comp. Sched.
Exhibit C-4
CE SNF Comp. Sched.
Exhibit C-5
CE Ancillary Comp. Sched.
Exhibit C -6A
CE Critical Access Hosp. Conip. Sched. A
Exhibit C-613
CE Critical Access Hosp. Comp. Sched. B
Exhibit C-7
CE Ancillary- DALE Comp. Sched.
Exhibit C-8
CE LTC and Rehab. Comp. Sched.
Exhibit C-9
CE Ancillary — Dialysis Comp. Sched.
Exhibit C-10
CE Ancillary— ASC Comp. Sched,
Exhibit C-'11
CE Ancillary BH Comp. Sched.
[Reserved for future Exhibits]
Attachment D: Indian Healthcare Provider Addendum
Attachment E: Delegated Credentialing Agreement
Exhibit E-1 Delegated Credentialing Agreement (CCC)
Exhibit E-2 Delegated Credentialing Agreement (CCW)
F: Medicaid — Foster Care Program
Exhibit'F-1
AHFC Medicaid Product Attachment
Exhibit F-12
AHFC Medicaid Hospital. Comp. Sched.
Exhibit F-3
AHFC Medicaid Practitioner Comp. Sched.
Exhibit F4
AHFC Medicaid Vision Comp. Sched.
Exhibit F-5
AHFC Medicaid SNF Camp. Sched.
Exhibit F-6
ARK Medicaid Ancillary Comp, Sched.
Exhibit F-7
AHFC Medicaid Critical Access Hosp. Comp. Sched.
Exhibit F-8
AHFC Medicaid Ancillary - DME Comp. Sched.
Exhibit F-9
AHFC Medicaid LTC and Rehab. Comp. Sched.
Exhibit F-10
AHFC Medicaid Ancillary - Dialysis Comp. Sched.
Exhibit F-1.1
AHFC Medicaid Ancillary - ASC Comp. Sched.
Exhibit F-12
AHFC Medicaid Ancillary BH Comp. Sched.
[Reserved for future Exhibits]
I
[Reserved for future Exhibits]
Health Plan to which Product Attachments Apply:
Each Attachment and related Exhibits checked above shall be a Product of Coordinated Care Corporation ("CCC")
from the Effective Date of this Agreement. On at least sixty (60) days' advance written notice (written or
electronic), CCC and Coordinated Care of Washington, Inc. (-CCW-) tiiayjoiiitiv notify Provider that an
Attachment (and related Exhibits if any) shall no longer be a Product of CCC and shall be a Product of CCW on the
date specified in the notice. As of such date, the designated Attachment(s) (and related Exhibits if any) shall
Z
WA PPA County of Grant dba Grant Integrated 11/02/2017 — 342' )231 - Public Page IS of 20
terminate with respect to CCC as the flealth Plan and commence with respect to CCW as the Health Plan for such
Product.
WA PPA Countv of Grant dba Grant Integrated 11/02/2017 — 342323 - Public Page 19 of 20
PARTICIPATING PROVIDER AGREEMENT
SCHEDULE C
CONTRACTED PROVIDERS
LP,NTI'rY/GROUP/CLI,N]C/FAC[LrFY NAME TAX ID# NPI #
Grant Mental Healthcare 91-6001319 1689677833
Grant County Prevention and Recovery Center 91-6001319 1982792537
NOTE: This Schedule is intended to capture all groups, clinics and facilities associated with the Agreement at the
time of contract signature; entities maybe added or removed from time to time, in accordance with the Agreement.
If the Agreement is for an individual practitioner, no roster is required; however, please enter the individual
practitioner's information in the table, above.
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ATTACIIYIENT A: Medicaid
EYI-IIBIT A -I
APPLE III ALTH
PARTICIPATING PROVIDER AGREEMENTATTACHMENT
This Apple Health Participating Provider Agreement Attachment (the "Attachment") is incorporated into
the Participating Provider Agreement (the "Agreement") entered into by and between Provider and Health Plan (as
such entities are defined in the Agreement).
ARTICLE I
RECITALS
I. l Health Plan or an affiliate of Health Plan ("Company") has contracted with. the Washington Health Care
Authority (' IICA") to arrange for the provision of medical services to Covered Persons under the Medicaid
managed care program mown as Apple Flealth, and formerly known as Healthy Options (tile "Apple
Health Program").
1.2 This Attachment is untended to supplement the Agreement by setting; forth the parties' rights and
responsibilities related to the provision of Covered Services to Covered Persons as it pertains to the Apple
Health Program. In the event of a conflict between the terms and conditions of the Agreement and the
teens and conditions of this Attachment, this Attachment shall govern as totheApple Health Program.
1, Provider agrees and unders tands that Covered Services shall be provided in accordance with the contract
between HCA and Company, including any exhibits, attachments, documents, or materials incorporated by
reference ("State Contract"), Payor requirements, any applicable State handbooks or policy and procedure
guides, and all applicable State and federal laws and regulations. To the extent Provider is unclear about
Provider's duties and obligations, Provider shall request clarification from Company.
ARTICLE 11
DEFINITIONS
Capitalized terms used and not otherwise defined herein shall have the meanings given to them in the .Agreement or
the State Contract. The definitions listed below will supersede any meanings contained elsewhere in the Agreement
with regard to this Attachment.
2.1 Covered Person shall. have the meaning set forth in the Agreement.
2.2 11CA means the State of Washington Health Care Authority and its employees and authorized agents.
2.3 Aledically ryecessary means health care services that: (a) are reasonably calculated to prevent, diagnose,
correct, cure, alleviate or prevent worsening of conditions in the Covered Person that endanger life, or
cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or
cause physical deformity or malfunction; and (b) are not more costly than any other equally effective or
more conservative course of treatment available or suitable for the Covered Person requesting the service.
Such services shall include services related to the Covered Person's ability to achieve age-appropriate
growth and development.
2A Physteian'.v Orders for Life Sustaining Treatment ("POLST") means a set of +guidelines and protocols for
how emergency medical personnel shall respond when summoned to the site of an injury or illness for the
treatment of a person who has signed a written directive or durable power of attorney requesting that he or
she not receive futile emergency medical treatment, in accordance with RCW 43.70.480.
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2.5 Primaty Care Provider or.PCP means a Participating Provider who has the responsibility for supervising,
coordinating, and providing primary health care to Covered Persons, initiating referrals for specialist care,
and maintaining the continuity of Covered Person care. PCPs include, but are not limited to pediatricians,
family practitioners, general practitioners, internists, naturopathic physicians, medical residents (under the
supervision of a teaching physician), physician assistants (under the supervision of a physician), or
advanced registered nurse practitioners (nurse practitioners), as designated by Company. The definition of
PCP is inclusive of primary care physician as it is used in 42 C.F.R. § 438. All Federal requirements
applicable to primary care physicians will also be applicable to PCPs as the term is used in this Attachment.
2.6 State means the state of Washington.
ARTICLE III
PROVIDER CONTRACT REQUIREMENTS
3.1 Provider shall have a signed Core Provider Agreement with HCA within one hundred twenty (120)
calendar days of contracting with Company. Provider may enroll with HCA as a "non -billing" provider if
Provider does not wish to serve fee -far -service Medicaid clients, but Provider must have an active NPI
number with .1 -ICA.
3.2 Provider shall comply with all applicable federal, State and local laws and regulations, and all amendments
thereto. Provider understands and agrees that this Attachment and/or the Agreement shall be amended as
necessary to comply with any applicable State or federal law or regulation, or any applicable provision of
the State Contract.
3.3 Provider shall comply with all applicable State and federal laws and regulations regarding the collection,
use and disclosure of (a) Personal Information, as defined in Governor.Locke's Executive Order 00-03, and
(b) Protected Health information ("PIiI"), as defined in 45 C.F.R. § 160. t03. Personal Information or PHI
collected, used, or acquired in connection with the Agreement shall be used solely for the purposes of the
Agreement. Provider shall not release, divulge, publish, transfer, sell, or otherwise make known to
unauthorized third parties Personal Information or PHI without the advance express written consent of the
individual who is the subject matter of the Personal Information or PHI or as otherwise required in the
Agreement or as permitted or required by State or federal law or regulation. Provider shall implement
appropriate physical, electronic, and managerial safeguards to prevent unauthorized access to Personal
Information and PHI. Provider shall fully cooperate with FICA's efforts to implement all requirements
under HIPAA.
3.4 Provider represents and warrants that it is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded by any federal department or agency from participating in
transactions. Provider shall immediately notify Company in writing if, during the term of the Agrcement,
(a) Provider becomes debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded, or (b) Provider or any of Provider's employees are subject to disciplinary action against
accreditation, certification, .license andlor registration.
3.5 Provider represents and warrants that it does not employ or contract, directly or indirectly, with:
A. Any individual or entity excluded from Medicaid or other federal health care program participation
under Sections 1128 (42 U.S.G. § 1320a-7) or t 128A (42 U.S.C. § 1320a) of the Social Security
Act for the provision of health care, utilization review, medical social work; or administrative
services or who could be excluded under Section 1128(b)(8) of the Social Security Act as being
controlled by a sanctioned individual;
B. Any individual or entity discharged or suspended from doing business with the HCA; or
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C. Any entity that has a contractual relationship (direct or indirect) with an individual convicted of
certain crimes as described in Section 1128(b)(8) of the Social Security Act.
3.6 Provider shall cooperate with audits performed by duly authorized representatives of the State of
Washington, the federal Department of Health and Human Services ("DHIiS" ), auditors from the federal
Government Accountability Office, federal Office of the Inspector General and federal Office of
Management and Budget. Upon reasonable notice, Provider shall provide access to its facilities and the
records pertinent to the Agreement to duly authorized representatives of HCA and/or DHHS so they may
monitor and evaluate Provider's compliance with the Agreement and Company's compliance with the State
Contract, including, but not limited to, the quality, cost, use, health and safety and timeliness of services,
and assessment of Company's capacity to bear the potential financial losses. Provider shall provide
immediate access to facilities and records pertinent to the Agreement for Medicaid fraud investigators
pursuant to 42 C.F.R. § 438.6(g)•
3.7 Provider shall maintain financial, medical and other records pertinent to the Agreement. All financial
records shall follow generally accepted accounting principles. Other records shall be maintained as
necessary to clearly reflect all actions taken by Provider related to the Agreement.
All records and reports relating to the Agreement shall be retained by Provider for a minimum of six (6)
years after final payment is made under die Agreement. However, when an audit, litigation, or other action
involving records is initiated prior to the end of said period, records shall be maintained for a minimum of
six (6) years following resolution of such action.
3.8 Provider shall provide interpreter services, free of charge, for all interactions with Covered Persons or
potential Covered Persons, including but not limited to. (a) customer service, (b) all appointments with any
provider for any Covered Service, (c) emergency services, and (d) all steps necessary to file grievances and
appeals.
3.9 All information to be provided to Covered Persons, e.g. marketing materials, must be accurate, not
misleading, comprehensible to its intended audience, designed to provide the greatest degree of
understanding, and written at a sixth grade reading level, in addition to any other requirements imposed by
Company based on the nature of the materials. Such materials must generally be approved by Company
prior to use, and must comply with the State Contract.
3.10 The services and benefits available under the Apple Health Program are secondary to any other medical
coverage, as provided by the State Contract. Provider shall not refuse or reduce services provided under
the Agreement solely due to the existence of similar benefits under any other health care contract, except in
accord with applicable coordination of benefitsrulesin WAC 284-51. Provider shall provide prenatal care
and preventive pediatric care and then seek reimbursement from third parties.
3.11 Provider may not subcontract any services under the Apple Health Program without the prior written
consent of Company. Any subcontract entered into by Provider must be in writing consistent with 42
C.F.R. § 434.6, and shall contain a requirement for the subcontractor to comply with all applicable
provisions of this Attachment.
3.12 Provider shall make reasonable accommodation for Covered Persons with disabilities, in accord with the
Americans with Disabilities Act, for all Covered Services and shall assure physical and communication
barriers shall not inhibit Covered Persons with disabilities from obtaining Covered Services.
3.13 If Provider is a hospital, ambulatory care surgery center, or office -based surgery site, Provider shall endorse
and adopt procedures for verifying the correct patient, the correct procedure and the correct surgical site
that meet or exceed those set forth in the Universal ProtocolTs' development by the Joint Commission.
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3.1 4 If Provider is a hospital, Provider may, upon HCA notice to Health Plan thereof, be subject to payment
reductions corresponding to an HCA -assigned percentage reduction for future inpatient admissions based
on the Navigant statistical readmission algorithm.
3.15 If Provider is a hospital, Provider shall not:
A. Fail to disclose or bill for Provider's own readmissions;
B. Bundle Provider's own separate hospital encounters/admissions into fewer encountedadmission
claims than actually occurred;
C. Withdraw one or more of Provider's own hospital encounter/admission claims and then resubmit
them bundled into fewer encounterladmissions than actually occurred;
D. Induce or collaborate with another hospital provider not to disclose, not to bill for or to withdraw
the other hospital's encounter/admissions/claims because they could be a potentially preventable
readmission for the hospital; uor
E. Engage in any activity, ceding changes or practices that are intended to, or have the effect of,
masking or hiding from Company or HCA the existence of a potentially preventable readmission.
3,16 Provider shall comply with applicable physical and behavioral health practice I,ruidelines adopted by
Company.
3.17 Provider shall offer access comparable to that offered to commercial enrollees or if Provider serves only
Medicaid enrollees, theta comparable to that offered to Medicaid fee-for-service enrollees.
3,18 Provider's hours of operation for Covered Persons shall be no less than the hours of operation offered to
any other of Provider's patients.
3.19 Unless otherwise directed by Company, Provider shall use and follow the most recent updated versions of:
A. Current Procedtiral'reriminology ("CPT");
B. .International Classification of Diseases ("ICD");
C. Healthcare Compton Procedure Coding System ("IICPCS");
D. CIMS Relative Value Units (`'RVUs");
E. CMS billing instructions and rules;
F. NCPDP Telecommunication Standard D.O.; and
G. Medi-SpanO Master Drug Data,
3,20 Provider shall meet the following appointment wait time standards with respect to Covered Persons:
A. Transitional healthcare services by a home care nurse or hoarse care registered counselor shall be
available within seven (7) calendar days of discharge from inpatient or institutional cure for
physical or behavioral health disorders or discharge from a substance use disorder treatment
program, if ordered by the Covered Person's PCP or as part of the discharge plan;
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B. Preventive care office visits shall be available from the Covered Person's PCP within thirty (30)
calendar days;
C. Routine care office visits shall be available from the Covered Person's PCP within ten 00)
calendar days;
D. Urgent, symptomatic office visits shall be available from the Covered Person's PCP within twenty-
four (24) hours; and
E. Emergency medical care shall be available twenty-four (24) hours per day, seven (7) days .per
week.
Company shall monitor Provider's compliance with this Section, In the event Provider fails to comply with
the applicable appointment wait time standards set forth in this Section, Provider shall comply with
Company's procedures For corrective action,
3.21 To the extent applicable, Provider shall make the following services available twenty-four (24) hours per
clay, seven (7) days per week:
A. Medical advice for Covered Persons from licensed health care professionals; and
B. Triage conceming the emergent, urgent or routine nature of medical conditions by licensed health
care professionals.
3.22 Provider shall maintain a health information system that complies with the requirements of 42 C.F.R.
438.242 and provides the information necessary to meet Company's obligations under the State Contract.
The health information system must:
A, Collect, analyze, integrate, and report data. The system must provide infonnation on areas that
include but are not limited to utilization, grievance and appeals, and terminations of enrollment for
other than loss of Medicaid eligibility; and
B. Ensure data provided to Company is accurate and complete by:
i. Verifying; the accuracy and timeliness of reported data;
ii. Screening the data for completeness, logic, and consistency; and
iii. Collecting; service information on standardized formats to the extent feasible and
appropriate.
3.23 Provider acknowledges and agrees to release to Company any nforntation necessary to pertonn any of
Company's obligations under the State Contract.
3.24 Provider shall submit complete, accurate and timely encounter data to Company in accordance with current
encounter submission guidelines published by FICA or as otherwise specified by Company. Provider
represents and warrants that it has the capacity to submit all data required by HCA to enable Company to
meet the reporting requirements in the Encounter Data Reporting Guide published by HCA.
3,25 Provider shall comply with the applicable state and federal statutes, rules and regulations as set forth in the
State Contract, including but not limited to the applicable requirements of 42 U.S.C. §§ 1396a(a)(43)
(early and periodic screening, diagnostic, and treatment services ("EPSDT")), 1396d(r) (definition of
EPSDT), 42 C.F.R. § 43.4.6(i) (advance directives).
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3.2E Provider shallcomplywith any term or condition of the State Contract that is applicable to the services to
be perforated under the Agreement, including but not limited to the Performance Improvement Project
requirements of the State Contract and the prohibition on direct and/or indirect door-to-door, telephonic, or
other cold -call marketing.
3.27 Provider acknowledges that Company wiI l comply with Washington laws regarding nonpayment for
provider preventable conditions as described in the State Contract, and with the provider payment
provisions of the State Contract, including but not limited to primary care physician adjustments described
in the State Contract.
3.28 Provider shall comply with Company's policies and procedures, including, but not limited to, credentialing
and recredentialing, utilization management, fraud and abuse, authorization of services, quality
improvement activities and provider payment suspensions. Provider shall comply with the Program
Integrity requirements of tate State Contract, as well as Company's program integrity policies and
procedures. To the extent that Provider is delegated authority for authorization of services, Provider shall
comply with all Utilization Management requirements described in the State Contract.
3.29 Provider referrals may be limited to Participating Providers except in the following circumstances:
A. Emergency services;
B. Outside the Service Areas as necessary to provide Medically Necessary services;; and
C. When a Covered Person has other primary comparable medical coverage, as necessary to
coordinate benefits.
3.30 Providers that are deemed to be "high categorical risk," including prospective (newly enrolling) home
health agencies and prospective (newly enrolling) DMEPOS suppliers or such other categories of providers
as defined under 42 C.F.R. § 424.518, shall be enrolled in and screened by Medicare, in addition to
complying with Company's policies and procedures regarding credentialing and recredentialing. Such
providers shall revalidate Medicare enrollment every three (s} years in compliance with 42 C.F.R.
455.101.
3.31 Provider acknowledges and agrees that no assignment of the Agreement shall take effect without the prior
written agreement of) ICA.
3.32 Provider shall maintain a quality improvement system tailored to the nature'and type of Covered Services
provided hereunder, which affords quality control for such services, including but not limited to the
accessibility ofMedically Necessary services, and which provides for a free exchange of information with
Company to assist Company in complying with the requirements of the State Contract. Providers that are
PCPs or specialty care providers shall comply with all duality improvement activities of the Company.
3.33 Activities that are delegated shall be agreed upon in writing,with such writing to include: assigned
responsibilities, delegated activities, a mechanism for evaluation and corrective action potic es and
procedures. As applicable to services rendered under the Agreement, Provider shall have a means to keep
records necessary to adequately document services provided to Covered Persons for any and all delegated
activities including quality improvement, utilization management, member rights and responsibilities, and
credentialing and recredentialing,
3.34 Provider agrees to accept payment from Company as payment in full and shall not request payment from
1 -ICA or any Covered Person for Covered Services provided under the Agreement. Provider shall report to
Company any instance in which a Covered Person is charged for services. Provider shall repay to a
Covered Person any inappropriate charges paid by such Covered Person, or shall reimburse Company to
the extent Company repays such inappropriate charges to the Covered Person.
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3.35 Provider agrees to hold harinless HCA. and its employees, and all Covered Persons in the event of non-
payment by Company. Provider further agrees to indemnify and hold harmless .IICA and its employees
against (a) 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, and (b) any damages
related to Provider's unauthorized use or release of Personal Information or PHI of Covered Persons
3.36 Either party to this Attachment may terminate this Attachment upon ninety (90) days advance written
notice to the other party. Notwithstanding the foregoing, in the event that (a) Provider is excluded from
participation in the Medicaid program, Company may immediately terminate the Agreement or this
Attachment upon written notice to Provider, and may immediately recover any payments for goods or
services that benefit excluded individuals or entities; or (b) HCA or Medicare has taken any action to
revoke Provider's privileges for cause, and Provider has exhausted all applicable appeal rights or the
timeline for appeal has expired. "For cause" tray include but is not limited to reasons related to fraud,
integrity or quality.
3.37 Provider acknowledges and agrees that Company shall conduct ongoing monitoring and periodic fonnal
review that is consistent with applicable industry standards and the regulations of the Washington State
Office of the Insurance Commissioner, if any. Such formal review shall be completed no less than once
every three years or more often if specified, and will identify any deficiencies or areas of improvement and
provide for corrective action of any such deficiencies. Such review shall include an evaluation of services
furnished by Provider to individuals with special health care needs. Inadequate performance under the
Agreement will be subject to the revocation of delegation or imposition of sanctions'in accordance with the
dispute resolution process detailed in Article VI of the Agreement.
3.35 Provider acknowledges that Covered Persons have a right to self -refer for family planning services and
sexually -transmitted disease screening and treatment services provided at family planning agencies, as well
as for immunizations, sexually -transmitted disease screening and follow-up, immunodeficiency virus (I IV)
screening, tuberculosis screening and follow-up, and family planning services through the local health
department.
3.39 In the event that the Agreement delegates administrative functions to Provider, the parties agree that they
shall enter into a delegated administrative services agreement that contains all provisions required pursuant
to the State Contract, including but not limited to the following:
A. If Provider is at financial risk, Provider shall maintain Health Plan's solvency requirements
throughout the term of the Agreement;
B. Health Plan shall have the authority to revoke delegation of administrative functions and/or impose
sanctions upon Provider in the event that either HCA or Health Plan determine that Provider's
performance of the delegated administrative functions has been inadequate (42 CTR
438.230(b)(2)); and
C. Prior to delegation, Health Plan shall evaluate Provider's ability to successfully perform and meet
the requirements of the State Contract for any delegated administrative functions.
3.40 Provider shall keep information about Covered Persons, including their medical records, confidential in a
manner consistent with State and federal laws and regulations. Provider shall ensure that all health
information relating to Covered Persons is shared with other providers in a manner that facilitates the
coordination of care while protecting Covered Person privacy and confidentiality.
3.41 Provider shall comply with any applicable federal and state laws that pertain to Covered Persons' rights and
shall protect and promote those rights when furnishing services to Covered Persons. Provider steal{
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guarantee each Covered Person the rights set forth below. Each Covered Person must be free to exercise
these rights and exercise of these rights must not adversely affect the way the Company or Provider treats
the Covered Person. These rights include
A. To be treated with respect and with consideration for Covered Person's dignity and privacy;
B. To receive information on available treatment options and alternatives, presented in a manner
appropriate to the Covered Person's ability to understand;
C. To participate in decisions regarding Covered Person's health care, including the right to refuse~
treatment;
Q. To be five from any form of restraint or sectusion used as a means of coercion, discipline,
convenience, or retaliation; and
E. To request and receive a copy of their medical records, and to request that they be amended or
corrected in accordance with applicable law.
3.42 Provider shall participate in and cooperate with Company's efforts to promote the delivery of services in a
culturally competent manner to all Covered Persons, including those with limited English proficiency and
diverse cultural and: ethnic backgrounds.
3.43 Provider shall (a) obtain informed consent prior to treatment from all Covered Persons, or from persons
authorized to consent on behalf of Covered Persons as described in RCW 7.70.065, (b) comply with the
provisions of the Natural Death Act (RCW 70.122) and state and federal law and rules concerning advance
directives and POLST (WAC 182-501-0125 and 42 C.F.R. § 438.6(i)), and (c) when appropriate, inform
Covered Persons of their right to make anatomical bills pursuant to RCW 63.50.540.
3.44 Provider shall ensure that whether a Covered Person has executed an advance directive or POLST shrill be
indicated in a prominent part of such Covered Person's medical records. and Provider shall not provision
care or otherwise discriminate against a Covered Person based on whether the Covered Person has executed
an advance directive or POLST.
3.45 Provider shall have and maintain insurance appropriate to the service to be performed under the
Agreement. Provider shall make copies of certificates of insurance available to HCA upon request.
3.46 If Provider is a PCP, Provider shall reasonably cooperate with the applicable care coordinator to conduct an
Initial Health Assessment ("MA") of Covered Persons within sixty (60) calendar days of the identification
of special needs or initial health screen that indicates the need for care coordination. Provider as PCP shall
help assure that arrangements are made for follow-up services that reflect the findings in the IHA, such as
consultations with mental health andlor substance use disorder providers. The WA shall be maintained in
the Covered Person's medical records and available during subsequent preventive health visits.
3.47 If Provider is a provider of Health Home services, Provider shall be subject to applicable provisions of the
State Contract, including but not limited to cooperating with the Care Coordinator to meet specified time
limits for Health Action Plan development and implementation.
3.48 If Provider is a home health agency, Provider represents and warrants that it is in compliance with the
surety bond requirements of federal law (Section 4708(d) of the Balanced Budget Act of 1997 and 42
C.F.R. § 441..16).
3.49 If Provider is at financial risk, as defined in the Substantial Financial Risk or Risk provisions in the State
Contract, Provider shall be subject to solvency requirements that provide assurance of Provider's ability to
meet its obligations. Such requirements shall be regularly monitored and enforced.
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3.50if Provider makes payment to any physician under a .Physician Incentive Plan, such plan shall meet all
applicable requirements under the State Contract, including but not limited to disclosure requirements and
stop -loss protection.
3.51 Provider shall reasonably cooperate with Company care coordination staff regarding transitional care
services and care coordination as required by the State Contract.
3.52 To the extent applicably, Provider acknowledges and agrees to comply with the coordination of benefits
provision in the State Contract.
3.53 Upon the request of Company or HCA, Provider shall furnish to HCA, within thirty-five (35) calendar days
of a request, the following information:
A. The ownership of any subcontractor with whom the Provider has had business transactions totaling
more than twenty-five thousand dollars ($25,000.00) during the previous twelve (12) month period;
and
B. Any significant business transaction between Provider and any wholly owned supplier or any
subcontractor during the previous five (5) year period.
Provider shal l provide any further information needed or reasonably` requested by Company for the purpose
of satisfying Company's HCA reporting requirements under the State Contract, or for the purpose of
verifying or screening for exclusion from federal or state health care programs, or for conviction of various
criminal or civil offences, among the individuals or entities who have an ownership or control interest in, or
who are a managing employee of, Provider.
3.54 All hospital delivery maternity care provided under the Agreement shall be in accord with RCW 48.43.115.
.All sterilizations and hysterectomies provided under the Agreement shall be in compliance with 42 C.F.R.
§ 441 Subpart F, and Provider shall use the HCA Sterilization Consent Form (HCA 13-364) or its
equivalent in connection therewith.
3.55 Company will provide the following information regarding Company's grievance system to Provider:
A. The toll-free numbers to file oral grievances and appeals;
B. The availability of assistance in filing a grievance or appeal;
C. The Covered Person's right to request continuation of benefits during an appeal or hearing and, if
the Company's action is upheld, that the Covered Person may be responsible to pay for the
continued benefits;
D. The Covered Person's right to file grievances and appeals and their requirements and timeframes
for filing;
E. The Covered Person's right to a hearing after the Company has made an adverse detennination on
a Covered Person's appeal, how to obtain a hearing and representation rules at a hearing; and
F. Provider may file a grievance or request an adjudicative proceeding on behalf of Covered Person
in accordance with the State Contract.
Such system shall be sufficient to meet the minimum requirements of the State Contract.
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3.55 Nothing herein shall be construed to delegate legal responsibility to HCA for any work performed under
the Agreement, nor for oversight of any functions and/or responsibilities delegated to Provider.
3.57 If Provider is operating in Oregon or Idaho, Provider must provide timely access to necessary care,
including .inpatient and outpatient services, and must coordinate with other providers to explore
opportunities for reciprocal arrangements that allow border residents to access care that is appropriate,
available, and cost-effective.
3.53 Unless Provider is an individual practitioner or a group of practitioners, Provider must disclose the
following items to Health Plan upon contract execution [42 C.F.R. 455.104(c)(1)(ii)], upon request during
the re -validation of enrollment process under 42 CER. 455.414 [42 C.F.R. 455.104(e)(1)(iii)], and within
thirty-five (35) business days after any change in ownership of Provider. 42 C.F.R. 455.104(c)(1)(iv).
A. List the name and address of any person (individual or corporation) with an ownership or control
interest in Provider. 42 C.F.R. 455.104(b)(1)(i)
B. If Provider is a corporate entity, the disclosure must include primary business address,'every
business location, and P.O. Box address. 42 CRR. 455.104(b)(1)(i).
C. If Provider has corporate ownership, the tax identification number of the corporate owner(s). 42
C.F.R. 455.104(b)(1)(iii)•
D. if Provider is an individual, the date of birth and Social Security Number. 42 C.F.R.
455.104(b)(1)(ii).
E, If Provider has a five percent (5°l0) ownership interest in any of its subcontractors, the tax
identification number of the subcontractor(s). 42 C.F.R. 455.104(b)(1)(iii).
F. Whether any person with an ownership or control interest in Provider is related by marriage or
blood as a spouse, parent, child, or sibling to any other person with an ownership or control interest
in Provider. 42 C.F.R. 455.104(b)(2).
G. If Provider has a five percent (5%) ownership interest in any of its subcontractors, whether any
person with an ownership or control interest in such subcontractor is related by marriage or blood
as a spouse, parent, child, or sibling to any other person with an ownership or control interest in
Provider. 42 G.F.R. 455.104(b)(2).
H. Whether any person with an ownership or control interest in Provider also has an ownership or
control interest in any other Medicaid provider, in the state's fiscal went or in any managed care
entity. 42 C.F.R. 455.104(b)(4), `
3.59 Unless Provider is an individual practitioner or a group of practitioners, Provider must investigate and
disclose to Health Plan, at contract execution or renewal, and upon request by Health Plan of the identity of
any person who has been convicted of a criminal offense related to that person's iinvolvement in any
program under Medicare, Medicaid, or the title XX services program since the inception of those programs
and who is [42 C.F.R. 455.106(a)];
A. A person who has an ownership or control interest in Provider. 42 C.F.R. 455.106(a)(1).
B. An agent or person who has been delegated the authority to obligate or act on behalf of Provider.
42 C.F.R. 455.101; 42 C.F.R. 455.106(a)(1).
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C. An agent, managing employee, general manager, business manager, administrator, director, or
other individual who exercises operational or managerial control over, or who directly or indirectly
conducts the day -today operation of, Provider. 42 C.F.R. 455.101; 42 C.F.R. 455.106(a)(2),
3.60 If Provider is a state or community physical or behavioral health hospital or long-term care facility, to
facilitate care transitions for Covered Persons, Provider shall develop and utilize a standardized discharge
screening tool encompassing a risk assessment for re -institutionalization or treatinent.recidivism to include
each of the elements required by the State Contract.
3.61 If Provider is a school-based health centers or family planning clinic, in order to promote delivery of
FPSD'T services to adolescents accessing Provider's services:
A. Provider shall follow EPS.DT requirements;
B. Provider and Heath Plan shall coordinate identified needs for specialty care, such as referrals for
vision or mental health evaluation and treatment services with the adolescent's PCP;
C. hlealth Plan shall not deny payment for EPSDT services delivered by more than one provider (PCP,
school-based provider or family planning clinic) within a calendar year;
D. The parties shall ensure the policies and procedures for accessing Provider's services are compliant
with applicable federal and state statutes; and
E. The parties shall coordinate to assure activities performed by Health Plan are not duplicated.
WA PPA County of Grant dba Grant Intetrated 11/0212017 — 342323 - Public
Page 11 of 11
Attachment A, Medicaid
EXHIBIT A-3
A ':PLE .HEALTH
CONIP)E:NSA'TION SCHEDULE
PRACTITIONER SERVICES
County of Grant dba Grant Integrated Services
This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for
Covered Services rendered to Covered Persons enrolled in a Medicaid Product. Payment under this Compensation
Schedule shall consist of the Allowed Amount as set forth herein less all applicable Cost -Sharing Amounts. All
capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the
applicable Product Attachment, or the Definitions section set forth at the end of this Compensation Schedule.
General.
1,,1 Payment In Full. Provider shall, and shall require its Contracted Providers, if applicable to such Contracted
Providers, to accept the applicable amounts set out in this Compensation Schedule as payment in full for Covered
Services rendered to Covered Persons.
1.2 Assigned Covered Persons, Covered Persons shall be assigned to Provider or Contracted Providers solely
by Health Plan and may be reassigned by Health Plan to other Participating Providers at any time. For purposes of
this Compensation Schedule, Assigned Covered Persons will include all Covered Persons in Grant County
Washington.
1.3 Termination. This Compensation Schedule may be terminated by health Plan with a one hundred eight day
prior written notice during the term of this Medicaid Product Attachment.
2. Capitation Payment.
2.1 Capitation Rate. The maxima n compensation for Capitated Services rendered to an Assigned Covered
Person shall be the "Allowed Amount." Except as otherwise provided in this Compensation Schedule, the Allowed
Amount for all Capitated Services rendered to an Assigned Covered Persons by one or more Contracted Providers
during the term of this Compensation Schedule shall be a Capitation Payment of Fifteen dollars and eighty cents
($15.$0) per Assigned Covered Person per month (PMPtit). For each Covered Person that is a Wise Assigned
Covered Person, compensation will be a Capitated Payment of Two Thousand Eight Hundred Seventy Three
dollars and fifty six cents ($2,873.56) PMPM
2.2 Payment. The Capitation Payments for each calendar month during the tenet of this Compensation
Schedule shall be made to Provider on or about the fifteenth (15th) day of such month.
2.3 Adjustments. Adjustments to Provider's Capitation Payments shall be made as follows.
2.3.1 Enrollment Errors. If Payor determines that there were enrollment errors in any preceding month(s), Payor
shall adjust accordingly a subsequent month's Capitation Payments by the amount of overpayment or
underpayment due to such errors to accurately reflect the Covered Persons assigned to a Contracted Provider for
such preceding month(s).
2.3.4 Capitated Services Provided by a. Non -Contracted Providers, Health Plan may periodically
review the Covered Services rendered to .Assigned Covered Persons. If Health Plan determines (i) that any
Covered Services were rendered to an Assigned Covered Person by a Participating Provider who is not a Grant
Integrated Services Contracted Provider, and (ii) that such Covered Services would have constituted Capitated
Services i f such Covered Services would have been performed by a Grant Integrated Services Contracted Provider,
WA PPA County of Grant dba Grant Integrated i r,0120t7-3 2323 - NP
Parc loft
Health Plan may reduce any subsequent month's Capitation Payment by the amount paid by Health Plan to the
Provider for such Covered Services. Notwithstanding anything to the contrary contained herein, in no event will
aggregate amount of the reductions to the Capitation Payments under this Section during a calendar year (or other
measurement period designated by Health Plan) exceed an amount equal to twenty-five percent (25%) of the
potential payments (as defined ;in 42 C.F.R. §417.479(0) for such calendar year (or other measurement period
designated by Plan).
2.4 Contracted Provider Payments.
2.4.1 Payments to Contracted Providers. A Contracted Provider shall look solely to
Provider for payment of Covered Services rendered to a Covered Person, Provider represents and warrants that-. (i)
Provider pays a Contracted Provider on a salaried or sub -capitation basis; and (ii) payments to -a Contracted
Provider for Covered Services rendered to a Covered Person are not on a fee-for-service or per claim/visit/service
basis. Payor reserves the right to withhold any Capitation Payments upon reasonable determination that Provider is
not paying a Contracted Provider for the Covered Services as required hereunder.
2.4.2 Physician Incentive Plan Compliance. Provider agrees that, in order to ensure
Health Plan's compliance with the federal physician incentive plan regulations at 42 C.F.R. §417.479, the amount
of any reductions to the Capitation Payments under Section 2.3.4 apportioned by Provider to any Contracted
Provider in any calendar year (or other measurement period designated by Health Plan) will not exceed a total of
twenty-five percent (25%) of the potential payments (as defined in 42 C.P.R. §417.479(0) during such time period.
In the event Provider's failure to comply with this provision results in any investigations or enforcement actions
a¢ainst Health Plan, or in the assessment of any fines, penalties or other amounts against Health Plan, Provider shall
indemnif} and hold Health Plan harmless against the costs (including reasonable attorneys' fees) of defending
against any such action or investigation and the amounts of any such assessments. At Health Plan's request,
Provider shall provide Health Plan with copies of Provider's compensation arrangements with the Contracted
Providers in order to allow Health Plan to verify Provider's compliance with this Section 2.5.2.
2.4.3 Federal Program Compliance. Provider agrees that, in connection with any
Medicare and Medicaid products, Provider shall and shall prohibit the Contracted Providers and other persons
under contract with Provider from claiming payment in any form directly or indirectly from a federal health care
program (as that term is defined in Section 1128B(o of the Social Security Act, 42 U.S.C. §1320a-7b(o) for items
or services covered under this Exhibit or the Agreement. Provider and each Contracted Provider acknowledge and
agree (i) that it, he or she has not given or received remuneration in return for or to induce the provision or
acceptance of business (other than business covered by this Exhibit or the Agreement) for which payment may be
made in whole or in part by a federal health care program on a fee -far -service or cost basis; and (ii) that it, he or she
will not shill the financial burden of this Exhibit or the Agreement to the extent that increased payments are
claimed from a federal health care program.
2.5 Term. This Compensation Schedule will be effective January 1, 2018 and continue through June 30, 2018
unless the Parties agree to continue it for another one hundred eighty (180) day period.
2.6 It is the intention of both Parties to implement the concepts and tenants of Integrated Managed Care in the
North Central Region as quickly as practical; however, the terns described herein may be extended by mutual
written agreement of the Parties.
2.7 Health Plan — Provider Monthly Meetings. Health Plan will support and assist Provider to prepare for
Integrated Managed Care in the North Central Region, via the implementation of monthly meetings that address the
following:
a. Health Plan and Provider will review utilization and quality reports.
b. Health Plan and Provider will discuss open episode of care report created by Provider for all Assigned
Covered Persons. For the purpose of this section, an open episode of care is defined as a report that identifies any
WA PFA County of Grant dba Grant Integrated 111012017 - 342323 - NP
Page 2 of 4
Assigned Covered Person who has received a Covered Services in the last thirty (30) days at any of the Provider or
Contracted Provider locations excluding utilization of crisis services. Health Plan will develop a template for this
report within thirty (30) days of the Effective Date of this Agreement.
2.8 Clinical Care Model Discussions. health Plan and Provider will discuss clinical care model discussions.
For example, the Provider will provide a report with the discharge disposition of each Assigned Covered Person
that who has been discharged (as a closed episode of care) in the previous thirty days by the first (Ist) day of each
month. The discharge reports are to address the following: The reports will include i) the Assigned Covered
Person (s) disposition(s); and, :i) identify the Participating Provider responsible for the ongoing treatment of the
Assigned Covered Person.
Additional Provisions:
1. Encounter Data Submission. Provider and Contracted Providers shall submit encounter data to Payor or its
delegate in a timely fashion, which must contain statistical and descriptive medical and patient data and identifying
information, if and as required in the Provider Manual. Payor or its delegate reserves the right to deny payment to
the Provider and/or Contracted Providers if the Provider and/or Contracted Provider fails to submit encounter data
in accordance with the Provider Manual and/or Policies.
2. Code Change Updates. Payor utilizes nationally recognized coding structures (including, without
limitation, revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or
their successors) for basic coding and descriptions of the services rendered. Updates to billing -related codes shall
become effective on the date ("Code Change Effective Date") that is the later of: (i) the first day of the month
following sixty (60) days after publication by the governmental agency having authority over the applicable
Product of such governmental agency's acceptance of such code updates (ii) the effective date of such code updates
as determined by such governmental agency or (iii) if a date is not established by such governmental agency or the
applicable Product is not regulated by such governmental agency, the date that changes are made to nationally
recognized codes. Such updates may include changes to service groupings. Claims processed prior to the Code
Change Effective Date shall not be reprocessed to reflect any such code updates.
3. .Pee Schedule Compensation. The fee schedule payment methodology set forth at Exhibit 3 to Attachment
B-3 shall be used for the following .purposes: (i) to calculate Covered Persons' Cost -Sharing Amounts and (ii) to
process claims submitted by Provider for Covered Services provided to Non -Assigned Covered Persons
4. Payment under this Compensation Schedule. All payments under this Compensation Schedule are subject
to the terms and conditions set forth in the Agreement, the Provider Manual and any applicable manual.
Definitions:
1. Allowed Amount means the amount designated in this Compensation Schedule as the maximum amount
payable to a Group Provider for any particular Covered Service provided to any particular Covered Person,
pursuant to this Agreement or its Attachments.
2. Assigned Covered Person means a Covered Person assigned to Provider by Health Plan.
3, Capitated Services means (i) Covered Services provided by any Contracted Provider who is a behavioral
health professional, including physicians, allied health professionals and other providers of behavioral health care
services.
4. Capitation Payment means the PMPM monthly fee for each Assigned Covered Person.
5. Cost -Sharing Amounts means any amounts payable by a Covered Person, such as copayments, cost-
sharing, coinsurance, deductibles or other amounts that are the Covered Person's fnancial responsibility under the
applicable Coverage Agreement, if applicable.
SVA PPA County of Grant dba Grant Integrated t t;021201 7 342323 - NP
Page 3 of 4
6. Deemed Assignment Date means the first clay of the first month following an Assigned Covered Person's
first date of assignment to Provider.
7. Non -Assigned Covered Person means a Covered Person who is not an Assigned Covered Person.
8. PIMPM means `Per Member Per Month," in which the Number of "Members" for a particular month is the
total number of Assigned Covered Persons on the first day of such month.
WA PPA County of Grant dba Grant Integrated i U0212017 —342323 NP
Pale 4 of 4
Attachment At Medicaid
EXHIBIT A-12
APPLE 11ENLTH
COMPENSATION SCHEDULE
CHEMICAL DEPF.NDF:NCY/RESIDENTIAL TRExrMENT[BERAVIGRAL HEALTH
(Certified residential treatment providers, Licensed Community Mental Health Agencies, Certified Chemical Dependency
Agencies, Certified medication assisted treatment (e.g., buprenorphine), Certified opiate substitution providers (Methadone
Treatment programs), DOH -licensed and D131iR-certified free-standing inpatient, hospitals or psychiatric inpatient facilities,
DOH -licensed and DBHR certified detox facilities (for acute and sub -acute), DOH licensed and DBHR certified residential
treatment facility to provide crisis stabilization services)
COUNTY OF GRANT DBA GRANT INTEGRATED SERVICES
This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for
Covered Services rendered to Covered Persons enrolled in a Medicaid Product. Payment under this Compensation
Schedule shall consist of the Allowed Amount as set forth herein less all applicable Cost -Sharing Amounts. All
capitalized terms used in this Compensation Schedule shall have the meanings set forth in the Agreement, the
applicable Product Attachment, or the Definitions section set forth at the end of this Compensation Schedule.
I. General.
1.1 Payment In Full, Provider shall, and shall require its Contracted Providers, if applicable to such Contracted
Providers, to accept the applicable amounts set out in this Compensation Schedule as payment in full for Covered
Services rendered to Covered Persons.
1.2 Assigned Covered Persons. Covered Persons shall be assigned to Provider or Contracted Providers solely
by Health Plan and may be reassigned by Health Plan to other Participating Providers at any time. For purposes of
this Compensation Schedule, Assigned Covered Persons will include all Covered Persons in Grant County
Washington.
1.3 Termination. This Compensation Schedule may be terminated by Health. PIan with a one hundred eight day
prior written notice during the term of this Medicaid Product Attachment.
2. Capitation Payment.
2.1 Capitation Rate. The maximum compensation for Capitated Services rendered to an Assigned Covered
Person shall be the "Allowed Amount." :Except as otherwise provided in this Compensation Schedule, the Allowed
Amount for all Capitated Services rendered to an assigned Covered Persons by one or more Contracted Providers
during the term of this Compensation Schedule shall be a Capitation Payment of Fifteen dollars and eighty cents
($15.80) per Assigned Covered Person per month (PMPM). For each Covered Person that is a Wise Assigned
Covered Person, compensation will be a Capitated Payment of Two Thousand Eight Hundred Seventy Three
dollars and fifty six cents ($2,873.56) PMPM.2;2 Payment. The Capitation Payments for each calendar
month during the term of this Compensation Schedule shall be made to Provider on or about the fifteenth (15th) day
of such month.
2.3 Adjustments. Adjustments to Provider's Capitation Payments shall be made as follows.
2.3.1 Enrollment Errors. If Payor determines that there were enrollment errors in any preceding month(s), Payor
shall adjust accordingly a subsequent month's Capitation Payments by the amount of overpayment or
underpayment due to such errors to accurately reflect the Covered Persons assigned to a Contracted Provider for
such preceding month(s).
WA PPA County of Grant dba Grant Integrated 11/02/2017 — 3423123 - NP Page I of 2
2.3.4 Capitated Services Provided by a Non -Contracted Providers. Health Plan may periodically
review the Covered Services rendered to Assigned Covered Persons. If Health Plan determines (i) that any
Covered Services were rendered to an Assignted Covered Person by a Participating Provider who is not a Grant
Integrated Services Contracted Provider, and (ii) that such Covered Services would have constituted Capitated
Services if such Covered Services would have been performed by a Grant_ Integrated Services Contracted Provider,
Health Plan may reduce any subsequent month's Capitation Payment by the amount paid by Health flan to the
Provider for such Covered Services. Notwithstanding anything to the contrary contained herein, in no event will
aggregate amount of the reductions to the Capitation Payments under this Section during a calendar year (or other
measurement period designated by Health Plan) exceed an amount equal to twenty -rive percent (25%) of the
potential payments (as defined in 42 C.F.R. §417.479(f)) for such calendar year (or other measurement period
designated by Plan).
2;4 Contracted Provider Payments.
2.4.1 Payments to Contracted Providers. A Contracted Provider shall look solely to
Provider for payment of Covered Services rendered to a Covered Person. Provider represents and warrants that: (i)
Provider pays a Contracted Provider on a salaried or sub -capitation basis; and (ii) payments to a Contracted
Provider for Covered Services rendered to a Covered Person are not on a fee-for-service or per claim/visit/service
basis. Payor reserves the right to withhold any Capitation Payments upon reasonable determination that Provider is
not paying a Contracted Provider for the Covered Services as required. hereunder.
2.1.2 Physician Incentive Plan Compliance. Provider agrees that, in order to ensure
Health Plan's compliance with the federal physician incentive plan regulations at 42 C.F.R. §§417.479, the amount
of any reductions to the Capitation Payments under Section 2.3.4 apportioned by Provider to any Contracted
Provider in any calendar year (or other measurement period designated by Health Plan) will not exceed a total of
twenty-five percent (25%) of the potential payments (as defined in 42 C.F.R. §417.479(f)) during such time period.
In the event Provider's failure to comply with this provision results in any investigations or enforcement actions
against Health Pian, or in the assessment of any fines, penalties or other amounts against Health Plan, Provider shall
indemnify and hold Health Plan harmless against the costs (including reasonable attorneys' fees) of defending
against any such action or investigation and the amounts of any such assessments. At Health Plan's request.
Provider shall provide Health Plan with copies of Provider's compensation arrangements with the Contracted
Providers in order to allow Health Plan to verify Provider's compliance with this Section 2.5.2.
2.4.3 Federal Program Compliance. Provider agrees that, in connection with any
Medicare and Medicaid products, Provider shall and shall prohibit the Contracted Providers and other persons
under contract -Mth Provider from claiming payment in any form directly or indirectly from a federal health care
program (as that term is defined in Section 1128B(0 of the Social Security Act, 42 U.S.C. §1320a-7b(f)) for items
or services covered under this Exhibit or the Agreement. Provider and each Contracted Provider acknowledge and
agree (i) that it, he or she has not given or received remuneration in return for or to induce the provision or
acceptance of business (other than businesscoveredby this Exhibit or the Agreement) for which payment may be
made in whole or in part by a federal health care program on. a fee-for-service or cost basis; and (ii) that it, he or she
will not shift the financial burden of this Exhibit or the Agreement to the extent that increased payments are
claimed from a federal health care program.
2.5 Term. This Compensation Schedule will be effective January 1, 2018 and continue through June 30, 2013
unless the Parties agree to continue it for another one hundred eighty(180) day period.
2.6 It is the intention of both Parties to implement the concepts and tenants of Integrated Managed Care in the
North Central Region as quickly as practical; however, the terms described herein may be extended by mutual
written agreement of the Parties.
2.7 Health Plan — Provider Monthly Meetings. Health Plan will support and assist Provider to prepare for
Integrated Managed Care in the North Central Region, via the implementation of monthly meetings that address the
following:
WA PPA County of Grant dba Grant Integrated 11/02/2017 - 342323 -NP Page 1 of 2
Health Plan and Provider will review utilization and quality reports.
b. Health Plan and Provider will discuss open episode of care report created by Provider for all Assigned
Covered Persons. For the purpose of this section, an open episode of care is defined as a report that identifies any
Assigned Covered Person who has received a Covered Services in the last thirty (30) days at any of the Provider or
Contracted Provider locations excluding utilization of crisis services. Health Plan will develop a template for this
report tivithin thirty (30) days of the Effective Date of this Agreement.
2.8 Clinical Care Model Discussions. Health Plan and Provider will discuss clinical care model discussions.
For example, the Provider will provide a report with the discharge disposition of each Assigned Covered Person
that who has been discharged (as a closed episode of care) in the previous thirty days by the first (Ist) day of each
month. The discharge reports are to address the following: The reports will include: i) the Assigned Covered
Person (s) disposition(s); and, ii) identify the Participating Provider responsible for the ongoing treatment of the
Assigned Covered Person.
Additional Provisions:
1. Encounter Data Submission, Provider and Contracted Providers shall submit encounter data to Payor or its
delegate in a timely fashion, which must contain statistical and descriptive medical and patient data and identifying
inforniation, if and as required in the Provider Manual. Payor or its delegate reserves the right to deny payment to
the Provider and/or Contracted Providers if the Provider and/or Contracted Provider fails to submit encounter data
in accordance with the Provider Manual and/or Policies.
2. Code Change Updates. Payor utilizes nationally recognized coding structures (including, without
limitation, revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or
their successors) for basic coding and descriptions of the services rendered. Updates to billing -related codes shall
become effective on the date ("Code Change Effective Date") that is the later of: (i) the first day of the month
following sixty (60) days after publication by the governmental agency having authority over the applicable
Product of such governmental agency's acceptance of such code updates (ii) the effective date of such code updates
as determined by such governmental agency or (iii) if a date is not established by such governmental agency or the
applicable Product is not regulated by such governmental agency, the date that changes are made to nationally
recognized codes. Such updates may include changes to service groupings. Claims processed prior to the Code
Change Effective Date shall not be reprocessed to reflect any such code updates.
3. Fee Schedule Compensation. The fee schedule payment methodology set forth at Exhibit 3 to Attachment
B-3 shall be used for the following purposes: (i) to calculate Covered Persons' Cast -Sharing Amounts and (ii) to
process claims submitted by Provider for Covered Services provided to bion -Assig=ned Covered Persons
4. Payment under this Compensation Schedule. All payments under this Compensation Schedule are subject
to the terms and conditions set forth in the Agreement, the Provider Manual and any applicable manual.
Definitions:
1. Allowed Amount means the amount designated in this Compensation Schedule as the maximum amount
payable to a Group Provider for any particular Covered Service provided to any particular Covered Person,
pursuant to this Agreement or its Attachments.
2. Assigned Covered Person means a Covered Person assigned to Provider by Health Plan.
3. Capitated Services means (i) Covered Services provided by any Contracted Provider who is a behavioral
health professional, including physicians, allied health professionals and other providers of behavioral health care
services.
WA PPA County of Grant dba Grant Integrated 11/0212017 — 342323 - NP Page] of 2
4. Capitation Payment means the PMPM monthly fee for each Assigned Covered Person.
S. Cost -Sharing Amounts means any amounts payable by a Covered Person, such as copayments, cost-
sharing, coinsurance, deductibles or other amounts that are the Covered Person's financial responsibility under the
applicable Coverage Agreement, if applicable.
h. Deemed Assignment Date means the first day of the first month following an Assigned Covered Person's
first date of assignment to Provider.
7. Non -Assigned Covered Person means a Covered Person who is not an Assigned Covered Person.
8. PMPM means "Per Member Per Month," in which the number of "Members" for a particular month is the
total number of Assigned Covered Persons on the first day of such month,
WA PPA County of Grant dba Grant Integrated 11/02/2017 — 342323 - NP Page I of 2
Attachment C: Commercial-Exchanue
EXHIBIT C-0
AM:BETTER
PARTICIPATING PROVII?ER AGREEMENT ATTACHMENT
This COMMERCIAL -EXCHANGE PRODucr - PARTICIPATING PROVIDER AGREEMENT
A'T'TACHMENT - (this "Product Attachment") is incorporated into the Participating Provider Agreement (the
"Agreentent") entered into by and between I Iealth Plan and Provider (as such entities are defined in the
Agreement).
RECITALS
WHEREAS, Health Plan and Provider entered into the Agreement, as the same may have been amended
and supplemented from time to time, pursuant to which Provider and its Contracted Providers or other Downstream
Entities participate in certain Products offered by or available from or through a Company; and
WHEREAS, pursuant to the provisions of the Agreement, this Product Attachment is identified on
Schedule B of the Agreement and, as such, the Contracted Providers identified herein will be designated and
participate as Participating Providers in the Product described in this Product Attachment, and will be considered to
be and will be governed under this Product Attachment as Downstream Entities, as defined in this Product
Attachment; and
WHEREAS, the Agreement is modified or supplemented as hereafter provided.
NOW THEREFORE, in consideration of the recitals, the mutual promises herein stated, the parties hereby
agree to the provisions set forth below.
TERMS
1. Defined Terms. For purposes of the Commercial -Exchange Product, the following terms have the
meanings set forth below. All capitalized terms not specifically defined in this Product Attachment will have the
meanings given to such terms in the Agreement.
1.1 "Canlrtercial-F-vchange.Producf% also referred to as "Amhetter'', refers to those
programs and health benefit arrangements offered by a Company that provide incentives to Covered Persons to
utilize the services of certain contracted providers. The Commercial -Exchange Product includes those Coverage
Agreements entered into, issued or agreed to by a Payor under which a Company furnishes administrative services
or other services in support of a health care program far an individual or group of individuals, which may include
access to one or more of the Company's provider networks or vendor arrangements, and which may be provided in
connection with a state or governmental -sponsored, employer-sponsored or other private health insurance
exchange, except those excluded by Health Plan. The Commercial -Exchange Product does not apply to any
Coverage Agreements that are specifically covered by another Product Attachment to the Agreement.
1.2 "Delegated Entity" means any party, including an agent or broker, that enters into an
agreement with Health Plan to provide administrative services or health care services to qualified individuals,
qualified employers or qualified employees and their dependents (as such teens are defined in 45 C.F.R.. § 156.20).
1.3 "Downstream E'ntiV' means any party, including an agent or broker, that enters into an
agreement with a Delegated Entity or with another Downstream Entity for purposes of providing administrative or
health care services related to the agreement between the Delegated Entity and health Plan. The term "Downstream
Entity" is intended to reach the entity that directly provides administrative services or health care services to
qualified individuals, qualified employers, or qualified employees and their dependents (as such terms are defined
in 45 C.F.R. § 156.20).
SVA PPA County of Grant dba Grant Integrated 11!0212017 — 342323 - Public Page 1 of
1.4 "Emergency"' or "Emergency Fare" has the meaning, set forth in the Covered Person's
Coverage Agreement.
1.5 "Esrrergency Medical Condition" has the meaning set forth in the Covered Person's
Coverage Agreement.
1.6 "State" means the State of Washington, or such other state to the extent that a Coverage
Agreement or Covered Person is subject to such other state's law.
2 Commercial -Exchange Product. This Product Attachment constitutes the "Commercial -Exchange
Product (Arnbetter) Attachment" and is incorporated into the Agreement. It supplements the Agreement by setting
forth specific teens and conditions that apply to the Commercial -Exchange Product with respect to which a
Participating Provider has agreed to participate, and with which a .Participating Provider must comply in order to
maintain such participation, This Product Attachment applies with respect to the provision of health care services,
supplies or accommodations (including Covered Services) to Covered Persons enrolled in or covered by a
Commercial -Exchange Product.
3. Participation. Except as otherwise provided in this Product Attachment or the Agreement, all -
Contracted Providers under the Agreement will participate as Participating Providers in this Commercial -Exchange
Product, and mill provide to Covered Persons enrolled in or covered by a Commercial -Exchange Product, upon the
same terms and conditions contained in the Agreement, as supplemented or modified by this Product Attachment,
those Covered Services that are provided by Contracted Providers pursuant to the Agreement. In providing such
services, Provider shall, and shall cause Contracted Providers, to comply with and abide by the provisions of this
Product Attachment and the Agreement (including the Company's policies and procedures).
4. Attachments. This Product Attachment includes the Compensation Schedules for the Commercial -
Exchange Product, as indicated on Schedule B of the Ag
reement, each of which are incorporated herein by
reference.
5. Construction. This Product Attachment supplements and forms a part of the Agreement. Except as
otherwise provided herein or in the ten -ns of the Agreement, the terms and conditions of the Agreement will remain
unchanged and in full force and effect as a result of this Product Attachment. In the event of a conflict between the
provisions of the Agreement and the provisions of this Product Attachment, this Product Attachment will govern
with respect to health care services, supplies or accommodations (including Covered Services) rendered to Covered
Persons enrolled in or covered by a Commercial -Exchange Product. To the extent Provider or any Contracted
Provider is unclear about its, his or her respective duties and obligations, Provider or the applicable Contracted
Provider shall request clarification from the Company.
6. Tenn. This Product Attachment will become effective as of the Effective Date, and will be
coterminous with the Agreement unless a Party terminates the participation of the Contracted Provider in this
Commercial -Exchange Product in accordance with the applicable provisions of the Agreement or this .Product
Attachment.
7. Federal Requirements. The following requirements apply to Delegated and Downstream Entities
under this Product Attachment, which includes but is .not limited to Provider and all Contracted. Providers.
7.1 Provider's delegated activities and reporting responsibilities, if any, are specified in the
Agreement or applicable attachment to the Agreement (e.g., Delegated Credentialing Agreement, Delegated
Services Agreement, Statement or Work, or other scope of services attachment) attached to this Agreement. If such
attachment is not executed, no administrative functions shall be deemed as delegated.
WA PPA County of Grant dba Grant Integrated 11x''02/2017 — 342323 - Public Page 2 of 3
7.2 CMS, Health Plan and Payor reserve the right to revoke the delegation activities and
reporting requirements or to specify other remedies in instances where CMS, Health Plan or the Payor determine
that Provider or any Downstream Entity has not performed satisfactorily.
7.3 Provider and all Downstream Entities must comply with all applicable laws and regulations
relating to the standards specified tinder 45 CFR § 156.340(a);
7.4 Provider and all Downstream Entities must permit access by the Secretary and OIG or their
designers in connection with their right to evaluate through audit, inspection or other means. to the Provider's or
Downstream Entities' books, contracts, computers, or any other electronic systems including medical records and
documentation, relating to Health Plan's obligations in accordance with federal standards under 45 CFR
§156.340(a) until ten (10) years from the termination date of this Product Attachment.
8. Other Terms and Conditions. Except as modified or supplemented by this Product Attachment, the
compensation hereunder for the provision of Covered Services by Contracted Providers to Covered Persons
enrolled in or covered by the Commercial -Exchange Product is subject to all of the other provisions in the
Agreement (including the Company's policies and procedures) that affect or relate to compensation for Covered
Services provided to Covered Persons.
WA PPA County of Grant dba Grant Integrated 11x02%2017 — 342323 - Public Page 3 of 3
Attachment C. Commercial -Exchange
EXHIBIT C-2
AMBETTER
COMPENSATION SCHEDULE
PRACTITIONER SERVICES
County of Grant dba Grant Integrated Services
This Compensation Schedule sets forth the maximum reimbursement amounts for the provision of Covered
Services to Covered Persons in a Commercial -Exchange Product offered through Health Plan and referred to as
Ambetter. For Covered Services rendered to a Covered Person and billed under a Contracted Provider's tax
identification number ("TIN") that has been designated by the Payor as subject to this Compensation Schedule,
Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider
according to the terms of the Agreement and this Compensation Schedule. Payment under this Compensation
Schedule is subject to the requirements set forth in the Agreement, which include reducing the Allowed Amount by
the applicable Cost -Sharing Amounts.
For Practitioner Covered Services provided to Covered Persons, Contracted Provider's maximum compensation
shall be the Allowed Amount. Except as otherwise provided in this Compensation Schedule, the Allowed Amount
is the lesser of: (i) the Contracted Provider's Allowable Charges; or (ii) ninety percent (90%) of the Payor's
Medicare Fee Schedule.
Multiple Procedure Pricing Rules. Multiple procedures performed during the same day will be reimbursed at one
hundred percent (100%) for the primary procedure, fifty percent (50%) for the second procedure, and fifty percent
(50%) for the third procedure, subsequent procedures shall not be eligible for reimbursement.
Additional Provisions
1. Code Change Updates. Payor utilizes nationally recog=nized coding structures (including, without limitation,
revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or their
successors) for basic coding and descriptions of the services rendered. Updates to billing -related codes shall
become effective on the date (`Code Change Effective Date") that is the later of. (i) the first day of the month
following sixty (60) days after publication by the governmental agency having authority over the applicable
product of such governmental agency's acceptance of such code updates, (ii) the effective date of such code
updates, as determined by such governmental agency or (iii) if a date is not established by such governmental
agency or the product is not regulated by such governmental agency, the date that changes are made to
nationally recognized codes. Such updates may include changes to service groupings. Claims processed prior
to the Code Change Effective Date shall not be reprocessed to reflect any such code updates.
2. Fee Chance Updates. Updates to the fee schedule shall become effective on the effective date of such fee
schedule updates, as determined by the Payor ("Fee Change Effective Date"). However, the date of
implementation of any fee schedule updates, i.e. the date beginning on which such fee change is used for
reimbursement ("Fee Change Implementation Date") shall be the later of. (i) the date on which Payor is
reasonably able to implement the update in the claims payment system; or (ii) the Fee Change Effective Date.
Claims processed prior to the Fee Change Implementation Date shall not be reprocessed to reflect any updates
to such fee schedule, even if service was provided after the Code Change Effective Date.
3. Modifier. Unless specifically indicated otherwise, the Allowed Amount represents global fees and may be
subject to reductions based on appropriate modifiers (for example, professional and technical modifiers). As
used in the previous sentence, "global fees" refers to services billed without a modifier, for which the Allowed
Amount includes both the professional component and the technical component.
SVA PPA County of Grant dba Grant Integrated 11!0212017 - 342323 - NP
Page t of 2
4. Anesthesia Modifier Pricing Rules. The dollar amounts that will be used in the calculation of Anesthesia
Management fees are in accordance with the Anesthesia Payment Policy. Unless specifically stated otherwise,
the Anesthesia Conversion Factor indicated is fixed and will not change. The Anesthesia Conversion Factor is
based on an anesthesia time unit value of 15 minutes.
5. PIace of Service Pricing Rules. Payor will follow CMS guidelines for determining when services are priced at
the facility or non -facility fee schedule (with the exception of services performed at Ambulatory Surgery
Centers, POS 24, which will be priced at the facility fee schedule).
Definitions.
I . Allowed Amount means the amount designated as the maximum amount payable to a Contracted Provider for
any particular Covered Service provided to any particular Covered Person, pursuant to this Agreement or its
Attachments for Covered Services.
2. Allowable Charges means a Contracted Provider's billed charges for services that qualify as Covered Services.
3. Cast -Sharing Amounts means any amounts payable by a Covered Person, such as copayments, cost-sharing,
coinsurance, deductibles or other amounts that are the Covered Person's financial responsibility under the
applicable Coverage Agreement, if applicable.
WA PPA County of Grant dba Grant Integrated 11 02x201 7 — 342323 - NP
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ATTACHMENTC: Connnercial-Exchange
EXIIH3IT C -i l
Ail BETTER
COMPENSATION SCHEDULE
CHEMICAL DEPENDENCY/RESIDENTIAL TREATMENT/BEHAVIORAL HEALTH
(Certified residential treatment providers, Licensed Community Mental Health Agencies, Certified Chemical Dependency
Agencies, Certified medication assisted treatment (e.g., buprenorphine), Certified opiate substitution providers (Methadone
Treatment programs), DOH -licensed and DBIIR-certified free-standing inpatient, hospitals or psychiatric inpatient facilities,
D011 -licensed and DBUIR certified detox facilities (for acute and sub-acutc), DOff licensed and DWIR certified residential
treatment facility to provide crisis stabilization services)
COUNTY OF GRANT DBA GRANT INTEGRATED SERVICES
This Compensation Schedule sets forth the maximum reimbursement amounts for the provision of Covered
Services to Covered Persons in a Commercial -Exchange Product offered through Health Plan and referred to as
Ambetter. For Covered Services rendered to a Covered Person and billed under a Contracted Provider's tax
identification number ("TIN") that has been designated by the Payor as subject to this Compensation Schedule,
Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider
according to the terns of the Agreement and this Compensation Schedule. Payment under this Compensation
Schedule is subject to the requirements set forth in the Agreement.
For Covered Services provided to Covered Persons, Contracted Provider's maximum compensation shall be the
Allowed Amount. Except as otherwise provided in this Compensation Schedule under Table I, the Allowed
Amount is the lesser of. (i) the Contracted Provider's Allolvable Charges; or (ii) one hundred percent (100%) of the
Payor's Medicare Fee Schedule.
If there is no established payment amount on the Payor's Medicare Fee Schedule for a Covered Service provided to
a Covered Person, the maximum compensation shall be one hundred percent (1000/x) of the State Medicaid fee
schedule in effect on the date of the Covered Service.
Table I —
Service Category Identifier
Codes
Reimbursement Contracted Rate
Methodology
.Partial Hospital (Da "treatment) 0912, 0913
Per Diem $1 10.00
Intensive Outpatient Treatment 0905, 0906
Per Diem $90.00
WA PPA County of Grant dba Grant Integrated 111102/2017 — 342323 — NP Page t of 2
Additional Provisions:
Code Change Updates, Payor utilizes nationally recognized coding structures (including, without
limitation, revenue codes, CP`1' codes, FICPCS codes, ICL? codes, national drug codes, ASA relative values,
etc., or their successors) for basic coding and descriptions of the services rendered. Updates to billing -
related codes shall become effective on the date ("Code Change Effective Date") that is the later of. (i) the
first day of the montli .following sixty (60) days after publication by the governmental agency having
authority over the applicable product of such governmental agency's acceptance of such code updates, (ii)
the effective date of such code updates as determined by such governmental agency or (iii) if a date is not
established by such governmental agency or the product is not regulated by such governmental agency, the
date that changes are made to nationally recognized codes. Such updates may include changes to service
g7roupings. Claims processed prior to the Code Change Effective Date shall not be reprocessed to reflect
any such code updates.
2. Fee Change Updates. Updates to the fee schedule shall become effective on the effective date of such fee
schedule updates, as determined by the Payor ("Fee Change Effective Date"). However, the date of
implementation of any fee schedule updates, i.e.. the date beginning on which such fee change is used for
reimbursement ("Fee Change Implementation Date") shall be the later of: (i) the date on which Payor is
reasonably able to implement the update in the claims payment system; or (ii) the fee Change Effective
Date. Claims processed prior to the Fee Change Implementation Date shall not be reprocessed to reflect any
updates to such fee schedule; even if service was provided after the Code Change Effective Date.
Defliddons
Allowed Amount means the amount designated as the maximum amount payable to a Contracted Provider
for any particular Covered Service provided to any particular Covered Person, pursuant to this Agreement
or its Attachments for Covered Services.
2. Allowable Charges means a_Contracted Provider's billed charges for services that qualify as Covered
Services.
3. Per Diem means a pricing method (i) that, for an inpatient stay, is based on each `Inpatient Day of an
inpatient stay and includes all Covered Services provided to a Covered Person during the inpatient stay, and
(ii) that, for outpatient services, includes all Covered Services provided to a Covered Person for one
calendar day of service. For purposes hereof, an "Inpatient Day" means a calendar day when a Covered
Person receives Covered Services as a registered bed patient; to qualify as an Inpatient Day, the Covered
Person. must be present at the midnight census.
WA PPA County of Grant dba Grant bite -gated 1110212017 —`342323 NP Page 1 of 2