HomeMy WebLinkAbout040912_ca04
"'~q, Consent Agenda
~~'. )~I JEFFERSON COUNTY PUBLIC HEALTH
'~$~..o~' 615 Sheridan Street . Port Townsend' Washington' 98368
,,/ www.Jeffel8OncountypubDchealth.org
March 26, 2012
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Philip Morley, County Administrator
FROM: Jean Baldwin, Director
DATE: A p r; I 9, J..6 I ~
SUBJEcr: Agenda Item - Group Provider Agreement for WA Medicaid
beneficiaries with Coordinated Care Corporation; upon signature - auto
renewal; fee for service
~~TEMENT OF ISSUE:
Jefferson County Public Health requests Board approval of the Group Provider Agreement for WA Medicaid
clients with Coordinated Care Corporation; upon signature - auto renewal; fee for servlce
ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S:
The Washington State Health Care Authority announced It has assigned WA counties five health plans,
awarded contracts, to provide managed care to Medicaid clients and Basic Health members. Coordinated
Care Is one of the five successful bidders to administer Managed Care, delivering healthcare servlces to
Basic Health members and Washington Medicaid benefldaries state-wide.
This agreement will allow JCPH to bIll and collect for clInic servlces provided to WA Medicaid eligible clients
who have chosen Coordinated Care Corporation as their Managed Care Organization. At present, there are
several clients elIgible to receive servlces such as family planning, Immunizations, etc.
By becoming a Preferred Provider we Impart a savings to our client In out-of-pocket deductlbles and
charges. This plan Is a beneflt to the patient, as they will choose their prOvider accordingly.
This contract will allow underlnsured dtlzens to receive much needed servlces.
FISCAL I~PAcrlCOST BENEFIT ANALYSIS:
This Is a 'fee for servlce contract.
COMMUNITY HEALTH
DEVELOPMENTAL D1SABIUTlES
MAIN: (360) 385-9400
FAX: (360) 385-9401
PUBLIC HEALTH
AlWAYS WORllIN& FOR A SAFER ABD
HEALTHIER COMMURIn
ENVIRONMENTAL HEALTH
WATER QUALITY
MAIN: (360) 385-9444
FAX: (360) 3794487
Consent Agenda
RECOMMENDATION:
JCPH management request approval of the Group Provider Agreement for WA Medicaid clients with
Coordinated Care Corporation; upon signature - auto renewal; fee for service
Y';)//-L
Date
(Routed to all Public Health Managers)
.
.
GROUP PROVIDER AGREEMENT
This GROUP PROVIDER AGREEMENT ("Agreement") is made and entered into as of
the effective date set forth on the signature page below ("Effective Date''), by and between
Jefferson County ("Group'') and Coordinated Care Corporation ("Managed
Care Organization." or "MCO").
WHEREAS, Group is comprised of one or more duly licensed physicians and, if
applicable, other health care profussiona1s;
WHEREAS, MCO is a duly licensed health maintenance organization; and
WHEREAS, MCO Wishes to contract with Group to provide or arrange for the provision
of certain Covered Services to Covered Persons; and
WHEREAS, Group desires to provide or arrange through Group Providers for the
provision of: Covered Services to Covered Persons under the terms and conditions set forth m
this Agreement; and
NOW, THEREFORE, in consideration of the mutual promises herein stated, the parties
hereby agree as follows:
ARTICLE I
DEFINITIONS
As used in this Agreement and each of its Attachments, each of the following terms (and
the plurals thereof: when appropriate) shall have the meaning set forth herein.
1.1. Affiliate(s) means a person or entity controlling, controlled by, or under common control
with MCO.
1.2. Attachment(s) means the attachments to this Agreement, including addenda and exlnbits,
all of which are hereby incorporated herein by reference, as set forth in Section 11.15 to
this Agreement.
1.3. Clean Claim means a claim that has no defect or impropriety, including any lack of any
required substantiating documentation. or particular circumstances requiring special
treatment that prevents timely payments from being made on the claim.
1.4. Covered Person means a person eligIble to receive Covered Services and emolled in a
health benefit plan that is issued or ailmini.tered by Mea, an Affiliate or Payor.
1.5. Covered Services means those Medically Necessary services covered under the terms of
the applicable Payor Contract.
W A Group base 2.22.12
Page 1 of35
1.6. Emergency Care or Emergency Services shall have the meaning set forth at 42 U.S.C.
1396u-2(b)(2)(B), as amended: inpatient and outpatient Covered Services furnished by a
qualified provider that are needed to evaluate or stabilize an Emergency Medical
Condition.
1.7. Emergency Medical Condition shall have the meaning set forth at 42 U.S.C. 1396-
u2(b)(2)(C), as amended: a medical condition manifeating itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in 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; (it) serious itnpairment to bodily functions; or (ill) serious
dysfunction of any bodily organ or part.
1.8. Group Provider means any physician, individual practitioner or other health care
professional who: (i) is employed, under written contract with or otherwise represented by
Group; (ii) both Group and MCO have agreed may provide Covered Services pursuant to
this Agreement; (ill) satisfies MCO credentialing criteria; and (iv) has indicated agreement
to comply with all provisions of this Agreement that are applicable to Group Provider by
executing a Participating Provider Attestation attached hereto as Exhibit 3.
1.9. HIPAA means the Health Insurance Portability and Accountability Act of 1996 and its
itnplementing regulations (45 C.F.R. Parts 160 and 164), any applicable state privacy
laws, any applicable state infurmation security laws, and itnplementing regulations and the
requirements of the Health Infurmation Technology for Economic and Clinical Health
Act, as incorporated in the American Recovery and Reinvestment Act of 2009, and its
itnplementing regulations adopted or to be adopted.
1.10. Medical Director means a physician or hislher physician designee duly licensed under
RCW Chapter 18.57 or 18.71 designated by Mca to monitor and evaluate the appropriate
utilization of Covered Services by Covered Persons.
1.11. Medically Necessary shall have the meaning defined in the applicable Payor Contract.
1.12. Participating Health Care Provider means any physician, hospital, ancillary, or other
health care provider that has contracted directly or indirectly with Mca to provide
Covered Services to Covered Persons and is credentialed in accordance with the MCO's
credentialing criteria. Participating Health Care Provider shall include all Group
Providers.
1.13. Payor means MCO or another entity that is responsible for funding Covered Services to
Covered Persons.
1.14. Payor Contract means Mca's contract with any Payor that governs provision of Covered
Services to Covered Persons. Where MCa is the Payor, "Payor Contract" means MCO's
contract with the State or federal agency or other entity that has contracted with MCa to
W A Group base 2.22.12
Page 2 of35
arrange fur the provision of Covered Services to eligxble individuals of such agency or
other entity.
1.15. State means the State of Washington.
ARTICLE II
MCO'S OBLIGATIONS
2.1. Admini~tration. MCa shall be responsible for the administrative activities necessary or
required for the commercially reasonable operation of a mAnReed care organization. Such
activities shall include, but are not limited to, quaIity improvement, utilization
mRnReernent, grievances and appeals for Covered Persons, claims processing, and
maintenance and publication of provider directory.
2.2. Policies and Procedures. MCa shall notify Group of its responsibilities with respect to
Payor's applicable admini~tive policies and procedures, including but not limited to
claims submission requirements, utilization review, quality assessment and improvement
programs, credentiaIing, grievance procedures, data reporting requirements, and
confidentiality requirements. Any and all such policies and procedures shall be avai1able
fur review by Group prior to contracting. Group shall be given reasonable notice of not
less than sixty (60) days of changes that affect Group's compensation and that affect
health care service delivery, unless changes to federal or state law or regulations make
such advance notice impossible, in which case notice shall be provided as soon as
possible.
2.3. Identification Cards. Mca or Payor shall issue to Covered Persons an identification card
that shall bear the name of the Covered Person, and a unique identification number.
2.4. Benefits and Eligxbility Verification. MCa or Payor, as determined by the Payor
Contract, shall be responsible fur all eligxbility and benefit determinations regarding
Covered Services and all communications to Covered Persons regarding final benefit
determinations, eligxbility, bills, and other matters relating to their status as Covered
Persons. MCO or Payor shall provide a method by which Group and Group Provider may
obtain timely information on Covered Person eligxbility for Covered Services, including
any limitations or conditions relating thereto, which method shall include, at minimnm,
one of the fullowing: (i) an electronic search on a secure provider portal; (it) a telephone
call to an automated member eligxbility interactive voice response (IVR) system; or (ill) a
telephone conversation with a provider services representative made avai1able through a
toll-free number. '
2.5. MCO's Medical Director. MCa shall provide a Medical Director to monitor and evaluate
the appropriate utilization of Covered Services by Covered Persons.
W A Group base 2.22.12
Page 3 of35
ARTICLE m
GROUP'S AND GROUP PROVIDER'S OBLIGATIONS
3.1. Relationship with Group Providers/Group Authority. Group represents and warrants that
it bas all legal authority to contract on behalf of and to bind all individual Group Providers
to the terms of this Agreement with MCa. Group shall maintain written agreements with
each of its Group Providers requiring the Group Providers to comply with all of the terms
and conditions of this Agree:ment applicable to Group Providers, which shall include the
following terms: Section 3.3 through 3.17 Article IV; Article V; Article VI; Article V11;
Article V1I1; Section 9.1; and Sections 10.4 through 10.7. The form of Group's standard
agreement with Group Providers and any material amendments thereto must comply with
applicable law and Mca requirements. Group represents and warrants that each Group
Provider shall execute a Participating Provider Attestation, in the form attached hereto as
Exhibit 3. Upon request, Group shall make available to Mca and to any applicable
regulatory authority a copy of each of its provider agreements with Group Providers.
3.2. Group Provider Panel Maintenance. Group and Mca agree that prior to any Group
Provider's provision of Covered Services under this Agreement, Group shall furnish to
Mca a list of Group Providers, which list shall include, at minimum, each Group
Provider's name, State license number, specialty, board status, National Provider
Identifier, and hospital affiliation. Group shall thereafter maintain and furnish updated
versions of the list to MCa on a regular basis to be agreed upon by the parties. Group and
MCa shall also mutually agree upon (i) any additional Group Provider information to be
included on the list, and (ii) the format of the list.
,
3.3. Covered Services. Group shall arrange for the Group Providers to provide to Covered
Persons those Covered Services in accordance with Payor requirements, the generally
accepted standards of medical practice and care in the Group Provider's community, the
scope of Group Provider's license, and the terms and conditions of this Agreement.
Group or Group Provider shall make necessary and appropriate arrangements to assure the
availability of Covered Services to Covered Persons on a twenty-four (24) hour per day,
seven (7) day per week basis, including arrangements to assure coverage of Covered
Persons after-hours or when Group Provider is otherwise absent. Group and Group
Provider further agree that such arrangements will be with a health care professional that
is a Participating Health Care Provider.
3.4. Group Provider Onalifications. Group Provider shall, at all times during the term of this
Agreement, (i) be licensed in good standing to practice medicine in the State; (il) mllint"in
medical staff membership and admitting privileges with at least one hospital that is a
Participating Health Care Provider (''Participating Hospital"); and (ill) be certified to
participate in the Medicare and Medicaid programs. Group and/or Group Provider shall
furnish evidence of the foregoing to MCa at any time upon request. If Group Provider
does not have admitting privileges at a Participating Hospital, Group or Group Provider
shall provide Mca with a written statement from another Participating Health Care
Provider who does have admitting privileges in good standing at a Participating Hospital
certifYing that such individual agrees to assume responsibility for providing inpatient
W A Group base 2.22.12
Page 4 of35
Covered Services to Covered Persons who are patients of the applicable Group Provider.
3.5. CO!I\Pliance with MCa Policies and Procedures. Group and Group Provider shall at all
times cooperate and comply with the policies and procedures of Mca and Payor,
including, but not limited to, the following:
A. credentialing criteria;
B. arlminirmative policies and procedures;
C. medical management program including quality improvement, utilization
mRnRgement, disease mRnRgement, and case mRnRgement;
D. Covered Person grievance and appeal procedures; and
E. coordination of benefits and third party liability recovery policies and procedures.
3.6. Determination of Covered Person Eligtbility. Group Provider shall verify, in accordance
with the Payor requirements, whether an individual seeking Covered Services is a
Covered Person. If Mca determines that such individual was not eligtble for Covered
Services at the time the services were rendered, such services shall not be eligtble for
payment under this Agreement.
3.7. Em~ency Care. Group and Group Provider shall provide Emergency Care to Covered
Persons in accordance with applicable federal and State laws. Group or Group Provider
shall notify MCa within twenty-four (24) hours or by the next business day of rendering
or learning of the rendering of Emergency Care to a Covered Person.
3.8. Acceptance of New Patients. To the extent that Group or Group Provider is accepting
new patients, Group or Group Provider must also accept new patients who are Covered
Persons of MCa. Group or Group Provider shall provide MCO forty-five (45) days
written notice prior to Group or Group Provider's decision to no longer accept Covered
Persons of MCa or any other Payor. In no event shall any established patient of any
Group Provider who becomes a Covered Person be considered a new patient.
3.9. Referrals: RtlpDrtinl'to Primary Care Physicians. Any Group Provider who is a specialty
physician ("Group Specialty Provider") shall provide Covered Services to Covered
Persons upon referral from a MCa primary care physician ("PCP") or MCa, and shall
arrange for any appropriate referrals and/or admissions of Covered Persons, in accordance
with Payor requirements. Group Specialty Provider shall, within a reasonable time
following consultation with, or testing of; a Covered Person (not to exceed one (1) week),
make a complete written report to the Covered Person's PCP, provided that, with respect
to findings which may indicate a need for immediate or urgent follow-up treatment or
testing or which may indicate a need for further or follow-up care outside the scope of the
referral authorization or outside the scope of Group Specialty Provider's area of expertise,
the Group Specialty Provider shall provide an immediate oral report to the Covered
W A Group base 2.22.12
Page 5 of35
Person's PCP, not to exceed twenty-four (24) hours from the time of Group Specialty
Provider's consultation or Group Specialty Provider's receipt of the report of the testing,
as applicable.
3.10. Preferred Drug ListlDrug Formulary. If applicable to the Covered Person's coverage,
Group Provider shall abide by Payor's formulary or preferred drug list when prescnbing
medications for Covered Persons.
3.11. Treatment Decisions. MCO will not exercise control over the manner or method by which
Group Provider provides or arranges for Covered Services. Group and Group Provider
understand that MCO's determinations, if any, to deny payments for services which MCO
does not deem to constitute Covered Services or which were not provided in accordance
with the requirements of this Agreement, the Attachments or the Payor requirements, are
admini!ltrative decisions only. Such a denial does not absolve Group Provider of Group
Provider's responsibility to exercise independent judgment in Covered Person treatment
decisions. Nothing in this Agreement is intended to interfere with Group Provider's
provider-patient relationship with Covered Person(s).
3.12. Covered Person Comnnmication. Group or Group Provider shall obtain Payor and
MCO's approval for Covered Person communication as required by the Payor Contract
and applicable State and federal law. Nothing in this Agreement shall be construed as
limiting Group Provider's ability to communicate with Covered Persons with regard to
quality ofhea1th care or medical treatment decisions or alternatives regardless of Covered
Service limitations under the Payor Contract.
3.13. Cooperation with MCO Vendors. Group and Group Provider acknowledge that MCO
directly and indirectly contracts with other participating providers for services that are
rendered under this Agreement for the benefit or at the request of Payor, as Payor deems
necessary to promote the quality and cost-effectiveness of services provided to Covered
Persons. During the term of this Agreement, ifMCO elects to provide Covered Services
via a third party vendor's network (for example, a behavioral health, dental or vision
vendor's network), Group shall be notified in writing ofMCO's decision sixty (60) days
prior to implementation. Within fifteen (15) days following receipt of written notification
from MCO of its election to use such vendor, Group and MCO agree to discuss Group's
and Group Providers' continued participation to provide the services offered by the
vendor's network. MCO will afford Group with the opportunity to (i) match the
reimbursement amounts offered to MCO by the vendor; or (h) participate in the vendor's
network assuming the Group Providers satisfy the vendor's participation criteria. In the
event Group elects not to match the reimbursement offered by the vendor or participates
in the vendor's network, MCO may elect to (i) continue Group and Group Provider's
participation under the terms and conditions set forth herein; or (h) contract with the
vendor. Nothing contained herein shallli1nit MCO's ability to contract with a third party
for the provision of utilization review or quality mAnAgement services.
3.14. Disparagement Prohibition. Group and Group Provider agree not to disparage MCO in
any manner during the term of this Agreement or in connection with any expiration,
W A Group base 2.22.12
Page 6 of35
.
termination or non-renewal of this Agreement. Group and Group Provider shall not
interfere with MCa's contractual relationships including, but not limited to, those with
other Participating Health Care Providers. Nothing in this provision, however, shall be
construed as limiting Group and Group Provider's ability to infurm patients that this
Agreement has been terminated or otherwise expired or to promote Group and Group
Provider to the general public or to post infurmation regarding other health plans
consistent with Group and Group Provider's usual procedures, provided that no such
promotion or advertisement is directed at any specific Covered Person or group of
Covered Persons.
3.15. Nondiscrimination. Group and Group Provider will provide services to Covered Persons
without discrimination on account of race, sex, sexual orientation, age, color, religion,
national origin, place of residence, health status, type of Payor source of payment,
physical or mental disability or veteran status, and without regard to such Covered
Persons' enrollment with Mca as a private purchaser of coverage or as a participant in
publicly financed programs of health care services, and will ensure that its fucilities are
accessible as required by Title III of the Americans With Disabilities Act of 1990. Group
and Group Provider recognize that as a governmental contractor, MCa is subject to
various federal laws, executive orders and regulations regarding equal opportunity and
affirmative action, which also may be applicable to subcontractors.
3.16. Written Notice. Group or Group Provider shall give written notice to MCa of. (i) any
action involving Group Provider's hospital privileges or conditions relating to Group
Provider's ability to admit patients to any hospital or inpatient fuci1ity; (ii) any situation
which develops regarding Group Provider, when notice of that situation has been given to
the State agency that licenses Group Provider, or any other licensing agency or board, or
any situation involving an investigation or complaint filed by the State agency that
licenses Group Provider, or any other licensing agency or board, regarding a complaint
against Group Provider's license; (iii) when a change in Group Provider's license to
practice medicine is affected or any furm of reportable discipline is taken against such
license; (iv) suspension or exclusion under a federal health care program, including, but
not limited to, Medicaid; (v) any government agency request for access to records; or (vi)
any lawsuit or claim filed or asserted against Group Provider alleging professional
malpractice, regardless of whether the lawsuit or claim involves a Covered Person. In any
such instance described above, Group or Group Provider must notify MCa in writing
within ten (10) days from the date Group or Group Provider first receives notice, whether
written or oral, with the exception of those lawsuits or claims which do not involve a
Covered Person, with respect to which Group or Group Provider has thirty (30) days to
notify MCa.
3.17. Use of Name. Group and Group Provider agree that MCO may use Group Provider's
name, address, phone number, type of practice, and an indication of Group Provider's
willingness to accept additional Covered Persons, in MCa's roster of Participating Health
Care Providers and marketing materials.
W A Group base 2.22.12
Page 7of35
3.18. Medical affice Soace. Group agrees that the medical office space at which Covered
Services are provided hereunder shall be maintained in accordance with applicable federal
and State laws.
ARTICLE IV
COMPLIANCE WITH LAW
Group, each Group Provider and MCa agree that each party shall carry out its obligations in
accordance with terms of the Payor Contract, including but not limited to the provisions set furth
on the Payor Contract Attachment attached hereto as ExhIbit 1. and applicable federal and State
laws and regulations, including but not limited to HIPAA. It; due to Group or Group Provider's
noncompliance with law, the Payor Contract or this Agreement, sanctions or penalties are
imposed on MCa, MCa may, in its sole discretion, offset sanction or penalty amounts against
any amounts due Group or Group Provider from MCa or require Group or Group Provider to
reimburse Mca for the amount of any such sanction or penalty. If Group subcontracts with such
other providers and facilities fur services provided hereunder, Group shall ensure that such
providers and facilities also comply with the requirements set furth in this Agreement and
applicable federal and State laws and regulations.
ARTICLE V
CLAIMS SUBMISSION. PROCESSING. AND COMPENSATION
5.1. . Claims or Encounter Submission. Mca shall not be required to pay Group's or Group
Provider's claims, and Mca shall not require Payor to pay Group's or Group Provider's
claims, unless Group or Group Provider, as applicable, submits such claims in accordance
with Payor requirements. If applicable, based on Group and Group Provider's
compensation arrangement, Group or Group Provider shall submit encounter data to Payor
in a timely fashion, in accordance with Payor requirements.
5.2. COl11{lensation. MCa shall pay, and shall require Payor to pay, Clean Claims submitted
by Group or Group Provider fur Covered Services provided to Covered Persons in
accordance with the applicable Compensation ExhIbit attached hereto as Exhibit 2. less
any applicable copayments, cost-sharing or other amounts that are the Covered Person's
financial responsibility. Group and Group Provider agree to accept such payments as
payment in full fur such Covered Services.
5.3. Financial Incentives. Nothing in this Agreement shall, or shall be construed to, create any
financial incentive for Group or Group Provider to withhold Medically Necessary
services.
5.4. Covered Person Hold Harmless.
A. Group and Group Provider hereby agree that in no event, including, but not
limited to nonpayment by Payor, Payor's insolvency, or breach of this Agreement
shall Group or Group Provider bill, charge, collect a deposit from, seek
W A Group base 2.22.12
Page 8 of35
.
compensation, remuneration, or reimbursement from, or have any recourse
against a Covered Person or person acting on their behalf; other than Payor, for
services provided pursuant to this Agreement. This provision shall not prolnbit
collection of any applicable copayments or other amounts, which have not
otherwise been paid by a primary or secondary carrier in accordance with
regulatory standards for coordination of benefits, from Covered Persons in
accordance with the terms of the Covered Person's health pIan.
B. Group and Group Provider agree, in the event of Payor's insolvency, to continue
to provide the services promised in this Agreement to Covered Persons of MCO
for the duration of the period for which premiums on behalf of the Covered
Person were paid to Payor or until the Covered Person's discharge from inpatient
facilities, whichever time is greater.
C. 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 benefits for services.
D. Neither Group nor Group Provider may bill the Covered Person for Covered
Services (except for deduct1bles, copayments, or coinsurance) where Payor denies
payments because Group or Group Provider, as applicable, has failed to comply
with the terms or conditions of this Agreement.
E. Group and Group Provider further agree (i) that the provisions of (A), (B), (C),
and (D) of this subsectioI\ 5.4 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 this provision supersedes any oral or
written contrary agreement now existing or hereafter entered into between Group
or Group Provider, and Covered Persons or persons acting on their behalt:
F. If Group and Group Provider contract with other providers or facilities who agree
to provide Covered Services to Covered Persons ofMCO with the expectation of
receiving payment directly or indirectly from Payor, such providers or facilities
must agree to abide by the provisions of (A), (B), (C), (D), and (E) of this
subsection 5.4.
Group and Group Providers acknowledge that willfully collecting or attempting to collect
an amount from a Covered Person knowing that collection to be in violation of this
Agreement constitutes a class C felony under RCW 48.80.030(5).
5.5. Overpayment Recovery by Payor. To the extent applicable by law, the parties shall
comply with the following provisions ofRCW 48.43.600, as amended. MCO, Group and
Group Provider acknowledge and agree that any requirement of "Payor" hereunder shall
apply to MCO directly if MCO is the Payor under this Agreement, and shall be made
applicable to Payor by MCO ifMCO is not the Payor under this Agreement.
WA Group base 2.22.12
Page 9 of35
.
A. Except in the case of fraud, or as provided in subsections (B) and (C) of this
section, Payor may not: (i) request a refund from Group or Group Provider of a
payment previously made to satisfy a claim unless it does so in writing within
twenty-four months after the date that the payment was made; or (it) request that a
contested refund be paid any sooner than six (6) months after receipt of the
request. Any such request must specify why Payor believes Group or Group
Provider owes the refund. If Group or Group Provider fails to contest the request
in writing to Payor within thirty (30) days of its receipt, the request is deemed
accepted and the refund must be paid.
B. Payor may not, if doing so for reasons related to coordination of benefits with
another carrier or entity responsible for payment of a claim: (i) request a refund
from Group or Group Provider of a payment previously made to satisfy a claim
unless it does so in writing within thirty (30) months after the date that the
payment was made; or (ii) request that a contested refund be paid any sooner than
six (6) months after receipt of the request. Any such request must specify why
Payor believes that Group or Group Provider owes the refund, and include the
name and mailing address of the entity that has pritnary responsibility for
payment of the claim. If Group or Group Provider fails to contest the request in
writing to Payor within thirty (30) days of its receipt, the request is deemed
accepted and the refund must be paid.
C. A carrier may at any time request a refund from Group or Group Provider of a
payment previously made to satisfy a claitn if (i) a third party, including a
government entity, is found responsible for satisfaction of the claim as a
consequence of liability imposed by law, such as tort liability; and (it) Payor is
unable to recover directly from the third party because the third party has either
already paid or will pay the provider for the health services covered by the claim.
D. Nothing in this section prohibits Group or Group Provider from choosing at any
titne to refund to Payor any payment previously made to satisfy a claim.
E. For purposes of this section, "refund" means the retorn, either directly or through
an offset to a future claitn, of some or all of a payment already received by Group
or Group Provider.
F. This section neither permits nor precludes Payor from recovering from a
subscriber, enrollee, or beneficiary any amounts paid to Group or Group Provider
for benefits to which the subscriber, enrollee, or beneficiary was not entitled
under the terms and conditions of the health pIan, insurance policy, or other
benefit agreement.
G. This section does not apply to claims for Covered Services provided through
dental-only health carriers, health care services provided under Title XVIII
(Medicare) of the Social Security Act, or Medicare supplemental plans regulated
under Chapter 48.66 RCW.
5.6 Ovel:payment Recovery by Group or Group Provider. To the extent applicable by law,
MCO, Group and Group Provider shall comply with the following provisions of RCW
W A Group base 2.22.12
Page 10 of35
.
48.43.605, as amended. MCa, Group and Group Provider acknowledge and agree that
any requirement of "Payor" hereunder shall apply to MCa directly ifMca is the Payor
under this Agreement, and shall be made applicable to Payor by MCa if Mca is not the
Payor under this Agreement.
A Except in the case offraud, or as provided in subsection (B) of this section, Group
or Group Provider may not: (i) request additional payment from Payor to satisfy a
claim unless Group or Group Provider does so in writing to Payor within twenty-
four (24) months after the date that the claim was denied or payment intended to
satisfy the claim was made; or (ii request that the additional payment be made any
sooner than six (6) months after receipt of the request. Any such request must
specify why Group or Group Provider believes Payor owes the additional
payment.
B. Group or Group Provider may not, if doing so for reasons related to coordination
of benefits with another carrier or entity responsible for payment of a claim: (i)
request additional payment from Payor to satisfy a claim unless Group or Group
Provider does so in writing to Payor within thirty (30) months after the date the
claim was denied or payment intended to satisfy the claim was made; or (it)
request that the additional payment be made any sooner than six (6) months after
receipt of the request. Any such request must specify why Group or Group
Provider believes Payor owes the additional payment, and include the name and
mailing address of any entity that has disclaimed responsibility for payment of the
claim.
C. Nothing in this section prolnbits Payor from choosing at any time to make
additional payments to Group or Group Provider to satisfy a claim.
D. This section does not apply to claims for health care services provided through
dental-only health carriers, health care services provided under Title XVIII
(Medicare) of the Social Security Act, or Medicare supplemental plans regulated
under Chapter 48.66 RCW.
5.7 COIIlPliance with Billing and Claims Payment Standards. To the extent applicable by
law, MCO, Group and Group Provider shall comply with the following provisions of
WAC 284-43-321, as amended. MCa, Group and Group Provider acknowledge and
agree that any requirement of "Payor" hereunder shall apply to MCa directly ifMCa is
the Payor under this Agreement, and shall be made applicable to Payor by Mca ifMCO
is not the Payor under this Agreement.
A. For Covered Services provided to Covered Persons, Payor shall pay Group or
Group Provider as soon as practical, but subject to the following minimum
standards:
(i) Ninety-five percent of the monthly volnme of Clean Claims shall be paid
within thirty (30) days of receipt by the responsible carrier or agent of
Payor; and
W A Group base 2.22.12
Page 11 of35
,
(it) Ninety-five percent of the monthly volume ofall claims shall be paid or
denied within sixty days of receipt by the responsible carrier or agent of
Payor, except as agreed to in writing by the parties on a claim-by-claitn
basis.
For the purposes of this section, the receipt date of a claitn shall be the date that
the responsible carrier or its agent receives either written or electronic notice of
the claim.
Payor shall establish a reasonable method for confirming receipt of claims and
responding to Group's or Group Provider's inquiries about claims.
B. In the event Payor fails to pay claims within the standard established under
Section 5.7(A) of this Agreement, Payor shall pay interest on undenied and
unpaid Clean Claims that are more than sixty-one (61) days old, until Payor meets
standard under Section 5.7(A). Interest shall be assessed at the rate of one percent
(1 %) per month, and shall be calculated monthly as sitnple interest, prorated for
any portion of a month. Payor shall add the interest payable to the amount of the
unpaid cJaitn without the necessity of Group or Group Provider submitting an
additional claim. Any interest paid under this Section 5.7(B) shall not be applied
by Payor to a Covered Person's deductible, copayment, coinsurance, or any
sitnilar obligation of the Covered Person.
C. When Payor issues payment in Group's or Group Provider's and the Covered
Person's names, Payor shall make cJaitn checks payable in the name of the Group
or Group Provider, as applicable, first and the Covered Person second.
D. Denial of a cJaitn must be communicated to Group or Group Provider and must
include the specific reason why the claitn was denied. If the denial is based upon
medical necessity or sitniIar grounds, then Payor, upon request of Group or Group
Provider, must also promptly disclose the supporting basis for the decision. For
example, Payor must describe how the cJaitn failed to meet medical necessity
guidelines.
E. Payor shall be responsible for ensuring that any person acting on behalf of or at
the direction of Payor or acting pursuant to Payor's standards or requirements
complies with the billing and claitn payment standards set forth in this Section
5.7.
F. The standards set forth in this Section 5.7 do not apply to claims about which
there is substantial evidence of fraud or misrepresentation by Participating Health
Care Providers or Covered Persons, or instances where Payor bas not been
granted reasonable access to information under Group's or Group Provider 's
controL
ARTICLE VI
RECORDSIINSPECTIONS
6.1. Advance Directives. Group and Group Provider shall document in the Covered Person's
medical record whether the Covered Person bas executed an advance directive, and Group
WA Group base 2.22.12
Page 12 of3S
and Group Provider agree to comply with all federal and State laws regarding advance
directives.
6.2. Records. Group and Group Provider shall maintain records related to services provided to
Covered Persons, including but not limited to a complete and accurate permanent medical
record fur each Covered Person to whom Group or Group Provider render services under
this Agreement, and shall include in that record all reports from other providers and all
documentation required by. applicable law, regulations, professional standards and Payor
requirements. Group shall further provide such medica~ financial and arlmini~trative
information to MCa and State and federal government agencies as may be necessary for
compliance by Mca with State and federal law and accreditation standards, as well as fur
the administration of this Agreement. MCa shall have access at reasonable times to
books, records, and papers of the Group and Group Provider relating to the health care
services provided to Covered Persons for Covered Services. Medical records provided to
MCa hereunder for audit purposes must be limited to only those necessary to perform the
audit. Group and Group Provider shall have access at reasonable times to books, records,
and papers of MCa relating to the health care services provided to Covered Persons for
Covered Services, including without limitation Mca's denials of Group's or Group
Provider's claims.
6.3. Consent to Release Medical Records. Group Provider shall obtain Covered Person
authorizations relative to the release of medical infurmation required by applicable law to
provide MCa or other anthorized parties with access to Covered Persons' records.
6.4. Access. Group and Group Provider shall provide access to Group and Group Provider's
records to the fullowing, including any designee or duly authorized agent:
A. Payors, during regular business hours and upon prior notice;
B. Appropriate state and federal authorities involved in assessing the quality of care or
investigating the grievances or complaints of Covered Persons; and
C. accreditation agencies.
Group and Group Provider shall provide copies of records to any of the above-listed
requestors at no expense to such requestor.
6.5. Record Transfer. Group and Group Provider shall cooperate in the prompt transfer of
Covered Persons' medical records to other health care providers. Neither Group nor
Group Provider shall charge for the cost of duplication in connection with such transfer.
W A Group base 2.22.12
Page 13 of35
.
6.6. On-Site lnl!pections. Group and Group Provider agree that medical office space or its
facilities, as applicable, shall be maintained in accordance with applicable federal and
State regulatory requirements. Group and Group Provider shall cooperate in on-site
inspections of medical office space by MCa, Payor, authorized government officials, and
accreditation bodies. Group and Group Provider shall compile any and all information in
a timely manner required to evidence Group and Group Provider's compliance with this
Agreement, as requested by such agency(ies), or as otherwise necessary for the
expeditious completion of such on-site inspection.
ARTICLE vn
INSURANCE
7.1. Grotq) and Group Provider Insurance. During the term of this Agreement, Group and
Group Provider shall maintain policies of general and professional liability insurance and
other insurance that are necessary to insure Group, Group Provider, and any other person
providing services hereunder on Group and Group Provider's behalf: against any claim(s)
of personal injuries or death alleged or caused by Group or Group Provider's perfurmance
under this Agreement. Such insurance shall include, but not be limited to, tail or prior acts
coverage necessary to avoid any gap in coverage. Insurance shall be through a licensed
carrier, and in a minimum amount of one million dollars ($1,000,000) per occurrence, and
have an annl!a! aggregate of no less than three million dollars ($3,000,000) unless a lesser
amount is accepted by MCa or where State law mannates otherwise. Group and Group
Provider will provide Mca with at least fifteen (15) days notice of such cancellation, non-
renewal, lapse, or adverse material modification of coverage. Upon MCa's request,
Group and Group Provider will furnish MCa with evidence of such insurance.
7.2. Other Insurance. MCO, Group and Group Provider shall maintain in full furce and effect
appropriate workers' compensation protection and unemployment insurance as required
by law.
ARTICLE VIII
INDEMNIFICATION
8.1. MCa Indemnification. Group and Group Provider agree to indemnify and hold harmless
(and at MCa's request defend) MCa, its Affiliates, officers, employees and agents from
and against any and all claims, loss, damages, liability, costs. expenses (including
reasonable attorney's fees), judgments, or obligations arising from or in connection with
third party claims alleging any negligence or otherwise wrongful act or omissions of
Group and Group Provider, its agents or employees in the performance of Group and
Group Provider's obligations under this Agreement.
W A Group base 2.22.12
Page 140f35
.
8.2. Group and Group Provider Indemnification. MCO agrees to indemnify and hold harmless
(and at Group or Group Provider's request defend) Group, Group Provider, its officers,
employees and agents from and against any and all claims, loss, damages, liability, costs,
expenses (including reasonable attorney's fees), judgments, or obligations arising from or
in connection with third party claims alleging any negligence or otherwise wrongful act or
omission of MCO, its agents or employees in the perfurmance of MCO's obligations
under this Agreement.
ARTICLE IX
DISPUTE RESOLUTION
9.1. Informal Dispute Resolution. In the event that Group or any Group Provider is aggrieved
by the actions ofMCO, Group or such Group Provider shall be heard after submitting a
written request for review. IfMCO fails to grant or reject such a request within thirty (30)
days after it is made, Group or Group Provider may proceed as if the complaint had been
rejected. A complaint that has been rejected by MCO may be submitted to nonbinding
mediation in accordance with the Mediation section of this Agreement by providing
written notice to MCO. In the event that MCO is aggrieved by the actions of Group or
any Group Provider, the parties shall attempt to resolve the dispute through good faith
negotiations between designated representatives of the MCO and Group that have
authority to settle the dispute. If the matter has not been resolved within sixty (60) days of
the request for negotiation, MCO may initiate non-binding mediation in accordance with
the Mediation section of this Agreement by providing written notice to Group.
Notwithstanding the above, MCO ~ render a decision on Group's or Group Provider's
complaints within a reasonable time for the type of dispute. In the case of billing disputes,
MCO must render a decision within sixty (60) days of a complaint.
9.2. Mediation. In the event the informal dispute resolution process set forth in Section 9.1
is exhausted without resolution, either party wishing to pursue the dispute shall submit it
to a non-binding mediation proceeding. which shall be attended by both parties and which,
unless both parties agree otherwise, shall be conducted by an independent mediator
mutually selected through the American Health Lawyers Association who is familiar with
manAged health care. The costs of the mediation shall be shared equally by all parties to
such mediation. Each party shall bear its own costs for participating in the mediation
proceeding. If as a result of the mediation, a voluntary settlement is reached, the parties
agree that such settlement shall be reduced to writing. Except as required by law or to
evidence compliance with the terms, any such settlement agreemeut shall remain
confidential and shall not be disclosed to any third party. In the event no settlement is
reached, the parties may pursue available remedies under applicable law.
9.3. Limitation Period. WIth respect to any dispute mediated hereunder, in no event may
either party file an action in a court of competent jurisdiction more than one (1) year
following the termination of a mediation proceeding held to mediate such dispute.
W A Group hase 2.22.12
Page IS of3S
ARTICLE X
TERM AND TERMINATION
10.1. Term. This Agreement shall have an initial term of three (3) years, commencing on the
Effective Date. Thereafter, this Agreement shall automatically renew for terms of one (1)
year each. Notwithstanding the foregoing, this Agreement may terminate in accordance
with the Termination sections below.
10.2. Termination of Agreement. This Agreement may be terminated under any of the
following circumstances:
A. By either party upon one hundred eighty (180) days prior written notice;
B. By either party upon ninety (90) days prior written notice if the other party is in
material breach of this Agreement, except that such termination shall not take place if
the breach is cured within sixty (60) days following the written notice;
C. Immediately upon written notice by Mca if there is inuninent harm to patient health
or fraud or malfeasance is suspected;
D. Immediately upon written notice by either party if the other party becomes insolvent
or has bankruptcy proceedings initiated against it;
E. Immediately upon written notice to the other party if MCa or Group, respectively,
loses, relinquishes, or has materially affected its certificate of authority to operate as a
managed care organization or the capacity to provide or arrange for the provision of
Covered Services in the State;
F. Immediately upon written notice by MCa if Group or any of its agents or managing
employees is convicted ofa criminal offense related to that person's involvement in
any program under Titles XVIII, XIX, xx, or XXI of the Social Security Act or has
been terminated. suspended, barred, voluntarily withdrawn as part of a settlement, or
otherwise excluded from any program under Titles XVIII, XIX, XX or XXI of the
Social Security Act;
G. Immediately upon written notice by Mca if Group or Group Provider fails to adhere
to Mca's credentialing criteria, including, but not limited to, if Group or Group
Provider (1) loses, relinquishes, or has materially affected its license to provide
Covered Services in the State, (2) fails to comply with the insurance requirements set
forth in this Agreement; or (3) is convicted of a criminal offense related to
involvement in any Medicare or Medicaid program or has been terminated,
suspended, barred, voluntarily withdrawn as part of a settlement agreement, or
otherwise excluded from any Medicare or Medicaid program; or
H. By MCa, in its sole' discretion, upon ninety (90) days prior written notice if a
substantial number of the Group Providers of any category (by practice area,
W A Group base 2.22.12
Page 16 ef3S
including any separate category of Group primary care physicians) participating as of
the Effective Date of this Agreement have their participation under this Agreement
terminated; or
I. If Group is in default of its payment obligations to any Group Providers with respect
to services rendered under this Agreement and fails to cure such defuult within ten
(10) days of notification by MCO, MCO may (i) elect to terminate this Agreement
pursuant to this Section 1O.2(B), and (it) during the time between MCO's election to
terminate and the effective date of termination, MCO may direct any and all
payments due Group hereunder directly to Group Providers. Such payments shall be
made, at MCO's election, either in accordance with the reimbursement arrangements
set furth in Group's provider agreements with Group Providers or in accordance with
MCO's fee schedule in effect at the time of service. MCO's or the applicable Payor's
payment obligations to Group hereunder shall be reduced to the extent of such
payments.
10.3. Group Provider ParticipationlNotice to MCO. Nothing herein shall in any way limit,
abrogate, or interfere with MCO's right to selectively exclude, reject, suspend, and/or
terminate any individual Group Provider from further participation under this Agreement
at MCO's sole discretion. Such termination of an individual Group Provider shall relate
solely to participation under this Agreement of the particular Group Provider and this
Agreement shall remain in full furce and effect with the respect to Group and the other
Group Providers.
Group shall provide MCO with ninety (90) days advance written notice of the termination
0:4 or amendment to, any agreement between Group and a Group Provider by which the
Group Provider would cease to provide Covered Services to Covered Persons under this
Agreement. Notwithstanding the furegoing, in the event that the Group Provider's
participation under this Agreement is terminated for cause and Group cannot provide
ninety (90) days advance notice of such termination, Group shall notliY MCO in writing
of such termination as soon as possible but no later than five (5) days after Group obtains
knowledge of such termination.
lOA. RiP'hts and Oblil!ations Upon Termination. Upon termination, the rights of each party
hereunder shall terminate, provided, however, that such action shall not release the Group
or Group Provider or MCO of their obligations with respect to: (a) payments accrued to
Group or Group Provider prior to termination; (b) Group and Group Provider's agreement
not to seek compensation from Covered Persons for Covered Services prior to
termination; and (c) completion of treatment of Covered Persons who are receiving care
until continuation of the Covered Person's care can be arranged by MCO as determined
by the Medical Director or as required by applicable law or the Payor Contract. Services
provided during continuation of care shall be reimbursed in accordance with the terms of
this Agreement. MCO shall make a good faith effort to assore that written notice of a
termination, within fifteen (15) business days of receipt or issuance of a notice of
termination hereunder, is provided to all Covered Persons who are patients seen on a
W A Group base 2.22.12
Page 17 of35
regular basis by Group or Group Provider, irrespective of whether the termination was for
cause or without cause.
10.5. Notification of Group Specialty Provider Termination. Group Specialty Provider
acknowledges the right of MCO to inform Covered Persons of Group Specialty Provider's
termination. In the event this Agreement is terminated. MCO shall provide written notice
within thirty (30) business days of receipt. or issuance of a notice of termination, to all
Covered Persons who are seen on a regular basis by Group Specialty Provider, regardless of
whether the termination was for cause or without cause.
10.6. Survival of Obligations. Any obligations that cannot be fully performed prior to the
termination of this Agreement including, but not limited to, obligations in the following
provisions set forth in this Section, shall survive the termination of this Agreement:
Section 3.14 (Disparagement Prohibition); Article IV (Compliance With Law); Section
504 (Covered Person Hold Harmless); Article VI (Records!Inspection); Article VII
(Insurance); Article VIII (Indemnification); Article IX (Dispute Resolution); Section lOA
(Rights and Obligations Upon Termination).
10.7 Primary Care Provider Rights. and Obligations Upon Termination Without Cause. If
Group or Group Provider is a primary care provider, in the event this Agreement is
terminAted without cause, MCO shall reimburse, pursuant to the terms of this Agreement
and relevant Attachments, Covered Services provided by Group or Group Provider for at
least sixty (60) days following notice of termination to the enrollees or, in group coverage
arrangements involving periods of open enrollment, only until the end of the next open
enrollment period. In such event, Group's or Group Provider's relationship with MCO
must be continued on the same terms and conditions as those of this Agreement, except
for any provision requiring that MCO assign new enrollees to Group or Group Provider.
The parties acknowledge and agree that the provision set forth in this paragraph shall
apply with respect to arrangements in which Group's or Group Provider's contract with a
subcontractor of MCO, pursuant to which Group or Group Provider agrees to provide
Covered Services to Covered Persons, is terminated without cause.
ARTICLE XI
MISCELLANEOUS
11.1. Relationship of Parties. The relationship among the parties is that of independent
contractors. None of the provisions of this Agreement are intended to create, or to be
construed as creating, any agency, partnership, joint venture, employee-employer, or other
relationship.
11.2. Conflicts Between Certain Documents. In the event of any conflicts between this
Agreement, or any Attachment hereto, and the applicable Payor Contract with respect to
what services constitute Covered Services, the Payor Contract shall control
W A Group base 2.22.12
Page 18 of35
11.3. AssiPmllent: Delegation of Duties. This Agreement is intended to secure the services of
and be personal to Group, and shall not be assigned, sublet, delegated or transferred by
Group without the prior written consent ofMCO.
11.4. He:'Itlinl!'s. The headings of the sections of this Agreement are inserted merely for the
PUIJlose of convenience and do not, expressly or by implication, limit, define, or extend
the specific terms of the section so designated
11.5. Governing Law. All matters affecting the interpretation of this Agreement and the rights
and obligations of the parties hereto shall be governed by and construed in accordance
with applicable federal and State laws.
11.6. Third party Beneficiary. Except as specifically provided herein, the terms and conditions
of this Agreement shall be for the sole and exclusive benefit of Group and MCO. Nothing
herein, express or implied, is intended to be construed or deemed to create any rights or
remedies in any third party.
11.7. Amendment. This Agreement, including all Attachments, may be amended at any time by
mutual written agreement oftbe parties. This Agreement and any of its Attachments may
also be amended by MCO furnishing Group with any proposed amendments. Unless
Group objects in writing to such amendment during the thirty (30) day notice, Group shall
be deemed to have accepted the amendment. Notwithstanding the foregoing, this
Agreement shall be automatically amended as necessary to comply with any applicable
State or federal law or regulation and applicable provision of the Payor Contract.
11.8. Entire Agreement. This Agreement and its Attachments contain all the terms and
conditions agreed upon by the parties and supersede all other agreements, oral or
otherwise, of the parties hereto, regarding the subject matter of this Agreement.
11.9. Severability. The invalidity or unenfurceability of any terms or provisions hereof shall in
no way affect the validity or enfurceability of any other terms or provisions.
11.10. Waiver. The waiver by either party of the violation of any provision or obligation of this
Agreement shall not constitute the waiver ofany subsequent violation of the same or other
provision or obligation.
11.11. Notices. Any notice required to be given pursuant to the terms and provisions hereof shall
be in writing and shall be sent by certified mail, return receipt requested, postage prepaid,
or by recognized courier service, addressed as follows:
To MCO at:
Coordinated Care Corporation
Attn: Susan Klamer
Director, Contracting and Network
Development
P.O. Box 2115
To Group at:
Jefferson County Public Health
Attn: r
Jean Baldwin
1
r
615 Sheridan St.
1
W A Group base 2.22.12
Page 19 of35
Seattle, W A 98401 r Port Townsend, WA 98368 1
or to such other address as either party may designate in writing.
11.12. Force Maieure. Neither party shall be liable or deemed to be in default for any delay or
failure to perform any act l.IDder this Agreement resulting, directly or indirectly, from acts
of God, civil or military authority, acts of public enemy, war, accidents, fires, explosions,
earthquake, flood, strikes or other work stoppages by either party's employees, or any
other similar cause beyond the reasonable control of such party.
11.13. ConfidentiaIitv. Neither party shall disclose the substance of this Agreement nor any
information acquired from the other party during the course of or pursuant to this
Agreement to any third party, unless required by law. Group and Group Provider
acknowledge and agree that all information relating to MCO's programs, policies,
protocols and procedures is proprietary information and further agree not to disclose such
information to any person or entity without MCO's express written consent.
11.14. Authority. The parties whose signatures are set forth below represent and warrant that
they are duly empowered to execute this Agreement.
11.15. Attachments. Each of the Attachments below is hereby made part of this Agreement:
Approved as ~ form only:
~ 312-9//')..
Exlnbit 1 - Payor Contract Attachment
Exlnbit 2 - Compensation Exlnbit
Exlnbit 3 - Provider Attestation
Jefferson Co. PrOseG11to s Oftieo
IN WITNESS WHEREOF, the parties hereto have executed this Agreement effective as of the
date set forth below.
MCO: Groun:
COORDINATED CARE CORPORATION
JEFFERSON COUNTY
Authorized Signature
Authorized Signature
Printed Name:
Printed Name:
Title:
Title:
Signature Date:
Signature Date:
Effective Date of Agreement:
Tax Identification Number: 91-6001322
WA Group base 2.22.12
Page 20 of35
(To be completed by MCa only)
To be completed by MCO only:
[Effective Date of Agreement:
W A Group base 2.22.12
National Provider Identifier: 1841225208
State Medicaid Number: 7900137
Page 21 of35
EXHIBIT 1
WASHINGTON BASIC HEALTH AND HEALTHY OPTIONS PROGRAMS
PAYOR CONTRACT ATTACHMENT
This Washington Basic Health and Healthy Options Payor Contract Attachment (the
"Attachment') is incoroorated into the Agreement (the "Agreement') entered into by
and between Jefferson County {''PruvideYj, an entity described more fully in the signature block,
and Coordinated Care Corporation ("Managed Care Organization" or "MCOj.
ARTICLE I
RECITALS
1.1 MCa has contracted with the Washington Health Care Authority to arrange for the
provision of medical services to Covered Persons under the Basic Health and Healthy
Options Programs.
1.2 Provider has entered into the Agreement with MCa. This Attachment is intended to
supp lement the Agreement by setting forth the parties' rights and respOIlSlbilities related
to the provision of Covered Services to Covered Persons as it pertains to the Basic Health
and Healthy Options Programs. In the event of a conflict between the terms and
conditions of the Agreement and the terms and conditions of this Attachment, this
Attachment shall govern.
1.3 Provider agrees and understands that Covered Services shall be provided in accordance
with the contract between HCA and MCa ("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 MCa.
ARTICLE n
DEFINITIONS
Capitalized terms used and not otherwise defined herein shall have the meanings given to them
in the Agreement. The definitions listed below will supersede any meanings contained elsewhere
in the Agreement with regard to this Attachment.
2.1 Certificate of Coverage means the Exhibit B-2 of the State Contract, published by the
HCA
2.2 Clean Claim means a claim that can be processed without obtaining additional
information :from the provider of the service or :from a third party.
2.3 Covered Person shall have the meaning set forth in the Agreement.
W A Group base 2.22.12
Page22of35
.
2.4 Emergency Medical Condition means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent layperson,
who possesses an average knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention to result in: (a) 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, (b) serious impairment to bodily functions, or (c) serious
dysfunction of any bodily organ or part.
2.5 Emergency Services means covered inpatient and outpatient services that are furnished
by a provider that is qualified to furnish these services under 42 C.F.R. ~~ 438.114(a).
2.6 HCA means the State of Washington Health Care Authority and its employees and
authorized agents.
2.7 Medically Necessary means health care services that: (1) 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 (2) 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.
2.8 Primary Care Provider or pcp means a Participating Health Care 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, fiunily
practitioners, general practitioners, internists, physician assistants (under the supervision
of a physician), or advanced registered nurse practitioners (nurse practitioners), as
designated by MCO.
2.9 State means the state of Washington.
ARTICLE m
PROVIDER CONTRACT REQUIREMENTS
3.1 Provider shall comply with all applicable federa~ State and local laws and regulations,
and all amendments thereto. Provider understands and agrees that this Attachment
and/or the Agreement shall be deemed antomatically amended as necessary to comply
with any applicable State or federal law or regulation, or any applicable provision of the
State Contract
3.2 Provider shall comply with all applicable State and federal laws and regulations regarding
the collection, use and disclosure of i) Personal Information, as defined in Governor
Locke's Executive Order 00-03, and ii) Protected Health Inforrnation ("PHI"), as defined
in 45 C..F.R. ~160.103. Personal Information or PHI collected, used, or acquired in
W A Group base 2.22.12
Page 23 of35
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 PID without the advance express
written consent of the individual who is the subject matter of the Personal Infurmation 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 PID.
Provider shall fully cooperate with HCA's efforts to implement all requirements under
HIPAA.
3.3 Provider represents and warrants that it is not presently debarred, suspended, proposed
fur debarment, declared ineligtble, or voluntarily excluded by any federal department or
agency from participating in transactions. Provider shall immediately notify MCO in
writing it; during the term of the Agreement, Provider becomes so debarred, suspended,
proposed fur debarment, declared ineligtble or voluntarily excluded.
3.4 Provider shall cooperate with audits performed by duly authorized representatives of the
State of Washington. the federal Department of Health and Human Services ("DHHS''),
auditors from the federal Government Accountability Office, federal Office of the
Inspector General and federal Office of Management and Budget. Upon thirty (30)
calendar days, Provider shall provide access to its facilities and the records pertinent to
the Agreement to monitor and evaluate Provider's compliance with the Agreement and
MCO's compliance with the State Contract, including, but not limited to, the quality,
cost, use, health and safety and timeliness of services, and assessment ofMCO's capacity
to bear the potential financial losses. Provider shall provide immediate access to facilities
and records pertinent to the Agreement fur Medicaid fraud investigators pursuant to 42
C.F.R. ~438.6(g).
3.5 Provider shall maintain financial, medical and other records pertinent to the Agreement.
All financial records shall follow generally accepted accounting principles. Medical
records and supporting tpAnAgement systems shall include all pertinent information
related to the medical mAnllgement of each Covered Person. Other records shall be
majntllined 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 fur a minimum of six (6) years after final payment is made under the
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 fullowing resolution of such action.
3.6 If Provider is a hospital, ambulatory care surgery center, or office-based surgery site,
Provider shall endorse and adopt procedures fur veri1}ring the correct patient, the correct
procedure and the correct surgical site that meet or exceed those set forth in the Universal
Protocol TM development by the Joint Commission.
3.7 Provider shall comply with applicable physical and behavioral health practice guidelines
adopted by MCO.
WA Group base 2.22.12
Page 24 of35
,
3.8 Provider shall offer access comparable to that offered to commercial enrollees or if
Provider serves only Medicaid enrollees, then comparable to that offered to Medicaid
fee-for-service enrollees.
3.9 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.
3.10 Provider shall meet the following appointment wait time standards with respect to
Covered Persons:
A Preventive care office visits shall be available from the Covered Person's PCP within
thirty (30) calendar days;
B. Routine care office visits shall be available from the Covered Person's PCP within
ten (10) calendar days;
C. Urgent Care office visits shall be available from the Covered Person's PCP within
forty eight (48) hours; and
D. Emergency medical care shall be available twenty-four (24) hours per day, seven (7)
days per week.
MCa shall monitor Provider's compliance with this Section. In the event Provider mils
to comply with the appointment wait time standards set forth in this Section, Provider
shall comply with Mca's procedures for corrective action.
3.11 Provider shall maintain a health information system that complies with the requirements
of 42 C.F.R. ~38.242 and provides the information necessary to meet MCa's
obligations under the Agreement. The health information system must:
A Collect, analyze, integrate, and report data. The system mnst provide information
on areas that include but are not limited to utilization, grievance and appeals, and
terminations of enrollment for other than loss of Medicaid eligtbility; and
B. Ensure data provided to MCa 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.
3.12 Provider acknowledges and agrees to release to MCa any information necessary to
perform any ofMCa's obligations under the State Contract.
W A Group base 2.22.12
Page 2S of35
.
3.13 Provider shall completely and accurately report encounter data to MCa. Provider in
addition represents and warrants that it has the capacity to submit all data required by
HCA to enable MCa to meet the reporting requirements in the Encounter Data
Transaction Guide published by HCA
3.14 Provider shall grant, upon request, access to its facilities and its financial and medical
records for duly authorized representatives ofHCA and/or DHHS for audit purposes, and
shall grant immediate access to the same for Medicaid fraud investigators.
3.15 Provider shall comply with the applicable state and federal rules and regulations as set
forth in the State Contract, including but not limited to the applicable requirements of 42
C.F.R. ~438.6(i).
3.16 Provider shall comply with any term or condition of the State Contract that is applicable
to the services to be perfurmed under the Agreement.
3.17 Provider shall comply with Mca's policies and procedures, including, but not limited to,
credentialing and recredentialing, utilization manaeement, authorization of services,
quality improvement activities, and provider payment suspensions. Provider shall comply
with the Program Integrity requirements of the State Contract, as well as MCa's program
integrity policies and procedures. Provider shall comply with all Utilization Management
requirements described in Section 10 of the State Contract.
3.18 Providers that are deemed to be "high categoricalrisk," including prospective (newly
enrolling) home heahh agencies and prospective (newly enrolling) DMEPas suppliers or
such other categories of providers as defihed under 42 C.F.R. ~424.5l8, shall be enrolled
in and screened by Medicare, in addition to complying with MCa's policies and
procedures regarding credentialing and recredentialing.
3.19 Provider acknowledges and agrees that no assignment of the Agreement shall take effect
without the written agreement ofHCA
3.20 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 of Medically Necessary services, and which
provides for a free exchange of information with MCa to assist MCa in complying with
the requirements of State Contract. Providers that are primary or specialty care providers
shall comply with all quality improvement activities of the MCa.
3.21 To the extent that Provider provides health home services fur Covered Persons with
special health care needs pursuant to the Agreement, Provider agrees as follows:
A Provider shall comply with all pre-delegation assessments, which shall be
conducted in accordance with all delegation requirements set furth in the State
Contract.
W A Group base 2.22.12
Page 26 of35
B. Provider shall adopt and use evidence-based guidelines.
C. Provider shall establish relationships with home care providers and commnnity
resources to filcilitate the care of Covered Persons, and with emergency room,
urgent care and hospital facilities to support timely sharing of information about
services accessed and to promote transitional health care services.
D. If validated by the pre-delegation assessment, Provider shall be delegated care
mRnRgement responsibilities as provided in the State Contract.
E. Provider shall, at MCO's request, produce utilization reports relating to Provider's
performance against established perfurmance measures compared to performance
goals, including information on Covered Persons with special health care needs
that require specific outreach or interventions to address under-, over- or mis-
utilization of health care services.
F. Provider shall comply with business processes established by MCO between
Provider and MCO's utilization mRnReement, care management and quality
improvement programs.
G. Provider shall report at least annually regarding performance measures, including
those linked to incentive payments.
H. Provider shall conduct periodic surveys of Covered Persons served by Provider to
assess such Covered PersOl)S' satisfilction with Covered Services furnished by
Provider.
3.22 As applicable to services rendered under the Agreement, Provider shall have a means to
keep records necessary to adequately docoment services provided to Covered Persons fur
any and all delegated activities including quality improvement, utilization mRn'lgement,
member rights and responsibilities, and credentialing and recredentialing.
3.23 Provider agrees to accept payment from MCO as payment in full and shall not request
payment from HCA or any Covered Person fur Covered Services provided under the
Agreement, except for copayments and coinsurance descnOed in the Certificate of
Coverage. Except for copayments and coinsurance, Provider shall report to MCO any
instance in which a Covered Person agrees to pay Provider for services. Provider shall
repay to a Covered Person any inappropriate charges paid by such Covered Person, or
shall reimburse MCO to the extent MCO repays such inappropriate charges to the
Covered Person.
3.24 Provider agrees to hold harmless HCA and its employees, and all Covered Persons in the
event of non-payment by MCO. Provider further agrees to indemnify and hold harmless
HCA and its employees against all injuries, deaths, losses, damages, claims, suits,
liabilities, judgments, costs and expenses which may in any manner accrue against HCA
W A Group base 2.22.12
Page 27 of35
.
or its employees through the intentional misconduct, negligence, or omission ofMCO, its
agents, officers, employees or contractors.
3.25 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
(i) Provider is excluded from participation in the Medicaid program, MCO may
immediately terminate the Agreement upon written notice to Provider, and may
immediately recover any payments for goods or services that benefit excluded individuals
or entities; or (it) RCA 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" may include but is not limited to reasons related to fraud,
integrity or quality.
3.26 Provider acknowledges and agrees that MCO shall conduct ongoing monitoring and
periodic formal review that is consistent with applicable industry standards and the
regulations of the Washington State Office of the Insurance Commissioner ("OlC"), if
any. Such formal review shall be completed no less than once every three years and will
identifY any deficiencies or areas of improvement and provide for corrective action of
any such deficiencies.
3.27 In the event that the Agreement delegates arlminilltrative functions to Provider, the parties
agree that they shall enter into a delegated administrative services agreement that
contains all provisions required pursuant to Section 8.6.1 of the State Contract.
3.28 Provider shall keep information about Covered Persons, including their medical records,
confidential in a manner consistent with State and federal laws and regulations.
3.29 Provider shall comply with any applicable federal and state laws that pertain to Covered
Persons' rights and shall take those rights into account when furnishing services to
Covered Persons. Provider shall guarantee each Covered Person the following rights set
below. Each Covered Person must be free to exercise these rights and exercise of these
rights mnst not adversely affect the way the MCO 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.
D. To be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience, or retaliation.
W A Group base 2.22.12
Page 28 of35
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.
3.30 Provider shall participate in and cooperate with MCQ'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.
3.31 Provider shall (i) obtain informed consent prior to the treatment from all Covered
Persons, or from persons authorized to consent on behalf of Covered Persons as described
in RCW 7.70.065, (it) comply with the provisions of the Natural Death Act (RCW
70.122) and state and federal rules concerning advance directives (WAC 182-501-0125
and 42 C.F.R. ~438.6(i)), and (iii) when appropriate, inform Covered Persons of their
right to make anatomical gifts pursuant to RCW 68. 50.540.
3.32 Provider shall comply with the requirements of State and federa1law regarding advance
directives. Provider shall ensure that whether a Covered Person has executed an advance
directive shall be indicated in a prominent part of such Covered Person's medical records,
and Provider shall not provision care or otherwise discriminate again a Covered Person
hased on whether the Covered Person has executed an advance directive.
3.33 Provider shall have and maintain insurance appropriate to the services to be performed
under the Agreement. Provider shall make copies of certificates of insurance available to
HCA upon request.
3.34 If Provider is a State or community physical or behavioral health hospital, Regional
Support Network, long-term care facility, or inpatient or outpatient Drug and Alcohol
Treatment program. Provider shall use a standardized discharge screening tool which
includes a risk assessment for re-institutionalization, re-hospitalization and/or substance
use disorder recidivism and which has been approved by HCA. Additionally, Provider
shall develop a Covered Person plan for interventions, to mitigate the risk for re-
institutionalization, re-hospitalization or treatment recidivism, consistent with the State
Contract.
3.35 If Provider is a PCP, Provider shall:
A. In consultation with other appropriate health care professionals such as care
m"n"gers, community health workers or community-based care m"n"gers, be
responsible for the provision, coordination, and supervision of health care to meet
the needs of each . Covered Person, including initiation and coordination of
referrals for Medically Necessary specialty care.
B. Ensure that all health information relating to Covered Persons is shared with other
providers in a manner that fucilitates the coordination of care while protecting
Covered Person privacy and confidentiality.
W A Group base 2.22.12
Page 29 of35
.
.
C. Coordinate with community-based and the State Department of Social and Heahh
Services, the Department of Health, local heahh jurisdictions and HCA
services/programs, including but not limited to the following:
i. First Steps Maternity Support ServiceslInfimt Case Management;
ii. Transportation and Interpreter services;
iii. Patient Review and Coordination (pRe) program. for Covered Persons who
meet the criteria identified in WAC 388-501-0135;
iv. Dental services;
v. Foster Care - Fostering Well-Being;
vi. Regional Support Networks for mental heahh services;
vii. Substance Use Disorder services;
viii. Aging and Disability Services, including home and community based
services;
ix. Skilled nursing facilities and community based residential programs;
x. Early Support for Infimts and Toddlers; and
xi. Department of Health and Local Heahh Jurisdiction services, including Title
V services for children with special heahh care needs.
D. Comply with MCO's policies and procedures that address the day-to-day
operational requirements to coordinate the physical and behavioral heahh services
and share the responsibility for Covered Person's health care.
E. In consultation with other appropriate health care professionals, assess and
develop individualized treatment plans for children with special heahh care needs,
which ensure integration of clinical and non-clinical disciplines and services in
the overall plan of care.
F. Identify those Covered Persons with special health care needs in the course of any
contact with Covered Persons or any Covered Person-initiated health care visit,
and report such Covered Persons to MCO.
G. Reasonably cooperate with the applicable care manager to conduct an Initial
Heahh Assessment ("IlIA") of Covered Persons within the timeframes set forth at
Section 13.5.2 of the State Contract, and to assure that arrangements are made fur
W A Group base 2.22.12
Page 30 of35
..~
~
follow-up services that reflect the findings. in the IHA, such as consultations with
mental heahh anJor substance use disorder providers.
H. In consultation. with the care mllnllger. and other treating providers; develop,
document and roaintain, fur all Covered Persons with Special Health Care Needs,
an individualized tr:eatment plan in the Covered Person's medical record
. Elements required in the tre.Ita1ent plan shall include, at m;nimllm:
i The CoverellPerson's self-mllnllgement goals;
ii Short and long-term treatment goals, and identification of barriers to
meeting goals or complying with the tr:eatment plan;
iii Time schedule for follow-up tr:eatment and communication with the
Covered Person;
iv. Clinical and non-clinical services accessedby the Covered Person or
recommended by Provider or care mamtger;
v. Integration and coordination of clinical and non-clinical services,
including follow-up to ensure disciplines and services are accessed;
vi Modifications as needed to address emerging needs of the Covered
Person;
vii Participation of the Covered Person ill. the development of the treatment
plan;
viii Progress or reason for lack of progress on self mllnllgement or treatment
plan goals;.
ix. Communication With specialty care providers, including mental health and
substance use disorder providers;
x. Identification of barriers to achieving self-mllnllgement or tr:eatment
planning goals and how such barriers were addreSsed;
xi. Health promotion activities, including scheduling of aPPOintments for
preventive care; and
. xii Approval of the care plan, ifrequiredby MCO.
The provisions set . forth this in Section 3.35 shall apply with respect to any
subcontract that includes physician services.
WA Group base 2.22.12
Page 31 of3S
,
.
3.36 Upon the request ofMCO, Provider shall furnish to RCA, within thirty-five (35) calendar
days ofMCO's 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.
B. Any significant business transaction between Provider and any wholly owned
supplier or any subcontractor during the previous five (5) year period.
Provider shall provide any further information needed or reasonably requested by MCO
for the purpose of satisfYing MCO's RCA 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
mRnllging employee ot; Provider.
3.37 All sterilizations and hysterectomies provided under the Agreement shall be in
comp1iance with 42 C.F.R. 441 Subpart F, and Provider shall use the RCA Sterilization
Consent Form (RCA 13-364) in connection therewith.
3.38 MCO will provide information regarding MCO's grievance system to Provider.
[SIGNATURE BWCK FOLLOWS]
W A Group base 2.22.12
Page 32 of35
MCO:
COORDINATED CARE CORPORATION
Authorized Signature
Printed Name:
Title:
Signature Date:
Effective Date of Addendum:
(fo be oompIcIed by MCO)
W A Group base 2.22.12
PROVIDER:
Jefferson County
o an entity organized under the laws of the State
of Washington; or
o a foreign entity qualified to do business in the
State of Washington
Authorized Signature
Printed Name:
Title:
Signature Date:
Tax Identi:licationNumber: 91-6001322
National Provider Identifier: 1841225208
State Medicaid Number: 79001 37
Approved as te form only:
() ])~}J2.
Jefferson Co. Prosecutor'
Page 33 of35
~
,
EXHIBIT 2
COMPENSATION SCHEDULE
WASHINGTON BASIC HEALTH AND HEALTHY OPTIONS PROGRAMS - GROUP
For Covered Services provided to Covered Persons, Payor shall pay Group lesser of (i) the
Provider's Allowable Charges; or (it) {Proprietary}
AdditJo1Ull Provisions:
1. Code ChAnge Updates. Updates to billing-related codes (e.g., CPT, HCPCS,ICD-9, DRG,
and reyenuecodes) shall become effective on the date (''Code Change Effective Datej that
is the later of (i) the first day of the month fullowing thirty (30) days after publication by the
governmental agency having authority over the applicable product of such governmental
agency's acceptance of such code updates; or (it) the effective date of such code updates, as
determined by such governmental agency. Claitn processed prior to the Code Change
Effective Date shall not be reprocessed to reflect any code updates.
2. Fee Chan~ Updates. Updates to such fee schedule shall become effective on the date ("Fee
Change Effective Date") that is the later of (i) the first day of the month fullowing thirty (30)
days after publication by the governmental agency having authority over the applicable
product of such governmental agency's acceptance of such feesched.ule updates; or (it) the
effective date of suCh fee schedule updates, as. determined by such governmental agency.
Claims processed prior to the Fee Change Effective Date sballnot be reprocessed to reflect
any updates to such fee schedule.
Dejinitions:
1. Allowable Charges mean those Group .billed charges fur services that qualify as Covered
Services.
WA Group base 2.22.12
Page 34 of35
EXHIBIT 3
PARTICIPATING PROVIDER ATTESTATION
WHEREAS, Coordinated Care Corporation ("Managed Care Organization" or "MCO"),
bas executed an agreement with Jefferson County ("Group") dated ,
pursuant to which Group bas agreed to provide Covered Services to Covered Persons through
Group Providers (the "Agreement'');
WHEREAS, Group bas requested that the undersigned provider ("Provider") serve as a
Group Provider under the Agreement and Provider so desires to participate; and
WHEREAS, as a condition of such participation and Provider's designation as a "Group
Provider" under the Agreement, Provider must satisfY MCO's credentialing criteria and execute
this Attestation acknowledging hislher agreement to comply with, and be bound by, the terms
and conditions of the Agreement that are applicable to Group Providers, as set furth below.
NOW THEREFORE, Provider hereby agrees as fullows:
1. As long as Provider qualifies and participates as a Group Provider under the Agreement,
Provider agrees to provide Covered Services to Covered Persons in accordance with the
requirements of the Agreement that are applicable to Group Providers, which shall
include the following terms: Sections 3.3 through 3.17; Article IV; Article V; Article VI;
Article VII; Article VIII; Section 9.1; and Sections 10.4 through 10.7.
2. Provider understands and agrees that hislher initial and continued participation as a
Group Provider under the Agreement is contingent upon hislher meeting and complying
with MCO's credentialing standards and otherwise complying with the terms and
conditions of the Agreement.
3. Provider acknowledges that MCO expressly reserves the right to reject, suspend, and/or
terminate hislher participation under the Agreement for breaching or otherwise failing to:
(i) comply with the term of the Agreement or any Attachment thereto; and (ii) meet
MCO's credentialing requirements.
4. This Attestation shall be effective as of
Provider
Is!
Name:
Specialty:
Date:
W A Group base 2.22.12
Page 35 of35