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HomeMy WebLinkAbout020215_ca05615 Sheridan Street Port Townsend. WA 98368 www.JeffersonCountyPublicHeciith,org C11 Public Healt Consent Agenda December 29, 2014 JEFFERSON COUNTY BOARD OF COUNTY COMMISSIONERI TO: Board of County Commissioners Philip Morley, County Administrator FROM: Jean Baldwin, Director Jessica Syska, Fiscal Support DATE: SUBJECT: Agenda Item - Provider Services Agreement, Molina Healthcare of Washington, Inc.; provision of services for members with gov. sponsored health programs, products; upon signature - annual, auto renewal; fee for services. STATEMENT CIF �1- Jefferson County Public. Health requests Board approval of the Provider Services Agreement with Molina Healthcare of Washington, Inc. to provide healthcare services to members with various government sponsored health programs; effective upon signature with annual, auto renewals; fee for services. '' 1� LIC'' 1�:' 11.''�iiiloiijkLS/PRO'S ANIUL''11101111' nfSTRATEG' and COWS: The purpose of this Tcon contract between JCPH and Molina Healthcare of Washington Inc is to provide health care services to Molina Health Plan members. This agreement will allow JCPH to bill and collect for clinic services provided to WA Medicaid eligible, clients, and private purchasers, who have chosen Molina Healthcare of Washington, Inc. as their Health Plan organization. This agreement allows JCPH to impart savings to out-of-pocket charges and to serve additional citizens who might otherwise be unable to find health care providers in this area, and as a result, to be compensated for those services. FISCAL BEN�EFIT ANALYSIS: This is a fee for service agreement. RE JCPH management request approval of the Provider Services Agreement with Molina Healthcare of Washington, Inc.; upon signature - annual, auto renewal; fee for services. REVIEWED BYO. _7 Philip Morley, county Administrator community de'alfh Developmentd 01sablPies 14r1-3%35-9400 Date 360-385-9401 N Alwnys working for a safer and healthier community Environmental health Water Quality 360 385 9444 {f) 360-379-4487 This Provider Services Agreement ("Agreement") is entered by and between Molina Healthcare of Washington, Inc., a Washington corporation ("Health Plan"), and Jefferson County Public Health ("Provider"). RECITALS A. Health Plan arranges for the provision of certain health care services to Members pursuant to contracts with various government sponsored health programs. Health Plan intends to participate in additional government sponsored health programs and offer other health products as the opportunities become available. B, Health Plan arranges for the provision of certain health care services to Members by entering into provider service agreements with individual physicians, groups of physicians, individual practice associations, hospitals, clinics, ancillary health providers, and other health providers. C. Provider is licensed to render certain health care services and desires to provide such services to Health Plan's Members in connection with Health Plan's contractual obligations to provide and/or arrange for Covered Services for Health Plan's Members. Now, therefore, in consideration of the promises, covenants and warranties stated herein, Health Plan and Provider agree as follows: ARTICLE ONE - DEFINITIONS Provider means the health care professional(s), or entity(ies) identified in Attachment A to this Agreement. 1.2 Capitalized words or phrases in this Agreement shall have the meaning set forth in Attachment B. ARTICLE TWO - PROVIDER OBLIGATIONS 2.1 Serving as a Panel Provider. Provider shall serve on Health Plan's panel of providers for the products specified in Attachment C. Provider agrees that its practice information may be used in Health Plan's provider directories, promotional materials, advertising and other informational material made available to the public and Members. Practice information includes, but is not limited to, name, address, telephone Dumber, hours of operation, type of practice, and ability to accept new patients. Provider shall promptly notify Health Plan of any changes in this practice information. 2.2 Standards for Provision of Care. Page I ol"32 Nil lwpj OV.042014 N401ijj�j q,MS rtI# 41249 a. Provision of Covered Services. Provider shall provide Covered Services to Members, within the scope of Provider's business and practice, in accordance with this Agreement, Health Plan's policies and procedures, the terms and conditions of the Health Plan product which covers the Member, and the requirements of any applicable government sponsored program. b. Standard of Care. Provider shall provide Covered Services to Members at a level of care and competence that equals or exceeds the generally accepted and professionally recognized standard of practice at the time of treatment, all applicable rules and/or standards of professional conduct, and any controlling governmental licensing requirements. c. Facilities, Equipment, and Personnel. Provider's facilities, equipment, personnel and administrative services shall be at a level and quality as necessary to perform Provider's duties and responsibilities under this Agreement and to meet all applicable legal requirements, including the accessibility requirements of the Americans with Disabilities Act. d. Prior Authorization. If Provider determines that it is Medically Necessary to consult or obtain services from other health professionals that are Medically Necessary, Provider shall obtain the prior authorization of Health Plan in accordance with Health Plan's Provider Manual unless the situation is one involving the delivery of Emergency Services. Upon anc' following such referral, Provider shall coordinate the provision of such Covered Services to Members and ensure continuity of care. e. Contracted Providers. Except in the case of Emergency Services or upon prior authorization of Health Plan, Provider shall use only those health professionals, hospitals, laboratories, skilled nursing and other facilities and providers which have contracted with Health Plan (,,participating providers"). Member Eligibility Verification. Provider shall verify eligibility of Members prior to rendering services. g. Admissions. Provider shall cooperate with and comply with Health Plan's hospital admission and prior authorization procedures. h, Emergency Room Referral. If Provider refers a Member to an emergency room for Covered Services, Provider shall provide notification to Health Plan within 24 hours of the referral. i. Prescriptions. Except with respect to prescriptions and pharmaceuticals ordered for in- patient hospital services, Provider shall abide by Health Plan's drug formularies and prescription policies, including those regarding the prescription of generic or lowest cost alternative brand name pharmaceuticals. Provider shall obtain prior authorization from Health Plan if Provider believes a generic equivalent or formulary drug should not be dispensed. Provider acknowledges the authority of Health Plan contracting pharmacists to substitute generics for brand name pharmaceuticals unless C01111ter indicated on the Page 2 of 32 M1 JWPROV.042014 Molina ff"NAS refO 41249 prescription by the Provider. Subcontract Arrangements. Any subcontract arrangement entered into by Provider for the delivery of Covered Services to Members shall be in writing and shall bind Provider's subcontractors to the terms and conditions of this Agreement including, but not limited to, terms relating to licensure, insurance, and billing of Members for Covered Services. k. Availability of Services. Provider shall make necessary and appropriate arrangements to assure the availability of Covered Services to Members on a twenty-four (24) hours a day, seven (7) days a week basis, including arrangement to assure coverage of Member patient visits after hours. Provider shall meet the applicable standards for timely access to care and services, taking into account the urgency of the need for the services. Treatment Alternatives. Health Plan encourages open Provider-Member communication regarding appropriate treatment alternatives. Health Plan promotes open discussion between Provider and Members regarding Medically Necessary or appropriate patient care, regardless of Covered Services limitations. Provider is free to communicate any and all treatment options to Members regardless of benefit coverage limitations. 2.3 Promotional Activities. At the request of Health Plan, Provider shall (1) display Health Plan promotional materials in its offices and facilities as practical, and (2) shall cooperate with and participate in all reasonable Health Plan marketing efforts. Provider shall not use Health Plan's name in any advertising or promotional materials without the prior written permission of Health Plan. 2.4 Nondiscrimination. a. Enrollment- Provider shall not differentiate or discriminate in providing Covered Services to Members because of race, color, religion, national origin, ancestry, age, sex, marital status, sexual orientation, physical, sensory or mental handicap, socioeconomic status, or participation in publicly financed programs of health care services. Provider shall render Covered Services to Members in the same location, in the same manner, in accordance with the same standards, and within the same time availability regardless of payor. b. Employment. Provider shall not differentiate or discriminate against any employee or applicant for employment, with respect to their hire, tenure, terms, condition-, or privileges of employment, or any matter directly or indirectly related to employment, because of race, color, religion, national origin, ancestry, age, sex, height, weight, marital status, physical, sensory or mental disability unrelated to the individual's ability to perform the duties of the particular job or position. 2.5 Recordkeeping. a. Maintaining Member Medical Record. Provider shall maintain a medical record for each Member to whom Provider renders health care services. Provider shall open each Member's medical record upon the Member's first encounter with Provider. The Member's medical Pagc 3 of 32 Nl [WpIzOV.042014 Molil, I.,,,CMs I,e894124c) record shall contain all information required by state and federal law, generally accepted and prevailing professional practice, applicable government sponsored health programs, and all Health Plan policies and procedures. Provider shall retain all such records for at least ten (10) years. b. Confidentiality of Member Health Information. Provider shall comply with all applicable state and federal laws, Health Plan's, policies and procedures, government sponsored program requirements regarding privacy and confidentiality of Members' health information and medical records, including mental health records. Provider shall not disclose or use Member names, addresses, social security numbers, identities, other personal information, treatment modalities, or medical records without obtaining appropriate authorization to do so. This provision shall not affect or limit Provider's obligation to make available medical records, encounter data and information concerning Member care to Health Plan, any authorized state or federal agency, or other Providers of health care upon authorized referral. c. HIPAA• To the extent Provider is considered a covered entity under the Health Insurance Portability and Accountability Act ("HIPAA"), Provider shall comply with all provisions of HIPAA including, but not limited to, provisions addressing privacy, security, and confidentiality. d. Delivery of Patient Care Information. Provider shall promptly deliver to Health Plan, upon request and/or as may be required by state or federal law, Health Plan's policies and procedures, applicable government sponsored health programs, Health Plan's contracts with the government agencies, or third party payers, any information, statistical data, encounter data, or patient treatment information pertaining to Members served by Provider, including but not limited to, any and all information requested by Health Plan in conjunction with utilization review and management, grievances, peer review, HEMS Studies, Health Plan's Ouality improvement Program, Consumer Assessment of Health Plans (CAHPS), or Claims payment. Health Plan will not pay copying fees when records are requested for any of the above listed programs. Provider shall further provide direct access to said patient care information as requested by Health Plan and/or as required by any governmental agency or any appropriate state and -federal authority having jurisdiction over Health Plan. e. Member Access to Health Information. Provider shall give Health Plan and Members access to Members' health information including, but not limited to, medical records and billing records, in accordance with the requirements of state and federal law, applicable government Sponsored health programs, and Health Plan's policies and procedures. f. National Provider Identifier ("NPI"). In accordance with applicable statutes and regulations of the Health Insurance Portability and Accountability Act ("HIPAA") of 1996, Provider will comply with the Standard Unique Identifier for Health Care Provider regulations promulgated under HIPAA (45 CFR Section 162.402, et seq.) and use only the NPI to identify HIPAA covered health care providers in standard transactions. Provider will utilize an NPI from the National Plan and Provider Enumeration System ("NPPES") for itself or for any subpart of the Provider. Provider will make best efforts to report its NPI and any Page 4 of 32 ,\41jWJ1JZOV,042014 F(;NJS ref# 41249 subparts to Health Plan. Provider will report any changes in its NPI or subparts to Health Plan within thirty (30) days of the change. Provider will use its NPI to identify itself on all Claims and encounters (both electronic and paper formats) submitted to Health Plan. 2.6 Program Participation. a. Participation in Grievance Program. Provider shall participate in Health Plan's Grievance Program and shall cooperate with Health Plan in identifying, processing, and promptly resolving all Member complaints, grievances, or inquiries. b. Participation in Quality Improvement Program. Provider shall participate in Health Plan's Quality Improvement Program and shall cooperate with Health Plan in conducting peer review and audits of care rendered by Provider. c. Participation in Utilization Review and Management Program. Provider shall participate in and comply with Health Plan's Utilization Review and Management Program, including all policies and procedures regarding prior authorizations, and shall cooperate with Health Plan in audits to identify, confirm, and/or assess utilization levels of Covered Services. If Provider is a medical group or IPA, Provider shall accept delegation of utilization management responsibilities from Health Plan at Health Plan's request. d. Participation in Credentialing. Provider shall participate in Health Plan's credentialing and re-credentialing process and shall satisfy, throughout the term of this Agreement, all credentialing and re-credentialing criteria established by the Health Plan. Provider shall immediately notify Health Plan of any change in the information submitted or relied upon by Provider to achieve credentialed status. If Provider's credentialed status is revoked, suspended or limited by Health Plan, Health Plan may at its discretion terminate this Agreement and/or reassign Members to another provider, If Provider is a medical group or IPA, Provider shall accept delegation of credentialing responsibilities at Health Plan's request and shall cooperate with Health Plan in establishing and maintaining appropriate credentialing mechanisms within Provider's organization. e. Provider Manual. Provider will follow the terms set forth in Health Plan's Provider Manual, which may be amended from time to time at Health Plan's sole discretion. Provider shall comply and render Covered Services in accordance with the contents, instructions and procedures set forth in Health Plan's Provider Manual, and any additional operating procedures and policies for Providers which are communicated to Provider in writing by Health Plan. Provider acknowledges it received Health Plan's Provider Manual as set forth in Attachment G- Government Contracts. Provider acknowledges that Health Plan has entered into contracts with state and federal agencies for the arrangement of health care services for Members through government sponsored programs. Provider shall comply with any tern or condition of those government sponsored program contracts that are applicable to the services to be performed under this Agreement. Pa�,,e 5 of 32 Tvii MIROV.042014 ,Molimi ECWS refO 41249 g. Health Education/Training. Provider shall participate in and cooperate with Health Plan's Provider education and training efforts as well as Member education efforts. Provider shall also comply with all Health Plan health education, cultural and linguistic standards, policies, and procedures, and such standards, policies, and procedures as may be necessary for Health Plan to comply with its contracts with employers, the state, or federal government. Provider shall ensure that Provider promptly delivers to Provider's constituent providers, if any, all informational, promotional, educational, or instructional materials prepared by Health Plan regarding any aspect of providing Covered Services to Members. 2.7 Lice,nsure and Standing. a. Licensure. Provider warrants and represents that it is appropriately licensed to render health care services within the scope of Provider's practice, including having and maintaining a current narcotics number, where appropriate, issued by all proper authorities. Provider shall provide evidence of licensure to Health Plan upon request. Provider shall maintain its licensure in good standing, free of disciplinary action, and in unrestricted status throughout the term of this Agreement. Provider shall immediately notify Health Plan of any change in Provider's licensure status, including any disciplinary action taken or proposed by any licensing agency responsible for oversight of Provider. b, Unrestricted Status. Provider warrants and represents that it has not been convicted of crimes as specified in Section 1128 of the Social Security Act (42 U.S.C. 1320a-7), excluded from participation in the Medicare or Medicaid program, assessed a civil penalty under the provisions of Section 1128, entered into a contractual relationship with an entity convicted of a crime specified in Section 1128, or taken any other action that would prohibit it from participation in Medicaid and/or state health care programs. c. Malpractice and Other Actions. Provider shall give immediate notice to Health Plan of: (a) any malpractice claim asserted against it by a Member, any payment made by or on behalf of Provider in settlement or compromise of such a claim, or any payment made by or on behalf of Provider pursuant to a judgment rendered upon such a claim; (b) any criminal investigations or proceedings against Provider; (c) any convictions of Provider for crimes involving moral turpitude or felonies; and (d) any civil claim asserted against Provider that may jeopardize Provider's financial soundness. d. Staffing Privileges for Providers. Consistent with community standards, every physician Provider shall have staff privileges with at least one Health Plan contracted hospital as necessary to provide services to members under this Agreement, and shall authorize each hospital at which he/she maintains staff privileges to notify Health Plan should any disciplinary or other action of any kind be initiated against such provider which could result in any suspension, reduction or modification of his/her hospital privileges. e. Liability Insurance. Provider shall maintain premises and professional liability insurance in coverage amounts appropriate for the size and nature of Provider's facility and the nature of Provider's health care activities. Every physician Provider shall maintain, at a minimum, professional liability insurance with limits of not less than $1 million per occurrence and $3 Page 6 of 32 MI 1\ IR()V.042014 1;,CMs rcf# 41249 million in the aggregate for the policy year and for each physician comprising Provider. If the coverage is claims made or reporting, Provider agrees to purchase similar "tail" coverage upon termination of the Provider's present or subsequent policy. Provider shall deliver copies of such insurance policies to Health Plan within five (5) business days of a written request by Health Plan. 18 Claims Payment. Submitting Claims. Provider shall promptly submit to Health Plan Claims for Covered Services rendered to Members. All Claims shall be submitted in a form acceptable to and approved by Health Plan, and shall include any and all medical records pertaining to the Claim if requested by Health Plan or otherwise required by Health Plan's policies and procedures. Claims must be submitted by Provider to Health Plan within one hundred eighty (180) days of providing the Covered Services that are the subject of the Claim. If Health Plan is not the primary payer under coordination of benefits, Provider must submit Claims to Health Plan within one hundred eighty (180) days from the primary payer's date of payment or date of contest, denial or notice. Except as otherwise provided by law or provided by government sponsored program requirements, any Claims that are not submitted by Provider to Health Plan within one hundred eighty (180) days from the date of providing the Covered Service or one hundred eighty (180) days from the primary payer's payment or date of contest, denial or notice, shall not be eligible for payment, and Provider hereby waives any right to payment therefore. b. Compensation. Health Plan shall pay Provider for Clean Claims for Covered Services provided to Members, including Emergency Services, in accordance with applicable law and regulations and in accordance with the compensation schedule set forth in Attachment Q and its applicable sub - attachments. Provider shall accept such payment, applicable co-payments, deductibles, and coordination of benefits collections as payment in full for services provided under this Agreement. Provider shall not balance bill Members for any Covered Services. C. Co-payment, Deductibles and Co-insurances. Provider is responsible for collection of co-payments, deductibles and co-insurances, if any, provided for in the Member's Health Plan product. d, Member Hold Harmless. Provider agrees that in no event, including but not limited to nonpayment, insolvency, or breach of this Agreement by the Health Plan, will Provider bill, charge, collect a deposit from, seek remuneration or reimbursement from, or have any recourse against a Member, or person acting on Member's behalf, for Covered Services provided pursuant to this Agreement. This does not prohibit Provider from collecting co- insurance, deductibles, or co-payments as specifically provided in the Member's evidence of coverage, or, subject to applicable law, fees for uncovered health care services delivered on a fee-for-service basis to persons referenced above, nor from any recourse against the health insuring corporation or its successor. This provision will survive the termination of Agreement regardless of the reason for the termination, including the insolvency of Health Plan. Pagc 7 of 32 M11WI)J�OV.042014 NIc '[vJS reW 41249 e. Coordination of Benefits. Health Plan is a secondary payer in any situation where there is another payer as primary carrier. Provider shall make reasonable inquiry of Members to learn whether Member has health insurance or health benefits other than from Health Plan or is entitled to payment by a third party under any other insurance or plan of any type, and Provider shall immediately notify Health Plan of said entitlement. In the event that coordination of benefits occurs, Provider shall be compensated in an amount equal to the allowable Clean Claim less the amount paid by other health plans, insurance carriers and payers, not to exceed the amount specified in Attachment D and its applicable sub- attachments. f. Offset. in the event that Health Plan determines that a Claim has been overpaid or paid in duplicate, or that funds were paid which were not provided for under this Agreement, Health Plan may make a written request for repayment: (1) within twenty-four (24) months after the date that the payment was made; (2) within thirty (30) months after the date that the payment was made if the request is related to coordination of benefits with another carrier or entity responsible for payment of the Claim; or (3) at any time if a third party is found responsible for satisfaction of the Claim as a consequence of liability imposed by law and Health Plan is unable to recover directly from the third party because the third party has either already paid or will pay Provider the health care services covered by the Claim. Provider may contest Health Plan's request in writing by participating in the Claims dispute process as outlined in Section 2.8f. Overpayment and duplicate payment disputes must be submitted in writing within thirty (30) days of receipt of request. If it is decided that Health Plan will recover the contested payment, such refund may be recovered by way of offset or recoupment from current or future amounts due Provider after six (6) months have passed from the date Health Plan received Provider's written notice contesting the repayment. In addition to any other contractual or legal remedy, if Provider fails to contest Health's Plan's request for a refund in writing within thirty (30) days of receipt of the request or if Provider contested the request and six (6) months has passed from the date Provider received Health Plan's refund request, Health Plan may recover the amounts owed by way of offset of recoupment from current or future amounts due Provider. Nothing in this section prohibits Provider from choosing at any time to refund to Health Plan any payment previously made by Health Plan to satisfy a Claim either by way of repayment by Provider or a request that Health Plan offset or recoup the money from current or future amounts due Provider. g. ciaims Dispute Process. In the event that Provider determines that a Claim has been improperly denied or underpaid, Provider may make a written request for payment: (1) within twenty-four (24) months after the date the Claim was denied or payment intended to satisfy the Claim was made; (2) within thirty (30) months after the date the Claim was denied or payment intended to satisfy the Claim was made if the request is related to coordination of benefits with another carrier or entity responsible for payment of the Claim. Provider may not request that payment be made any sooner than six (6) months after Health Plan's receipt of the request. Any request for review of denied or underpaid Claims must be submitted to Health Plan in accordance with the requirements stated in this section and conform to the following instructions: j.'Fhe request must specify why the Provider believes Health Plan owes the payment; fla�e 8 of 32 MIMPROV.041,014, Nv1c)9ill,j J�CMS refO 41249 ii. In the case of coordination of benefits, the request must include the name and mailing address of any entity that has disclaimed responsibility for payment; iii. The request must be addressed to the attention of Health Plan's Provider Services Department; iv. The request must clearly indicate "Denied Claims Review Request" or "Adjustment Request"; and, v. The request must include all pertinent information, including, but not limited to, Claim number, Member identifier, denial letter, supporting medical records, and any new information pertinent to the request; vi. Health Plan will render a decision on all disputed Claims within sixty (60) days of receipt of the Claim; vii. Should Provider not be satisfied with Health Plan's decision, Provider may proceed to the mediation steps outlined in Section 5.8. h. Claims Review and Audit. Provider acknowledges Health Plan's right to review Provider's Claims prior to payment for appropriateness in accordance with industry standard billing rules, including, but not limited to, current UB manual and editor, current CPT and HcPCS coding, CMS billing rules, CMS bundling/unbundling rules, National Correct Coding Initiatives (NCCI) Edits, CMS multiple procedure billing rules, and FDA definitions and determinations of designated implantable devices and/or implantable orthopedic devices. Provider acknowledges Health Plan's right to conduct such review and audit on a line-by-line basis or on such other basis as Health Plan deems appropriate, and Health Plan's right to exclude inappropriate line items to adjust payment and reimburse Provider at the revised allowable level. Provider also acknowledges Health Plan's right to conduct utilization reviews to determine medical necessity and to conduct post-payment billing audits. Provider shall cooperate with Health Plan's audits of Claims and payments by providing access to requested Claims information, all supporting medical records, Provider's charging policies, and other related data, Health Plan shall use established industry claims adjudication and/or clinical practices, state and federal guidelines, and/or Health Plan's policies and data to determine the appropriateness of the billing, coding and payment. j, Payments which are the Responsibility of a Capitated Provider. Provider agrees that if Provider is or becomes a party to a subcontract or other agreement with another provider contracted with Health Plan who receives capitation from Health Plan and is responsible for arranging for Covered Services through subcontract arrangements ("Capitated Provider"), Provider shall look solely to the Capitated Provider, and not Health Plan, for payment of Covered Services provided to Members that are covered by Health Plan's agreements with such Capitated Providers, 2.9 Compliance with Applicable Law. Provider shall comply with all applicable state and federal laws governing the delivery of Covered Services to Members including, but not limited to, title VI of the Civil Rights Act of 1964; title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; the Balanced Budget Act of 1997; and the Americans with Disabilities Act: Vage 9 of '32 M I l�VJROV.042W lvloliml RNS Tel . #41249 a. Provider acknowledges that this Agreement and all Covered Services rendered pursuant to this Agreement are subject to applicable state licensing statutes and regulations. Accordingly, Provider shall abide by those provisions set forth in Attachment E. b. Provider acknowledges that all Covered Services rendered in conjunction with the state Medicaid program are subject to the additional provisions set forth in Attachment F. the effect of which provisions is limited solely to activities and Covered Services related to the state Medicaid program. c. For covered Services rendered to Members enrolled in a Molina Health Benefit Exchange Product, Medicaid statutes and regulations referenced in this Agreement are inapplicable, and Provider shall comply with all statutory and regulatory requirements of the Washington Health Benefit Exchange Act, including the 2012 regular session laws, chapter 87 Affordable Care Act Implementation and regulations adopted pursuant to RC W 43,71. 2,10 Provider Non-solicitation Obligations. Provider shall not unilaterally assign or transfer patients served under this Agreement to another medical group, IPA, or provider without the prior written approval of Health Plan. Nor shall Provider solicit or encourage Members to select another health plan for the primary purpose of securing financial gain for Provider. Nothing in this provision is intended to limit Provider's ability to fully inform Members of all available health care treatment options or modalities. 2.11 Fraud and Abuse Reporting. Provider shall report to Health Plan's compliance officer all cases of suspected fraud and/or abuse, as defined in Title 42, of the Code of Federal Regulations, Section 455.2, where there is reason to believe that an incident of fraud and/or abuse has occurred, by subcontractors, Members, providers, or employees within ten (10) business days of the date when Provider first becomes aware of, or is on notice of, such activity. Provider shall establish policies and procedures for identifying, investigating, and taking appropriate corrective action against fraud and/or abuse in the provision of health care services under the Medicaid program. Upon the request of Health Plan and/or the State, Provider shall consult with the appropriate State agency prior to and during the course of any such investigations. 2.12 Advance Directive. Provider shall document all patient records with respect to the existence of an Advance Directive in compliance with the Patient Self-Determination Act (Section 4751 of the omnibus Reconciliation Act of 1990), as amended, and other appropriate laws. 2.13 Reassignment of Members. Health Plan reserves the right to reassign Members from Provider to another provider or to limit or deny the assignment or selection of new Members to Provider during any termination notice period or if Health Plan determines that assignment to Provider poses a threat to the Members' health and safety. If Provider requests reassignment of Member, Health Plan, in its sole discretion, will make the determination regarding reassignment based upon good cause shown by the Provider. When the Health Plan reassigns Member(s), Provider shall forward copies of the Member's medical records to the new provider within ten (10) business days of receipt of the Plan's or the Member's request to transfer the records. Page 10 of 32 MI. I W1,('W'.04201 4 Moli I,,,, ref# 41249 2.14 Confidentiality. Each party agrees that the terms set forth in this Agreement are strictly confidential, and neither party shall disclose such terms to any person or entity for purposes other than the administration of the Agreement without receiving prior written consent of the other party, except as required by law or government programs. ARTICLE THREE - HEALTH PLAN'S OBLIGATIONS 3.1 Compensation. Health Plan shall pay Provider in accordance with the terms and conditions of this Agreement and the compensation schedule set forth in Attachment D and its applicable sub - attachments. 3.2 Member Eligibility Determination. Health Plan shall maintain data on Member eligibility and enrollment. Health Plan shall promptly verify Member eligibility at the request of Provider. 3.3 Prior Authorization Review. Health Plan shall timely respond to requests for prior authorization and/or determination of Covered Services. 3.4 Medical Necessity Determination. Health Plan's determination with regard to Medically Necessary services and scope of Covered Services, including determinations of level of care and length of stay benefits available under the Member's health program shall govern. The primary concern with respect to all medical determination shall be the interest of the Member. 3.5 Member Services. Health Plan will provide services to Members including, but not limited to, assisting Members in selecting a primary care physician, processing Member complaints and grievances, informing Members of the Health Plan's policies and procedures, providing Members with membership cards, Providing Members with information about Health Plan, and providing Members with access to Health Plan's Provider Directory, updated from time to time, identifying the professional status, specialty, office address, and telephone number of Health Plan contracted providers. 3.6 Provider Services. Health Plan will maintain a Provider Manual describing Health Plan's policies and procedures, Covered Services, limitations and exclusions, and coordination of benefits information. Health Plan will maintain a Provider Services Department available to educate Provider regarding Health Plan's policies and procedures. 3.7 Medical Director. Health Plan will employ a physician as medical director who shall be responsible for the management of the scientific, technical, and medical aspects of Health Plan. ARTICLE FOUR - TERM AND TERMINATION 4.1 Term. This Agreement shall commence on the date this Agreement is signed by Health Plan (Effective Date) and shall continue in effect for one (1) year; it shall automatically renew for successive one (1) year terms unless and until terminated by either party in accordance with the- provisions of this Agreement or in accordance with applicable state licensing statutes and regulations set forth in ,Attachment E and Attachment F. Page I I of 32 Njjjwpj� ()V.042014 M,0ji1jjj T�,CMS ref# 412,19 4.2 Termination without Cause. This Agreement may be terminated without cause by either party on at least one hundred twenty (120) days written notice to the other party. 4.3 Termination with Cause. In the event of a breach of any material provision of this Agreement, the party claiming the breach will give the other party written notice of termination setting forth the facts underlying its claim(s) that the other party has breached the Agreement. The party receiving the notice of termination shall have thirty (30) days from the date of receipt of such notice to remedy or cure the claimed breach to the satisfaction of the other party. During this thirty (30)-day period, the parties agree to meet as reasonably necessary and to confer in good faith in an attempt to resolve the claimed breach. If the party receiving the notice of termination has not remedied or cured the breach within such thirty (30)-day period, the party who provided the notice of termination shall have the right to immediately terminate this Agreement. 4.4 Immediate Termination. Notwithstanding any other provision of this Agreement, Health Plan may immediately terminate, this Agreement and transfer Member(s) to another provider by giving notice to Provider in the event of any of the following: a. Provider's license or certificate to render health care services is limited, suspended or revoked, or disciplinary proceedings are commenced against Provider by the state licensing authority; b. Provider fails to maintain insurance required by this Agreement; C. provider loses credentialed status; d. Provider becomes insolvent or files a petition to declare bankruptcy or for reorganization under the bankruptcy laws of the United States, or a trustee in bankruptcy or receiver for Provider is appointed by appropriate authority; e. If Provider is capitated and Health Plan determines Provider to be financially incapable of bearing capitation or other applicable risk-sharing compensation methodology; f. Health Plan determines that Provider's facility and/or equipment is insufficient to render Covered Services to Members; g. provider is excluded from participation in Medicare and state health care programs pursuant to Section 1128 of the Social Security Act or otherwise is terminated as a provider by any state or federal health care program; h. provider engages in fraud or deception, or knowingly permits fraud or deception by another in Connection with Provider's obligations under this Agreement; i. Health Plan determines that health care services are not being properly provided, or arranged for, and that such failure poses a threat to Members' health and safety. Page 12 of 32 M[jWpg()V,()42014 .4J()Jina F('"s rVt4 41249 4.5 Termination NotificatiOu to Members. Upon receipt of termination by either Health Plan or Provider, Health Plan will inform affected Members of such termination notice in accordance with the process set forth in the Provider Manual. Health Plan will make a good faith effort to ensure that such notice is Mailed within no less than sixty (60) days of the expected termination effective date for a termination without cause and fifteen (15) days for a termination with cause. Members may then be required to select another provider contracted with Health Plan prior to the effective date of termination of this Agreement. ARTICLE FIVE - GENERAL PROVISIONS 5.1 Indemnification. Each party shall indemnify and hold harmless the other party and its officers, directors, shareholders, employees, agents, and representatives from any and all liabilities, losses, damages, claims, and expenses of any kind, including costs and attorneys' fees, which result from the duties and obligations of the indemnifying party and/or its officers, directors, shareholders, employees, agents, and representatives under this Agreement. 5.2 Relationship of the Parties. Nothing contained in this Agreement is intended to create, nor shall it be construed to create, any relationship between the parties other than that of independent parties contracting with each other solely for the purpose of effectuating the provisions of this Agreement, This Agreement is not intended to create a relationship of agency, representation, joint venture, or employment between the parties. Nothing herein contained shall prevent any of the parties from entering into similar arrangements with other parties. Each of the parties shall maintain separate and independent management and shall be responsible for its own operations. Nothing contained in this Agreement is intended to create, nor shall be construed to create, any right in any third party, including but not limited to Health Plan's Members. Nor shall any third party have any right to enforce the terms of this Agreement. 5.3 Entire Agreement. This Agreement, together with Attachments, Amendments and incorporated documents or materials, contains the entire agreement between Health Plan and Provider relating to the rights granted and obligations imposed by this Agreement. Additionally, as to the Medicaid products offered by Health Plan and listed in Attachment C, the contract between the Washington Department of Social and Health Services and the Health Plan shall be the guiding and controlling document when interpreting the terms of this Agreement. Any prior agreements, promises, negotiations, or representations, either oral or written, relating to the subject matter of this Agreement are Of DO force or effect. 5.4 SeverabilitY. If any term, provision, covenant, or condition of this Agreement is held by a court of competent jurisdiction to be invalid, void, or unenforceable, the remaining provisions shall remain in full force and effect and shall in no way be affected, impaired, or invalidated as a result of such decision. 5.5 Notice. All notices required or permitted by this Agreement shall be in writing and may be delivered in person or may be sent by registered or certified mail or U.S. Postal Service Express Mail, with postage prepaid, or by Federal Express or other overnight courier that guarantees next day delivery, or by facsil-aile transmission, and shall be deemed sufficiently given if served in the manner specified in this Section. The addresses below shall be the particular party's address for 11age 13 of 32 M111WpIZOV.042014 Molina LCMI� lef# C249 delivery or mailing of notice purposes: If to Health Plan: Molina Healthcare of Washington, Inc 21540 30th Drive SE Suite ##400 Bothell, WA 98021 Attention. President If to Provider: Iefferson County Public Health 615 Sheridan Street, Port Townsend, WA, 98368, Attention: President /CEO The parties may change the names and addresses noted above through written notice in compliance with this Section. Any notice sent by registered or certified mail, return receipt requested, shall be deemed given on the date of delivery shown on the receipt card, or if no delivery date is shown, the postmark date. Notices delivered by U.S. Postal Service Express mail, Federal. Express or overnight courier that guarantees next day delivery shall be deemed given twenty -four (24) hours after delivery of the notice to the United States Postal Service, Federal Express or overnight courier. If any notice is transmitted by facsimile transmission or similar means, the notice shall be deemed served or delivered upon telephone confirmation of receipt of the transmission, provided a copy is also delivered via delivery or mail. 5.6 Amendment. Health Plan may, without Provider's consent, immediately amend this Agreement to maintain consistency and /or compliance with any state or federal law, policy, directive, or government sponsored program requirement. Health Plan may otherwise amend this Agreement upon sixty (60) days prior written notice to Provider. If Provider does not deliver to Health Plan a written notice of rejection of the amendment within that sixty (60) day period, the amendment shall be deemed accepted by and shall be binding upon Provider. 5.7 Assignment. Provider may not assign, transfer, subcontract or delegate, in whole or in part, any rights, duties, or obligations under this Agreement without the prior written consent of Health Plan. Subject to the foregoing, this Agreement is binding upon, and inures to the benefit of the Health Plan and Provider and their respective successors in interest and assigns. Neither the acquisition of Health Plan nor a change of its legal name shall be deemed an assignment. 5.8 Dispute Resolution Process. a. Submission of Non- 'Maims Payment Related Disputes i. Provider shall submit any dispute (other than a dispute relating to Claims, which are subject to Section 2.8(f)) to Health Plan in writing within sixty (60) days of when the is arises. ii. Provider shall submit such disputes to the attention of Health. Plan's Provider Services Department. Page 14 of 32 M14"SfpJ9 ()V,042014 vlolina k C,95 rdO 41249 b. Health Plan Response to Non-Claims Related Disputes i. Health Plan shall use best efforts to acknowledge by phone, e-mail or other writing, receipt of a dispute (other than a dispute relating to Claims, which are subject to Section 2.8(f)) within seven (7) business days. ii. Health Plan's decision regarding disputes shall be communicated within sixty (60) days of Health Plan's receipt of Provider's written correspondence requesting review. If additional tirne is required, Health Plan shall communicate this information to Provider within sixty (60) days. iii. Health Plan shall use its best efforts to investigate and resolve disputes within sixty (60) days of Health Plan's receipt of Provider's written correspondence. c. Nonbinding Mediation. If Provider is dissatisfied with Health Plan's final resolution of a dispute or if Health Plan fails to grant or reject Provider's request for review of a dispute within thirty (30) days after it is received, Provider may submit the dispute to nonbinding mediation pursuant to chapter 7.07 RCW. Nonbinding mediation shall not be utilized to adjudicate matters that primarily involve review of Provider's professional competence or professional conduct, and shall not be available as a mechanism for appeal of any determinations, made as to such matters. 5.9 Corrective Action, Fair Hearing Plan, and Reporting to the State of Washington Medical Quality Assurance Commission and the NPDB. Provider has a procedural right to appeal in the event that Health Plan's peer review committee recommends filing a report to the Washington Medical Quality Assurance Commission and the NPDB. The appeal right, Fair Hearing process, and the requirement to report to the Washington Medical Quality Assurance Commission and NPDB are described in Health Plan's Fair Hearing Plan. 5.10 Arbitration. Health Plan and Provider agree, as a condition precedent to the commencement of any civil action in any court of competent jurisdiction, to submit to arbitration all disputes arising from or related to this Agreement and the rendition of services to Members pursuant to this Agreement which are not otherwise resolved pursuant to the processes set forth at Sections 2.8(f), Or 5.8; provided, however, that arbitration shall not be utilized to adjudicate matters that primarily involve review of Provider's professional competence or professional conduct, and shall not be available as a mechanism for appeal of any determinations, made as to such matters. Arbitration shall proceed according to the rules and regulations of the American Arbitration Association, then in effect, and shall be conducted in King County, Washington. The arbitrator shall have no authority to award damages or provide a remedy that would not be available to such prevailing party in a court of law. Nor shall the arbitrator have the authority to award punitive damages. The parties recognize that the arbitrator's decision is not binding and that either party may seek judicial remedies following the arbitration of a dispute. The panel of arbitrators shall be selected as follows: one arbitrator shall be designated by Health Plan; one arbitrator shall be designated by Provider; and the third arbitrator shall be selected by the arbitrators designated by Provider and Health Plan. Health Plan and Provider shall divide and share equally the cost of arbitration. Each party shall be responsible for its own attorneys' fees, Page 15 (A32 ,,111WpJt()V,042014 Molina ECMS ret# 41249 5.11 Attachments. Each of the Attachments identified below is hereby made a part of this Agreement: Attachment A - Provider identification Sheet Attachment B — Definitions Attachment C - Products Inventory Attachment D — [Compensation Schedule] Attachment E - Required Provisions (Health Care Services Plan) Attachment F - Required Provisions (HCA) Attachment G - Acknowledgment of Receipt of Provider Manual [Attachment 1 — Medicare Program Requirements — Health Care Services] 5,12 Conflict with Health Plan Product. Nothing in this Agreement modifies any benefits, terms or conditions contained in the Member's Health Plan product. In the event of a conflict between this Agreement and the benefits, terms, and conditions of the Health Plan product, the benefits, terms or conditions contained in the Member's Health Plan product shall govern. IN WITNESS WHEREOF, the parties hereto have agreed to and executed this Agreement by their officers thereunto duly authorized. The individual signing below on behalf of Provider acknowledges, warrants, and represents that said individual has the authority and proper authorization to execute this Agreement on behalf of Provider and its constituent providers, if any, and does so freely with the intent to fully bind Provider, and its constituent providers, if any, to the provisions of this Agreement. Jefferson County Public Health Provider Signature: Signatory Name (Printed): Signatory Title (printed): Signature Date: �411WPROV.042014 Njohna 11'(7.,MS ref# 41249 Molina Healthcare of Washington, Inc. Molina Signature: Signatory Name (printed): Signatory Title (Printed): Signature Date: Paf,,e 16 of 32 Laurel Lee Chief Operating Officer ATTACHMENT A Provider Identification Sheet Mark applicable category(�ies) below. For those Providers representing multiple health care professionals) or entity(ies), please check all the categories that apply. N/A X N/A N/A N/A N/A Provider Tlele ho F acsirni Tax LTA License NPI NPI Tax code DEA N Primary Care Provider N/A Specialist: Women's Health Care N/A (a list of constituent members with their License and DEA numbers is attached and Group/IPA Address T incorporated herein) ne No. 360-385-9400 Hospital Ancillary Provider N/A N/A Other N/A Name Jefferson County Public B Billing 6 615 Sheridan Street, Port Health A Address T Townsend, WA, 98368, ne No. 360-385-9400 1e No. 360-385-9401 No. 91-6001322 P Physical 6 615 Sheridan Street, Port No. A Address T Townsend, WA, 98368, onomy 0. Please provide a raster submit bills to Health Plan. Use continuation page(s) if multiple providers under common ownership will submit bills under more than one TIN. 1, the undersigned, am authorized to and do hereby verify the accuracy of the foregoing Provider information. Provi er Signature 4,0 Signatory Name (Printed) Signatory Title (Printed) Signature Date Page 17 of 32 MI1W IROV042014 Malin, WNIS ref# 41219 ATTACHMENT B Definitions 1. Advance Directive is a Member's written instructions, recognized under state law, relating to the provision of health care when the Member is not competent to make a health care decision as determined under state lavv- Examples of Advance Directives are living wills and durable powers of attorney for health care. 2. Agreement means this Provider Services Agreement, all attachments and incorporated documents or materials. 3, Capitated Provider is a Provider who receives a monthly premium from Health Plan for each Member assigned to provider. Capitated Provider may be responsible for payment of all covered health services (professional, institutional, pharmacy) incurred by Member. 4. CMS is the Centers for Medicare and Medicaid Services, an administrative agency of the United States Government, responsible for administering the Medicare program. Claim means an invoice for services tendered to a Member by Provider, submitted in a format 5. approved by Health Plan and with all service and encounter information required by Health Plan. 6. Clean Claim means a Claim for Covered Services that has no defect, impropriety, lack of any required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment from being made on the Claim. 7. Covered Services means those health care services that are Medically Necessary, are within the normal scope of practice and licensure of Provider, and are benefits of the Health Plan product or a Health Plan affiliate's product which covers the Member. S. Emergency Services are Covered Services necessary to evaluate or stabilize the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. For Health Plan's Medicaid Members, Emergency Services also includes any services defined as emergency services under 42 C.F.R. §438.114. Health Plan reserves the right to investigate certain emergency care Claims to determine if a Claim meets the definition of Emergency Services. If Health Plan denies a Claim on the basis that a reasonably prudent layperson would not have believed that an emergency health condition existed, the Member may exercise the right of appeal under the Grievance Program. 9. Grievance Program means the procedures established by Health Plan to timely address Member and Provider complaints or grievances. to. HCA means The Washington State Health Care Authority. Page 18 of 32 5,V1 I I wpROV.0420 A ;CMS reP 41249 Health Benefit Exchange means the Washington health benefit exchange established in RCW 43.71-020, et seq., the Health Benefit Exchange Act. 12. Health Plan means Molina Healthcare of Washington, Inc. 13. HEDIS Studies means Healthcare Effectiveness Data and Information Set. 14. IPA means Independent Practice Association. 1,5. Medicaid means the joint federal-state program provided for under Title XIX of the Social Security Act, as amended. 16. Medicare is the Hospital Insurance Plan (Part A) and the Supplementary Medical Insurance Plan (Part B) provided under Title XVIII of the Social Security Act, as amended. 17. Medically Necessary means those medical services and supplies which are provided in accordance with professionally recognized standards of practice which are determined to be: (a) appropriate and necessary for the symptoms, diagnosis or treatment of the Member's medical condition; (b) provided for the diagnosis and direct care and treatment of such condition; (c) not furnished primarily for the convenience of the Member, the Member's family, the treating provider, or other provider; (d) furnished at the most appropriate level which can be provided consistent With generally accepted medical standards of care; and (e) consistent with Health Plan policy. 18. Member(s) means a person(s) enrolled in one of Health Plan's benefit products or a Health Plan affiliate's benefit product and who is eligible to receive Covered Services. 19. Molina Health Benefit Exchange Product means those health benefit programs offered and sold by Health Plan to individuals or employers who obtain health coverage through the Washington Health Benefit Exchange. 20. provider means the person(s) and/or entity identified in Attachment A to this Agreement. Where Provider is a Group/IPA or Hospital, Provider means and includes all constituent physicians, allied health professionals and staff persons who provide health care services to Members by and/or through the Group/TPA or Hospital. All of said persons are bound by the terms of this Agreement. 21. Provider Manual means the compilation of Health Plan policies, procedures, standards and specimen documents, as may be unilaterally amended or modified from time to time by Health Plan, that have been compiled by Health Plan for the use and instruction of Provider, and to which Provider must adhere, 22. Quality Improvement Program means the policies, procedures and systems developed by Health Plan for monitoring, assessing and improving the accessibility, quality and continuity of care provided to Members. Page 19 of 32 M 11 WJ,1ZOV.04'2014 Molina 1_'cMS ref# 41249 21 Utilization Review and Management Program means the policies, procedures and systems developed by Health Plan for monitoring the utilization of Covered Services by Members, including but not limited to under - utilization and over - utilization. Page 20 o8 32 M11W1,1ZOV�042M4 MoX jj, IC:IMS refit 41249 ATTACHMENT C Products Inventory Provider hereby agrees to participate as a contracted provider for each of the Health Plan products below. Medicaid — including but not limited to Healthy Options and Washington Medicaid Integration Partnership. 2. Medicare - including but not limited to Molina Medicare Options (Medicare Advantage) and Molina Medicare Options Plus (MA-SNP). 3. Molina Health Benefit Exchange Product Page 21 o1' 32 M I I \k pROV.042014 N tj()ji1j,, 1�.CMS 1,0# 41249 ATTACHMENT D — STANDARD Compensation Schedule Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in accordance with Health Plan's programs as specified in Attachment C, on a fee-for- services basis, at the lesser of; (i) Provider's allowable charge description master rate, or (ii) the amounts set forth below, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any: Medicaid* Covered Services shall be paid at one hundred percent (100%) of the State of Washington Medicaid Fee- For-Service Program fee schedule in effect on the date of service. Notwithstanding the above, payment for Covered Services, including, but not limited to, certain Covered ,services where there is no payment rate in the State of Washington Medicaid Fee-For-Service Program fee schedule as of the date(s) of service, shall not exceed one hundred percent (1➢0%) of the Medicare Fee-For-Service Program allowable payment rate, as of the date of service. Medicare Programs: Covered Services shall be paid at one hundred percent (100%) of the Medicare Fee-For-Service Program allowable payment rates, as of the date of service. Molina Health Benefit Exchange Product: Covered Services shall be paid at an amount equivalent to one hundred ten percent (110%) of the payment Provider would otherwise have been entitled to had the Covered Services been billed directly under the prevailing Medicaid Fee-For-Service Program allowable payment rates, as of the date(s) of service. if there is no payment rate in the prevailing Medicaid Fee-For-Service Program as of the date(s) of service, payment shall be at one hundred percent (100%) of the prevailing local and geographically adjusted Medicare Fee-For-Service fee schedule, as of the date(s) of service. Page; 22 of 32 r,tvjwpi�ov.042014 Mc,)Iina ECM 1"IAO 41-749 ATTACHMENT E REQUIRED PROVISIONS (14EALTH CARE SERVICE PLANS) The following provisions are required by (i) federal statutes and regulations applicable to Health Plan, or (ii) state statutes and regulations applicable to health care service plans. These provisions shall be automatically modified to conform to subsequent amendments to such statutes, regulations, and agreements. Further, any purported modifications to these provisions inconsistent with such statutes, regulations, and agreements shall be null and void. Provider hereby agrees that in no event, including, but not limited to nonpayment by Health Plan, Health Plan's insolvency, or breach of this Agreement shall Provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a Member or person acting on their behalf, other than Health Plan, for services provided pursuant to this Agreement. This provision shall not prohibit collection of deductibles, co- payments, coinsurance, and /or noncovered services, which have not otherwise been paid by a primary or secondary carrier n accordance with regulatory standards for coordination of benefits, from Members in accordance with the terms of the Member's health program. 2. Provider agrees, in the event of Health Plan's insolvency, to continue to provide the services promised in this Agreement to Members of Health Plan for the duration of the period for which premiums on behalf of the Member were paid to Health Plan or until the Member's discharge from inpatient facilities, whichever time is greater. 3. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be construed to modify the fights and benefits contained in the Member's health program. 4. Provider may not bill the Member for Covered Services (except for deductibles, co-payments, or coinsurance) where Health Plan denies payments because Provider has failed to comply with the terms or conditions Of this Agreement. 5. Provider further agrees (i) that the provisions of (1), (2), (3), and (4) of this Attachment shall survive termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of Members, and (ii) that this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and Members or persons acting on their behalf. if Provider contracts with other providers or facilities who agree to provide Covered Services to 6. Members of Health Plan with the expectation of receiving payment directly or indirectly from Health Plan, such providers or facilities must agree to abide by the provisions of (1), (2), (3), (4), (5), (7), (11) and (12) of this Attachment. 7. Willfully collecting or attempting to collect an amount from a Member knowing that collection to be in violation of this Agreement constitutes a class C felony under RCW 48,80.030(5). Page 23 of 32 Nj I jWjjZOV,042O 14 MOjijj,,j f;,(.;,MS rcf# 41740 $. Health Plan will provide Provider not less than sixty (60) days notice of changes that affect Provider's compensation and that affect health care service delivery unless changes to federal or state law or regulations make such advance notice impossible, in which case notice shall be provided as soon as possible. Subject to any termination and continuity of care provisions of the contract, Provider may terminate the contract without penalty if the Provider does not agree with the changes. No change to this Agreement may be made retroactive without the express consent of Provider. Providers are encouraged to inform Members of the care they require, including various treatment options, and whether in their view such care is consistent with medical necessity, medical appropriateness, or otherwise covered by the patient's service agreement with Health Plan. Health Plan will not prohibit, discourage, or penalize Provider if otherwise practicing in compliance with the law from advocating on behalf of a Member with Health Plan. Members are free to contract at any time to obtain any health care services outside their Health flan on any terms or conditions the Members choose. Nothing in this section shall be construed to authorize Provider to bind Health Plan to pay for any service. itl. Provider may discuss the comparative merits of different health carriers with Members or those paying for coverage for Members, even if those discussions are critical of Health. Plan. l 1. Provider will make health records available to appropriate state and federal authorities involved in assessing the quality of care or investigating the grievances or complaints of Members subject to applicable state and federal laws related to the confidentiality of medical or health records. 12. Provider shall furnish Covered Services to Members without regard to the Member's enrollment in Health Plan as a private purchaser of the plan or as a participant in publicly financed programs of health care services, 'Phis requirement does not apply to circumstances when Provider :should not render services due to limitations arising from lack of training, experience, skill, or licensing restrictions. 13. Provider may, in good faith, report to state or federal authorities any act or practice by Health Plan that jeopardizes Member health or welfare or that may violate state or federal law. l4. Terms and Conditions of Payment a. For Covered Services provided to Members, Health Plan shall pay Provider, and Provider shall pay any of its subcontractors, as soon as practical but subject to the following minimum standards including any applicable federal regulations (i.e. 42 CFR 422.520(b).): i. Ninety -five (9�5 %) percent of the monthly volume of Clean Claims shall be paid within thirty (30) days of receipt by Health Plan or Health Plan's agent; ii, ninety -five percent (95 %) of the monthly volume of all Claims shall be paid or denied within sixty (60) days of receipt by Health Plan or Health Plan's agent; Page 24 of 32 mjiWpIs C)v.()42014 7olinsr FC MS rerP 41249 iii.Ninety-nine percent (99%) of the monthly volume of Clean Claims shall be paid within ninety (90) calendar days of receipt, except as agreed to in writing by the parties on a Claim-by-Claim basis. b. A Claim is a bill for services, a line item of service or all services for one Member within a bill. c. The date of receipt of a Claim is the date Health Plan or Health Plan's agent receives either written or electronic notice of the Claim. d. The date of payment is the date of the check or other form of payment. e. Health Plan shall establish a reasonable method for confirming receipt of Claims and responding to Provider inquiries about Claims. f. For those State products/programs covered by the Washington Administrative Code (WAC), failure of Health Plan to abide by the timely Claims payment standards delineated in 14.a above shall result in a requirement to pay interest on undenied and unpaid Clean Claims as described in WAC 284-43-321. g. When Health Plan issues payment in Provider's name and the Member's name, Health Plan shall make Claim checks payable in the name of the Provider first and the Member second. h. These standards do not apply to Claims about which there is substantial evidence of fraud or misrepresentation by Providers, facilities or Members, or instances where Health Plan has not been granted reasonable access to information under Provider's control. i, Health Plan and Provider are not required to comply with these terms and conditions, of payment if the failure to comply is occasioned by any act of God, bankruptcy, act of a governmental authority responding to an act of God or other emergency, or the result of a strike, lockout, or other labor dispute. 15. Notwithstanding any other provision of this Agreement, Provider is not required to grant Health Plan access to health information and other similar records unrelated to Members. This provision shall not limit Health Plan's right to ask for and receive information relating to the ability of Provider or facility to deliver health care services that meet the accepted standards of medical care prevalent in the community. 16. Notwithstanding any other provision of this Agreement, any access Provider must grant Health Plan to medical records for audit purposes must be limited to only that necessary to perform the audit. IT Provider maintains a reciprocal right to audit Health Plan's denials of Provider's Claims when health Plan audits Provider's Claims. 1� of 32 MI IWIJiOV.042014 ,Molina ECAS ref# 41240 18. in the event Provider participates in Health Plan's Medicare Programs, the following provisions shall apply: a. Provider shall make all of its "Relevant Records" available for inspection, examination and copying by all federal and state agencies with regulatory authority over the subject matter of this Agreement. Provider shall permit such inspection at Provider's place of business and at all reasonable times. "Relevant Records" shall mean all books and records of Provider related directly or indirectly to the goods and services furnished under the terms of this Agreement. Provider shall maintain such Relevant Records for the period of time required by applicable federal and state statutes, but in no event less than ten (10) years. This provision shall survive termination of the Agreement. (42 CFR 422.504(e)(2), 422.504(e)(3), 422.504(c)(4), and 422.504(i)(2)(ii)). b. Provider shall comply with the confidentiality and enrollee record accuracy requirements set forth in 42 CFR 422.118. (42 CFR 422.504(a)(13)). c. Provider agrees that under no circumstance shall a subscriber or enrollee in Health Plan's Medicare Programs be liable to the Provider for any sums owed by Health Plan to Provider. (42 CFR 422.504(g)(1)(i) and 42 CFR 422.504(i)(3)(i)). d. it Provider is delegated any of the activities or functions of Health Plan as required in its contract with CMS, Provider agrees to comply with all applicable contractual provisions in the same manner as if Provider had executed such contract with CMS directly. The activities or functions delegated to Provider are set forth in the Agreement. In the event CMS or Health Plan determines, in its sole discretion, that Provider has not performed the delegated activities or functions satisfactorily, the delegated activities shall be revoked upon not less than five (5) days prior written notice. The performance of such delegated activities shall be monitored by Health Plan on an ongoing basis, and Provider shall cooperate with all reasonable requests made by Health Plan in order to accomplish such monitoring. if Provider is delegated credentialing activities, Provider's credentialing process will be reviewed and approved by Health Plan, and such credentialing process will be audited by Health Plan on an ongoing basis; further, Provider agrees that its credentialing process will comply with all applicable NCOA standards. (42 CFR 422.504(i)(3)(iii) and 422.504(i)(4)). e. Provider agrees that any services it performs will be consistent with and comply with Health Plan's contractual obligations with CMS. (42 CFR 422.504(i)(1) and 422.504(i)(3)(iii)). f. In the event of termination of this Agreement or Health Plan's insolvency, Provider agrees to comply with the continuation of benefits provisions included in the Provider Manual. (42 CFR 422.504(8)(2)). l Upon termination of this Agreement without cause, Provider will continue to render Covered Services to Members until the earliest of the following: (1) the date Covered Services being rendered to Member by Provider are completed or medically appropriate provisions have been Page 26 of 32 MIIWI)JkOV,042014 ,Mofina RNS ref,4 41249 made by Health Plan for another provider to assume responsibility for providing such Covered Services; or (2) sixty (60) days following notice to the Member of Provider's contract termination. The provision of such Covered Services and the reimbursement to Provider for such Covered Services shall be subject to all applicable terms of this Agreement on the same basis as Covered Services provided during the term of this Agreement. Page 27 of 32 M,,Wf,[ZOV.042014 J.a,CNJS rofo 41249 ATTACHMENT F REQUIRED PROVISIONS (Health Care Authority) The following provisions are required by (i) federal statutes and regulations applicable to medical assistance programs for the indigent, (ii) state statutes and regulations applicable to medical assistance programs for the indigent, or (iii) contracts and agreements between the Health Plan and the state agencies responsible for regulating risk-based medical assistance programs for the indigent. These provisions shall be automatically modified to conform to subsequent amendments to such statutes, regulations, and agreements- Further, any purported modifications to these provisions inconsistent with such statutes, regulations, and agreements shall be null and void. 1. Provider shall provide reasonable access to facilities and financial and medical records for duly authorized representatives of the CMS, HCA, Department of Social & Health Services ("DSHS") or the Department of Health & Human Services ("DHHS") for audit purposes and immediate access for Medicaid fraud investigators. 2. provider shall completely and accurately report encounter data to Health Plan. Provider shall have the capacity to submit all required data to enable Health Plan to meet the requirements in the Encounter Data Transaction Guide published by HCA. 3. provider shall comply with Health Plan's fraud and abuse policies and procedures. 4. provider shall not assign this Agreement without HCA's written agreement. 5. Provider shall comply with any term or condition of Health Plan's contracts with HCA that is applicable to the services to be performed by Provider. Provider shall accept payment from the Health Plan as payment in full and shall not request payment from HCA or any enrollee for Covered Services performed under this Agreement. 7. provider agrees to hold harmless HCA and its employees, CMS and its employees, and all enrollees served under the terms of this Agreement in the event of non-payment by Health Plan. Provider further agrees to indemnify and hold harmless HCA and its ployeagainst al injuries, deaths, losses, damages, claims, suits, liabilities, j�udgments, co ad expenses which may in any manner accrue against HCA, or its employees through the intentional misconduct, negligence, or omission of Provider, its agents, officers, employees or contractors. 8. provider agrees to comply with the HCA appointment wait time standards. Provider agrees to Health Plan's regular monitoring of timely access to Provider's services, and agrees to corrective action up to and including termination for cause in the event that Provider fails to comply with the appointment wait time standards. 9, provider shall assure that all sterilizations and hysterectomies performed under this Agreement are in compliance with 42 CFR 441 Subpart F, and that the Sterilization Consent Form (DSHS 13-364(x)) Or its equivalent is used. Page 28 of 32 M1 1Wp1t0v'.0420 14 Nlolilia 1, (,. M S ref# 41249 10, provider shall make reasonable accommodation for enrollees with disabilities, in accord with the Americans with Disabilities Act, for all Covered Services and shall assure physical and communication barriers shall not inhibit enrollees with disabilities from obtaining Covered Services. Provider shall comply with all Program Integrity provisions as documented in Health Plan Provider Manual and as set forth by 42 CPR 438.608 and the Health Plan's contracts with HCA. Pa�,e 29 ol'32 .\,qJWPROV.042()14 Nj,, ij n,,, EC, M S ref# 41,249 Acknowledgment of Receipt of Provider Manual Provider hereby acknowledges that Health Plan's Provider Manual was made available to Provider for review prior to Provider's decision to enter into this Agreement. Health Plan's Provider Manual is available at the Health Plan's website at: 179, L�eaj hnedicai icier v-g 'Y" _thcqre.cojnLn Date of receipt: initials of authorized representative of Provider 41 Page 30 of 32 MljWPJZ()V.O42QIeA Molina 9 .�(' -,MS refO 41249 ATTACHMENT I P TRITON, R R This Attachment i sets forth Medicare program requirements that are hereby incorporated into contracts and/or agreements with Providers covering the provision of health care services. The Agreement and this attachment shall be automatically modified to conform to subsequent amendments to Medicare program requirements. In the event of any inconsistency between the terms of this attachment and the Agreement, the terms of this attachment shall control. L Downstream C—Oni-Pliance- Provider agrees to require all of its downstream, related entity(s), and transferees that provide any services benefiting Health Plan's Medicare enrollees to agree in writing to all of the terms provided herein. 2. —Right to Audit. 1411S, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any books, contracts, records, including medical records and documentation that pertain to any aspect of services performed, reconciliation of benefit liabilities, and determination of amounts payable under Health Plan's contract with CMS, or as the Secretary may deem necessary to enforce Health Plan's contract with CMS. Provider agrees to make available, for the purposes specified in this paragraph, its premises, physical facilities and equipment, records relating to its Medicare enrollees, and any additional relevant information that CMS may require. HES, the Comptroller General, or their designee's right to inspect, evaluate, and audit extends through ten (1 0) years from the end of the final contract period or completion of audit, whichever is later. (42 CFR 422.504(e)(2), 422.504(e)(3), 422.504(e)(4) and 422.504(i)(2)(ii)•) 3. Confidentiality. Provider shall comply with the confidentiality and enrollee record accuracy requirements set forth in 42 CFR 422-118- (42 CFR 422.504(a)(13).) 4. Hold Harmless/Cost Sharing. Provider agrees that under no circumstance shall a Member be liable to the Provider for any surns owed by Health Plan to the Provider. Members who are dually eligible for Medicare and Medicaid shall not be held liable for Medicare Part A and B cost sharing when the State or another payor such as a Medicaid Managed Care Plan is responsible for paying such amounts. Provider agrees to accept payment from Health Plan as payment in full, or bill the appropriate responsible party, for any Medicare Part A and B cost sharing that is covered by Medicaid. (42 CFR 422.504(g)(1)(i).) 5. llele anon. Page 31 of 32 M[iW1"ltoV.042014 molixla F,,cms reP 41249 Health Plan may only delegate activities Or functions to a first tier, downstream, or related entity, in a manner that is consistent with the provisions set forth in Attachment 2, if applicable., Any services or other activity performed by a first tier, downstream, Or related entity in accordance with a contract Or written agreement shall be consistent and comply with the Health Plan's contract with CMS. (42 CFR 422.504(i)(3)(iii) and 422.504(i)(4).) 6. Rrompt �Pa rpe nt. Health Plan and Provider agree that Health Plan shall pay all Clean Claims for services that are covered by Medicare within sixty (60) days of the date such Claim is delivered by Provider to Health Plan and Health Plan determines such Claim is complete/clean. Any Claims for services that are covered by Medicare that are not submitted to Health Plan within six (6) months of providing the services that are subject of the Claim shall not be eligible for payment, and Provider hereby waives any right to payment therefore. Health Plan reserves the right to deny any Claims that are not in accordance with the Medicare Claims Processing Manual and Medicare rules for billing. (42 CFR 422.520(b).) 7. RQQ�Ttin - Provider agrees to provide relevant data to support Health Plan in complying with the requirements set forth in 42 CFR 422.516 and 42 CFR 422.310. (42 CFR 504(a)(8).) 8. Acco i_ntabil. Health Plan may only delegate activities or functions to a first tier, downstream, or related entity, in a manner that is consistent with the provisions set forth in Attachment H. (42 CFR 421504(i)(3)(ii).) 9. Q_om liance- with Medicare �Laws Laws �Reula�lions. p� Provider shall comply with all applicable Medicare laws, regulations, and CMS instructions. (42 CFR 422.504(i)(4)(v)•) 10, Benefit conti_nuawn. Provider agrees to provide for continuation of enrollee health care benefits (i) For all Members, for the duration of the period for which CMS has made payments to Health Plan for Medicare services; and (ii) for Members who are hospitalized on the date Health Plan's contract with CMS terminates, or, in the event of an insolvency, through discharge. (42 CFR 422.504(g)(2)(i), 422.504(g)(2)(ii) and 422.504(8)(3).) Page, 32 ot'32 NI I IWpIt0V,042014 Molina F(, �MS rvfN 41240