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HomeMy WebLinkAbout072213_ca07Consent Agenda °~~~ `< JEFFERSON COUNTY PUBLIC HEALTH ^4„Tk2 615 Sheridan Street o Port Townsend o Washington o 98368 www.jeffersoncountypu blichealth. org June 21, 2013 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERS AGENDA REQUEST TO: Board of County Commissioners Philip Morley, County Administrator FROM: Jean Baldwin, Director DATE: ~u ~ y a~, SUP }j SUBJECT: Agenda Item -Group Provider Agreement for WA Medicaid beneficiaries with Coordinated Care Corporation, Amendment #1; January 1, 2014 -annual auto renewal; fee for service STATEMENT OF ISSUE: Jefferson County Public Health requests Board approval of the Group Provider Agreement for WA Medicaid clients with Coordinated Care Corporation, Amendment #1; upon signature -annual auto renewal; fee for service ANALYSIS/STRATEGIC GOALS/PRO'S and CON'S: This amendment centers on the health insurance Exchange. An Exchange is a mechanism for organizing the health insurance marketplace to help consumers shop for coverage in a way that permits easy comparison of available plan options based on price, benefits and services, and quality. President Obama promoted the concept of a health insurance exchange as a key component of his health reform initiative. Coordinated Care, as part of a Managed Care Organization, will offer this additional coverage to Washington residents who transition between eligibility for Medicaid and for the Exchange. ]CPH will continue to bill and collect for clinic services provided to WA Medicaid eligible clients who have chosen Coordinated Care Corporation as their Managed Care Organization. This plan is a benefit to the patient, as they will choose their provider accordingly. This contract allows underinsured citizens to receive much needed services. FISCAL IMPACT/COST BENEFIT ANALYSIS: This is a fee for service contract. COMMUNITY HEALTH PUBLIC HEALTH ENVIRONMENTAL HEALTH DEVELOPMENTAL DISABILITIES WATER QUALITY MAIN: (360) 385-9400 ALWAYS WORRIN6 FOR A SAFFR AND MAIN: (360) 385-9444 FAX: (360) 385-9401 HEALTHIER CONIMUNITy FAX: (360) 379-4487 Consent Agenda JCPH management request approval of the Group Provider Agreement for WA Medicaid clients with Coordinated Care Corporation, Amendment #1; upon signature -annual auto renewal; fee for service REVIEWED BY: ~~ - ! C c ~~( f`~i ip Morl oun Admire strator Date (Routed to all Public Health Managers) G1~(3L3~' AG1~EE11!.NT AN~ENI[~1!1tENT AND CflNI~~~RCIAL-E~CHANC;-E >€'R~7Il>C7C~' A'I`TACHIVIEN'll' This Group Agreement Amendment and Commercial-Exchange Product. Attachment preferred to herein as this "Amendment and Attachment"} is made and entered iota betvaeen Jefferson County ~"Grarrp") an entity described mare fully in the signature black, and Coordinated Care Corporation ("managed Gare flrganizatian" ar " l~i1CC7"}. ~-IEREAS, MCA and 'Crain entered into that cartain ~ro~rider agreement, including all Attachments, as may have been amended and supplemented from tirr~e to time (the ~. ursuarat to which Group agrees to provide to covered persons those covered Agreemment '}, P services described itr the ~,.greement; W~-IEREAS, MCp desires to amend the Agreement (i} to include Group and Group providers as "Participating Providers" has hereafter defined) in the "Cornrnercial~ExChange Prnduct," as defined and described in this ~.rnendment and Attachment, and (ii) to add the Commercial-Exchange Product Attachment. (as defined below) as a binding attachment to the Agreement; WHEREAS, pursuant to the provisions of the Agreement, the Agreement may be amended by MCa providing at least sixty {6l7} days writtezt; notice thereof to Group, provided that Group does not abject to such amendment by notifying N1Ct7 in accordance with the Agreement; and WHEREAS, the Agreement is amended as hereafter provided an accordance with the natic:e provisions in the Agreement. 1~G~' T HEI~EFORE, in consideration of the foregoing, and tar other good and valuable consideration, the Agreement is amended as set Earth below. 1. Ames t. 1.1 >Jffect~v~ Date. This Amendrrrent and Attaehrraent is effective as of January 1, 2U14 ('`1ffective Tate")- 1.2 1~efizled Terms. All capitalised terms not specifically defined ixz this Amendment anti rl,ttachrrrertt. 4a ill ha~'c tllc meanin~,s ~~i~°czz to such terms in the Agrcemerrt. 1.3 N1c~clificatian to I~etned Terms. Ear purposes of this Commercial-Exchange 1'radtrct only, Article I of the Agreement is hereby deleted in its entirety and replaced with the fallowing: ARTICLE I t'a~e - cif f3 CE Product Attachment GraL~p 1(7.1.12 DEF'I~i 'rI ®;til S 1.1 rl~,f~tiate~`s} means a person or entity cor~tralling, c4ntralled by, or under common control with N1CC~. 1.2 Attachments rneazas the attachments to this Agreement including addenda and exhibits, all of which. are hereby incorporated herein by reference, as set Earth in Section 1.1.15 co this Agreement. 1.3 Clean Claim means a claim that has no defect or impropriety, including any lack c>f any required substantiating documcrztation, or particr.~lar circirrxzstances requiring special. treatrrient that prevents timely payments frorri being made on the claizrt. 1.4 Compensation Schedule means at any given tirrre the then effective schedules} of rraaxizrrurr! rates applicable to the Comzzaercial-Exchange Pradttct under which Group and Group Providers will be caznpensated far the provision of Covered Services to Covered Persons, Such Compensation Schedules} wi11 be set forth. or described in an exhibit to the Commercial-Exchange Product Attachment. 1.5 Commercial-Exchange Product means thane pragrarrrs and health benefit arrangemezzts offered by or available from ar through N1C0 or a Payor that prow°ide incentives to Covered Persons to utilize the services o certain contracted providers. The Cczrnmercial-Exchange Product includes those Coverage Agreements entered irrtr~, issued or agreed to by a Payor under which 1v1CD, an Affiliate, or its delegate furnishes adrnizristrative services or other services in support of a health care program far an individual or group of individuals, which zrra~y include access to one ar mare of tlxe 1'vTCO's or Payor's provider networks or vendor arrangements, and which may be provided in connection with a state ar governmental-sponsored, emplayFer-sponsored, or other private health insurance exchange. T`he Commercal_Exchange Product dies not apply t:o any Coverage Agreements that are specifically covered by another Product Attachment to the Agreement. 1.6 Coverage Agreement means any agreement, program or certificate entered into, issued or agreed to by a Payor, Linder which the Payor arranges for the delivery of health care services to Covered Persons throLrgh one or rxaore network(s) of providers ar ether ti°endar arrangerxrcnts. 1.7 C~vvered Fers+?n means any individual ea~titIed to receive Covered Services pursuant to the terms of a Coverage Agrecrnerzt. 1.8 Covered Services rxzear~s these services and iterrrs far which benefits are available and payable Linder the applicable Coverage Agreement and which are determined, if applicable, to be medically necessary under the applicable Coverage Agreement. CE 1'rc~duct Attachrrrent Croup 141.1,12 Page 2 of 1 3 L~,mergency Care or Emergency .Services has the meaning set forth in the Covered Person's Overage Agreement. 1.1(1 Entergeney Medical Condition has the meaning set forth in the Covered Person's Coverage Agreement. 1.11 Group Provider meaxas any physician, individual practitioner or other health care professional who: (i} is employed, trader written contract with or otherwise represented by Group; (ii} both Croup and 1'~ZC4 have agreed rrray provide Covered Services pursuant to this Agreement; (iii} satisfies 1v1CC3 credentaling criteria; and (iv} has indicated agreement to comply with all pr®visions of this Agreement. that are applicable to Group Provider by executing a Participating Provider Attestation attached hereto as Exhibit 3. 1.12 hl'IPAA means the Health insurance Portability and Accountability Act of 1936 and its irrrplcrrrentirrg regulatarzs (4~ C.p'.R. Parts 16(i and 1~aA~}, any applicable state privacy laws, any applicable state information security laws, and implementing regulations and the requirements of the Health lrrfortnation Technology for Economic and Clinical Health Act, as incorporated irr the American Recovery and Reinvestment Act of 2(1[)3, and its implementing regulations adapted. or to be adopted. 1.13 Medictxl Director means a physician or hisllrer physician designee duly licensed under RC~+I Chapter i$.57 or 18.71 designated by 1VlCC} to monitor and evaluate the appropriate utiliaaton of Covered Services by Covered Persons. 1.14 Medically Necessary has the meaning set forth in the Covered Person's Coverage Agreement. 1.1~ Pccrticipatir~g Health Care Provider or Participating Provider means, with respect to a particular Product, any physician, hospital, ancillary, or ether health care provider that has contracted, directly err indirectly, with 1V1CtJ or Paynr to provide Covered Services to Covered Persons,. and that is designated by iV1CU or Payor as a "participating provider" in such Product. Group and Group physician are Participating Providers pursuant to this Amendment and Attachment. 1.1b Puyor means the entity that bears direct financial responsibility for paying from its own funds, withor~t reiznburserxrent from another entity, the east of Covered Services retrdered to Covered Persons under a Coverage Agreement.. 1.17 Payor Contract means the contract w=ith a Paynr, pursuant. to which MCO or art Affiliate furnishes administrative services or other services in support of the Coverage Agreements entered into, issued or agreed to by a Paynr, which services may include access tea one or more of provider networks or vends}r arrangements of N1CC} or an Affiliate. The terra `Paynr Contract includes a contract with a governmerYtal authority (also referred to herein as a "Gc~vernrnental Contract"} under which MCU, an Affiliate car Paynr arranges for the provision of Covered Services to eligible individuals. ,~,~ 1'rodctct .t~ttach.mcnt Group 1f1.1.12 t'at;e ~ of 8 1.18 ~roduet means any prograrr~ ar health benefit aa~-angement design~~ted as a "product" by MC(] ar a Payar (~.~., C[~ Product, ~vledicaid Praduct, ~:onrmercial- Exchange Praduct, Payar specific Praduct, etc.) that is now or hereafter offered by ar awailalale frarri or thra~.igh lV1G~D, an Affiliate or a Payar that provides Covered Persons in such product with incentives or acce4s to Participatirg 1'raviders in such product. Por purposes of the Commercial-Exchange Product Attachment, "Praduct" mans the Corrrrnercial-Exchange Product. 1.1~ 5tat~ means the Stag of Washington. ~. +Garr-irnercial-Exchange Product Attachment. 2.1 Product Attachment. 'T`his Section 2 constitutes the "Corrimercal-Exchange Product Attachment" this "Praduct Attachment"} and is incorporated into the Agreement }~etween Group and N1C`U. It supplements the Agreement by setting forth specific ferias and conditions that apply to the Commercial-Exchange Praduct with respect. to which Gz~oup has agreed that Group and Graup Pi-owiders will participate, and with which Graup anal Group Providers rriust comply in order to maintain such participation. The provisions of this Section constitute a rtew Praduct Attacllrnent to the Agreement and do not delete or replace any language in the Agreement. ?? l~'artici ati~n. [Jnless otherwise specified in this Froduet Attachment Group and all Graup Providers trader the Agreement will participate in the Commercial-Exchange Product as "Participating Providers," and will provide to Covered Persons enrolled in or covered by a Cornrnercial-Exchange Product,. upon the same terms and carrditians contained in the Agreeixlent, gas supplerriented or modified by this Product Attachment, those Covered Ser~°ices that are provided by Graup and Group Providers pursuant to the Agreement. In providing such services, Group Shall, and shall cause Group Providers, to comply with and. ak~ide by the provisions of the Agreement,. including this Praduct Attachment and the policies and procedures of N1CC3 anal a Payar. 2.3 Attachment. This. Product Attachment includes a Cornpensatiorr Schedule at Exhibit 1. 2.4 `Terirr. "The term of Groiip and Group Pro~•iders' participtrtan in the Carnmerci<zl- Exchange Product will coinrnence as of the lffective 17ate and, thereafter, will lie coteririinozrs with the terra of the Agreement unless teririintrted pursuant to this Product Attachment. The participation of Grotrp or arry Group Provider as a '`Participating Provider" in the Carrrinercial- Exchange Praduct may be terminated 'hy either Croup or MCG by giving the other party apt bast tine Hundred eighty (1~4} days' prior written notice of such termination; in such event, Group shall irnnrediately notify Groz~p Providers of such termination. 2.5 Corrf~ict and Constr-irctic~n. This Anrendment and Attachnent nradifies, si~ppleinents and forms a part of the Agreement. Except as otherwise provided irr this Ainendnrent and Attachment, the terms and conditions of the Agreement will remain unchanged CE Product Attachiraent Groiip 14.1.12 Page ~ at acrd irr full farce and effect. In the event of any canflict ar irrcansistEncy iaetween tine pravisions ~,f the ~reement {or any ather Attachrnenf} and the pravisions of this Product A.ttachruent, the terms and carrditians of this Praduct Attachment will tavern with respect to health care services, supplies ar accammadatians (izrcluding Covered Services} rendered to Covered Persons enralled irr ar covered by the Cozrrmercial-~xchan~e 1'raduct. To the extent Group or any Croup 1'ravider is unclear about its, his ar her respective duties and abli~atiatas, gaup or the applicable Group Provider shall reclrlest clarification from 1~C~1. C~ Product. ~lttachrrtent Crra~p 1~, l . l ~ ~a~e S c33' Ii~l WITLESS ~G'HERE[J~", the ~artie5 hereto ha~'e executed this Agreement effecti~re as of the date yet forth below. iV~TC[): Cgf)1tI7IN~'~~'Eil' C:~I~E ~{]RFt1R~Ti{)N Authori~cd S~natr3re Prirztec~l l~iame: 't'itle: Group: ,~effers{gin ['aunty Authorised Sigraattire Printed. IV ame: ~C'itle: Si nat~xre bate: Si natrire Date: ~ffecti~e bate of Agreement: ~'ax Identification N~tntber: (~"o be completed by MCQ only) To be completed try VIC4 only: EffECtz~e Date of A reemznt: 1'~ational Pro~~ider Identifier: :~tat.e Medicaid Nun~her: P ~ ~~~' ~c r~ CE Prodrict Attachn~er~t ~ro~~ ](}.l.l`? Pale ~ of 8 >1;XHIBi~' 1 PRQVTDER C~MIr'~NSATI(l~ SC~I)U`Cl~ - Commercial - Exchartge Products . PRC)>l )~~SS1iQNAL SFRVIIC~S 1~'ear Covered Services provided to Covered Persons, Payer Shall pay Provider the lesser of: +(i} the 'Provider's A,llawable Charges, ar (ii} one hundred percent (10~°l~} of the Payer Medicare fee schedule irr effect on the date of service acid specific to the services rendered, less axay applicable coinsurancr: or deductible, This fee schedule is based on the CMSIMcdicare RBRVS relative values acrd for certain codes alternative fee sorrrces may be used. Addtiorta! Provisions. C an~~ Updates, lJpdates to existing billing-related codes shall became effective on the date ~`°Code Change Eff iicatiaDb ethe feersources used by health Pan car (ii} the ffec~ive d t~ sixty {6[~} days after pub `~ of such. code updates, as determined by Payer. China processed prior to the Cade Change Effective Bate shall not be reprocessed to reflect any code updates. gsl,„ ~. t3nless specifically indicated atherw~ise, Fie Am.aunts listed in the fee schedule represerxt global fees and may be srrb~ect to reductions based an appropriate 1'~Iodifier (far exarraple, professional and technical raaodifiers}, As cued in the previous sentexace, "global fees>, refers to services billed without a Modifier, far which the Fee Amount includes Bath the professional component and the technical component. Any co-payment, deductible ar coinsurance that the customer is responsible to pay under the customer's benefit contract will be subtracted froraa the listed Fee Artaourrt in determinixag the amount to be paid by the payer. The aLcual payment amoLlnt is also subject to matters described. in dais agreement, streh as the Payment Policies. Fie e5. Ixx the event CAS contains na published fee ara-rount, alternate (ar "gap fill") Fee Sources may be used to supply the Fee Basis amount far deriving the Fee Amorrrtt. For example, if a new CP'TIFICPCS code has been created within the Type of Service category of codes described above, and CMS has rant yet established an RBRVS valrre fc3r that code, we use one of the Fee Sources that exist within the industry to fill that gap, strrch as but xaot limited to ~ptuxn RgR~tS, Far that CPTIHC=P~CS code, we adopt the RBR'VS value established 1?y the gap-fill l~oe Source, axzd dc:terrnine the Fee Amount for that CP'I'II~CPCS cede by applying to the gap-#ll ~gR~iS the same Coxaversican Factor and Pricing 1_.evel that we apply to the Cl~1S RSRVS for Haase CPTIf-I~PCS ccacles that have CN1S RBR'VS values.. At srrch tixaae ire floe future as CMS publishes its ouvn R13RVS ~falue far that CPTIFICPCS cede, we would begin using the Clu"lS fee arrrar.rnt far that code and raa longer use the alternate Fee Source. ~'~raestlaesia Mt~c~ifier Pricin Rules. The dollar amount that will be used in the calculation of time based and raon-tiraae based Araestlaesia Management fees in accordance with tyre Anesthesia 1?aynaent Policy. Unless specifically stated otherwise, the Anesthesia Conversion Factor indicated. is fixed and will eat change. The Anesthesia Conversion Factor is based orr an anesthesia tixrae unit value caf 15 minutes. P;~y~e 7 €af $ CE Proclrret Attachment Crcat~p 1(}.1.12 I4'lult _ le Procedure Priciz~~ R~rle~. Multiple procedures performed will be reimbursed at 1(ail%~ far the primary procedure, 5~°la far the second procedure:, and 5[1°la Fc~r the third pracedttre. Default Pricin for Cosies with No Va~~es, Carrier Cadcs. Ir7 the event that CMS dues nc~t publish. a campl~ete set of fee arrtaunts far a specific cede, Cooa~dinated Care mill use reasonable carrunerciai efforts to establish fee amounts far all services and modifiers associated with the code ba4ed an fee iraformatian available. Place of Service Pricing, Rules. `T'his fee schedule follows C1VIS ~uicielizles far determining when services are priced at the facility ar non-facility fee schedule (with the exception of services performed at Ambulatory Surgery Centers, PQS 24, which will be priced at the facility fee schedule}. Pavmer~t under this Exhii~it. All payments ender this 1/xhibit are subject to the terms and conditions set forth in the Agreement. llefrrtti~rts: 1. Allr~wable Charges tnean those Provider billed charges far services that qualify as Covered Services. CE 1'racl~~ct Attachment Group 1.~. l . l ~ t'uge t3 ~#' ~~-~~N~~ Gl2U~[JP P~,QVII7tiR ~~ ~:~~LV1l4+~NT Tlris C-~~G~I' ~'>~UVZ~]El~ ACiREI?MENT ~"~~ Bement"} is made anal entered izitc~ as of the effective elate set Earth nz~ the signature P~~e below ("Effective Date"}, by a:iad bctweez~ Je~ferso~ ~ou~-~~-~_ _ ("(gaup") and Caardiuated Care ~c~r~paratiarz {`:ar~a~ec~ ~~ 73 Care Qrga?~.i~atior3, ar "M CC7"}. ~~,p,~AS, Croup is comprised of one ar rnnre duly licensed physicians arid, if applicable, nth.er health care prnfessionals; ~~I~l<lRl/AS, MCC3 is a duly licensed health maintenance arganizatic~n, and ~,~~~~ AS, ~Cp wishes to cnnfiract with Grnup to provide nr arrange for the provision of certain Covered Services to Covered Persons; and '-IIREAS, Clroup desires try provide nr arrange through Grn~zp Providers far the prnvisinn nf, Covered Services to Covered l'ersnns under the terirzs arzd carzditinns set forth in this Agreement; arzd NO~~, T~EI~~F~R-E, ~ a°~siderafiaxa nl-th~e mutual premises herei~z~ stated, tl~e partzes hereby agree as follnws: rLRTI'C:L)N:. i DIEF'INI"l'i[3NS As used iax this ~.~reement and each of its Attachments, each afthe following terrns hand the plurals tl~tereof, when appropriate} shall have the m~;ani.ng set forth herein. l.l. ,~f~liute{s) means a person or entity contrnllitzg, cnrztrolled by, nr under canaznan control with >~~CC~. 1.2. ~ittuchr~ent(s) n~zeans the attachments to this Agreerrzent, including adciezzrla axzd exhilzits, all of which are hereby incorporated herein by reference, as set Earth in Section 11.I ~ to this Agreement. 1.3. Clean Clcxirn rrmeazls a claim that leas no defect ar uz~prnpriety, including any lack of any required sulastaa~tiating dacumenfiation, or particular circumstances recluiri_ng special treatment that prcve~~ts tiraaely payments frarr~ being rrzade on the olairn. 1.~. Cr~vered person rrzeares a person eligible to r~c.eiv°~: C`ravered Services a~ld ezzz-c~llad irz a health benefit plan that is issued or administered by~ SIC"(~, an Affiliate nr Payor. 1.~. C'avered Services mcarzs tliase l~.fledically ?~Iecess~zry services covered under the terzr~s of the applicable F'aynr Contract. 1r~~'.rt Group base 2.?2. t2 T'age l of 3~ 1,6. Eaner;ency 'arc yr Ernergeaacy Servieex shall have the meai-auig set forth at ~Z U.S.C. 139Gu-2(b)(Z}~I3}, a.s amended: inpatient arid. outpatient Covered Services firrniyhed by a qualified provider that are needed to evaluate or staliilixe an Emergency itiledical Cronditiori. 1.7. ,~razer~;ency .~erlcal Cvnclitinn shall have the mearzia7b set forth. at 42 U.S.C:. 13~76- u2~b}(2}~C}, as azneirded: a ineclical condition manifestixig itself by acute symptoms of sufficient severity {including severe pain} such that a pri:~dent laypersoir, ~vho possesses an average knowledge of health and medicine, ec~uld reasoraai=aly expect the aE~seaice of irrimediate medical. attention to result in the following: {i} placing the health of the iiaclividual for, with respect to a pregnant woanan, the health of the woman or her unborn child) in serious }eopardy; iii} serious impairment to bodily functions; or (iii} serious dysfunction of any bodily organ or part. 1.8. C;rr~up prraayirler means any physician, iridividiaal practitioner or other health care professional who: Vii} is employed, under w°ritten coi~:tract with or otherwise represented by Group; (ii) both Group and. i'1~7CD Dave agreed may provide Covered Seq-vicos pursuant to this Agreemexit; (iii} satisfies I/ICC] credentialing criteria, and {iv°} has iiidieated areer~-ient to comply with. all provisions of this Agreement that are applicable to Group Provider b~T executing a Participating Provider Attestation attached lYere.to as >~.~hibit 3. l.c}. HII~A~ means the Health Insurance Portability and rh.ccountability Act of 19~1G and its implementing regulations X45 C.l~.R. Parts 160 and 164}, any applical7le state privacy laws, any applicalale state information security° laws, and implementing regulations and the recluirernents of the Health lnf~rmation ~'echnology for Economic aiid Clinical Health Act, as incorporated in the American Recovery aril Reinvestrneiit Act of X4109, and its iripleixieilting regulations adopted or to be acioptcd. 1.10. ~l~edical .director means a pliysicari or his/liar physician designee duty liceiased under RC'~V Chapter 15.57 or 18.71 desigiratecl by MCC.} to monitor and evaluate the appropriate utilisation of Covered. Sei~.rices by Covered Persons. 1.11. ?Medically Necessary shall hay°e the meaning defined in the applicable I'ayor Contract. 1.12. Participa~itag I,~ealtla Care PrUVirler means any physician, hospital, ancillary, or other health care provider that has contracted directly or indirectly with MCD to prop°ide Covered Services to Covered Persons and is credentialed in accordance with the CC7's credentialing criteria. Participating Health Care Provider shall include all Group Providers. 1.1:3. Paycar means '-'1'1Cd or another entity that is responszble for funding Covered Services to Covered Persons. 1.I4. Paver Contract means MCC3's contract with any Payer that governs provision ofCo~°ered Services to Covered Persons. 'G~~here MC[~ is the Payer, "Payer Contract" means MC'D's contract ~,vith the state or federal agency or other entity that has contracted with I~1CC] to 4'v'A C3roup base 2.~~.12 Page 2 of ~i5 arrange far the gra~'isiar' of Covered Services to eligible individuals of such agency ar other entity- 1.15. State means the State of V+Iashingtan. ARTICLE XI v1CC)'S Dk~L1C~ATC)l~iS -1, ~df~istration. 1v1CC~ ~ all breasonableboeeratnn af~a marzaaed caretortani ~tiarxSaSucla required. f'ar the cari~rn ~' p g g activities shall izzclude, but are not lizxiited to, duality imprc~vezxzent, utilizati~zn management, grievances and appeals far Covered. Persons, claims processing, and zxzairitenance and publicat}an of provider directory. ~.~. ~~li~~s~ i~rczeedures: N1CU slaa.ll ns~tify group of its respansil~ilities with respect to Payor's applicable a~rninistrative policies and procedures, including but not lizxzited to c3aizns submissiarz requirements, utilization review, duality assessment and izxzprovernent credentialing, grievance praceciures, data reporting requirements, and pragramsa con~zdentiality regzaireirzents. ~y and all such policies grid prac;edures shall be available far review by Croup prior to contracting. Crroup shall be given reasoii:able notice o#' not less than sixty (Gla) days of changes that affect Croup's compensation and that affect health care service delivery, unless changes to federal or stag law ar regulations rnalce such advance notice impassible, iz-i which case notice shall be provided as soon as passible. 2.3. ld~n~il-z~~ti~ Q~ Cards, MCC) ar }~ayar shall issue to Cavored Persons air idozztifi~atian card that shall bear tl~e name of the Covered Person, and a unique identification number. 2.4. ~3etzefits~ a~ ~~ilit Verilicatiun. iti~1C4 ar I'ayar, as determined by the Payar Cazatract, shall be responsible far all eligibility aizd benef"zt determinations regarding Covered Services arzd all cammunications to Ctzvered Persons regarding final benefit determ~ations, eligibility, bills, and other zxaatters relating to their status as Covered Persons. MCC or Payar shall provide a method by which Ciraup and CYroup Provider may obtain timely information on Covered Person eligibility fdr Covered Services, iz~zcludzng any lizrzitations or conditiozzs relating thereto, which method shall include, at minimum,. one of the follawving. (i) an electroziic search on a secure provider portal; (ii) a telepharae call to an automated member eligibility interactive voice response (1V1~) system; or (iii) a telephaz~e caz~versatian with a provider services representative rrzade available through a toll-free zaurnber. `.~. Nl~~}`s Ivledical Director. N1C[~ shall provide a Nleclical I7izectar to zrzanitar aid evaluate the appropriate utilization tzfCavered Services by Covered Persons. ~'.^~ C.iraup base .?2.12 Page 3 of 3 ~A~R'TI+C~"LlG III GR(~LTP'S AI~JI ~R(3UP FRGVI<D1ER'S [)~3I,TC~~,Ti(71~:'4 3_l. Itelatxorisl~i~ ~~ith'Crv?~p pr~viderslGrvu~~ut~i~a:r~. Graup repraserrts anti warrants that it has all legal authority to contract on behalf of and to bind all individual Group Providers to tl~e terms of this Agreement with IvICO. Group shall znaintaiti rvrtte.u agreezn~nts ~vitl~ each of its Group Providers requiring the Graup Praviders to comply with all of the tez-zns azxd conditions of this Agz-eez~ent applicable to Group Providers, which. shall In~,lude the following terza~s: Section 3.3 through 3.17 Article lV; Article V; Article Vl, Ar~i~;ic. V.II; Article VIII; Scctioza 9.1; and Sections I~l.~ tlarazxgh 1D.7. The faun of Group's standard al;reernent with Group Providers and ar~y material ai-nendrrrents thereto zrzust oazlzply with applica~rle la~v and MCfl requirements. Group represents and v~rarrants that each Gratap provider shall execute a Participating Provider Attestation, irz the farm, attached l~creto as Exhibit 3. Upon request, Group shall. rnal:e available to 1'v1Ca and to any applicable regulatory authority a copy of each of its provider agreements vv=itia Group I'ravidcrs. 3.2. Crraup Provider Panel 1ylaizltenance. Group and MC() agree that prior to any Group Provider's provision of Covered Services under this Agreement, Group shall furnish to MCG a list of Group Providers, which list shall uiclude, at minirx~ktm, each Group Provider's naz~ne, State license number, specialty, board. status, Natianal 1'rovrider ldentilier, and hospital affiliation., Group shall thereaer n~aintairz and furnish updatcel versions o f the list to N1CG on a regular basis to be agreed upon by the parties. Group anci lv1CQ steal] also rnut~aally agree upoza (i) azay additional Group Pz•ovider information to he included on the list, and iii) the format of the list. 3,3. Cav~r~_ e~ S~z"!'Ga~. Group shall arrange for the CirDUp ~'roviders to provide to Cover~cl. Persons those Covered Sertirices in acccarclance with Payer requireiraents, the lcnerally accepted standards of medical practice az~d care in the Group Provider's conzznunity, the scape of ~Ciroup Provider's license, and the terms and conditions of this Agreement.. Group or Grorrp Pravider shall make necessary and appropriate arrangerr~errts to assure tlae availability of Covered Services to covered Persons an a t~.venty-four (24) l~nur per day, seven (7~ day par week basis, including arrangements to assure coverage of Covered Persons aflcr-hours or ti~rhen Group Provider is otherwise absent. Group and Group Provider further agree that such. arraz~gen~er~ts will be with a health care professianal that is a Participating Health C'.are Provider. 3,~. Grau~Provider C~alificatiaz~s. Graup Pravider shall, at alI tirri~s during the term cif this Agreement, (i~ be licensed in good standing to practice zrlerlicine in the. State; 4ii) rr~auztairr medical. staff i-nezzibership and adzxzitting :privileges with at least one hospital tlirit is a Participating Ilealtl~ Care Provider ~"Participating l-laspital"); and viii} be certified to participate iza the Medicare and lvledicaid pragrarns. Group andlor Group Provider shall furnish evidence of the foregoing to 11~1C~7 at any tune upon request, If C'~roup Provider duos not ha4~e adznittizzg privileges at a Participating Hospital, Caroup or Group Provider shall provide lvlCt7 with a written state~nezzt from another Participating f-lealth Care provider wl~a does Izave adzaaittizag privileges in gaad standing at a Participating Hospital certifying that such individual agrees to asszame resparisibility for providing inpatient ~~A Graup base 2.22.12 Page 4 of 3S Cavered Services to 'hovered Persons who are patients of the applicable Graup Provider. 3.5. ~om~ance with MCA Policies end Procedures. Group and Graup Provider shall at all tirrres cooperate and carrzply with the policies and procedures of MCA and P`ayor, including, but not limited to, the following: ~. credentialing criteria; B_ administrative policies and procedures; C. medical ~auageent prograrn inclzzding duality izxzpravernent, utilization management, disease management, and case management; I]. Covered Person grievance and appeal procedures, and E. coordination of benefits and third Marty liability recovery palicies and procedures. .6. ~~t- ~~lz~~atio,~ n a~ Gav~red Person Eli~zblit~. Graup Pravid~r shall verify, iza accvrdanaa with the Payar requirements, whether an individual seeking Cavered Services is a Covered Person, if 1'v'Ct7 determins that such individual was not eligible far Covered Services at the time theementces were rendered, such services shall not be eligible fc~r payment under this Ag ~..~. ~Pncv Care. Group aizd Group Provider shall provide Emergency Care to Cavered Erz~er~=-~..-~~- Persons in accordance with applicable federal and State laws. Group or Graup Provider shall zxatify 1VlGC7 within twenty-four (24~ livers or by the next business day of rendering or learning of the rendering of Emergency Care to a Covered Persan. 3.8. ,p~c~e~tance of flew Patients. To the extent that C7roup ar Group Provider is accepting new patients, Graup or Graup Provider must also accept new patients who are Covered Persons of MC(~. Group ar Graup Provider shall provide MCC7 forty-live ~`l~) days written notice prior to Group or Graup Provider's decision to no longer accept Covered persons of ~°"1CG or becam sea Covered Parson be considered a new lea ~ d patcrzt of any Graup Provider who P+~~rtin to ~'ri~nary Care P_ hysi~ia~as. ~L~zy Graup Provider who is a specialty ~.`~. Refez-z"a~~.~---~~ ccalt Provider'' shall iovide Covered Services to Cavered physician (".Group Sp ~ y ~ P Persons upon reFerral from a I~ICC) primary care physician ("PCP") car MCC, and shall arrange far any appropriate re~'errals ancp`or admissions of Covered Persons, in accordance with Payar requirements. Croup Specialty Provider shall, within a reasonable tune following cans~altation with, or testing of, a Cc}vexed 1'ersaz~ (not to ~xce~d one (1) vaoalc}, make a ccmplete written report to the Cavered Person's PCP, provided that, with respect to 1-mdiags which may indicate a need far irrzmediate or urgent fallow-up treatment ar testing or which rnay~' indicate a need for iiirther ar follow-a.ip care outside the scope of the referral authorization ar outside the scope of Gro~cp Specialty Provider's area of expertise, the Group Specialty Provider shall provide an izrzmediate oral report to the Covered ~~ A Graup base ~.Z?.1?. Page S of 3~ Person's PCP, not to exceed twez-zty-four (24} hours frozrz the time of Group Specialty Provider's consultation or Group Specialty Provider's receipt of the report of tle testizrg, as applicable. 3.1 ~3. Preferred Arum ListlL7r~~ 1? orznulary. if applicable to the Covered Person's coverage, Group Providor shall abide by Payer's forznulary° or preferred drag list when. pr.~cribizlg medications for Covered Persons. 3.11. Trea~ t~or?t p~~isions. 1V~CCl will not. exercise control over the manner or method ~y ~,~vl~icla Group Provider provides or arranges for Covered Services. Crorzp azid Gro2zp Provider understand that Z~wiCU's deterrninatians, if any, to deny payments for services ~~rhich 1~AIC~) does not deem to constitute Covered Services or which were not procrided in zzccordanco with the requirements of this Agreonaent, the Attachments or the Payer requircrz~ents, are adn~inistrati~~e decisions only. Such a denial does not absolve Group Providor ~~f Group Provider's responsibility to exercise independent judgment in Covered Person treatment decisions. Nothing ur this Agreerzrent is intended to interfere with Group Provider's provider-patient relationship avith Covered Persons}. 3, I2_ ~Co~ered Person Communication. Group or Group Providor shall obtain Payer and. C,p's approval for Covered Person cozrzrzrunication as required by the Payer Contract and applicable State and federal law. Nothing irz this A~-eerrzent shall be constnred as limiting Group Provider's ability to corrzrnunicate with Govored Porsoais with regard to quality of health taro or n~odical troatrrzont docisior~s or alternatives regardless of Covered Service lizx~.itations under the Payer Contract. 3.13. Cn~eration tivith MC(] Vendors. Group and Gz-oup Provider acknowledge that 11~1CQ directly and indirectly contracts with other participating providers for services that are rendered under this Agreement for the benefit or at the request of Payer, as 1'ayor doerns necessary to promote the quality and cost-effectiveness of services provided to Covered Persons. During the term of this Agreement, if NICC) elects to provide Covered Services via a third party vendor's n~tGVorl{ for exarrzple, a b~;havioral health, dental or vision voridor's network}> Group sha11 be notified in writing of lIr1CQ's decisinrx sixty ~fi(}) dziys prior to in'zplernentation. ~,'Vithin ~#leen X15} days following receipt of written notificatioza from MG[] of its election to use such vendor, C7roup anti MC© agree to diseuss Group's and Group Providers' continued participation to provide the services offered by the vendor's net~,vnrlc. 1vICG vY•ill afford Group ~vitlz the opportunity to ~i) match the reimbursezxaent amounts offered to N1C[) by the vendor; or (ii} participate izr the vendor's network assuming the Group Providers satisfy the vendor's participation criteria. 1n the event Group elects not to match the rein~bursomont offered by the vendor or participates irz the vendor's network, ~~CC~ may elect to ~i} continue Group and Group .Provider's participation under the towns and conditions set forth herein; or (ii} cc~r~tract with the vendor. Nothing contained hereua shall limit 1v1Cf3's ability to contract with a third party for the provision ofutili~ation review or quality managernont services. 3.1~. f7is ara emont Prahibitiozi. Group and Group Provider agree not to disparage MCp in any manner during the term of this Agz-eeznent or in connection with arty expiration, WA Group base 2.22.12 Page 6 of35 terzr~.inatiou ox nou-reue~val of this Agreemerst. Croup and Group Provider shall not interfere `'With MC[~'s contractual relationships including, brit not limited ta, those with. other Participatixrg Wealth Dare Providers. hrothing in this provision, hou~~ever, sha11 be construed as lia~itizag Grozlp and 'Cnra€zp Provider's ability to infornx patients that this Agreement has beau ral~ ubli~ or the asteinforzxzatiorz tregardingeathar hc~ ltl~ plan Provider to the geue and Crau Pravz~der's usual procedures, provided that no such consistent with GrnuP P promotion or advertisement is directed at any specific Covered Person ar grozap of Covered Persons. in.ation. Group and Group Provider will provide services to Covered Persons 3.15. l~ ~nd~rzzn~~- withaut discrirraination on account of race, sex, sexual orientation, age, color, religion, national arigiu, place of residence, health status, t~~pe of Payer source of payment, physical ar mental disability or veteran status, and without regz~rd t such Covered Persons' enrollment with itilCC~ as a private purchaser of coverage ar as a participant za phblicly ~zna~riced pr©~u-arras of health care services, and will ensure that its facilities are accessible as re€luired by Title Ili of the Americans 'With Disabilities Act of 1 ~r}0. C~ronp and .Croup Provider recognife that as a governmental contractor, MCC] is subject to various federal laves, executive orders and regulations regarding equal opportunity anal af{'rrmative action, wb,iel~ also may be applicable to subcontractors. 3. i ~, ~rittcn ~lotce- Group ar Croup Pr€~vider shall give written notice to ~ICf~ of: {i} azay action irivalving Group Provider's hospital privileges or conditions relating to Group Provider's ability to adroit patients to any hospital or inpatient facility, iii} any situation which develops regarding Croup .Provider, when notice of that situation has heart given to the Mate agency that licenses C~raup Provider, ar any other licensing agency or board, ar ,any situation involving an investigation or corrzplairit filed by the State agency that licenses pup Provider, ar any other licensing agency or board, regarding a cat~tplaint against Group Provider's license; viii} when a change in Group Provider's license to practice medicine is affected or any farm of reportable discipline is taken against such license; (iv} suspension ar exclusiart under a federal health care program., iztcluding, but not limited t, Medicaid; (v) any government agency request far access to retards; err ~~'i) any lawsuit ar ciairn filed. ar asserted against Cratzp Provider alleging professional malpractice, regardless of whether the lawsuit or claim involves a Covered Person. In arty such instance described above, Group or Grarrp Provider trust notify iV1CC7 in tivriting within ten { l0) da~~s ~azn thy: date Group or Group Provider tzrst receives zaotice, whether. vrritten or Drat, with the exteptiort of those la~,vsuits ar claims which da oat involve a Covered Person, with respect to r~vlticl~ Group ar Group Provider ltas tFtu~ty (30} days to notify MCC- t5e of Marne. Group and CJraup Provider agree that `~1C0 rtaay use CTraup Provider's 3.17. ~<_ --~---~ bane nztrriber, type of practice, and an indication of CJraup Provider's name, address, p willingness to accept acklitional Covered Persons, in MC(=7°s raster afParticipating. Health Care Providers and marketing rrtaterials. S,~~A Clroup base 2.22. t2 Page 7 of 35 3.1 ~. Medical ~Office ~ ace. Group agrees that the medical office space at tivhich Covered Services are provided hereundLr shall be maintained accordance with applicable federal and Stag laws. AAt 1 ~Ll.e.[J 1 M CQ1VU1(Plv~r~l~ClE W~Tf"I Lr"~'W Group, each ~rQZ-rp Pro~ridor azzcl l~~C:C} agree that cacti party shall carry out its obligations in accordance with terrrzs of tltie Payer Contract, inclz:tding but. not limited to the provisions set forth on the Payer Conta~act Attachment attached hereto as 1~`x~iib~ 1, and applicable federal ;ind State laws and regulations, includirr.g bzrt not liznitod to 1~lIPAA. lf, due to Group or Group Provider's noncompliance with law, the Payer Contract or this Agreerrzez~t, sanctions or perr~lties ar-e imposed on MC[~, iVECa rxaav, in its sole discretion, offset sanction or penalty amount; against any amounts due Group or Group Provider Born MCO or require Group or Group Provider ~to reiirrl~urse MCA) for the amount of any such sazaction or penalty. ff Group subcontracts °~~~itl-~ such ether providers and facilities for serv=ices provided hereunder, Grorrp shall ensure that. such providers and facilities also comply with the requirerr~ents set forth iz~ this Agreement azad applicable federal and State laws and regulations. ~~R"~'iCli.,E V C'k~AINiS Sti'Bi1~ISSfUN i'Rt7C>E~SI1~+1C~ Al~l7 Cf31'V1Pf<111TSA'I'1C3:~i ;.1. Maims or l~;ncourrter St~bzxlission, ll!1CC~ shall not be required to pay Group's or Group Provider's claims,. and 1vfCC] shall not requiz~c Payer to pay Croup's or CTroup Provider's claims, unless Group or Group Provider, as applicable, submits such clairris in accordance v~rith Payox requiz-ements, if applicable, based on Group and Group Provider's con7pensation arrangement, Group or Croup Provider shall submit encounter data to 1'ayor in a tirraely fashion, in accordance ~vitla Payer requirLZnents. 5.~. ~c~rrrpezlsatic~n. 1vfC~ shall pay, and shall require, Payer to pay, +Clean Claims subzrzittcd by Croup or Group Provider for Covered Services provided tcz Covered I'crsons in accordance w°ith the applicable Compezisation Exhibit attached hereto as I;xhibit~~, less any applicable copayments, cnst~shaz-iz~g or other amounts that are the Covered Person's financial responsibility. Group and Croup Provider agree to accept such paymc;nts as payment in full for such Covered Services. ~,3. ~'inanci~l fncenti~aes. Nothing ire this rl,greemezrt shall, or shall be construed to, create any financial incentive for Group or Group Provider to withhold 1vledically Necessary ser~~ices. 5.4. C©w~'ered Person l~lald Harmless, A, Group and Group Provider hereby agree tlrat in no event, inelrzdu~g, but not limited to nonpayzrrent by Payer, Payer's insolvency, ar breach of this Agreement shall Cirorzp or Group Provider bill, charge, collect a deposit frorrr, seek ~,~~~, Group base Z.L?,12 Page ~ of35 con~pensatitaxx, remuneration, or rei~xabursemerit flanl, or have. any recourse against a Cowered Person or person acting on their behalf, other than Payer, far services pr~,wided pursuazat to this Agreer~nent. phis provisiozr shall not prohibit collection of any applicable copayments or other amounts, which. 'have not otherwise been Paid by a primary or secondary carrier in accordance with regn-latory standards for coordination of benefits, from Cowered Persons in accordance with tl~e terxx~ris oftlie Covered 1'ersou's health plan. B Group and Group Provider agree, in the event of Payer's insolvency, to coiitiraue to provide the services promised in this Agreement to Covered Persons of` I'~CC~ for the duratiorr of the period for which premiums on behalf of the Covered Person were paid to Payer or until the Covered Pcrsan's discharge from inpatient facilities, whichever time is greater. C l~otwitlistandixig any ether provision of this Agreement, nothing in this Agreemerrt shall be construed to modify the rights and benefits contained iia the Covered Persons benefits for services. l~either Group nor Group Provider may bill tl}e Covered I'ersozi for Covered ~~ except for deductibles, copaynr~ents, or c:ainsurance} where Payer denies Services payments because Group or Group Provider, as applicable, has failed to corriply with floe terrris or conditions ofthis agreement. ~. Group and Group Provider further agree (i} that the provisions of (!~), ()v3}, (C), and (D} of this subsection 5.4 shall survive termination of this r'~greement regardless of the cause giving rise to termination and Shall be construed to be far the benefit of Covered Persons, and (ii) that this pra~~ision supersedes any oral ar written. cai~trary agreement novr existing nr hereafter entered into between Group or Croup Provider, and Covered Persons or persons acting on their behalf, F. If Croup and 'Group Provider contract with other providers or facilities who agree to provide Covered Services to Covered Persons of MCC with the expectation of receiving payment directly or indirectly Born Payer, such providers or facilities must agree to abide by the provisions of ~A~, (l3), (C}, ~l~), and {~'~ of this subsection 5.~. Group and Gr°up providers acknowledge that willfully collecting or atteriipting to collect an a-~ioiiilt from a Covered Person knoE~~ing that callectian to be in violation of this Agreement constitutes a class C felony under RCW 41~.80.f]3~0(5~. 5.5. U~~e~ a~ vm~~t ~~c~svery by Payer. ~o the extent applicable by 1a4~', the parties sl~ail 1 with the following provisions of 1~CW' 4~.~3.6(Jd~, as amended. i'v1C~fl~, Group and comp y Group Provider ~~~° ~~ i ~CC~dis the P~yor underltlt si Agreements andl shall ber ode apply to ~11t_,O ~ipplicable to 1'ayor ~}' lv1C~} if MCt) is not tl~e Payer under this r~~;reetnent. 'v~'A Group base 2.2.12 Page 9 of 3 A. Except in the case of fraud, or as provided iia sut~sectians (f3) aaad (Cl of this section, Payor naay not: (i) request a refiancl f~-arra Group or Group Prac~itler of a payment preciously made in satisfy a clam unless it does so ira ~vritira~l ~vitliin twenty-four months afiler the date that tl~,e payment i~ras rxaade; or (ii} request that a contested refund be paid any sooner than six (6) months after receipt of the request. Airy such request zraust specify why Payor believes Group c~r Graup Provider owes the refund. If Group ar Croup Pnc~vider fails to contest floe request >l~ writing to Payor ~~=ithin thirty (3tl} days of its receipt, the request is deemed accepted and the refund must be paid. g. Payor may not, if doing so for reasons related to caordinatiora of benefits with. another carrion or entity responsible for paymezat of a claim: (i) request ~ reliund from Group or Group Pravicler of a payanent previously made to satisfy a claim unless it does sa in tivritirrg within thirty (3[7) months after the date that the payaraerat was made;. or (ii} request that {i contested refund be paid any sooner than six (6) months atl:er receipt of the request. Any such request must specify wlay Payor believes that Graup or Group Provider a~~•es the refund, and incl~~de the naaxie and ra~ailing address of the entity that has primary respoa~asibility far payrraent of the claim. If Graup or Group Provider fails to contest the request in writing to Payor within thirty (~~) days of its. receipt, the request is deearae~l accepted and tl~e refund must be paid. C• A carrier Xnay at any time request a re£tand from Group or Group Provider of a payment previously rraade to satisfy a claim it (i} a third party, iracludirag a gavernrnent entity, is found responsible for satisfaction of the claim as a consequence of liability irraposed by la~v, such as tort liability; and (ii} Payor is unable to recover du•ectly from the thud. party because the third party bas either already paid or will pay the provider for the health services covered by the claim. ~. a~lotl~aing in this section prohibits CTroup ar Gr©ttp Provider from claoasing at any time to refund to Payor any ,payment previously made to satisfy a claim. ~. Far purposes of this section, '"refund'" means the return, either directly ar through an offset to a future claim, of same or all of a payment already received by Group or Group Provider. p. This section neither permits nor precludes Payor from recovea•ing from a subscriber, enrollee, or beneficiary any amcaunts paid to Graup or Group Pravic~lcr for benefits to which the subscriber, eau-ollee, or beaaeFciary was not entitled under floe terms grad conditions of the health plain, insurance policy, ar other benefat agreement. Cr. This section does not apply to claims for Covered ~erviees provided through dental-onlyr health carriers, health care services provided under Title VIII (lvledicare) of the social security Act, or 11!Iedicare saapplemental plans r~l,~lated under Chapter ~~.6~ I~C:W. ~.6 Q~,er ~a menu Reca~~ery by Ciraut~ ar Grain Provider. To the extent applicable by Iati~°, NICG, Group and Graup Provider shall cramply with the following provisions of RC'4~V LVA Graup base ~.22.1Z Rage X it a f 3 4~.~1~.~p~, as amended. MCQ, group and Croup Provider acknowledge and agree that re uirement of "paYor" hereunder shall apply to MCA directly if lv1CC) is the Payor any ~ een-~ent, and shall be made applicable to i'ayor by MCCC~ if MCfl is zaot the under t'dis mgr regiment, Payer under this Ag ~, Except in the case of fraud, or as provided in subsection (l3} of this section, Group or Crroup provider may not: Vii} request additional payrment from Payer to satisfy a claim unless Carp after tl~e date the ~ he cclaim was~den~ dfor payment lintcnd~dtt four (?~}} rxianths satisfy the claim was made; or iii request that flee additional payment be made any sooner than six (6) months after receipt of the request. Any such rerluest must specify why Graup car Group Pravider believes Payor o~~'es the additional payment.. ,Cramp or Gr~?up Provider may net, if doing so fog- reasons related to c:e~ordiziation 13. of benefits with another carrier or ea7tity responsible for payment of a claim: (i) rc,~~.iest additional payment from Payer to satisfy a claim unless Group or Crroup Pravider does s® i~ writing to payer within thirty (30) mcir~ths after the date the claim was denied cir payment intended to satisfy the claim was made; ©r (ii) request that the additional payment be made any sooner than six ~d} months a;~er receipt of the request. Any such request must specify why Ga~oup or Group provider believes Payer owes the additional payment, and include the name and mailing address of any entity that has disclaimed responsibility for payment of tike claim. C. Nothing ~ this section prohibits Payor frorrz choosing at any tune to rr~al~e additional payments to Group or Group Provider to satisfy a claim. D. This section daes not apply to claims for health care services provided through dental only health carriers, health care services provided under 'Title XVill (Medicare} of the Social Security Act, or Medicare supplemental puns regulated under Chapter ~18.661~CW. 5.7 Com fiance with Billing and Claims Pa_yrne~t; Standards. `1`o the extent applicable by law, MCC, Group and Group Provider shall comply °~vith the following provisions of '4~AC 24.43-3~1, as aancnded. MCG, Group and Graup Pravider acknowledge anti agree that any rcciuirement of "payor" hereunder small apply tei M.C[3 directly if MC:(~ is the Payor under this agreement, and shall lie made applicable to i'ayor by MCC if MCC) is not the Payor under this 1lgreernent, ~,. fcir Covered Services provided to Coy°ered Persons, Payor shall pay Gro~.ip or Crorip provider as soon as practical, but subject to the following minimum standards: (i} Vi~iety-five percent cif the rxionthly volume of Clean Clairrrs sliail be paid witl~ti~z thirty (30} days of receipt by the responsible carrier or agent cif payer; and G'v`r'1 Circ3up base 2.??.1 ~ Page X l ot` 35 iii} ~linety-eve percerbt of the monthly volurrze of all claims shall b;; paid ar denied within sixty days of receipt by the resl~~rnsible carrier ar agent of Payer, except as agreed. to iar w°rititrg by the parties an a claim-by-claim basis. Per the purlaoses of this suction, the receipt date of a claim shall be tl^ie date that the resporrsiblc carrier or its agent receives either written or electronic ~aatice of the claim. Payer shall. establish a reasonable method far confzrmirrg receipt of clairrrs and responding to Grcpup's ar Group Provider's in~luiries about claims. T3. In the event I'ayor fails to pay claims within the standard established zrnder Section 5.7(A} of this Agreement, I'ayar shall pay interest oar arndenied and unpaid Clcarr Claims that are ra~are than sixty-one ~{1} days old, uzrtil Payer meets standard rinder Section 5.7(A}. Interest shall be assessed at the rate cif one percent (I~/~} per nxonth, and shall he calculated z~orztl7ly as simple int~.rest; prorated #'or any portion of a month. I'ayor shall add the interest payable to the amount of the unpaid claim r~vithout the necessity of Group or Group 1'ravider subzraittir7g err additional claim. Any interest paid under this Section 5.7113) shall not he applied by Payer to a Covered Person's deductible, capayrrrent, coinsurance, or any sizuilar obligation of the Cavared I'ersan. C. 4~~hen Payer issues payrrzent iB~ Group°s ar Group Prflvider's azrd the Covered Person's names, Payer shall make claim checks payable in the name of the Group ar Croup Provider, as applicable, fret and the Covered Persozr second. p. l7enial of a claim nrzzst be crrmrzrunicated to Group or Group Provider and roust include the spccili.c reason wlry the claim was denied. If tkre dezrial is based upon medical necessity or similar groutrtls, thezr 1'ayar, upon request of Croup or Group Provider, rrbust else promptly disclose the supporting basis for the decision.. Per ~:xample, 1'ay~3r must describe how the clainr failed to meet medical necessity guidelines. ~, F'ayor shall be responsible far ensuring drat any person acting on behalf of or at the direction of Payer ar acting pursuant to 1'ay°or's standards dr requircnrents complies with the billing azrd clairxr payrrrent standards set forth in this Section 5,7. P. The standards set forth irr this Section 5.7 da not apply to claims about which there is substantial. evidence of liraud or misrepresezrtation by Participating Health Crare; Providers or Covered Persarrs, or instances where I'ayor has not bear granted reasonable access to infornration under Group's or Croup Proviciler- °s control. A~IZ'1'ICLI~, VI ~t_F_.+C[1I~17SfrNSi'p~:`I'I~3i~ S ~.1. Advance Directives. Cirortp and Croup Provider shall docurneYrt irr the Covered Pz;rsora's rrzedical record ~°hether the Covered Persarr has executed an advance directive, and Group WA Group base ?.22.T2 Page 12 af~35 and Group Provider agree to comply with all federal and State. laws regarding advance dixectivres• Records Group and group Provider shall maintain records related to services provided to ~.2, Covered PersQ~, including but not Tirr~ted to a complete and accurate permanent ine ica. record, for each Covered Pew lode irr drat re ~ord al ~ epnprts fromeoth rdprov tiers and all this Agreerzlerit, and sh documentation required by applicable law, regulations, professional standards and Payor requirements. Group 'shall further provide such medical., finasrcal acid administrative information to I'~t[C'~J and Mate and federal government agencies as may be necessary for compliance by MCC7 With State and federal levy and accreditatioxi standards, as well as for the administration of this Agreerrient. MCA] sha11 have access at reasonable times to books, records, and papers of the Group and Croup Provider relating to the lrealtlr care services provided to Covered persons for ~C:overed Services. Medical records provided to M,C[7 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 MCQ relating to the health care services provic~led to Covered Persons for Covered Services, hreliiding without limitation MC+O's denials of Group's or Cxroup Provider's claims. 6.3. Consent to Release Ivledical Records. Group Provider shall obtain Covered Person authorizations relative to the release of medical information required by applicable lave to provide NICO or other autlrori~ed parties with access to Covered Persons' records. ~.~. Access. Group and Group Provider shall provide access to ~Csroup and Group Provider's records to the following, including any designee or duly authorized agent: ~,. Payors, during regular business hours and upon prior notice; l3. appropriate state and federal authorities involved. in assessixrg the quality of care or investigatiirg the grievances or corriplairats of Covered Persons, and C. accreditation agencies. Group and Crroup provider shall provide copies of records to any of the aboveWlisted requestors at no expense to such requestor. ~.~, Record Trairsfe~r• Group and Group Provider shall cooperate !n the proiript transfer of Covered Persons' iriedical records to other health care providers. Neither Croup nor Group Provider shall charge for the cost of duplication in connection with such transfer. V+Ta Group base 2.22..12 Page 13 of 35 6.6. C}n-Site Irzst~ectc~z?s. Group and Grazzp Pravider agree that medical office spice ar its facilities, as applicable, shall be rraaintained in accQrdarzce with applicable federal and State regulatory requirements. Graup axzd Group Provider shall cooperate za c~rz-site inspections of zxzedical office space by ~vICG, Pa.yar, autharired government officials, and accreditation. badzes. Graup and Graup Pravider shall caza~tpile any anal all inforra~ation in a timely manner requ~ed to evidence Graup and Graup Provider's campliaixce tivith this t~lgreement, as requested Icy such agency(ies}, ar as otherwise necessary far the expeditious completion of such on-site inspectiozz. ARTI:C~:LF VI1i >fNSUI!;L41~C>I, 7.1. Grazi and Grarzp Pravider Insur~rzce. T?rtriz~g the term al~ tlxis ~greeznent, GraYtp azad Graup Pravider shall maintain policies of genez-al and professional liability inszzraizce and other insurance that. are necessary to insure Group, Graup Provider, and any other person providing services hereunder on Graup and Crraup iE'ravider's behalf, against any claim(s) afpersonal injuries ar death alleged ar caused by C:xroup or Graup Provider's performance under this Agreement. Such. insurance shall izzcliide, but not be lirizited to, tai) or prier acts coverage necessary to avoid ang~ gap in coverage. Insurance shall be through a licensed cam-ar, anal in a rniniurn amount of one million dollars (~ 1,~7~O,Q(1[3) per accurrerzce, and have an annual aggregate of no less than three rrzillion dollars (`~3,OI}[l,~ClC3~ unless a lesser anaaunt is accepted. by I~I~G or where State law zrzandatcs otherwise. Graup and Group 7ravider will provide 1v1C:(~ with. at least #ifleen (15} clays notice ol'sizch caz~cellatiori, naz~- rene~val, lapse, or adverse material rrzadi#icatian of coverage. ~1poi~ MCC)'s request, Group and CJraup Pravider witl furnish 1'vlC;~a with evidence of such insurance. ~.~. C7ther lnsurance. ~1CG, Graup and Graup Provider shall maintain in full l:arce and effect appropriate workers caznpensation protection and unerriployznent uzsurance as requiz-ed by lam=. ~~.ItTI[~Lla. VII.[ 11~iU1•i'.PItT~II~ IC;~~TI~7i' ~.1. ~,,I~p lnderr~niiicatian. Group and Group I~ravider agree to indenuri#'y arzd bold harzz~zziess (and at i`~C:~''s request defend) 1VICC~, its Affiliates, officers, employees and agents tram and against any and all clairrrs, lass, damages, liability, casts, expenses (including reasonable attorney's fees}, judgments, or obligations arising ~~orrt or iza conriectioiz ~vitlz third party claims alleging any negligence oi- «therwise wrongful at~t or amissiaris of Crroup anal Graup Pravider, its agents or employees in the perf~rmaz~ce of Graup and Graup Provider's obligations under this ~"~green~ent. 4~4'~ Crroup base x.22.1 Z Page 1~ of 3s and Grou _ Provider ln~lemnifcatiaz~. I~SG® agrees to indemnify az-zd bald harz~aless 1s.2. ~~au -~~"~~ Provider's re vest defend} Group, Grnzbp Provider, its officers, (arid at Group ar Grasp '~ errrployees anal agents fraxxzl and agaixist any and all claims, lass, damages, liability, costs, reasonable attorney's fees}, jzzdgments, or abligati©ns arising Barn ar expenses (including ~ claims alle in an ne li ence or otherwise wrongfitl act or in cor~.nection with third p y g g Y g g omission of 1t~1GC), its agents or employees in the performance of MGa's obligations under this Agreerraent. ARTIC~~1~ IX )IISPU~`E ~S(ILCI'T~ON Izxform~l Dzs u_te lies©lutinn. In the event that Ciraup ar any Group 1'ravidar is aggriav~d ~.1. by the actzans of ~G©~ Gra IvIC© fail tar~r~nt~~r re ect such~a request within hirty (ga} oast far Tevzew. if g J varitte'u req Grou ar Grou Provider may proceed as if the eomplaix~t lzad been days after it is made, p P rejected- ~ caxrzplaint that has been rejected by N1GC~ zrkay be subrr~itted to nonbinding mediatiarz in accordance ~~ eh enlt~that tlvlGC3ezs$a ~ r~evedz by the actions of Group ogr written notice to ~iIGC?. I gg Group provider, the parties shall attempt to resolve the dispute through gaud faith any negotiatiaris between designated representatives of the lvlGC~ and Group that have authority to settle tlic dispute. if the matter has not been resolved within sixty ~~iJ} days of the request for negotiation, IvIGC) may initiate rznn~binding mediation iza accordance with the. ~ediatian section of this Agreement by providing vVritten rsotice to Group. ~atwithstanding the above,lVlG(] must render a decision oxz Group°s ar Ciraup Provider's complaints within a reasonable tinne for the type of dispute. In the case t~fbillirzg dispzrtes, 1V1GQ n~:ust render a decision within sixty (b~]} days of a complaint. 9.~.- iuledn. In the event the informal dispute resolution process set forth irz Section 9.1 is exhausted without resolution, either party wishing to pursue the dispute shall szzhmit it to a non-binding mediation proceeding, which shall be attended by both parties and ti~~hich, unless both parties agree otherwise, shall be conducted by az~ independent rxzediatar mutually selected through the American Health La~~ryers Associatiozi wbn is familiar with z~,anaged health care. the costs of the mediation shall be shared equally by all parties to such mediation. Each party shall bear its own costs far participating in the mediation proceeding. If as a result of the mediation, a v°oiurrtary settlexrzent is reached, the parties agree that. such settlezrzent shall be reduced to writing. Except as reclzzired by la~v or to evidence carrzpliance with the terms, az~y such settlezraent agreement shall remain confidential and shall notub ~di~c~lo~ ble~ernedies ~nder appl gable law t no settlement is reached, the parties maY p 9.3. , Lzmtatinr_ Per'Q~- with aspect to any dispute madiated hereun~i~r, in nc~ event may either party file an action ~ a catirt of canapetent jurisdiction more than one (l} yeaz- follo~~'ing tl~e termination of a znediatioz~ proceeding held to mediate such dispute. 4?~'A Group base 2.2.1? ['ale 17 ~f ~5 A]~TICL_~~ X T"EItM AN1Cl 1>~,R1~~T~`AT"C)1~' lf~.l. Tez-~~. T11is A~re~rrzomt shall 1?a~ve an aizzitial tez-am of tl~_ree (3) years, camxrzeaacin~ cn the effective Date. Tllereal$er, this Agreement shall automatically renew for tez-ms of one (l } year each. Not~vithstandu~g the foregoing, this Agreement nzay terzxrinate in acUordance with the Terrzji~ation sections below. l Ct.2. `Fer-rninatian. o~ A~r~eznent. 'T'his Agreement bray be terniin~~teri under arl4 of tl•se following circumstances: A. ley either party upon oxie hundred eighty ~l€'sQ} days prier written notice; F3, gy either party upon ninety t)~} days prior written notice if the other party is in material breach of this Agreement, except that scrch terinrration shall rrot t•rlre place if the breacl~r is cured within sixty ({~~} nays following the writtezY notice; C. In3txrediately upon written notice by MC{7 if there is irrrminent harm to patient health or fraud or rraalfeasance is suspected; ~. lrnrr~ediately upon written notice by either party if the other patty becorzres insolvent or has barzlcruptcy proceedings initiated. against it; ~. lmznediately upon written notice to the other paz~y if MCC] 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 far the provisir~tz of Covered Services ia~ the State; F. lz~hmediaiely upon written notice by 1!~~ICC7 if Group or any of its agents or managing erxrployees is convicted of a orfrrzinal offense related to that person's in~Jolvement irr any program under Titles ~Vlll, ~1X, KX, or 1 o f the Social Security .Act or .has peon terminated, suspended, barred, voluntarily withrirawzz as part of a settlement, or otherwise excluded frorrx any program under Titles ~'~'T1I, XIS, or ~ of the Social Security ~^,ct; G. rxzux-aediately upon written. notice by MCG if Croup or Croup Prouislor fails to ad£zere to MCG's eredentialing criteria, irrcludizig; but not lirrzited to, if Group or Group Provider (l} loses, relinquishes, or has materially affected its license to provide Covered Services in the State, ~~} fails to coanply with. tl'ie insurance requirements set fartl~ in this Agxeeznent; or ~3} is convicted of a criminal oft~nse related to irawolvement ~r any Medicare or Medicaid pz-agran~ or has been terminated, suspended, barred, voluntarily ~vithdra~vn as part of a settlement agreement, or othcr`~n~ise excluded. from any Medicare or ?bZedicaid program;. or 1-1. Fay ivlCC~, in its sole discretion, upon. ninety (90} days prior written notice if' a substantial number of the Group Providers of any category Eby practice area., `~'A t:rroup brio ,?2.12 Pale 1 ~i crf 3 i_nciudi-ng any sepaxate category of Graup primary care physicians) participatin; as of the Effective L3ata of dais Agreement have their participation under this ,~~greerrzent terrniaaated, or 1. if Group is ~ default of its paymezat obligations to any Group Providers vaith respect to $aryiCes rendered under this Agreement and fails to cure such default within ten ~ l p) days of natificatioza by MC'[3, lvtCO may (i} elect to terminate this Agreement pursuant to this Section 10.~(B}, and (ii) during the time between IV~CG~'s election to terxzainate anal the affective date of tez-minatian, 1'vIGO may direct any and all payzxaexzts drae Group hereunder directly to Group Providers. Such payments shall be Made, at .i~'C(-Q's aleatian, either in accordance v~~ith the reimbursezaacnt arrangements sat. forth ~ Group's provider agreements with Group Providers or in accord=zaace with ~Gp's fee schedule ~ effect at the tune of service. MC=Q's or flee apialicalr}la l'ayer's payznant obligations to Graup hereunder shall be reduced to the extent of such payments. 10.3_ ~~.QUp Irovider Pa~t~cipationfNo~i~e tc~_ 11~1C+C~. Natlzir~g herein shall hz azzy way limit, abrogate, or interfere with k~lCO's right to selectively c;xclude, reject, suspend, and,~or taz~rninate any individual Group Provider from further participation under this Agreement at ~~,(~'s sole discretion. Such termination of an individual Group provider shall relate solely to pa-rtiaipation u~'der this Agreez~nent of the particular Group Provider and this ~graament shall rcmaiz7 i~ full farce arzd effect with the respect to Group and the cattier Group Providers. Group shall provide NiCQ with ninety {9Q} days advance written. native of the termination o f, or amendrrsant to, any agreement between Group and a Group Provider by wlzicla the Group Provider would cease to provide Covered Services to Covered Persons under this p, .a~rnant. Notwithstanding the foregoing, in the event that the Graup Provider's participation under this Agreement is terminated far cause and Graup cannot provide ninety ~`~0} days advance notice of such termination, C~rc~up shall notify 1vlC[~ in uniting of snub terza~inationte~ rationpossible but na later than five (5) clays after Graup obtains ~ourladge of such a r~hii~atans U1aan Termination. Upon termination, the rights of each party 10.x. Ri~~~'ts d~u ~~ hereunder shall terminate, provided,. however, that such actioal shall not release the Graup or Cfroup Provider or MCO of their obligatiozas with respect to: (a} payments accrued to Graup ar Graup Provider prier to termitaatian; (b) Graup and Group Provider's agreement rat to seek cozrzpansation frnm Covered Persons for Covered Services prior to ternainatian; grad (c} cazaapletian of treatme~at of Covered Persons tivho are rece~vzrzg care until continuation of floc Covered Person's care can be arranged by 1v1CG as determined. by the medical l7iractor or as rewired by applicable law ar the Payor Ctontract. Services provided durizag continuation of care shall be reimbursed in accordance with the terms of this Agrueznent. MCO shall make a goad faith effort to assure that written. notice of a tecrmination, within fifteaza (1 ~) business days of receipt or issuance of a notice of tcr~nnation hereunder,. is provided to all Covered Persons 4vho are patients seen on a ~ r~ Group base x.22.1 ~ Pale t 7 of~ 35 regular basis ley Group or Group .Provider, irrespective of wlietl~er the ternainatio:~ was for cause or rvit}~out cause'. Yf).~. Notification o~ Grou~~~ooialtw I~rovid~r Ten~ination. Crroup Specialty Providor acknowledges the right of MCC) to ir~orrn Cowered I'ersoz~.s of Crroup Specialty Provider's terrninaton. In the wont this Agreement is tertnit~ated, 1~~IC© shall provide wrttwn notice tivithin tllirt~° (3~} business days of receipt, or issuance of a notice of termi~~atit}n, to all Co~~erecl Persons whn are seen on a reglzlar basis by Group Specialty Provider, regardless of~ wlletl~er the terrr~ination was for cause or without cause. l p,5. S~xrvival of~ (]~b~atio~s. ,Any obligations that cannot be fully performed prig to the termination of dais Agreement including, but not lirnitcd to, obligations in the following provisions set forth iaa this Section, shall sua-vive tl~e termination of this Agj~eez~aent: Section 3..14 {Disparagement Prohibition; Article IV (C;ornpliance ~~Vith l.~aw}; Seetic~n ~.~ (Covered 1?ersen P[old ~larrnless}; Article VI ~Recordsllr~spectior~}; 1~.rticle VII Insurance}; Article VdII (Indernnificaton); Article I~; (Dispute I~esolutior,); Suction 1 ~.4 (fights and Qbligations ~Ipon Terrrlination~. 1~.7 Primar Care Provider Fti~hts and i7bli ag tions=L3taon Termination V~Tithout Ca~~s~. If Group or Group Provider is a primary care provieler, in the event this Agreement is ter-~ni_nated without cause, ~C~ shall reimburse, pursuant to the terms of this Agreement and relevant Attachrnernts, Covered Services provided by Crroup oa- C7roup Provider for at Ieast sixty (~4~~ days following notice of tenr~ination to the ez~-ollees or, in group coverage arrangements involving periods of open e~.~roltrnent, only until the encl of the next opera enrollment period. In such event, Croup's or Group Provider's relationship 4vitl~ 1VICC) must be continued on the same terms and conditions as those of this Agreezrrezat, except for any provision requiring ghat MC[J assign new enrollees to Group or Croup prowider. 'I"he parties acknowledge and agree that the provision sot forth in tlYis paragraph shall a1~'p1Y with respect to arrangements in which Gre~up's or Group Provider's contract with. a subcontractor of 1V1Ca, pursuant to which Croup or Croup Provider agrees to prow ide Covered Services to Cowered Persons, is terminated without cause. ~~it'I'ICLI~/ K~ IyTISCE I,I.~"~NE±,t~CIS 11.1. ~elationsh~? vf~ Parkes. The relationship among the parties is that of independent contractors. None of the provisions cif this Agreerraent are intended to create, or to be construed as creating, any agency, partr~erslaip, ~}oint venture, ernployec-erriployer, or other relationship. 1 {.~. Gontlicts Between Certain Documents. In the event of any conflicts between. this Agreement, or any Attachrrient hereto, and. the applicable Payor Contract with respect to what services cor~titutc Covered Serwiees, the Payor Contract shalt control. WA Group base L.2?-1 ~a~e 18 cif' i 3 1 l .3. Assi zirr~ent' I7ele atia~n of ~ ~ shallTnot b e ass ~ned~ss bleu delegated ~artt ansf~rreci by and be personal to G p {gaup ~~rithaut the prior written consent of Tv1C~. T°he headings of the sections of this .Agreement are inserters merely far the 1 i .4. Hea__~ ~. purpose of conveniezace and da eat, expressly or lay implication, limit, defzne, ar extend the speCi~c terms of the season sa designated.. 11.5. Governin ~,a~r. ,Ail rr~atters affecting the intez-pretatian of this Agreerxaent and the rights and obligations of tla~= parties hereto shall be governed say and construed in accordance with applicable federal and State lams. 1~.~. .l,h~r~~r~l3eraeficiar .Except as specifically provided herein, the terms and. conditions of this Agreement shall be for the sale and exclusive benefit of Group and ivICC~. l~iathing ress ar implied, is i~xtended to be construed or deemed to create any rights ar herein, exp third party. remedies in any . A~-n,~~drrient. This Agreement, ncludixag all Attachments, may be amended at any tame by 11.7. reerrrent of the parties. This Agreement and any of its Attachments may mutual written ag also be amended by N&CC~ faarziibing Group with any proposed arnenriments. ~t_Inless Group objects in writing to ~~~d theeamenb t~g l~iatwifhstanditixgytheotifaregairrg, sthis be deemed to have accep e Agreement shall be automatically amended as necessary to caznply with any applicable State ar federal law or regulatiarx and applicable provision of tlae 1'ayor Contract. Entare P, n-eemer~t' This A~eeme~`t and its Attachments contain all the terrr-s and 11 •S• ~-~:"Y~ on h tlae artier and supersede all oti7.er a~~-eements, aral ar aanditrans agreed up y p otherwise, of the parties hereto, regarding the subject matter of this Agreement. l 1.9. Se~~ e~~~~~ the 1~``~aliclity ar unenfarceability of any terms ar prati°isians hereof sl~allzn na way affect tlxe validity or enforceability of any other teens ar provisions. '1~aiver The waiver by either party of the vicalatian of any provision or obligation of this 1 l.l(l- ~~.-~-- A~•eCment shall not constitute the waiver ai`any subsequent violation at`thc saYx~e ar other provision. ar at~ligation. 11.11. ~c~ti~e5. r^~ny notice required to be given pursuant to tlae terms and provisions hereof shall be in writing ar~d our%r service~addresseds follo,,v~ receipt requested, postage prepaid, ar by° recagnzzed To 1vlCC~ at: Coordinated t=are Corporation Attn: Susan Kiaxner and Network 17irectar, Contracting.. ' ~eveitapgx~ent To Ciraup at: ,Jefilersan ~aunty_4~ubiic_Heait Attn: l_ ,}can Ba4dwira _ ~ 6l5 5he~fdam t. p.t7. 13ox 211 { ~A G raup base 2.2? . l 2 P~sg~ t9 of 3a Seattle., WA ~}4~tll Part Townsend, WP, 9838 or to such other address as either party may designate i~a writi.ng. I1.1~. farce Ma_~. Neither party shall he liable or deemed to be in default f`or any delay or failure to perform. any act under this Agreeznczit resulting, directly or in.dia•ectly, fi~arr~ acts of Cad, civil or military authority, acts of public ezae~sy, war, accidents, #ires, explosions, earth~uafe, flood, strifes or other warp stapp~~ges lay either party's emplayee~, or atay~ other similar cause beyond the reasonable control afsuc;la party. 11.I3. ±~anf dent~ali~. Neither party shall disclose the substance of this Agreerraealt nos- aYay information acquired from the other party dt~rirxg the course of or pursua7at to dais Agreement to a~ay third party,, unless rewired by lave. Croup and Ciroup Provider acovyledge and agree that all in,fcarxnatia~? relatir*g to ~w1CC~'s programs, policies, protocals and procedures is proprietary informatior, and firrther agree not to disclose such ir~forrraatiori to any person or entity without IVIC~'s express written consent- I I.l~. Autharit Tl,e parties ''hose signatures are set forth below represent grad warrant that they are duly empowered to execute dais Agreement. 11. l5. Attachments. Each of the ~.ttachments below is hereby made part of dais Agreement: ~~~prf~v~~ ~.~~ ~ ~} l~°~rr~ ~~~ Exhibit 1 ~ 1'ayor Contract Attachment ~' hxlaibt 2 - Campe~asation Exhibit .. r ~C,. Exhibit 3 -Provider Attestation ,,~(~,Pt,~-a,:~ i ~ ~ ~ ~,r, y ]~~ _ _ ~~ r .. ~N' '~'4~lGT-~IESS V~-IEREC)P~, tlae parties hereto leave exeei~ted this Agreerrient etfecti~e as at the date set Earth belov~r. ~~ FF~RS~}~ C~[I'~'~'Y Rutharized Signature ~,~' • ~~ .. _. j ~J f i { Pruated Narrie:' ~ ~e7)1 ~atht, ~~ T~.~.~s+c~~nt and +C~C1 N__ Printed S'~aTlae: _~ ~ ~.t ,~ ,'~-,`1~ ,` ~.~ `Title: Title: !_. ~ ~,f~ ~.4 ~`1't.i_~§'`~ ~ ' ° •;'` Sz natrsre Date: `~ " ~-~ Signature Date: ~ , ~ ~ '~ ~`_---- _ j , y ` ~ 1 ~ L 5 ~'_ l;ffcc:tin=e Date of Agreement: ,..~;,~,~~ r~'.~ ~.~ I ? Tax ldentif cation ~irrrnber: 91 - 6 0 Q 1 3 2 WA Group base x.22.12 F~~~4re 2~ of 35 ('T~o lie c~m}~~e!t~d by MC[7 ar~ly) National Pravicier Ir~enti~er: ~;t~r~; i~TLdicai~i Number: 184~2~~2(78 7~0013T feted by NCO only: I T~ be e;omp I _ effective Date cif A~ V~~A Clrc~u~s base 2.2.12 Pale 2l cif 35 ~°x~trr~tT i wASH~~v~sTaN B~sl<C xEA.>1~T>E>< Alva x~Al~~rrz~~ a~T>~ca~ls ~lRaua~A~~ >PA~a~~. CC)\"1'1tACT ATl~`1C`HVIF;N';p This ~vVashington Basic Health and Healthy (~ptians Eayar contract Attachment (the "Attr~elr~raent"~ is i_ncorr~orated rota the ~, (~? ~ '~ agreement (the "~~rc~errterxf''} entere4l hrta by rSL' ]P ~ y and between s~fferson bounty (` 1'rovirle~ , an .nt~t desc-ibc:cl mare fully in the signature black, and Gaarclinated Dare Corporation {"Ma~~c~~;erl Crcre Qrgcini~,utirrn" nr "1M1~lCC)")- ARTTC'~..T I I~CY'1 ~~Y,S 1.1 ~!lC~ has contracted with the 1~'~ashington Health Care Authority to arrange far the provision of rr~edical services to Covered 1'ersans under the >3asic health and ~lealthy Qptions i'rograrr~s. l.~ Provider has entered rota the Agreement with MCC7. `T'his ~.ttacl~~nent is intended to supplerrtent the Agreement by setting forth the parties' rights and responsibilities related to the provision ofC'avered Services to covered i'ersons as it pertains to the Basic Health and )-ie:.althy ~ptians Programs. 1n the event of a c.anflict between the terms and conditions of the Agreement and the tersrts and conditions of this Attacl7merat, this Attachment shall. govern. l.3 Provider agrees and understands that Gavered Ser~rices shall be provided in accordance with floe contract between HGA and tl~CC) (``State C'vxatr~ct"}, Payor requirements, any applicable State handbooks or policy and procedure guides, anti all applic~~ble Stag and federal laws and regr~lations. Tc~ the extent l'ravider is unclear about I'ravidar's duties and obligations, Provider shall request clarification from 1'~1C:D. Aft 1`IC.' lE~ E I f 111FF~l~~~T'I[3~S Gapitali~ed terms used and not od~envise defined herein shall have the rneanit~tgs given to them in the Agreement. The def~nitians listed below will supersede any meanings contained elsewhere u~ the Agreement with regard to this Attachment. 2.l ~'ertrfic~te ~?f ~overu~=~ means the :Exhibit l3-~ of the State Contract, published by ~}~e HGA, ~.~ Clean ~'lt~irn means a claim that can be processed without. obtaining additional information from the provider of the service ar froze a third party. 2.3 C'r~~?earl Perstln shall have the meaniz~zg set Earth in the Agreement. ~?~~ ~'~ C7roup base 2.2Z. l ~ Pale 22 of 35 ~ Bm~Y~ency Nfedical Cr~nditrt~t~ means a zriedical cora.dition manifesting itself by a~.utc, Z. symptoms of sufficient seti'erity (including severe laaizi) such that a prudent laylaerson, Qe knowledge of health and medicine, could reasonably expect ~vho possesses an avera~ the absence of irrrt T~dia~ t toea pregnantti~orrsan~thelheal'tha}fpthe woman rar her uribarr~ individual (o~, ~vytli p ire serious jeopardy, t`b) serious impaixrnent to bodily functzozis, or (c} serzous child) bodily organ or part. dysfunction of any ~a~~r~;ency Scrvice~ means covered inpatient and outpatient serwie:es that are furnished Z.S ualified to furnish these services under ~? C.F'.R. §~ 438• l l4(a). by a provider that is cl ~ ~ ~~,~~, means the State of Washington. Health Care Authority and its employees and .. authored agents.. ~ ~ ~Yledical~y ErVecessar-y rraeans health care services that: (l~ are reasonably calculated to diagnose> correct, cure, alleviate or prevent worsening of conditions in the prevent, Covered Person that endanger life, or cause suffering or pain, or result fn an illness or ~l"irrnity, cir threaten to cause or aggravate a handicap, or cause physical deformity or malfunction; and (~) are not more costly than any other ec}ually effective or more conservative course of treatment eludeaber~iceslre ated to the Covered Person's alail'ty tgO the service- Such Services shall us achieve age-appropriate growth and developnnent. 2.8 p~i~r~ar`y Care P~ovader or PCP means a Participating Health Care Provider who lass the responsibility for supervising, coordinating, and providing primary health care to [;®vered Persons, initiating referrals for specialist care, and maintaining the continuity of Covered Person care. PCPs include, but ~i~s ciari la~sistants (p der the super~i~ion practztioners~ general practitioners, internists, p of a physician), or advanced registered nurse practitioners (Horse practitioners), as designated b}~ NICG• ,, ~ Stt~te means the state of Washington. AlEtT11CI.,T XILT PRQV>11~~;R C(3i~i7'~ACrT ~r,(~UIREI'uIENTS prodder shall corrzplY with all applicable federal, State and local laws and regulations, and all azncndrt~ents thereto. Provider zindez-stands anti agrees that this Attachment 3.l anchor the A gn-cement shall Lie deemed automat.icaily amended as necessary to coanply with any applicable State or federal law ar regulation, or any applicable provision of the State Contract.. Prodder shall comply with ali applicable State anti federal laws and regulations regarding 3.~ r use and disclosure of i) l3ersonal lnlorrszation, as defined in Governor the colle.cton> I,ocke's Executive Order 00-~03, and ii} Protected Health Information ("Pl"lI"), as defined 4~ C P.1~. ~l{l},1~3. Personal Information or l'HI collected, used, or acquired in ~~]A Group base 3.?Z.l~ Pa~e?3 c~#'37 connection with the .Agreement shall be used solely for the purposes of the A~~eerxrent. Provider shall not release, di~~r.lge, publish, trairsfcr, sell, or otherwise males l:~ro~v~n to unauthorized third parties Personal lnforxnation or I~HI without tl7e advance express yvritten consent of the individual who is the subject matter of the Personal lnforr.:iatic3n or PHI or as otherwise required ixa the Agreement or as permitted or required by Mato or federal law or regulation. Provider shall iraxplerxxent appropriate physical, electronic, and managerial safeguards to prevent unautlxori~ed access to Personal Information ~~nd I'I~I. Provider shall fully cooperate with HCA's efforts to implement all requirerner_ts under fI[PAA. ,3 Provider represents and warrants that it is not presently debarred, suspended, proposed far debarment, declared ineligible, or voluntarily excluded by any federal departrxrent or agency from partrcrpating m transactions. Provider shall icnxnediately z-rc3tify ~'I(-:[) ix~ writing if, during the terra of the Agreement, .Provider becomes so debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded. 3 _~ Provider shall cooperate with audits performed by duly authorized representatives of the Stag of ~vVashingtort, the federal Department of Health and Hun~ian Services ("OTITIS"), auditors from the federal Government Accountability [)face, Iederal Office of the Inspector General and federal Office of ''~Ianagexnent and Budget. I~pon thirty {3€l) calendar clays, Provider shall providr; access to its facilities and the records pertinent to the Agreerrient to rrionitor and evaluate Provider's compliance with the Agreerr~ei~t and 1vIC0's corr~l7liancc with the State Contract, including, lout riot limited to, the quality, cost, ease, health and safety and timeliness of services, and assessxrient ofiVIC~?'s capacity to hear the potential financial Ir~sses. Provider shall pro~~ide imrx-kediate access to facilities ax}cl records pertinent to the Agreement far -Nledicaicl fraud investigators pursuant t€~ 42 C.F.I. ~~13~.6~g~- 3.5 Provider shall maizxtain financial, ,medical. and other records pertinent to the Agreement. All financial records shall follow generally accepted accounting principles. Medical records and suppox-ting management systems shall include all perfiinent iriforination related to true medical management of each Covered Person. Other records shall he rruaintained as necessary to clearly reflect all actions taleen by Provider related to the Agreement. All records and reports relating to the Agreement shall lie retained ley l~rnvider for a minimum of six (G~ years after fi~rual payment is made under the Agrecirient. However, when. an audit, litigation, or other action involving records is initiated prior to the eruct of said period, records shall l7e inaintairued for a mixrimum of six (6) years following resolution cif such action. 3.~; if Provider is a hospital, ariabulatory care surgery center, or office-based surgery site, Provider shall endorse and adopfi procedures for verifying the correct patiexYt, the ct>rrect proceclrire and the correct surgical site that meet or exceed those sot f©rtla in the Universal Protocolr~ develnpmeiit by the Joint ~Commissian. 3,`7 Provider shall comply ~~~ith applicable physical and behavioral health practice guidelines adopted by ILIC'(7. 1VA Group base 2.'?2.12 ~'~a~e 2~ «f`_3{ ~.~ Pr©vider shall offe~ a~ ~ cad e~~ol~ees ~ them comf pardable to tha eol`fere ixtollMed~ aid Provider serves on y fee-for-service enrollees. oration for Covered Persons shall lac no less than the hours of ~.g Provider s hours of op operation offered tv any other of Provider's patients. Provider shall. meet the followilag appointment wait time sttsndards with respect to ~.1~ Covered Persons: ~. Preventive Bare office visits slxall be available from the Covered Person's PCP witl~iin thirty (~'~) calendar days; B. Routine care dOaridaysisits shall be available frorra the Covered Person's PCP within ten (l~} calm C- 1[~rgerit ,Care office visits shall be available frorib the Covered Person's I'CP ~.~rithi~x forty eiglxt (`l8} hours, and ~. Emergency medical care slxall be available twenty-four (2~} hours per day, severx (`7} days per week.. MCC) shall ix~onitor Proti°ider's corxapliance with this Section. Ira the event Provider fails l r~vith the appohitment wait time standards set fortlx ux this Section, Provider to comp y (,O's rocedures far corrective action. shall comply with ~ ~' p 3. l i Provider shall rrbaixatain a health information system that complies with the requirements srl,3~.242 and provides the infoxrnatiora necessary to meet 11~C~3's of ~2 C.F.R. ©lxligatioixs under the Agr~eernent. The health infarrnation sypstem mast: A. Collect, analy~e> irxtegrate, and report data. The system must provide information orb areas that include but are not limited to utilisation, grievance and appeals, and terminations cif ebxrollment for otlxer than loss of Medicaid eligibility grad ~, Ensure data provided to MCC] is accurate and complete by: Verifyibxg the accuracy arad timeliness ofreported data., ii. Screening the data for completeness, logic, and consistency; and iii. Collecting sere-ice information on standardized formats tc~ the extent feasible and appropriate. 3.I2 Provider ac4crxowle.dges and agrees to release to NICfJ any nfE>rb~ation necessary to perform any of MCA s obligations under the State Contract. ~~~, Crroup base 2.2~~. l ~ Page ~5 oE~ 35 3.13 Provider shall corxipletoly and accurately report onc.ountor data to ~1.~1[~'C~. Provider in addition represents and warrants that it has the capacity to submit all. data recuired by ~~C:~ to enable MC[~ to nreet the reporting requirements ixr the ~rrcoun=er Data Transaction Guide publislred by HCA. 3.1~} Provider shall grarrt, upon request, access to its facilities and its financial and medical records for duly authorized representatives of 1-1~C'~ audlor D~IIIS for audit purposes, anti. shall grarrt irrrrrrediato access to the same for Medicaid fraud ia7vestigators, 3.1~ Provider shall comply with the applicable state and ferleral ra~los and rogarlatiorls as sot forth in the State Carztract, irrcluding but not lirrrted to the applicable requirements of ~2 C.P'.1~. 435.6{i~}. 3.16. Provider shall corrrply with any terzrr or condition of the Mate Contract that is applicable to tl~o services to be porforrrrod under the Agreornont. 3.17 Provider shall corz~ply with MC"f3's policies anal procedures, including, bars not limited to, credentialiaag and recredentialing, utilization rr~anagorncr~t, authori?atiora of scr`~Tices, quality irxrproverrrerlt activities, and provider payrraent suspensions. Provider shall corrrply with the Program Integrity requirements of the State Contract, as well as MCC3's prograira ntogrit}~ policies and procedures. Provider shall corrkl~ly with all Utilization Management requirements described in: Section. 1 ~ of the State Contract. 3. l g 1'rovidors that are deemed to be "high categorical risk," irrcluding prospective r;newlyr enrolling} i~ome health agencies and prospective (ne~~~~ly enrolling) D~rI~P()S suppliers or- such other categories ofprovidors as dofrned under 42 C.P.R.. §424.515, shall. be enrolled iar and screened by Medicare, in addition to cornplyirrg with, MC.O"s policies and procedures regarding croclentialing and recrederrtiaing. x,19 Provider acknowledges and agrees that no assignrraent of the ~groerrAent shall take effect without the writterr agreerraont of IdCA. 3.24 Provider shall rriaintain a quality in~provernent system tailored to ttae nature avid lvpe of Covered Services provided hereunder, which affords duality control for such services, inclarding but not limited to the accessibility of Medically Necessary services, and which provides for tr free exchange of information with MCCI to assist MCC in complyirrg with the requiromorats of State Contract. Providers that are primary or specialty care providers shall c.ornply with all quality improvement activities of the MC:[3. ;,21 To the extent that Provider provides health taome services for Covered Persons with special health care needs pursuant to the Agreerraent, Provider agrees as follows:. ~. Provider shall eorrrply with all pre-delegation assossnrents, which shall be condarcted in accordance with all delegation requirernonnts set forth in the State C;or~traet. ~~fA ~;roaap base 2.22.12 Page 26 of 3~ ~. pravider shah adopt and use evidence-based guidelines. C. Provider shall establish relationsflCowe ~d Personsrai~do~ tlareme~ e7cy~ooirri, resources to facrlrtate the care o ~ger~t cart aid hospital facilities to support timely sharing of information about services accessed and to promote transitional health care services. If validated by the pre-delegation assessment, Provider shall be delegated taro I7. rnanagernent responsilailities as provided in the Mate Contract. ~, Provider shall, at l1~lCC3's request, produce utilization reports relating to Provider's perforrr~ance against established performance nrreasures compared to performance goals, incl~adirxg information on Cowered Persons tivith special health care needs tlhat require specifrc outreach or interventions to address under-, aver- or xrris- utilization. of health care services. ~. Provider shall comply with business processes established by MCC] between Provider and MC:C)'s utilization management, care r~nanagement and quality irnproverrient programs. Cl. Provider shall report at least annually regarding perforxxrance measures, including those lir7ked to incentive payments. ~. Provider shall condr~ct periodic surveys of Cowered Persons served by Provider to assess such Covered Persons' satisfaction with Cowered Services furnished by Provider. 3.22 As applzcable to ser~~ices rendered under the Agreement, Provider shall have a means to beep records necessary to ac]ecluately document services provided to Covered Persorys for any and all delegated activities including duality inrprowement, utilizatioxq znanagernent, mer~7ber rights and responsibilities, atad credentialing and recredentialing. Provider agrees to accept payment fxom MCC) as payment in full and shall not request x•23 or an Covered Person for Covered Services provided antler the payment from HCA y p,greerr~ent, except for copayrnents and coinsurance described in tlxe Certificate of Coverage, >xtioPt for copay~nents anal coinsurance, 1?ravider shall report to MC:C~ any instance in which a Covered Person agrees to pay Provider :for services, Provider shall repay to a Cowered Person any inappropriate charges paid by such Covered Person, or y~all reimb'arse NICC) to the extent MCA repays such inappr~+priate Lharges to the Covered Persan- 3.2~ provider agrees tent byalvlCC) 5 Pro~iderdfurtherpagrees to rndemrrafyeand hold harmless event of non~pay I~IC:A and its employees against all injuries, deaths, losses, damages, clarn~s, suits, liabilities, judgrrcents, costs and expenses ~vhieh may in any manner accrue against HCA 4~v=E~ t-jrt~~,p base 2.22.12 Pale 27 e~f 3 or its employees t~rou~ .the intentional misconduct, ne~li~ence, oa- orraassion of it1CU, its agents, officers, employees or contractors. 3.25 dither part}~ to this r'~ttaclrrnent Wray terminate this ~ttachrxcent rcpon ninety (~D} days advance: ~~'ritten notice to the other party. Notwithstarcdi~~g the foregoing, in the e4~erat that ti} Provider is excluded l~ozn participation i_n the Medicaid program, 1viC0 may. ir~~-nodrately terrz~irrate the A~reerne~at ~rpon written notice to Provider, and rnay~ immediately recover an~F payments for goods or services that benefit exclud~;d individuals or entities; or (ii} INCA or l~Iedicare has taken any action to revoke Provider's' p:-ivileges for cause, arcd provider laas exhausted all applicable appeal rights or tl~e timr~.line for appeal has expired. `1~or cause" rcaay include b~ct is nc~t limited to reasotas related to fraud, integrity or quality. 3.2G Provider acknowledges and agrees that MCA shall conduct ongoicrg monitorial; and periodic formal review that is consistent ~vitl~ applicable industry standards and the regulations of the '~'~rashington State ~fCtce o#` the Insurance Ccacnmissioner ("C)IC"}, if any. 'Such forrr~al review shall be completed no loss than once every three years and will identify any deficiencies or areas of itnprovecnent and provide far eon-ective action. of any such deficiencies. 3..27 In the event that tlae 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 Section x.6.1 of the S#ate C~t~ntraet. 3.2~ Provider shall keep information about Covered Persons, including their medical. records, carcfidential in a manner consistent with State and federal laws and regulations. 3.?9 Provider shall cocr~ply vritl~ any applicable federal and state laws that pertain to Covec-ed Persons' rights and shall take those rights into account r~vhen furnishing services to Covered Persons. Provider shall guarantee each Covered Person the following rights set below. Pac:h G'overoci Person must be flee to exercise these rights and exercise of these rights must not adversely affect the way the lV1Cd or Provider treats the Covered Person. These rights znclude: ~. To be treated with respect arad with consideration for Covered Person's dignity and privacy. ~. TQ receive icrforn~ation on available treatrriet~t options and alternatives, presented in a manner appropriate to tl~e Covered Person's ability to undcrstanrl. C. To participate in decisions regardinb Covered Person's health care, including the right to reface treatment. ~. To be free from any force of restraint or seclusion used as a means ofcoercion, discipline, convenience, or retaliation. WA Group base 2.2.12 Page 2~ c~f`~?S ~. To regxzest ~~rrected in a~cpordance rvx h applicabledla anal to rcq?rest that they be arrr~:nderl or c Provider shall. participate in and cooperate with MCC]'s efforts to promote the delivery of •3Q a culturally coxx~petent manner to ail Covered Persons, ixxcluding those with services in lixx~ited ~ngiish prof}c1ency and diverse cultural and ethnic backgrounds. Provider slxall (i) obtain informed consent prior to the treatment from all Covered 3.3 l er-sdxis autht~ri~ed to consent ©n behalf of Covered 1'Lrsons as described Perso3as, or from p ii corn 1 with the rovisions of the Natural Death Act (F~t~W 7D.122~ and state and federal rules concerning advance directives (WAC 182-5~1-(312 axrd 42 C.P.T. ~~38.E7{i~}, and, viii) when appropriate, inform Covered Persons of their right tea tn~ke anatomical gibs pursuant to RC~~1 f 8. 5~.54Q. l'r°~ ider shall comply with the requirements of State and federal law regardirxg advance 3.32 ' directives. Provider shall ensure that whether a Covered Person leas executed an advance directive shall be indicated ~ aopr°are or totheru~ser discirnirxate ago nr a C ~ er d Per ~ n and Provider shall not proves based on whether the Covered Person has executed an advance directive. 3..33 provider shall have and maintain insurance appropriate to the services to be perftanried under the Agreement. Provider shall make copies of certificates of insurance available to f1CA upon request. if Provider is a State or community physical or behavioral health hospital,. l~:egional 3.3~ long-term care facility, or inpatient or outpatient Drug anal ~s.lcohol Support Network, Treatxxieiit program, Provider shall use a standardized discharge scree:nirig toed which includes a risk assessment for r ch hasubeen a~a roved bh~HCA ~ Addit~otially,sPro ider pp ~' use disorder recidivism an ~ i shall develop a Cor~crc~l. Person. plan for intcrvexrtions, to mitigate the risk fear re- izistitiitieanaiization, re~lxospitalization or treatment recidivism, consistent rh,+itli the State Contract. 3.35 if Provider is a PCP, Provider sha A. In consultation with other appropriate health care professionals such as care mangers, community health workers car community-based care xi7arzagers, be responsl~le for the provision, coordination, and supervision of health care tea meet the needs of each Covered Person, including initiation and coordination of referrals for Medically Necessary specialty care. ~. ~ns~rre that alI health information relating to Covered Persoris is shared ~;vith other providers irr a manner that facilitates the coordination of cure ~~~hile protecting Covered Person privacy and confielentiality. Vir~'1 GroiEp base ?.~~-1? '~Pa~~ 24 of 35 ~, Coordinate with caznmunity~based and the State Department of Social a~i[i I~lealth Services, the Department of )r:lealth, local he{filth jurisdictions aad fIC~ sere=iceslprograrns, incl>.ading but not limited to tl7e, falloi~ring: i. First Steps Mater~aity Srappart Ser<=iceslinfant Vase Management; ii. Transportation and :interpreter ser~••ices, iii. Patient review and Coordination (PRC} program, for Covered Persons rvho r~aeet tlae criteria identified in'ti~Tr1C ~~~-501~U135; iv. Dez7tal services; v. Faster Care - l~ostea-ing Well..Being; vi. Regional Support Networks for mental health services; vii. Substance Use f3isorder services; viii. .t~ging and Disability Services, including hoa~ae and cc~rxxrntrnity based services; ix. Skilled nursing facilities and comrrrunity based residential programs; ~. Early Support for ln.fants and Toddlers; and ~. Departrraent aFHealth and Local Health Jurisdiction services, including Title ~~ services for children with speciak health care needs. ~. Comply writh 1`v1CQ's policies. and procedures that address the day-ta-clay operational requirements to coordinate the physical and bclia~~ioral health services and share the responsibility .for Covered Person's health care. E. In consultation with other appropriate health care professionals, assess anti develop individualized treatment plaa7s for children with special ]health care needs, which ensure integration of clinical and non-clinical disciplines and services in the overall plan of care. h. Identify those Covered Persons with special health care needs in tl~e course of any contact with Covered Persons or any Covered Person-initiated health care visit, and a-eptprt such Covered Persons to MC.D. (;. Reasonably cooperate ~°ith the applicable care manager to conduct an Initial Health assessment ~"1HA"} of Covered Persons ~rithin the tiineframes set forth at Secti.oaa 13.x.2 oPtho State Contract, and to assure that arrangements are ,mach #or 4~v'A Group tease 2.22..1.2 Page 3[~ ui 35 follow-up sc~`'~iCeS that reflect the findings ul the IIIA, s~xch as cansi~ltatiot~s with. mental health ardor sut~stance use disorder providers. In, consultation With the care manager and other treating providers, develap, docurr~ent arkd maintain., for all Covered Persons with special health. Care Needs, an individualised treatment plan in the Covered Person's medical record. dements regaxired in the treattr~ent plan.. shall include, at minimum: ~l'he Covered Person's self-rnanagernent goals; ii. ,hort and long-term treatment goals, and identification of harriers to meeting goals oar complying with floc treatment plan; iii. ~'ime schedule for fallow-up treatment and cammu.nication with the Cc,vered Person; iv. Clinical and non-clinical services accessed by the Covered Person or r,ecomrnended l?y Provider or care manager; ~, Integration and coordination of clinical and non-clinical services, Including follow-up to ensure disciplines and services are accessed; vi. odiccations as needed to address emerging needs ofthe Covered Person; 'vii. Participation of the Covered Person in tl~e developme~~t of tl~e treatme~~t plan; viii. Progress or reason for lack of progress on self management or treatment plan. goals; i~, Co>?-s~nunication with specialty care providers, including mental health and substance ~.~se disorder providers; x, l~eritiftcatian of barriers to achieving self-mai~aagemer~t ar treatment planning goals and how such barriers ~~=ere addressed; ~. health promotion activities, includi~rg sched~iling of appointments frsr preventi~Fe care; and iii. t-lpproval c]f the care plan, if rerluired by 1v1CU. the provisir~ns set forth this in Section 3.35 shall apply with respect to any sul~coritract that includes physician services. ~~',~ Group base L.~.2.12 Page 3I Uf 35 3.3 ~; Upon the request of MCt3, Provider shall furnish to ACA, Within thirty-hve (3 ~) calendar days ofMC+t~'s request, the following information; ~. The ownership of any subcontractor with tivhorx~ the Pravider has l7ad business transactions totaling mare than twenty-eve thousand dollars ($~S,dOC-.[l0} d'aril~g the previous twelve ~ 12} month period. ~. ~4riy sigrii~cant business transaction between Pravider and any wkaoll~ owned supplier ar any subcontractor during the previous five (5} y~;ar period.. Pravider shall provide any f~-irther ir~farmation need4•d or reasonably requested lay It~~Q for the purpose of satisfying MC[?'s l~C"A reporting requirements u~~der the State Contract, ar for the purpose of verifying ar screening tar exclusion lrc7m .ledez•al or state health care pragrarx,s, or for caz~~^ictian of various criminal ar ci~ril offences, an~ang tl7e individuals or entities who have an ownership ar control interest in, ar who are a zxaanagu7g ei~nployee of, Provider. 3.37 A11 sterili7ations and hysterectomies provided under the Agree .meat sl~ali be i~~ corr~pliance with ~~ ~=.~'.~- x}41 Subpart F, .and Provider shall use the l1C`A Sterilization C:or~sent f'or~n (PICA 13-3E4} in connection therewith. 3.38 ivtCQ tiWi11 provide it~forrnation regarding lMCO's grievance system to Provider. [SICNAI`~.TRI~ SLACK ~~LLf3W5 J ~~A C_rraup base 2.~2.1Z Pale 3~ cif 3 ~~i C;(~ C~t7RDiNA~T~I~'C~L~.E CC}RP[7.~'~~[7ltii Autklari,~ed Signa f_ ,~ ~ _ E~ ~ {~ Panted ~arrre:r. ,_~- P'C`~'S~t~~E~'~ ~l7t1 G'E'C! S'R~C1'L'I L~ ER: ~7~f~~r~on Ccrunt;v - ~ aa~ entity organi_~ed under the laws Uf the State Uf~ W ashingtan; ar a foreign entity quali#~ied tU do }~~rsiness in the State af~'~ashngton Author' .ed ~' ~ nature Frixrte 'arne: ~ ~'~~`lV"1 ~~t~~`~`~_!"~'~ title: 1~,.~ ~ ~~i ~" Y~+'1 ~L~ 4' ~ ~rtle: .-~ _. v ( t ~r- ~ ~ ~ ; ~. r. _ Signature I7ate;_ r'~ ~~ti :? ~ ~ ~.C;~~ - Signature 1)~}te=__------~_ Effeet~ve Date ol`Addendurrg: ~ ~ ~~ ~ ,~ ["I'o be campletec~ by'.vlCf)] "I"ax Identi~icatian Number: ~ 1 - ~ ~ ~ 1 3 2.2 National Provider- IderYtifier ~~~~~~~J~~~ State Medicaid ~Curnber: 794137 pp~~~d ~s ~~~~~ ~~ only: ~efFer 4 Prs~~e~:x~^t~rs ~f~t~~ Ve'.~ Group base 222.12 t'~ge 33 c~t'3S E~~iIBTT 2 C'Ll!+II'I=; R'~~"i'tC}`ti SC'Fi~UCfI~F°; ~~';t4I-II~GTC)"ti ~3r~SI~' HEAIr~I"II A'~°.'I7'#[~:i-I,`I"II~' [7~'TI{~i4S I'FZt}GI~r~~I~ - {J[~f~U[' Fc~r C"csscrec~ Viers re4 ~r~,as iUed tai ~"'~sere~! Persc~r€S, F'rs}~c3r shall Fr~iy Cirt~t€~ tze PC7Ser c f: [i 1 tip C~rr~!s~'~ Alla~~t iihlc C'hsr~~:~; nr P ii} t~n~ hren~ar~d F~~.~rccnt { I ~IrJ`.'~ j ~~C t;l~ ~tEotc'~ P~'Ict~l caii! F~ ,rhe~i~tie in efFect nn tl~e d:atc c~F wers~ice zinc[ wp,:c;ific tc> the sers~ice~ rendered. For Ct~set'ec~ 5ecsi~'e, Ft~r ssl~i~'I~ ihirc iti nti e:~t~it-lii~tred fee an~~at€nt, ~{l}c7r sh.~1P pad C~i~~e€~ tss~ent,'~Iisi' }~cr~crit (?;`~) cal t9~e r'~,Plosstihl~: C'li~it~ca ~€r3til st€ch ti€?1e ri5 Pit}~z7r cwt€F~Ii~he~ ~€ rats. ,~Lrfci"rtiorrad l'rrri'isir~tts: C'nde C"han~L [lpd~ttti to hillin~-related cc~d~'~, {.c.a., ~'PT, ~oC'F'C`S, ~Cp-LJ, F~~G, send resen~tc codes ~h~€11 h~ec~€Zll eFtcctise tin the d~~tc ("Cnde Ch~inWe ~lt.ctise P~atc") that i~ the later of~. (i1 ttie firtit da} r}f- the mc~rttt~ foPl~es~ir~ shirt}' 4 ~(~} dEi}~~ :~fi~ r ~~tE~lic~rti~n h}° tlic ~4~s-err€nlenta{ merit} has ink ticithc~rit} user thr rip~lic~thPe ~°Prc~dt€cC c,f st€Lh ~c~s ernmentnl a~cncy's accL}?t~~r€ce c7 srt~'ti ~:r7dc ~€~date,; nr [iij the i:Fe~`tis~e d.zte nF st€c~h cede t€hdsste~, a. dc[~:rs~?sued h}' such ~c,sernrt~i°ntal a~enc}'. Cl~tirn ire}ees~;ed ,iris}r t~~ the C"nde ~'h~rrt~~: F;ffectis~c t7ate tihEili nt~t he re~roceti5ed tc~ rellcct any' cede tt,pdc~tes. ?. ~"ee Ch~sn~e ~.1~4ate,. FJpdatLS t~ st€ch fec scheds€Ie steal! heccarnz effectisc can the date (``FGa° Change ~Ff c;ctis~c. Date°') th~it is the baler 4~F: (i) the Fiat da} nF the rt~onth f€~Iloss~in~ thirty {?(3) dot}•s alter pttL~licatinn h} the ~oserrin~erital wens}' h~a~in~ atothority~ cis~er lhr anpPiciihle product of ;rich ~nvernt~icntal a~ens:y~'s accef,tance of such Fer schtdttlz t€pdat~:s; car {ii} the eFf¢ctis~e ddtte of such fee schedtte Gipc#ates, ati determined by st€a:h ansernrnrntal aWer;cy°. Clairta~ prs~cetised prior try tle Fce Chari~e ~.ffec;tis~e Date shall nt?t be reprocessed to reflect any' updates try sttch fee sctiedt€le. ~1Efrr~ rt"t[~1 f5: I. Al1o~c~ble Charge €~iLan those Grottp hilfed cliar~e;; far sersices that cPt€alify a5 Cos•ered Servic~5. ~ ,~~-. ~~ ~'A Group ha4e 2.~?.12 F's~e ~-t t}r ~; E~IFIT 3 P~RT~~IP~TING PR(]V.T~ILR .~~'~'~'~S'.X'ATif~.~ ~E~'S, Coardi-mated Cy,are Corporation. ~"lVlanaged Care {~rgaraizatian" or "NIC:O"}, a Ueirner-1t ~r=tiY~k~ ,lel~ers{aa'I CouT~ty ~"Grotzpl'r) datei~i , hiss executed ~ eed to reavide Covered Serti~ices to Covered persons thrc~u~h pursuant to ~,vhich Group has a.gr p Group Pro~riders (the «~~eemerat"}; Group has reclzzested that the undersigned provider ("Provider") serve as a VJT~E~S~ reerszent and Provider so desires to participate; and Group Provider under the A~ E~S~ as a condition of such participation anti Provider's designation as a "Grc~~zp Vv'H ee-znerat, provider z-nust satisfy t~~CG's credezztialirzg criteria grad execute Provider" Lznder the .~~ hislher a Bement to comply tivitlz, and be hound ley, the terrxzs ee~zent tiaat are applicable to Group providers, as set forth below. this p,ttestationo fthe Mgr d~ar~g ~ arad corzditious ly[~~,;' THEREpG1zE, Provider hereby agrees as follows: as Pro ~ ider qualifies and participates as a Troup provider under the A~reernLrzt; a.s lo?'g r xovide Covered Services to Covered persons in accnrclarzce with the 1- reel top - provider ag ~, regiment that are applicable to Group providers, which shall requirements of the g iricl2zde tlae follow~g terrrzs: Sections 3.3 through 3.17; Article IV; ~rticie ~~+; ArticEe VI; icle VII; Article ~flll; Section 9.1; arad Sections l [].~ through 1 ~3.`~. provider understands and agrees that hisfher g7atiai and contiriized participation as a C~rouP provider under the, ~,gzeeinent is contingent upon hisfher mee4:wag azad cozrzplyrrag with ~'leG3' credentializag standards ~az~d otherwise cornplyh~g with the terrzas and conditions ofthe Agreement. Provider acknowledges that IvZCQ expressly zeserves the right to reject, suspend, axxdlor 3. r anticipation under the ~greerrient for l~reacl~ing or otlaeru~ise failing to: terrr~iiaate l~is+her P terzxa of the Agreerraerat or arly Attaclatxient thereto; aa~cl (ii} meet (i) comply witYz the NlCO's credentialin~. re~~uiremerits. f ~.. ,, This ~ittestation staall lie effective as of ' Fro'~'icier 4 ~~'~" ~ ~~ r'Sf __------._ -- - Ttaomas Lucke Ma ~1 ariae : _~ Y. __---_~.~ Specialty: i t.~~~~~ `~"'=- E''`;~_ti~: s~. ~w.s date= ~~~.' f f' 1 ase ~-~~ • }'7 V~'~~ L;ronp ~ Pabe 35 of 3Z E-%~IT 3 ~,r~~T~rC'J:P~I'~tfGYR~V~D~'.R A'1`T'~~~T~.~':iC)i'~f V~"IfEI~~.AS, Cr~nrd~;nated Care Car~axatiozr ("1'vlanaged Care C~xganizatiorn" or `i~l~,~„,~~ a~reerxte~t `,x,'ith Jefters4s~ CQUnty ("Ga-oup"} clal~ed s. !.~ ', has executed- an .~ ~ eed t`a - 4ovide Covered Services to C;overec3 persona thr~~_l~r ~h ~nrsus~t to which Cxraup b~~lEnt"?a pr C7roz~p Providers (the ':_~gr Wl-3~.I~~,,~5, CYxoup has requested that the uzndersi ;ued provider ("Provider"} serve ~s a Grorr~ provider under the Agr`veFnent and provider so desu~es to partzczpate; and ~~A~, as a condition of s7ackz participatiaza arxd pravider's desigriatir~z~ as a "Gr3rp ,~ reader the ~,-~:eezrzent5 provider must satisfy ~!IC:f~'s credentiali~~g criteria and execute Provider P ~ hislher a . cement to Dann zl with arxd be bound b the tez-rzns Y, tlris Attestation ack~avvl~dg ~ az?d conditiarzS of tl?e AgreerrA~rzt that are applicable to Croup l'rovtclers, as set forth below. ~~~~ TPIER~I'L7-~-~,1'rovider h~.reb~T agrees as fallotvs: As long as Provider qualifies and participates as a Group Provider under tkzc Agreement, provider agrees to pravide Covered Sezti~zces to C'r~vescd persons ira accordanea with the rri~exnents of the ~,green~ent t}aat are applicable to Group Providers, v,Fhich sha11 req ,~ terms: Sections _i.3 through 3.17 Article IV; Az-tit:le V- Article VI; ;rxclude Ck=~, following, > ,~~-tide dill; Az-ticl~ ~1`ITI; Section ~.1; and Sectaans ID.~ throuala IU-7. Provider uYadersta2?rls and ab ~ees tkiat his.~'her ixiitial arxd cantitaued partici~iation as a Grorlp provider render the Agreerneznt is contingent upon hi.slher zreetizxg and cozxzplying ~~,Fitli NICC)'s cred~ntialing standards arxd otherwise corrplyug with the terms and canditiorzs c~ftl~e Abreezrieni:. provider ac~owledg~s tl^~at IvI:CC~ expressly reserves the right to ,-eject, suspez~r_I, and:'or terrrsirnate hislher pa;;•ticipation eider the Agreement for t~reac.hi~rg or other~visr: failiz~~, to: ~i~ eon-,pl~~ vaiih tine terxnn of tlne Agrcerrient. or any ~'Lttachzxzer~t thereto; and (ii} meet ACC's credentialu~~ requireal~zezats. "al~~~~, This Att?station shall be effective as of o, ~~, v ides: ~~~~ ~' ,lean Ba1d~'~n ^ Nurse Fam-~ V ~r.a-c~itioner Specialty ~-~_ 4f2a1~z Date. ~ ---- >`~`~? ~" t'a~e 35 ~f 3~ E~.C~31:~ 3 ~_~~`~~'~~~'~TC~C~ J?R~3VLD~~ ATT~S'7~~~~TI.[~N ~®c~~d~a-tE;d Car° ~or~aratian {``Managed Care [}rgar.i7aiian" car `i C:t3"}, F~?,.5, -t~ Jei~~rsc~n Gaunty ("Group") dated ¢ ~,~~1 ~ , ~~ a~eeme~t wz has executed. a~?q,, orxp }aas ~~ eed to prr~vi~'e Covered Services tee Covered Persons thrc~tzgh ~7jZj$1]~S,YLt t0' tiv~llG (L' cc n (~leL`}t"~~ ~ira~~ P~p~I1C1~r~ ~t~e ~~'~~ loos requested that the undersigraet} provider ("Provider"} serve as a r®~,rider ~~~~ th,e agreement arzd Provider so desires to particrpate; and ~~~~, as a cr~xrdition of such participation any Provider's desrgnatz~}~ as a "Crrc~up W eement~ Provider must satisfy i~CC)'s credentaaling criteria and execute i,rovi(i.er" under the ~ laislher agreerrzent to cornpl~° with, and be found by, the terrris p~ttestat.i~rj. ackrio',vled~;ii~g the - the ~~~ ee~xent that are applicable to ~sroup ~'raviders, as set forth he1o~T. and core{litions of ~IC)~ °p~~I~~QR~'> Provider hereby agrees as folla~vs: as Provider grxalifies and participates as a {group 1'ravider iixicler the Agreeri`~ent, ~ As brig rovi~lc ~:'avered Services to Caverecl Persons ~ aecc~rdance ~vitl~ the provider a~ yes to P A eeineni that are applicable to [lraup Providers, ~n~hicl~ .skull eats of t1~e gr . rer~iairexn terms: Se.ctians 3.3 through 3.17; Article IV; Article ~T; Article VI; izaclude _the follolv~g ~icle VIA; Article V11I; Section ~-1; arad Sections l t.}.~ tl~~rr~ugh 10.7- arid agrees that hislher initial a?~d continued participati~ra as a provider ,:~rderstands ,- Provider uri~,er the Agreement is contingent upon hisllier nkeetirig aril corzlplyhig ,v~i~ll ~,r1Ct~'s crederrtialing standards arYd otherv~ise corxiplyizag ~~vith tine te-c-iris and Group cozidiiiCarzs oftkie Ag}rerrrerit. ~~vledc~es that t,~'1C~ expressly reserves the righi to z~.jec:t, suspend, an~l.~ar provider a~lnt, ~, . ~- terrnir~aie 1~i-lhar i~articipation under the t~greerner~t fir hreachirig ar ot:herwise failing t~: v~ith tk+e te:rsn of the Agreement or any Attackunent thereto; grid (ii j meei (i) cempl~' re uireixaents- ~,1C~J's Gre~lentialiia~ r- ~ rh15 :^~tiestatioza slial~ lie effective as of a. G'~~ y~ (rJ~-~-~ s __L~-- Marne __~ ~p;~taft°~ ~ -~r-~e--~`-a~n~~y -~c~itioner A/2C1f 12~ }}ate. ~= = 1UA C~rutlp base.2.2`F'-i=~ [pane 3_`~ c~~ 3 rXC-C1_I31T 3 ~?~EZ-r?.CII'ATG I'I~t7V~>.i~~ -"~T"~'~S'.i'r1.TI[=)1'~ Coordinated Care Coz~oratiors ~``~Iauaged Care Cr~;ar;izatiaz~" ar ~1(<<,~~}, t~4iHE-I~A~, tivith ,fe~f~rson County ~"Crrotlp" dated a'~ ~` e~;.ecrated axr areeTrze~-t _ ~_ ~, ) .~ ~ :,.~ ~ ~ ,. 1~a5 ~;~srxa~.~'~ to which ~ z« ~~-AI~F ~er~e}7cl to pro vide CQVered Services to Covered Persoxzs ti~rcugh Cro~~, Pxc~~riders { ~~`H~I~~S, Group ~~ re~luested that the undersigned provider ("Pravidez"} Serve 3; a Croup provider,~der the Ag~eerzzent and l'ravider sc~ desires to partkczpate, acrd V~~~rI~~AS, as a caudition a such parkicipation arzd ~'ravider's designati©n~. as a "Cxroup ee~exit, ~'rovidar must satzsfy MCf~'s crede~.tialing crzteria arzd exe:~zzte pxc}vid~r' under ~h~ ~'~ ~ klislbar a e~zneni tc~ catrrrl tNitl~ arzd Fie boa?r:d b tip . ttrrris ~ ~ Y ~ Y, t'rais n~ttestatian acl~nawledg P and cQndtio~s afthe ~'-greez~e~-t that are applicable fo gaup Providers, as set forth below- ~YC?~i T~-~~~p~}~-~, pr°vider hereby agrees as follov~~s: ;~.s Iorzg as provider qualifies acrd participates as a Croup Pr~~vider under the Agreerz~:ezzt, Prea~ridex at~-rees to provide Covered Services to Co~~ez-ed Perscaus ~r accordance with tkie Aareernent that axe applicable to Grorzp Providers whc;~a shah requirements of tl" tertrLs: Sections ~.3 tbxc7~.z~b 3.17- 'Laticla IV; Article ~'" article VI; inciiacle the fallau%irz~ ~ ~ ` , -tial~; VI.I; ~rticla VIII; S~.ctzor~ 9.1 and Sectinrrs 10.4 tllrau~h 10.7. ~, Fzovider urid.erstar~ds and agrees that hisll~e~ initial and carztirzued particil~atiorr as a Group Pr~~vider under the Agreezraen~ is cantirzgerit upon his~her rzieeti_ng aad carrz~~sly~in~ ~,vith vlC~'s credentFalir7g standards azid otl~erw~zse compl.yiug ~vitl~ the terrris ar~cl conditions o f~ floe, A~eemerrt. Pravicler ac~a~,v`icdaes that NICE expressly reserves the right to reject, szisperrd, antl.~'ar ter?xrinate hislher partcipacaan under the ,A.greernezrt far bz-eachirig ar ctliez-4vise failing tc~_ (i) canaply wit]i the ter~i of tkre Agreezner~t or azly Attachment therein; azrd (ii} zrzeet i~1C0's credentaaling requireznents_ ~~~ ~ ~ ~ `flris Att.estatic!zr ,hall be effective as of t _. ~airye- Denis Lan~l.ois ~ Nur ~~y n-~~f-.±itic~rier- ~necia,ty _- ~fzai~? _ C}ate: ~ ~-_- ~srrA Gro~.4f! base ~..'~~'-l~' Pave ; s c,: , , EX~-IIBXT 3 P~,~Z:T-~~~P~,TING PR[}V:~D~R AT'TE~T~TICIN Gaardiz~ated Care Car~c~z~atian ~"ivFaxiaged Car° C)rgarrizatior~" or " ~CC~"}, ~G'~H~~'-~S' Fith ,~~tt~rson County ~"C7roup") dated `~~~ 4 f~ a has executed an a~eement ~ _ Group 1~as agreed to provide Covered Services to Covered Persons through pursuant to ~vhicla er~t" Group prc,viders ~fl'e «~~ eem - ) ~ ' GrotiF has requested that the urrders~gnvd provider {"Provider") serve as a ~~,~IE~R~AS e~rnent and Provider sa desires to participate.; and Group Pre~vider under the Age . ~,rxIERTAS, as a condition of such participation and 1'rovi~ler's designatron as a "Group eem,ent, Provider rriust satisfy 1V~CG's credentialirag criteria and execute provider" under the A~ ~ hislher agreement to comply with, and be bound by, the terms the Attestation ackno~ ledg g d conditions ofthe Agreerneut that are applicable to Group Providers, as set forth below. an I,j~}~~ T~dl1l~~t~~, Provider hereby agrees as follows: as provider qualifies and participates as a Group Provider under the A~t~eenrerxt, As long rovicle Covered Services to Covered '?ersorrs in accordance uritla the d Provider agrees to P sots of the Agreerrient that are applicable to Group Providers, which shall requixem terFr~s: Sections ~.3 through 3.17; Article IV; Article ~'; Article VI; include the tlaxti 1 ~v'III; Section 9.1; arrd Sections 1~.~ through 1[1.7. P,rticle VII; provider understands and agrees that hi5lher initial and contirr~zed participation as a ~ pro~~ider under tl3e Agreer7~ent is contingent upon, hislher meeting and complying Gr°up credentialing standards and otherwise corx~plyia~g with the terrrxs and with ~'ICC)'s e~rnent. cozrditions of tl~e Agr ' , ., rovider acknowledges that 1'~'1CG expressly xeserves the right to reject, suspend, andJor s. P anticipation under the Agreement for breacl7~-ag or otherwise failing to: terminate hislher p r~rith the terra of the Agreement or an}# Attachzuent thereto; ai-~d (ii) meet (;~ cor~plY ~7C,~'s creelentialir?g recluirerrzents. ~ ~ ~-, ;~ttestaticn sljall he e~Iectivp as of ~_~_~ .__i ~~ L~1` -- ro v icier Sarah Kirks ward ~a~c.: €'r~~ci-mot Q n ~ r ~atc;. Y-- _---- Page 35 ~#~35 ~~;`;~~ Group horse `'•~~-1? ~~~x ~ 111_~:1~ ~ PART CCIP~t'I ~i~C~ P~t~"~r~]3ER ATTES".C'r7,TIQ1~ V~~HEI~AS, Coardiz-ated Care Cora~aration ~"Managed Care C~z-gan~atiozx" or "~.!CC)"}, has e~ectTted aza agreement witix Jefferson County ("Group''} dated ~~> ;i~,. - ptzz-suant to which Crroup has agreed to provide Covered Services to C©vered Persczns t ough Croup ;providers the .~greezr~errt"}; ~~~EREAS, Grox~p izas regzzested that the u~d~rsigzaed provider ("~'z~ovider"} scree as a Croup Provider uzxder the Agreement and Provider so desires to participate; atxd t~IH~l~~~!.S, as a corxdition o~ such participation anti I'rovicier's desigzxatiorx as a ``CXroup Provider°' under the Agreezx~ent, Provider rzxust satisFy NIGC3's credentiaiing criteria and e-cecute this Attestation acknow lec3gg hislher agreement to coznpiv ~~ ith, and he boizrxd by, tixe teens an. d cc~nciitians o l~ thE =~~~~~~ut that are applcahie to Ci-roup Prodders, as set f©ztix h~low. N~~~ TI-IEIZE~'~J~l, Provider hez-ei~y agrees as zollo~vs. As Iozxg as Provider qualii`tes and particil~ates as a Croup Provider under tkxe Agx-eerxxent, Provider a~-~~,s to provide Covered Sert~i~.es to Covored Feasc~ns irx a~cordax-TCe w=th the rec~uiremerxts of the AgreeTxTent that are appiicahle to group Providers, Wixici: shall include the I4llouris~g terms: Sections 3.3 tixxouglt 3.1~; :lrticlt I~r'; Arti~;le ~'; ~:~icle L'I; ~~rtcle VII; Article VCII; erection 9,:1; azxd SectiorTS 10.4 through it].7. ~ Provider utxderstarxds and agrees tlxat 17s:her izxital and cc~ntuxued paa-[icipatiotx as a ~. Group Provider ~.tnder tl~e Agreement is contingezxt upon his,~her meeting. and corrzplying with i~~CC~'s credeTxtialirTg standards and otherwise eonxplyz~ig ~°tix the ten~xs and conditioTxs of the Agx-eement_ Prnvicler acknowledges tlxat IUIC[3 expressly reserves thy: night to reject, ,suspend, azxcl/ar cermiz3ate hislhex participatitin under the r'~greernent ~nr breaching or otlxerwse failing toi (i} corxxpl}~ with the terTxx of the t'Lgreeznent or ar~y AttachrTxent thereto; ar~d (ii} nxe°t fvICC~'s creclentiaiing requrenxents. 1lxis Attestation shall be effective as of _ ~}Vf fs3- I'rovicier r5~ ~___~.~-~u.'' e ~c`3Y'l~ ~'UL.PT'1S~'1 ~pt;~Cirllt}I: ~'~~ ~ - 1 ,~ 'r l- L3ate: ~~.f ~, L~T'oLip ~aSe x_77, ~ ~. Page 3~ of 35 EXHIBIT 3 )'A~T'iC~Y.~T~G PR()VTD'~R ATTF.STATI(7\' Coordinated Care Corgaratian (°`Vla~aaged. Care Grgataization" or `U1CC"}> LF~~S' vaitPn ,Yeftersbr~ County ("C~ranp„) dated ~ ~ `-' ~ i :y: , has ax~a~-rted` an a~r~'`~rr~ent ursuatat to which Group has agreed to pra~Fide Covered Services to Ca~~ered Persons tlaro~.igh Y7 tha `~,~.greement"3; Groin providers `~~~~~ Group has requested that the urxdersigr~ed provider ("Provider") serve as a Group Provider under the Agreement azad provider sc~ desixes to participate; and WI~~R-EAS, as a cc~nditian of such participation and Provider's desigzaatian as a "C~rotip eeraxent, Provider rxaust satisfy MCC}'s creder~tializ~g criteria and execnta provider' under the ~€~ in hisJher a reerraent to comply with, anal be bau~~d by, the ter~aas tla~s Attestation acknaw ledg ~ g and conditions of the ~,greernent that are applicable to Group Pravidcrs, as set Earth. below. ~C~~ THEI~F(~T~.~> Provider hereby agrees as follows: As long as provider qualifies and participates. as a Group Provider under the ~lgreerraer~t, provider agrees to provide Covered Services tee Covered Persons in accordance ~ritl~ the requ~"cnaents of the Agreement that are applicable to Gr~~up Providers, which sha11 incltirde the faYlowia3g terms: Sections 3.3 through x.17; Article IV; Article V; Article VI; Article VII; Article Vl1I; Sections 9.1; and Sections 1(1.4 through lCt.7. Pravide1 understands and agrees that his~her uaitial and cantiaaued participatiaz~ as a [croup provider under the Agr"eezr~ent is ~~ t~ ar wis~a corn? 1v~ta~cwith the taasl~and p~ g ~~~ ith ~I.CU's crcdc~een~ent. starxdar s a. c.onditio~ls of the A~ Provider acknowledges that Yv~ICU e~cpressly reserves the right to reject, suspend, and.~'c~r terl~inate hislher p~ticipation wader tl-ae A.greernent for breaching or otherwise failizag to: ~i~ Goia~ply ~vitl~ the terra of the Agreeraaent ar aray Attachment thereto; and (ii} nlcet r,i~`~'~ ~~re~lentialing requiremersts. .' is Attestation shall be effectiv as of ~ ~ ~ f `'~ . provider ~ ~ --~ , ~'~-' / ? ~~ ~+ E~. ~ Zc"i' E~~ .~ . Batt~rlbUrg ?'~' aloe: -`~ ; ., , ~ C W '~- t ' '~ _ L ~p~C.l~ilt4': r: f ~=-_ - I~ - L3ate: ~ '~ ~ } ~, 1~T A C~rnup base <...2. Page _~5 ut„