HomeMy WebLinkAboutPH Community Health Plan615 Sheridan Street
Port Townsend, WA 98368
�ensan www.JeffersonCountyPublicHealth.org
Consent Agenda
Public Hegalt
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, County Administrator
FROM: Apple Martine, Public Health Director
Veronica Shaw, Deputy Public Health Director
DATE:
SUBJECT: Agenda item — Provider Agreement for covered services: Community Health
Plan of WA (CHPW); March 31, 2023 — until terminated; fee for service
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH), Community Health Division, requests Board approval of the Provider
Agreement with CHPW to provide health care service; March 31, 2023 — until terminated; fee for service
This contract was previously approved and signed by Jefferson County. Subsequently, CHPW returned a
revised version of the contract with new sections 2.5.1.4, 3.6.2 and 3.9, which are required by Washington
state Office of the Insurance Commissioner.
ANALYSIS/STRATEGIC GOALS/PRO'S and CONS:
CHPW is one of Washington's Medicaid health options providers, providing health care services to individuals
enrolled in its Benefit Plans.
This agreement will allow JCPH to bill CHPW and collect for clinic services provided to WA Medicaid eligible
clients who have chosen CHPW as their managed care organization. By participating in CHPW's Provider
Network, savings are imparted to clients in out-of-pocket deductibles and charges. This contract will allow
underinsured citizens to receive much -needed services.
FISCAL IMPACT/COST BENEFIT ANALYSIS:
This is a fee for service contract.
Community Health
Developmental Disabilities
360-385-9400
360-385-9401 (f)
Always working for a safer and healthier community
Environmental Public Health
360-385-9444
(f) 360-379-4487
N-23-014
RECOMMENDATION:
JCPH management requests approval of Provider Agreement with CHPW to provide health care service;
March 31, 2023 — until terminated; fee for service
REVIEWED BY:
Mark McCauley, C u ty Administrator Date
Community Health
Developmental Disabilities
360-385-9400
Always working for a safer and healthier community
Environmental Public Health
360-385-9444
(f) 360-379-4487
COMMUNITY HEALTH PLAN OF WASHINGTON
PROVIDER AGREEMENT
This Agreement ("Agreement") is made by and between Community Health Plan of
Washington ("CHPW"), a not for profit Washington Corporation, and Jefferson County DBA
Jefferson County Public Health ("'Contractor") and is effective 3/31 /2023 ("Effective Date").
RFC1TA1 N%
A. Community Health Plan of Washington ("CHPW") is a 501(c)(4) tax exempt entity,
accredited by the National Committee on Quality Assurance ("NCQA") and certified as a
health care services contractor, organized and operating under the laws of the State of
Washington to provide or arrange for provision of covered health care services to
individuals enrolled in its Benefit Plans ("Members");
B. CHPw arranges for provision of covered health services to Members pursuant to its
contracts with state and federal agencies, including Washington State Health Care
Authority ("HCA"), and Centers for Medicare and Medicaid Services ("CMS"), that
sponsor various health programs (collectively, `state and federal sponsored health
programs");
C. Contractor has employed or contracted with duly licensed providers of health care services
located in the State(s) in which it provides health care services and has met CHPW's
criteria to be a provider of health care services for Members; and
D. CHPw desires to contract with Contractor to provide Covered Services to Members
pursuant to this Agreement and CHPw Benefit Plans, and Contractor desires to contract
with CHPw to provide such services. This Agreement is written in compliance with 42
CFR 434.6.
Now THEREFORE, in consideration of the recitals, mutual promises, covenants, and
agreements set forth herein, both parties agree as follows:
AGREEMENT
1, DEFINITIONS
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-23-014
The following definitions shall apply to this Agreements except to the extent that they may be
superseded by definitions that are specific to a particular health benefit plan on the applicable
Benefit Plan Exhibit in Exhibit B and/or available at www.CHPW.om.
1.1 "Agreement" means this Provider Agreement, entered into between CHPW and
Contractor, with all amendments, schedules and exhibits hereto.
1.2 "Benefit Plan" means a healthcare benefit product, defined by the applicable plan sponsor,
which is offered or administered by CHPW for the payment of Covered Services provided
to Members, including without limitation state and federal sponsored health programs.
Each Benefit Plan is governed by one or more Benefit Plan Exhibits as indicated on Exhibit
B.
1.3 "CHPW Health Benefit Exchange Product" (also referred to as "the CHPW Exchange
Product" or "CHPW HBE Product") means those health benefit programs offered and sold
by CHPW to individuals or groups who obtain health coverage through the Washington
Health Benefit Exchange.
1.4 "Clean Claim" means a reimbursement claim for provision of Covered Services submitted
by Contractor to CHPW that is (i) in the form required by CHPW, (ii) complies with the
Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and
Administrative Simplification for Electronic Data Interface, and (iii) has no defect or
impropriety that may prevent timely or accurate payment of the claim such as failure to
include necessary substantiating documentation, encounter data or documentation of
particular circumstances requiring special treatment.
1.5 "Contracted Participating Provider" is an individual or entity that is a duly licensed,
certified or registered health care provider, is employed or subcontracted by or otherwise
associated with Contractor, and who, upon credentialing by CHPW, becomes a
Participating Provider.
1.6 "Copayments, Coinsurance and Deductibles" (also referred to as "Cost Sharing") are
payments a Member may be required to make to Contractor in accordance with the
conditions of the Member's Benefit Plan.
1.7 "Covered Services" are the Medically Necessary health care services that are reimbursable
under a Member's Benefit Plan.
1.8 "Critical Incident" means a situation or occurrence that places a Member at risk for
potential harm or causes harm to a Member. Examples include homicide (attempted or
completed), suicide (attempted or completed), the unexpected death of a Member, or the
abuse, neglect, or exploitation of a Member by an employee or volunteer.
1.9 `Emergency Medical Condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain), such that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in: (i) placing the health of the individual
(or, with respect to a pregnant woman, the health of the woman or her unborn child) in
2023—CSNegAgmt—JeffersonCounty Page 2 of 55 Contract #300090-232143
serious jeopardy, (il) serious impairment to bodily functions, or (iii) serious dysfunction of
any bodily organ or part.
1.10 "Emergency Services" means inpatient and outpatient services furnished by a provider
qualified to furnish the services needed to evaluate or stabilize an Emergency Medical
Condition.
1.11 "Health Benefit Exchange" (also referred to as "the Exchange" or "HBE") means the
Washington health benefit exchange established in RCW 43.71. 020, et seq., the Health
Benefit Exchange Act and regulated by the Washington State Office of the Insurance
Commissioner ("OIC").
1.12 "Individual with Special Health Care Needs" ("ISHCN") means a Member who meets the
diagnostic and risk score criteria for Health Home Services, or is a child with special health
care needs, or has a chronic or disabling condition that: (i) has a biologic, psychologic, or
cognitive basis; (ii) is likely to continue for more than one year; and (iii) causes either
significant limitation in areas of physical, cognitive, or emotional functions, or dependency
on medical or assistive devices to minimize limitations of function or activities.
1.13 "Medically Necessary" means a service or supply which meets all of the following criteria:
1.13.1 is consistent with the symptoms or diagnosis and treatment of the Member's
condition;
1.13.2 is the most appropriate supply or level of service that is essential to the Member's
needs and meets the recognized standards of medical care;
1.13.3 when applied to a Member inpatient, cannot be safely provided to the Member in a
less restrictive setting;
1.13.4 is not experimental or investigative;
1.13.5 is consistent with good medical practice;
1.13.6 is not provided primarily for the convenience of the Member, Contractor or
Contracted Participating Provider; and
1.13.7 is the most cost-effective of the alternative levels of service or supplies that are
adequate and available.
1.14 "Member" is an individual enrolled in a Benefit Plan, who is entitled to receive Covered
Services pursuant to that Benefit Plan.
1.15 "Non -Participating Provider" means a professional health care provider, facility, or legal
entity that does not have a written agreement with CHPW to participate in CHPW's
Provider Network and has not been credentialed by CHPW but may provide health care
services to Members upon referral and prior authorization.
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1.16 "Participating Provider" means an individual healthcare practitioner or entity that is duly
licensed, certified, and/or registered by the appropriate state or other governmental board
or agency, is credentialed by CHPW or its delegate, and under a written agreement with
CHPW that is current at the time Covered Services are rendered. Participating Providers
are collectively referred to as CHPW's "Provider Network".
1.17 "Primary Care Provider" or "PCP" means a Participating Provider who is responsible for
(i) providing primary health care, (ii) initiating referrals for specialist and inpatient care,
and (110 supervising, coordinating and maintaining continuity of Members' health care.
1.18 "Provider Manual" refers to applicable CHPW manuals, policies and procedures, and
documents, as periodically revised, including those that refer to Program. Integrity
requirements, credentialing, utilization management, prior authorization requirements,
claims, and encounter submission, payment, drug formulary, and Participating Provider
lists. The Provider Manual and associated information are available to Contractor online
through www. CHP W or)-.
1.19 "Provider Preventable Condition" is an umbrella term for acquired conditions (hospital and
nonhospital) identified by the HCA for nonpayment to ensure the high quality of medical
services provided to Apple Health enrollees. Provider Preventable Condition(s) includes
Other Provider Preventable Conditions and Health Care -Acquired Conditions, as those
terms are defined in WAC 182-5 02-0022.
1.20 "Service Area" means those geographic areas in which CHPW is contracted to provide
Covered Services to Members.
1.21 "Urgently Needed Services" means Covered Services, other than Emergency Services, that
are provided without a written referral when a Member is experiencing an Urgent Medical
Condition and is either (i) temporarily absent from CHPW's Service Area or CHPW's
Provider Network is temporarily unavailable or inaccessible, or (ii) when it is
unreasonable, under the circumstances, for the Member to obtain such services through
CHPW Participating Providers.
1.22 "Urgent Medical Condition" means a medical or behavioral health condition manifesting
itself by acute symptoms of sufficient severity such that if services are not received within
24 hours of the request, the individual's situation is likely to deteriorate to the point that
Emergency Services are necessary.
1.23 Additional Definitions. Additional definitions pertinent to CHPW's state sponsored health
benefit plans are available at www.CHPW.org.
2. OBLIGATIONS OF CONTRACTOR
2.1 Engagement. CHPW hereby engages Contractor to participate in CHPW's Provider
Network, and Contractor hereby accepts such engagement pursuant to the terms and conditions
hereunder.
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2.2 Contractor and Contracted Participating Providers, Licenses and Credentialing.
2.2.1 Contractor shall select each individual Contracted Participating Provider in
accordance with Contractor's written procedures, which shall include consideration of the
individual's professional qualifications, experience, and ability to deliver efficient, effective health
care services to Members. Each Contracted Participating Provider who provides Covered Services
to Medicare Advantage Members must be a Certified Medicare Provider.
2.2.2 Contractor shall cooperate and comply with CHPW credentialing criteria and
verification procedures for Participating Providers. Contractor represents and warrants that each
of its Contracted Participating Providers is fully qualified and duly licensed and/or certified by the
appropriate state or other governmental board or agency to provide healthcare services within the
scope of the Contracted Participating Provider's license. Contractor and Contracted Participating
Providers shall maintain such license(s) and/or certification(s) in good standing. Contractor will
provide prompt written notice to CHPW of any changes in the license or certification of any of its
Contracted Participating Providers, any legal or governmental action, or any other situation which
may adversely impair the Contracted Participating Provider's ability to provide Covered Services
to Members pursuant to this Agreement, in no case longer than five (5) days after Contractor
becoming aware of any such circumstances.
2.2.3 Contractor shall provide an accurate list of Contracted Participating Providers with
status designations as "employed by Contractor" or "subcontracted with Contractor" in Exhibit A.
Contractor shall promptly notify CHPW in writing of changes in its list of Contracted Participating
Providers and/or their status designations by providing a revised Exhibit A in accordance with the
procedures outlined in the Provider Manual, and in no case more than thirty (30) days after a
change becomes effective.
2.2.4 Contractor shall orient Contracted Participating Providers, employees and
subcontractors to the applicable terms of this Agreement, the Provider .Manual, and to other areas
specifically designated by CHPW, including Member rights, marketing, enrollment and
disenrollment procedures, risk management, customer service, claims preparation and
authorizations, hospital admission notification and certification, transfer and discharge procedures.
2.2.5 In performing its duties hereunder, Contractor shall require its Contracted
Participating Providers to comply with all applicable terms of this Agreement and the Benefit Plans
listed on Exhibit B. and applicable requirements of the Provider Manual, as amended by CHPW
from time to time at its sole discretion.
2.2.6 Contractor shall ensure that Contracted Participating Providers participate in
continuing education programs required by law. Contractor shall participate in and cooperate with
CHPW's education and training programs for Contracted Participating Providers and for
Members.
2.2.7 CHPW may terminate a Contracted Participating Provider's participation upon
thirty (30) days' notice to Contractor due to a violation of the terms of this Agreement, and
immediately upon a Contracted Participating Provider's failure to maintain compliance with
CHPW's credentialing requirements. A Contracted Participating Provider's exercise of any rights
they may possess to appeal such termination shall not change the effective date of such termination.
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2.2.8 Contractor represents and warrants that neither it nor its Contracted Participating
Providers is or has been excluded from participation in any state or federally funded health care
program, including Medicare and Medicaid. Contractor shall promptly notify CHPW of any
threatened, proposed, or actual exclusion of Contractor, a key employee or a Contracted
Participating Provider from any state or federally funded health care program.
2.2.9 Contractor shall have and maintain for the term of this Agreement all necessary
licenses, certifications, permits, and other permissions required by law for the performance of its
obligations hereunder. Contractor shall notify CHPW immediately in the event of a change in the
status of Contractor's required licenses, certifications, or other required permissions. Contractor's
loss or suspension of licensure or its exclusion from any federally funded health care program,
including Medicare and Medicaid, shall constitute cause for immediate termination pursuant to
Section 6.2 of this Agreement.
2.3 Services.
2.3.1 Contractor has service locations and Contracted Participating Providers listed on
Exhibit A attached hereto. Subject to Section 2.4.7, Contractor shall notify CHPW in writing
within sixty (60) days of changes in its list of locations, Contracted Participating Providers and
their status as employees or subcontractors. The process for updating Exhibit A is contained in the
Provider Manual.
2.3.2 Contractor shall provide or arrange for provision of efficient and effective Covered
Services through its Contracted Participating Providers to Members of those Benefit Plans
identified on Exhibit B. Covered Services shall be Medically Necessary and appropriate to each
Member's clinical condition in accordance with the Provider Manual, industry standards,
accreditation requirements, and applicable state and federal laws and regulations.
2.3.3 Contractor shall participate in and cooperate with CHPW's education and training
programs for Participating Providers and for Members.
2.3.4 Contractor shall provide all Covered Services hereunder to Members in the same
manner and timeliness as such services are made available to non -Members, without regard to an
individual's participation in private health care coverage or in a publicly funded Benefit Plan, in
accordance with this Agreement and industry standards.
2.3. S Before providing Covered Services, other than screening and treatment for
Emergency Medical Conditions, Contractor shall verify each Member's eligibility either
electronically at www .I-IPW.o g, as set forth in the Provider Manual, or by calling CHPW's
Customer Service Department at the telephone number printed on the back of Member's CHPW
identification card.
2.3.6 Contractor shall not delegate the provision of Covered Services without CHPW's
prior written approval. To the extent Contractor subcontracts provision of any Covered Services,
such subcontracts shall be in writing and include a requirement for compliance with all provisions
of this Agreement, including without limitation the credentialing, insurance and hold harmless
sections.
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2.3.7 If Contractor provides primary care services, Contractor shall assure that each
Member is assigned to a PCP Participating Provider.
2.3.7.1 In consultation with other appropriate health care professionals such as care
managers, community health workers or community -based care managers, PCPs shall
provide, coordinate, and supervise health care to meet the needs of each Member, including
initiation and coordination of referrals for medically necessary specialty care.
2.3.7.2 In consultation with other appropriate health care professionals, PCPs shall
assess and develop individualized treatment plans for Members meeting the definition of
an Individual with Special Health Care Needs. Such treatment plans shall ensure the
integration of appropriate clinical and non -clinical disciplines and services in the overall
plan of care.
2.3.8 Each Contracted Participating Provider shall exercise independent medical
judgment and control over his/her professional services. Nothing herein shall give CHPW
authority over Contracted Participating Provider's medical judgment or direct the means by which
s/he practices within the scope of his/her licensed, certified, and/or registered practice.
2.3.9 Each Participating Provider is responsible for their relationship with each Member
the Participating Provider treats, and for the quality of health care services provided to Members.
Contractor shall be solely responsible to each Member for medical care provided.
2.3.1 o Contractor shall assist CHPW with the transfer of any Member who has selected a
Contracted Participating Provider and is receiving Emergency Services or other authorized care
from a non -participating facility to a participating facility at which the Contracted Participating
Provider or another suitable Participating Provider has admitting privileges in accordance with the
CHPW Medical Director's determination of the medical acceptability of such transfer.
2.3.11 To the extent that Contractor's PCPs have capacity, Contractor's PCPs shall accept
enrollment of any Member at CHPW's request. Contractors providing primary care services may
close enrollment of new Members due to lack of capacity, after providing forty-five (45) days
written notice to CHPW and with written approval from CHPW, which shall not be unreasonably
withheld. Contractor's enrollment of Members shall not be closed if enrollment remains open to
other plans or lines of business.
2.3.12 Contractor shall cooperate with, participate in, and provide information and data
necessary to support, CHPW's Care Coordination activities and to meet HCA care coordination
obligations.
2.3.13 Critical Incident & ortin . Contractor shall provide immediate notification to
CHPW of any Critical Incident involving a Member. Notification shall be made during the
business day on which Contractor becomes aware of the Critical Incident. If Contractor becomes
aware of a Critical Incident involving a Member after business hours, Contractor shall provide
notice to CHPW as soon as possible the next business day. Contractor shall provide to CHPW all
available information related to a Critical Incident at the time of notification, including: a
description of the event, including the date and time of the incident, the incident location, incident
type, information about the individuals involved in the incident and the nature of their
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involvement, the Member's or other involved individuals' service history with Contractor, steps
taken by Contractor to minimize potential or actual harm, and any legally required notification
made by Contractor. Upon CHPw's request and as additional information becomes available,
Contractor shall update the information provided to CHPw regarding the Critical Incident and, if
requested by CHPW, Contractor shall prepare a written report regarding the Critical Incident,
including any actions taken in response to the incident, the purpose for which such actions were
taken, any implications to Contractor's delivery system, and efforts designed to prevent or lessen
the possibility of future similar incidents.
2.3.14 Discharge Planning Services. If Contractor provides Covered Services in twenty-
four (24) hour care settings, Contractor must provide discharge planning services, which shall
include, at a minimum:
2.3.14.1 Coordination of a community -based discharge plan for each
Member, beginning at intake, and regardless of length of stay or whether the Member
completes treatment;
2.3.14.2 Coordination of information with the referring entity, including
ensuring the exchange of assessment, admission, treatment progress, and continuing care
information, where applicable. Contact with the referring entity must be made within the
first week of residential treatment, where applicable;
2.3.14.3 As applicable, establishment of referral relationships with
assessment entities, outpatient providers, vocational or employment services, and courts,
which specify aftercare expectations and services, including procedure(s) for involvement
of entities making referrals in treatment activities;
2.3.14.4 As applicable, coordination with appropriate community resources
and services, including, for example, DBHR prevention services, vocational services,
services available through the DSHS Children's and Economic Services Administrations,
and/or housing services and supports; and
2.3.14.5 Coordination of medical services, as needed, for eligible Members.
2.3.15 Behavioral Health Screening and Assessment. If Contractor provides Behavioral
Health services, Contractor shall utilize the Global Appraisal of Individual Needs -Short Screener
(GAIN -SS) and assessment process, including use of the quadrant placement. If the results of the
GAIN -SS are indicative of the presence of a co-occurring disorder, Contractor shall consider this
information in the development of the Member's treatment plan, including appropriate referrals.
In addition, Contractor shall implement, and maintain throughout the term of this Agreement, the
Integrated Co -Occurring Disorder Screening and Assessment process, including training for
applicable staff. If Contractor fails to implement or maintain this process, CHPw shall require
and monitor Contractor's compliance with a corrective action plan designed to ensure compliance
with the requirements of this Section.
2.4 Member Access to Services.
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2.4.1 Contractor shall provide Members with access to Covered Services on the same
basis as such services are made available to individuals who are not Members.
2.4.2 A PCP Participating Provider must provide Members with 24-hour-a-day, seven -
days -a -week access by phone to a health care professional for the purpose of rendering medical
advice concerning emergent, urgent or routine medical conditions, and for authorizing Emergency
Medical Services and out of area urgent care services. Such advice shall be provided by a health
care professional licensed to practice independently or a physician's assistant.
2.4.3 A specialty care Participating Provider must provide Members with 24-hour-a-day,
seven -days -a -week access by phone to a health care professional for the purpose of rendering
medical advice concerning emergent, urgent or routine medical conditions. Such advice shall be
provided by a health care professional licensed to practice independently or a physician's assistant
2.4.4 Contractor shall maintain an appointment system for Members' prompt access to
health care in compliance with the following appointment wait time standards:
■ To the extent applicable, transitional healthcare by a PCP available for clinical
assessment and care planning within seven (7) calendar days of discharge from
4.
inpatient or institutional care for physical or behavioral health disorders or
discharge from a substance use disorder treatment program.
• To the extent applicable, transitional health care by a home care nurse or home
care registered counselor within seven (7) calendar days of discharge from
inpatient or institutional care for physical or behavioral health disorders or
discharge from a substance use disorder treatment program, if ordered by a
Member's PCP or as part of the discharge plan.
• Non -symptomatic (Le., preventative care) --- 30 calendar days.
• Non -urgent, symptomatic (i.e., routine care) — 10 calendar days.
• Urgent -- 24 hours.
• Emergency care access — 2417 provided at area Hospital Emergency
Departments.
In the event that CMS, HCA, or another applicable state or federal authority, enact more
stringent appointment wait time standards, Contractor shall adopt and abide by the most stringent
standard(s) applicable for all CHPW Members. CHPW shall monitor Contractor's compliance
with applicable appointment wait time standards and may take corrective action in the event
Contractor fails to comply.
2.4.5 At least annually and upon CHPW request, Contractor shall provide to CHPW a
report on its capacity for additional primary care enrollment or capacity to provide specialty
Services.
2.4.6 Contractor shall provide CHPW at least one hundred twenty (120) calendar days
written notice before Contractor, any Contractor location, or any Contracted Participating Provider
ceases providing Covered Services to Members.
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2.4.7 If a Contracted Participating Provider's participation with CHPW is discontinued
by either party, Members undergoing an active course of treatment (including treatment for second
or third trimester pregnancy and postpartum care) with a terminated Contracted Participating
Provider, shall be given the option to continue such treatment with the terminated Contracted
Participating Provider for ninety (90) days following the effective date of the Contracted
Participating Provider's termination or completion of the active course of treatment, whichever
occurs first. A Member who is receiving inpatient care on the effective date of Contracted
Participating Provider's termination shall continue receiving Services from the terminated
Contracted Participating Provider until the Member has been discharged from inpatient treatment
or transferred to another Participating Provider. CHPW shall reimburse Contractor in accordance
with the reimbursement rate provided herein for any Covered Services rendered in accordance
with this Section after the effective termination date. Contractor shall work with the terminating
Contracted Participating Provider and impacted Member(s) to develop a reasonable transition plan.
This Section 2.4.7 shall not apply to Contracted Participating Providers terminated for
incompetence, unprofessional conduct, or loss of license or exclusion from Medicare or Medicaid.
2.4.8 Termination of Contracted Primary Care Providers . CHPW shall provide written
notice to each Member affected by the termination or cessation of practice of the Member's
Contracted PCP at least thirty (30) calendar days prior to the effective date of such termination or
cessation. Such notice shall include the PCP's name, effective date of termination, the procedure
for selecting another PCP, and an offer to assist the Member to select a new PCP.
2.4.9 Termination of Contracted Spec ialtCare Provider or S ecialt Grou . Contracted
specialty groups and individual specialists shall provide timely written notice to Members of
pending termination or cessation of their practice. Notwithstanding the foregoing, CHPW shall be
responsible to notify in writing each Member affected by termination or cessation of a specialty
group's or individual specialist's practice. CHPW shall provide such notice to affected Members
prior to the effective date of such termination or cessation of practice.
2.4.10 Contractor shall give CHPW at least ninety (90) calendar days written notice before
opening any additional sites or satellite facilities that are not currently listed on Exhibit A. Within
sixty (60) calendar days of receiving the notice, CHPW shall approve or disapprove in writing the
use of such locations for providing Covered Services to Members.
2.4.11 CHPW will monitor Member access to and availability of Contracted Participating
Providers and inform Contractor of significant concerns and Member complaints about access to
or availability of Covered Services. If a CHPW access study shows excessive Member wait times
for appointments, CHPW may suspend further enrollment or referrals of Members with Contractor
until capacity improves and another access study shows acceptable wait times.
2.5 Member Rights.
2.5.1 Contractor and Contracted Participating Providers shall in all instances obtain
informed consent prior to treatment.
2.5.1.1 Without regard t
Contracted Participating
Members (1) about their
o Benefit Plan limitations or cost, Contractor and
Providers shall communicate freely and openly with
r health status, and treatment alternatives (including
2023_CSNegAgmt JeffersonCounty Page 10 of 55 Contract #300090-232143
medication treatment options); (ii) about their rights to participate in treatment
decisions (including refusing treatment); and (1*11) providing them with relevant
information to assist them in making informed decisions about their health care.
2.5.1.2 If applicable, Contractor shall assure that all sterilizations and
hysterectomies performed for Members are in compliance with 42 CFR 441
Subpart F, and that the Washington State Health Care Authority ("HCA")
Sterilization Consent form HCA 13 W 3 64 or its equivalent is used. No payment shall
be made under state sponsored Benefit Plans for sterilization procedures and
hysterectomies that do not comply with the requirements of this paragraph.
2.5.1.3 Contractor shall comply with the Natural Death Act, HCA, CMS and other
applicable rules concerning advance directives and, when appropriate, inform
Members or their representatives of their right to male anatomical gifts. Contractor
shall assure that the existence of an Advanced Directive is documented in each
Member's record in compliance with the Patient Self Determination Act of 1990.
2.5.1.4 In accordance with Washington state law, if a provider intends to bill a
patient or CHPW for an audio -only telemedicine service, the provider must obtain
patient consent for the billing in advance of the service being delivered. A
provider's failure to obtain such consent may result in disciplinary action against
the provider.
2.5.2 Contractor shall provide care in a culturally competent manner and shall provide or
arrange for interpretive services for each Member who is hearing impaired, or whose oral or written
language creates a barrier to access, for all contacts between Contractor and Member including
appointments for provision of Covered Services, emergent and urgent services, telephone contacts,
and assistance with all steps necessary to file Member complaints and appeals. v shall assure that
all generally available written materials provided to Members are developed at the 6th grade
reading level, translated into the Member's primary reading language, or audibly in the Member's
primary language or provided in an alternative medium or format acceptable to the Member and
approved by CHPW.
2.6 Utilization Review and Quality Assurance.
2.6.1 Contractor shall maintain a quality improvement system (i) tailored to the nature
and types of Covered Services provided hereunder, (ii) which affords quality control for health
care provided, including Covered Services, and (iii) provides for free exchange of information
between CHPW and Contractor.
2.6.2 Contractor shall comply with, and cooperate and participate in, utilization review,
applicable Performance Improvement Projects ("PIPs") and PIP requirements, quality
improvement, quality assurance programs, necessity of care evaluations, coordination of benefit
activities, health care coding reviews and cost containment activities, as set forth in the Provider
Manual and as CHPW deems necessary, including concurrent and retrospective reviews, audits
and/or reviews by independent quality improvement organizations and accreditation agencies.
2423_CSNegAgmt JeffersonCounty Page 11 of 55 Contract #300090-232143
2.6.2.1 Contractor shall cooperate with CHPW's collection, production and
distribution of comparative data for quality assurance and utilization review. CHPW may
use such data regarding Contractor and its Contracted Participating Providers' performance
in activities such as quality improvement, public reporting to consumers, preferred status
designations and other activities that promote transparency to consumers and Members.
2.6.2.2 Contractor shall cooperate and communicate freely with CHPW regarding
quality issues and notify CHPW of any Member's medical situation or special health care
needs that may benefit from case management in accordance with the conditions of the
Members' Benefit Plans and the Provider Manual.
2.7 Member Complaint Procedures. Contractor shall cooperate and comply with CHPW's
Member complaint and appeals procedures as set forth in the Provider Manual, for resolution of
any Member complaints or appeals that may arise from Contractor's provision of services, or
CHPW's denial of coverage, under this Agreement. Contractor shall notify CHPW of Member
complaint or appeal that it receives and the subsequent resolution. Contractor shall cooperate with
CHPW in the investigation and resolution of Member complaints or appeals received by CHPW
regarding Contractor or a Contracted Participating Provider's provision of services.
2.8 Record Keeping and Access. Contractor shall prepare, maintain, and retain accurate
Member health records including appropriate medical, administrative and financial records related
to this Agreement and to Covered Services provided hereunder in accordance with the Provider
Manual, industry standards, applicable state and federal sponsored health programs, and applicable
federal and state statutes and regulations. Such records shall be maintained for the maximum
period required by federal or state law as set forth in Section 5.5, below. CHPW shall have
continued access to Contractor's records necessary for CHPW to perform its obligations
hereunder, to administer its Benefit Plans, and to comply with federal or state law or regulations
and applicable accreditation requirements. CHPW prefers electronic copies of such information,
data and records, but Contractor may provide hard copies at its own expense.
2.9 Member Copayments, Coinsurance, Deductibles.
2.9.1 Contractor shall collect and may retain Member Cost Sharing amounts authorized
under the applicable Member's Benefit Plan for Covered Services.
2.9.2 Copayments that Contractor charges a Member hereunder shall not exceed the
actual cost of providing the associated Covered Services.
2.9.3 Members enrolled in a CHPW Medicare Advantage Special Needs Plan and for
whom a state provides coverage ("Dual Eligible Enrollees") will not be required to pay any Cost
Sharing Amounts for Services covered by Medicare Parts A or B, when the applicable state
Medicaid Program is required to pay.
2.9.3.1 In lieu of collecting such Cost Sharing Amounts under the Medicare
Advantage Benefit Plan, Contractor may either (i) bill such Cost Sharing Amounts to the
appropriate state Medicaid source, or (ii) forego collecting Cost Sharing Amounts and
accept the Medicare Advantage Benefit Plan reimbursement as payment in full.
2023—CSNegAgmt JeffersonCounty Page 12 of 55 Contract #300090-232143
2.9.3.2 Contractor may determine that a Member is a Dual Eligible Enrollee by
reviewing plan information on the Member's ID card, or through CHPW's electronic
provider portal(s).
2.10 Non -Covered Services. Contractor and Contracted Participating Providers shall notify
Members of their personal financial obligations for non -Covered Services before rendering such
services. Contractor and Contracted Participating Providers shall not bill a Member for non -
Covered Services unless the Member has, prior to the provision of non -Covered Services, signed
a written acknowledgement and acceptance of financial responsibility after full written disclosure
of (i) Contractor's intent to bill Member for non -Covered Services, and (1'l*) the non -liability of
CHPW for such non -Covered Services.
2.11 Hold Harmless and Insolvency.
2.11.1 In no event, including, but not limited, to non-payment by CHPW, CHPW
insolvency, or breach of this Agreement, shall Contractor bill, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any recourse against a Member, a
person acting on a Member's behalf, or HCA for Services provided under this Agreement. This
provision shall not prohibit Contractor's collection of copayments, coinsurance and deductibles,
or fees for non -covered services, which have not otherwise been paid by a primary or secondary
carrier in accordance with regulatory standards for coordination of benefits, from a Member in
accordance with the terms of Member's Benefit Plan.
2.11.2 In the event of CHPW's insolvency, Contractor shall continue to provide the
Services promised under this Agreement to Members for the duration of the period for which
premiums on behalf of Members were paid to CHPW or until Member is discharged from inpatient
facilities, whichever time is greater.
2.11.3 Notwithstanding any other provision herein, nothing in this Agreement shall be
construed to modify the rights and benefits contained in a Member's Benefit Plan.
2.11.4 Contractor may not bill Members for Covered Services (except for copayments,
coinsurance and deductibles) when CHPW denies payment because Contractor failed to comply
with the terms of this Agreement.
2.11.5 If Contractor contracts with other care providers who are not Participating
Providers, and who agree to provide Covered Services to Members with the expectation of
receiving payment directly or indirectly from CHPW, such providers must agree in writing to abide
by the provisions of this Section 2.11.
2.11.6 Contractor further agrees that this Section 2.11 shall survive termination of this
Agreement regardless of the cause giving rise to such termination, and shall be construed to be for
the benefit of CHPW Members. This provision supersedes any oral or written contrary agreement
now existing or hereafter entered into between Contractor and Members or persons acting on a
Member's behalf.
2023_CSNegAgmt_.leffersonCounty Page 13 of 55 Contract #300090-232143
2.11.7 If Contractor willfully collects or attempts to collect an amount from a Member
under any of the provisions outlined above, the act will constitute a class C felony under RCW
48.80.030(5).
2.12 Referrals and Authorizations.
2.12.1 Contractor shall not refer a Member to a Non -Participating Provider without prior
written authorization from CHPW, except when necessary in the case of Emergency Services or
Urgently Needed Services. Contractor must notify CHPW of referrals for Emergency Services or
Urgently Needed Services by the next business day.
2.12.2 Contractor shall cooperate and comply with prior authorization, hospital admission
and certification procedures required by the then current Provider .Manual.
2.12.3 Consistent with applicable law and the Provider ..Manual, Contractor shall use best
efforts to refer Members to other Participating Providers for appropriate, Medically Necessary
Covered Services when such Services are not available from Contractor.
2.12.4 To the extent that Contractor is billing for pharmacy claims, Contractor shall be
subject to the Provider Manual terms with regard to prior authorization procedures including
policies regarding emergency fill authorizations.
2.13 Insurance Requirements.
2.13.1 Contractor shall maintain the insurance coverage limits set forth below, to cover all
of Contractor's Services under this Agreement, in the minimum amounts specified in this Section,
except as otherwise agreed:
2.13.1.1 Professional liability coverage, including negligence and errors and
omissions coverage, with a minimum limit of One Million Dollars ($1,000,000) per
occurrence, and Three Million Dollars ($3,000,000) annual aggregate. These limits must
apply per Contracted Participating Provider, and shall not be shared amongst Contractor's
Contracted Participating Providers.
2.13.1.2 Commercial and comprehensive general liability coverage, with a
minimum. limit of One Million Dollars ($1,000,000) per occurrence, and One Million
Dollars ($1,000,000) annual aggregate.
2.13.1.3 Applicable state statutory limits for workers compensation.
2.13.1.4 Other usual or customary insurance coverage, or an equivalent
program of self-insurance, applicable to the work being performed and the Services
Contractor provides under this Agreement, and acceptable to CHPW. Contractor warrants
that Contractor's coverage under its memorandum of liability insurance with the
Washington Counties Risk Pool satisfies the insurance coverage requirements of this
section 2.13.
2023_CSNegAgmt—JeffersonCounty Page 14 of 55 Contract #300490-232143
2.13.1.5 To the extent applicable, coverage for Federally Qualified Health
Centers under the Federal Torts Claims Act will be deemed to meet the requirements of
this Section 2.9.
2.13.2 By requiring insurance herein, CHPW does not represent that coverage and limits
will necessarily be adequate to protect Contractor. Such coverage and limits shall not be deemed
as a limitation on Contractor's liability under the indemnities granted to CHPW herein.
2.13.3 Contractor will promptly notify CHPW of any cancellation, reduction, or other
material change in the amount or scope of Contractor's required coverage. Upon CHPW's request,
Contractor will furnish to CHPW a certificate of insurance evidencing all of the policies of
insurance and limits required hereunder.
2.13.4 All policies maintained by Contractor shall be primary with respect to any
insurance maintained by CHPW. Failure to maintain the required insurance constitutes cause for
termination of the Agreement.
2.13.5 The requirements of this Section 2.9 shall survive termination or expiration of this
Agreement.
2.14 Administrative Matters. In performing its duties hereunder, Contractor shall comply,
and require its Contracted Participating Providers to comply, with applicable requirements of the
Provider Manual that CHPW may amend from time to time at its sole discretion. Without limiting
the generality of the foregoing:
2.14.1 Contractor shall comply with RCW 48.135 concerning Insurance Fraud Reporting
and notify CHPW's Compliance Department of all incidents or occasions of
suspected fraud, waste or abuse involving Services provided to a Member.
Contractor shall report a suspected incident of fraud, waste or abuse, including a
credible allegation of fraud, within five (5) business days of the date Contractor
first becomes aware of, or is on notice of, such activity. The obligation to report
suspected fraud, waste or abuse shall apply whether the suspected conduct was
perpetrated by Contractor, Contractor's employee, agent, or subcontractor, or
Member. Contractor shall establish policies and procedures for identifying,
investigating, and taking appropriate corrective action against suspected fraud,
waste or abuse. Upon request by CHPW or the State, Contractor shall confer with
the appropriate State agency prior to or during any investigation into suspected
fraud, waste or abuse. For purposes of this section, the terms fraud and abuse shall
have the same meaning as provided for in 42 CFR §455.2.
2.14.1.1 CHPW shall not penalize Contractor because Contractor, in good
faith, reports to state or federal authorities any act or practice by the health carrier that
jeopardizes patient health or welfare or that may violate state or federal law.
2.14.1.2 Contractor will maintain policies and procedures that require its
managers, officers, and directors, who are involved in work that relates to Members, to
2023—CSNegAgmt—.leffersonCounty Page 15 of 55 Contract #300090-232143
complete and sign a Conflict of Interest Statement upon hiring or appointment, and
annually thereafter, and to report potential conflicts of interest that may arise. r
3. OBLIGATIONS of CHPW
3A Reimbursement. CHPW shall reimburse Contractor for Covered Services it has provided
to Members in accordance with this Agreement, the Provider Manual, and applicable state
and federal law, regulation, guidance and instruction.
3.2 Eligibility. CHPW or its designee shall confirm a Member's eligibility for Covered
Services upon Contractor's request.
3.3 Identification Cards. CHPW shall provide an identification card to each Member. The
card will display status of membership with CHPW, Member's name, Benefit Plan
identification number, name of Primary Care Clinic, copayment amounts, telephone
number for prior approval authorization requests and notifications, and the claims address.
3A Data Requirements. CHPW shall provide Contractor with claim, encounter, and referral
format requirements.
3.5 CHPW Insurance Coverage. CHPW shall maintain general comprehensive liability
insurance in the amounts of $1.000,000 per occurrence and $3,000,000 in the aggregate
and will provide Contractor evidence of such coverage upon request.
3.6 Provider Manual.
3.6.1 CHPW shall maintain and make accessible to Contractor its Provider ..Manual and
associated information, policies and procedures, on its website, ww. H31W.org. The
Provider Manual covers topics such as utilization review, general benefits information,
quality assessment and improvement programs, credentialing, grievance procedures,
billing and data reporting requirements, reimbursement terms and other relevant
information.
3.6.2 CHPW may revise and update the Provider Manual from time to time. CHPW will
provide Facility not less than sixty (60) days' notice of a change that substantially
affects Facility's reimbursement or Covered Service delivery, unless changes to federal
or state law or regulations or other circumstances make such advance notice impossible,
in which case notice shall be provided as soon as possible. Subject to the termination
and continuity of care provisions in Section VI., below, Facility may terminate this
Agreement, as set forth in Section 6.3, below, if the change is unacceptable to Facility.
If there are any conflicts between the Provider Manual and this Agreement, this
Agreement shall prevail.
3.7 Non -Discouragement.
' A conflict of interest may arise if a person or a member of his/her family has an existing or potential interest or relationship that
impairs or appears to impair the person's independent judgment.
2023_CSNegAgmt_JeffersonCounty Page 16 of 55 Contract #300090-232143
3.7.1 CHPW shall not in any way preclude or discourage Contractor from informing
Members about healthcare they require, including various treatment options and whether, in
Contractor's view, such care is consistent with medical necessity, medical appropriateness, or
coverage under the Member's Benefit Plan. CHPW shall not prohibit, discourage or penalize
Contractor from legally advocating on behalf of a Member with CHPW. Nothing in this Section
3.7, however, shall be construed to authorize Contractor to bind CHPW to pay for any service.
3.7.2 CHPW shall not preclude or discourage Contractor, Members, or those paying for
their coverage, from discussing the comparative merits of different health carriers, even if such
discussion is critical of CHPW.
3.7.3 Notwithstanding any other provision herein, CHPW shall not prohibit, directly or
indirectly, any Member from freely contracting at any time to obtain any health care services
outside a CHPW Benefit Plan on any terms or conditions a Member chooses. Nothing herein,
however, shall be construed to bind CHPW to pay for services delivered outside a CHPW Benefit
Plan.
3.8 Notification. CHPW will notify Provider of any adverse benefit determination that
involves the pre -service denial of a treatment or procedure request by Provider.
3.9 Prescription Drug Utilization Management. In accordance with RCW 48.43.420,
CHPW maintains a prescription drug utilization management program applicable to any Health
Benefit Exchange Benefit Plans covered under this Agreement, including a clear, readily
accessible, and convenient process to request an exception. Detailed information can be found on
CHPW's website at https://www.cascadeselect.org/member-center/member-
resources/prescription-drug-coverage/.
4. BILLING AND REIMBURSEMENT
4.1 Requirements.
4.1.1 For all billing and reimbursement activities, the parties shall comply with
applicable billing instructions, practices and policy guidelines referenced herein, and as published
and periodically updated in the Provider Manual and, as applicable, with HCA and CMS
instructions and coverage/non-coverage determinations. If there is a conflict between the substance
or interpretation of HCA billing instructions or guidelines and the Provider Manual, the Provider
Manual shall control. If there is a conflict between the substance or interpretation of CMS
instructions or determinations on coverage and the Provider Manual, the CMS instructions or
determinations shall control.
4.2 Claims and Encounter Submission.
4.2.1 Contractor shall comply with the claims, encounter reporting, payment, and billing
procedures set forth in the Provider .Manual, and shall submit Clean Claims for Covered Services
rendered to the address set forth on the Member's identification card in nationally approved
standard formats, and through a CHPW approved clearinghouse. Contractor shall use best efforts
2023_CSNegAgmt_JeffersonCounty Page 17 of 55 Contract #300090-232143
to submit claims/encounters electronically. without limiting the generality of the foregoing,
encounters shall be submitted within thirty (30) days of the end of the month in which the service
was rendered. Except as otherwise stated, Contractor shall use best efforts to submit
claims/encounters electronically.
4.2.2 Upon request, Contractor shall furnish all information reasonably required by
CHPW to substantiate the provision of and charges for Covered Services, at no charge to CHPW.
Claim approval and payment for claims or encounters are contingent upon CHPW's receipt of
complete and accurate information from Contractor.
4.2.2.1 CHPW's prior authorization through prospective and/or concurrent review
does not guarantee payment.
4.2.2.2 CHPW reserves the right to assure, through audit and retrospective
evaluation of a Member's documented medical care, and based on the information
available to the attending physician or ordering provider at the time services were provided,
that those services were Medically Necessary and claims were accurately coded. Such
review or audit may result in denial of claims for services on the basis of medical Necessity
or errors in claims submission and may adversely impact payment.
4.2.2.3 If it is determined that all or part of the payment of a claim for Services,
other than Emergency Services, was based on information that, in the opinion of CHPW,
is significantly different from the information that was available at the time of CHPW or
its designee's original certification that the Member was eligible for the Covered Services
authorized or provided, CHPW may request a refund.
4.2.3 CHPW shall not pay a claim received (i) more than three hundred and sixty-five
(365) calendar days after the date a Covered Service was rendered, or (ii) more than sixty (60)
calendar days after Contractor first receives notice that CHPW is a secondary payer under
applicable coordination of benefit procedures.
4.3 Reimbursement.
4.3.1 CHPW shall reimburse Contractor for timely submitted Clean Claims for Covered
Services Contractor provides to Members in accordance with this Section 4 and the applicable
Benefit Plan Exhibit(s) in Exhibit B. Contractor shall accept such reimbursement, plus any
applicable Cost Sharing Amounts, as payment in full for such Covered Services.
4.3.2 CHPW shall not pay a claim received (1) more than three hundred and sixty-five
(365) calendar days after the date a Covered Service was rendered or the date of discharge,
whichever is later or (11) more than sixty (60) calendar days after Contractor first receives notice
that CHPW is a secondary payer under applicable coordination of benefit procedures.
4.3.3 CHPW reserves the right to change the reimbursement rates set forth on each
Benefit Plan Exhibit by written notice to Contractor in accordance with changes in rates paid by
applicable federal, state, or other third -party payers. Such reimbursement shall be accepted by
Contractor as payment in full.
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4.3.3.1 CHPW will provide Contractor at least sixty (60) days' notice of changes
that affect Contractor's reimbursement rates pursuant to Section 7.6.1 below, 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. Contractor may terminate this
Agreement pursuant to Section 6.3 if it does not agree with the changes.
4.3.3.2 The parties acknowledge that configuring new rates into CHPW's
reimbursement system to begin paying claims at a new rate requires up to 30 days. In
situations where federal or state rate changes do not allow CHPW to provide 60 days'
advance notice to Contractor, new rates will be implemented on the later of the date CHPW
has completed configuring its system, or on the published effective date of the new rates.
Where a change allows for 60 days' notice, the new rates will be implemented on the
published effective date of the rate change.
4.3.3.3 CHPW will apply new rates only to claims received on and after the
implementation date described in the previous Section. If such action results in a substantial
negative impact to either party, the impacted party may request that the parties negotiate a
settlement payment in lieu of retroactive adjustment of individual claims.
4.3.4 CHPW shall deny or recover payment(s) to Contractor related to the treatment of a
Provider Preventable Condition. At the request or direction of the HCA, the Washington State
Medicaid Fraud Control Unit ("MFCU"), or a state or federal law enforcement agency, CHPW
may suspend part of or all payments related to a credible allegation of fraud, as determined by the
requesting or directing agency.
4.3.5 Except as agreed to by the parties on a claim -by -claim basis, CHPW shall pay not
less than ninety-five percent (95%) of all Clean Claims received from Contractor within thirty (30)
days of receipt, and pay or deny ninety-five percent (95%) of all claims received from Contractor
within sixty (60) days of receipt. A Clean Claim is "received" on the date CHPW receives either
written or electronic notice of the claim. For state sponsored Benefit Plans, if CHPW fails to meet
its obligations in this paragraph, CHPW shall pay Contractor interest at the rate of one percent
(I%) per month of the contract amount of all unpaid Clean Claims that have not been denied and
which have aged sixty one (61) or more days, until such time as CHPW is again in compliance
with the requirements of this Section.
4.3.6 If Contractor is a chiropractic provider, CHPW will reimburse Contractor for
services deemed by CHPW to be Medically Necessary if (i) the service is a Covered chiropractic
health care Service, (ii) provided by Contractor or the Contractor's employee in accordance with
applicable state law, and (iii) Contractor has otherwise complied with the terms and conditions of
this Agreement.
4.4 Coordination of Benefits and Third -Party Payment.
4.4.1 Contractor will cooperate with CHPW's coordination of benefits, subrogation and
third -party payment policies as set forth herein and in the Provider .Manual. CHPW will not
unreasonably delay payment of a claim by reason of the application of its coordination of benefits
policies.
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4.4.2 Contractor shall promptly notify CHPW if it becomes aware that a Member has a
subrogation claim or right to reimbursement from a third -party, and shall assi st CHP W in arranging
for assignment of such right to CHPW for collection. Contractor shall also notify CHPW of
Members that may approach stop -loss deductibles, have other insurance coverage available, or be
eligible for Social Security coverage.
4.4.3 Except as otherwise required by Chapter 284-51 WAC, under no circumstances
shall CHPW reimburse Contractor any amount greater than that provided for under this
Agreement. If Contractor has received payment from another coverage plan or entity that has
primary payment responsibility under coordination of benefits rules, and that payment is equal to
or greater than the rates set forth herein, Contractor may not seek additional reimbursement from
CHPW. In addition, Contractor shall promptly refund to CHPW any amount CHPW has already
paid to Contractor which, when added to amounts paid by another coverage plan or third party for
the same Covered Services, are in excess of the rates set forth in this Agreement.
4.4.4 With regard to state sponsored Benefit Plans, payment for Services and benefits
shall be secondary to any other medical coverage exception in accord with the applicable rules of
WAC 284-51-205(1)(a). CHPW shall not refuse or reduce Services provided hereunder solely due
to the existence of similar benefits under another health care contract. CHPW shall pay claims for
prenatal care and preventive pediatric care and then seek reimbursement from third parties.
4.5 Retrospective Review and Recovery Rights.
4.5.1 CHPW reserves the right to assure through audit and retrospective evaluation of a
Member's documented medical care that, based on the information available to the attending
physician or order provider at the time services were provided, services provided were Medically
Necessary and claims were accurately coded. Such review or audit may result in denial of claims
for services on the basis of Medical Necessity or errors in claims submission and may adversely
impact payment.
4.5.1.1 CHPW may retrospectively deny a claim (a) if it is determined that prior authorization
was based upon a material misrepresentation by Contractor or a Contracted
Participating Provider, and/or (b) if information provided to CHPW is materially
different from information that was reasonably available at the time of the original
determination
4.5.2 Any payments made to Contractor by CHPW that are determined to be
inappropriate in accordance with applicable law, or to which Contractor is not entitled under the
terms of this Agreement or the Provider Manual, shall be considered an overpayment.
Overpayments shall be refunded to CHPW within thirty (30) days of the date Contractor is notified
of the overpayment or within sixty (60) days of identification of an overpayment by Contractor,
whichever is earlier. Alternatively, CHPW may, in its discretion, immediately offset or recoup
any and all overpayments or other amounts owed by Contractor to CHPW against amounts owed
by CHPW to Contractor.
4.5.3 Contractor agrees that all recoupment and any offset rights under this Agreement
will constitute rights of recoupment authorized under State or federal law and that such rights will
not be subject to any requirement of prior or other approval from any court or other government
2023_CSNegAgmt JeffersonCounty Page 20 of 55 Contract #300090-232 1 43
authority that may now have or hereafter have jurisdiction over Contractor. Notwithstanding the
foregoing, except in the case of fraud, CHPW may not request (a) a refund of a payment previously
made to satisfy a claim unless CHPW does so in writing within twenty-four (24) months (or within
thirty (30) months for reasons related to coordination of benefits) in accordance with RCW
48.43.600 or (b) payment of a contested refund sooner that six (6) months after receipt of the
request. This section is not applicable to subrogation claims.
4.5.4 Except in the case of fraud, Contractor may not request payment from CHPW to
satisfy a claim unless it does so in writing within twenty-four (24) months after the date the claim
was denied or payment intended to satisfy the claim was made. In the case of coordination of
benefits, Contractor must request any additional balances owed from CHPW within thirty (30)
months after original payment was made. Additional payment cannot be requested any sooner
than six (6) months after request is made. This section is not applicable to subrogation claims.
5. MUTUAL OBLIGATIONS
5.1 Independent Contractors. CHPW and Contractor are independent entities. No provision
of this Agreement is intended to create, nor shall be construed to create, any relationship
other than that of independent entities contracting with each other solely for the purpose of
effecting this Agreement. Neither party nor any of its respective employees and
subcontractors shall be construed to be the principal, agent, employee, or representative of
the other party.
5.2 Representatives. Each party shall designate a representative who is responsible for
coordination and communication between Contractor and CHPW in performance of this
Agreement, including review of the Provider Manual and subsequent updates. Each party's
representative and their respective contact information are set forth in Exhibit E. attached
hereto and incorporated herein. Each party shall promptly notify the other in writing
pursuant to Section 7.6 of any changes to the party's designated representative or their
contact information.
5.3 Compliance.
5.3.1 Each party shall comply in all material respects with requirements of applicable federal
and state laws and regulations, the terms of this Agreement and applicable terms and
conditions set forth in the CHPw's contracts with state and federal agencies obligating
it to administer all or some of the Benefit Plans referred to herein, including:
5.3.1.1 Applicable Medicare laws, regulations, and CMS Instructions;
5.3.1.2 Title VI of the Civil rights Act of 1964 implemented by regulations at 45 CFR 84;
5.3.1.3 The Age Discrimination Act of 1975, implemented by regulations at 45 CFR 91;
5.3.1.4 The Rehabilitation Act of 1973;
5.3.1.5 The Americans with Disabilities Act;
5.3.1.E The False Claims Act (32 U.S.C. §3729 et seq.);
5.3.1.7 The Anti -kickback Statute (Section 1128B(b) of the Social Security Act);
5.3.1.8 Other laws applicable to recipients of federal funds;
5.3.1.9 Applicable federal and state laws that pertain to enrollee rights; and
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5.3.1.10 As applicable, additional provisions included in a Benefit Plan Exhibit in Exhibit
B, including but not limited to Medicaid Additional Provisions set forth in Exhibit
B--1 -B, attached hereto and incorporated herein, and Medicare Advantage
Additional Provisions set forth in Exhibit B-2-B, attached hereto and incorporated
herein.
5.3.2 Each party agrees to require that all subcontracts related to this Agreement will be
written and will specify that the subcontractor must also comply with terms of this Agreement and
any applicable federal and state laws, regulations and requirements.
5.3.3 As a condition to entering into this Agreement, and in compliance with 42 CFR
45 5.101- 106, Contractor shall provide to CHPw a completed, accurate Disclosure of or Change
in Ownership and Control Interest form. Contractor shall promptly provide updates to the
Disclosure of or Change in Ownership and Control Interest form when information on the current
form changes. Failure to provide a complete accurate form or updates to it shall be deemed a
material breach of this Agreement.
5.4 Confidentiality and Privacy.
5.4.1 All information provided by a party in the process of negotiation or performance of
this Agreement, identified by a party as confidential or proprietary, including reimbursement rates,
fee schedules, and Member and CHPw group information, is confidential and shall not be
disclosed to any third person or entity in any format without the express prior written consent of
providing party. This provision shall not preclude duly authorized and appropriate access to
records in order to allow billing and duality assurance review with respect to Covered Services
delivered under this Agreement. Upon termination of this Agreement, any information identified
by either party as confidential or proprietary shall be returned or otherwise disposed of as mutually
agreed to by the parties. This section shall survive termination of the Agreement.
5.4.2 Each party is a covered entity and in performing this Agreement, each party may
have access to and receive from the other party Protected Health Information ("PHI") as those
terms are defined under HIPAA, and Chapter 70.02 RCw, the Uniform Health Care Information
Act.
5.4.2.1 Each party shall maintain the confidentiality of PHI and shall not use or
disclose Member PHI except as necessary to carry out the terms and conditions of this
Agreement or as permitted or required by federal or state law or regulations.
5.4.2.2 Each party shall implement a documented health information system and a
privacy security program that includes administrative, technical and physical safe guards
designed to prevent the accidental or unauthorized use or disclosure of Member PHI and
medical records. The information system and the privacy and security program shall, at a
minimum, comply with applicable HIPAA regulations regarding the privacy and security
of PHI, including but not limited to 42 CFR § 438.242; 45 CFR § 164.306(a); and 45 CFR
§ 162,200 as well as the HIPAA privacy provisions in Title 13 of the American Recovery
and Reinvestment Act of 2009 ("ARRA") including the Health Information Technology
for Economic and Clinical Health ("HITECH") Act.
2023_CSNegAgmt_JeffersonCounty Page 22 of 55 Contract #300090-232143
5.4.2.3 This Section 5.4 shall be interpreted as broadly as necessary to implement
and comply with applicable current and future HIPAA requirements, and resolve any
ambiguity in favor of a meaning that complies and is consistent with HIPAA requirements.
5.4.3 Each party shall comply with 42 CFR Part 2, as applicable. If Contractor is a "Part
2 program" as defined under 42 CFR §2.11, Contractor shall obtain signed written consent, which
complies with the requirements of 42 CFR Part 2, from each Member prior to disclosing the
Member's Patient Identifying Information to CHPw. For the purposes of this section "Patient
Identifying Information" shall have the same meaning as under 42 CFR §2.11. Such consent shall
explicitly name CHPw as an authorized recipient of the Member's Patient Identifying Information.
Contractor shall maintain copies of each Member's consent form in accordance with Section 5.5.
CHPw reserves the right to audit Contractor's records to ensure compliance with this Section.
5.4.4 This Section 5.4 shall survive termination of the Agreement.
5.5 Record Retention, Access and Audits.
5.5.1 Each party shall cooperate and assist in providing access to records reasonably
required or permitted for inspection, evaluation and audit as set forth herein.
5.5.2 Consistent with industry standards and applicable state and federal law and
regulations, including OIC regulations, each party or its authorized representative(s) may, during
normal business hours and upon giving reasonable notice to the other party, audit, examine and
inspect (to the extent necessary to perform the audit) the other party's books and records, including
medical and financial records and electronically stored data, related to this Agreement, transactions
between CHPW and Contractor hereunder, and to surveys and audits for accreditation and
compliance.
5.5.3 Each party shall retain and protect all applicable books and records for at least ten
(10) years after termination of this Agreement. Each party acknowledges that certain government
agencies, including the Secretary of the Department of Health and Human Services (HHS) and the
Comptroller General of the United States General Accounting Office, or any of their duly
authorized representatives, have the right to inspect and audit each party's books and records for
ten (10) years beyond the termination of this Agreement, or until the completion of any
governmental audit that pertains to such books and records, whichever is later, unless: (1) HHS
determines there is special need to retain a particular record or group of records for a longer period
and notifies the party at least thirty (30) days before the normal disposition date; (ii) there has been
a termination, dispute, or allegation of fraud or similar fault by either party, in which case the
retention may be extended to six (6) years from the date of any resulting final resolution of the
termination, dispute, fraud, or similar fault; or (iii) HHS determines that there is a reasonable
possibility of fraud or similar fault, in which HHS may inspect, evaluate, and audit either party at
any time. without limiting the foregoing, following the commencement of any audit by a
government agency, the party subject to the audit shall retain its relevant books and records until
completion of said audit. This Section shall survive termination of this Agreement for the period
of time required by state and federal law. Contractor shall provide copies of all such records to the
auditing agency at Contractor's cost.
2023_CSNegAgmt-JeffersonCounty Page 23 of 55 Contract #300090-232143
5.5.4 Pursuant to 42 CFR 422.504(e)(2), CMS may access Contractor's records
(including medical records) that are to be used for risk -adjustment data validation (RADV)
purposes to determine amounts payable under a Medicare Advantage contract.
5.6 Marketing.
5.6.1 CHPW may use Contractor's name for publication in its directory of clinics and
providers, and to otherwise carry out the terms of this Agreement. At its discretion,
Contractor shall display CHPW-approved signs and material related to provision of
services, participate in CHPW-approved marketing programs for its products and
perform other marketing duties CHPW may request.
5.6.2 Contractor shall obtain prior written approval for any publication or distribution of
promotional materials using the CHPW name or logo. Unless such material requires
review and approval by HCA or CMS, CHPW shall decide whether to approve the
materials within fifteen (15) working days of the submission of the material to CHPW.
5.6.3 Contractor shall not engage in direct and/or indirect door-to-door, telephonic, or other
cold -call marketing of enrollment with Members or potential Members. Member
information and marketing materials must be developed at the 6th grade reading level
and require prior written approval of CHPW.
5.7 Dispute Resolution.
5.7.1 If a dispute between CHPW and Contractor arises with regard to performance or
interpretation of any of the terms of this Agreement, the parties shall first meet informally in good
faith to attempt to resolve the dispute. The complaining party shall send written notice to the other
party expressly referencing the provisions of this Section 5.7 and the nature of the dispute. The
parties shall meet and in good faith work to resolve the dispute.
5.7.2 If a dispute is not resolved informally within thirty (30) days of receipt of the notice
described in Section 5.7.1, either party may send written notice to the other requesting formal
consideration of the disputed matter and describing its position on the disputed matter. The party
receiving such request shall review the matter and send a written response, describing its position
on the matter and the basis for its position, to the requesting party within thirty (30) days of receipt
of the request for formal consideration. Where the party receiving the request for formal
consideration fails to respond within thirty (30) days of receipt, the requesting party may proceed
as if the request has been rejected.
5.7.3 Where a request for informal or formal resolution fails to result in resolution of a
dispute, the parties may agree to non -binding mediation, conducted under the mediation rules of
the American Health Lawyers Association, or another mutually agreed organization. The
mediator's fees shall be born in equal shares by the parties. All other related costs incurred shall
be the sole responsibility of the party incurring the cost.
5.7.4 If the parties cannot resolve the matter through non -binding mediation either party
may initiate an action in any Superior Court of competent jurisdiction in King County,
Washington.
2023_CSNegAgmt_JeffersonCounty Page 24 of 55 Contract #300090-232143
5.8 Responsibility for Own Acts. Each party shall be responsible for its own acts and
omissions and shall be liable for payment of that portion of any and all legal claims, liabilities,
injuries, suits, demands, or expenses of any kinds that may result from or arise out of any alleged
malfeasance or neglect caused by said party, its employees, agents or subcontractors. If a claims is
made against both parties, each party shall cooperate in the defense and cause its insurers to do
likewise. Each party shall, however, retain the right to take any action it believes necessary to
protect its own interests.
5.9 Indemnification.
5.9.1 Each party agrees to indemnify and hold harmless (and at such party's request, defend)
the other party, its directors, officers, employees and agents from any third party claims,
judgments, damages, costs, suits, losses, or liabilities (including reasonable attorney's
fees) arising solely and exclusively out of the negligence, wrongful act or omission, or
breach of this Agreement by such indemnifying party, or any of its respective officers,
directors, agents or employees.
5.9.2 CHPw shall not be liable to Members for any act of malpractice on the part of
Contracted Participating Providers. Contractor shall indemnify, defend, and hold
harmless CHPw from any such liability. The indemnity in the immediately preceding
sentence shall not apply to any alleged act of independent liability on the part of CHPW,
or any of its employees or agents.
6. TERM OF AGREEMENT AND TERMINATION
6.1 Term. This Agreement shall take effect on the date specified on page one as the Effective
Date, and shall remain in force for an initial term of twelve (12) months from the effective
date. Thereafter, this Agreement shall automatically renew for successive one (1) year
terms unless written notice of intent not to renew is given at least one hundred twenty (120)
days prior to the expiration date of any such annual term, or unless otherwise terminated
as provided hereunder.
6.2 Termination upon Breach. Either party may terminate this Agreement if (i) it believes
the other party has committed a material breach of the Agreement, (ii) it gives the breaching
party written notice describing the breach and (iii) such breach is not corrected, or a
corrective action plan approved by both parties is not in place, within thirty (30) days
following the written notice. Further, this Agreement may be terminated immediately if a
party or any of its Directors, Officers, Owners or employees is excluded from participation
in a state or federally sponsored health program, is convicted of a crime, has its license or
certification revoked, or fails to accurately complete or timely return the Disclosure of or
Change in Ownership and Control Interest Form.
6.3 Termination without Cause. Either party may terminate this Agreement without cause
upon at least one hundred twenty (120) days' advance written notice to the other party
given pursuant to Section 7.6 below.
2023—CSNegAgmt_JeffersonCounty Page 25 of 55 Contract #300090-232143
6.4 Continuing Responsibilities upon Termination. Neither party shall be released from
obligations hereunder prior to the effective termination date of the Agreement. Contractor
shall cooperate with and assist CHPW in working with affected Members to develop a
reasonable transition plan.
6.5 Member Notification. whether the termination was for cause or without cause, CHPW
will make a good faith effort to ensure that written notice of termination is provided at least
thirty (30) days prior to the effective date of the termination, or immediately for a
termination for cause that results in less than thirty (30) days' notice, to all Members who
are patients seen on a regular basis by a specialist, by a provider for whom the Member has
a standing referral, or by a primary care provider.
7. MISCELLANEOUS
7.1 Assignment. Contractor may not assign its duties, rights, or obligations under this
Agreement without prior written approval of CHPW, which shall not be unreasonably
withheld, and, in regard to state sponsored Benefit Plans, the approval of HCA.
7.2 Discrimination. Neither party shall discriminate against any person because of race, color,
national origin, ancestry, religion, gender, marital status, age, sexual orientation, presence
of physical or mental handicaps, and any other reason(s) prohibited by law, in the provision
of services or in employment practices.
7.3 'Washington State Law. This Agreement shall be governed by and construed in
accordance with the laws of the State of Washington irrespective of choice -of -law
principles, except to the extent pre-empted by federal law. venue for any action or
proceeding related to this Agreement shall be in Ding County, Washington.
7.4 Amendments.
7.4.1 This Agreement may be amended by the written agreement of both parties.
7.4.2 CHPW may amend this Agreement on sixty (60) days written notice to Contractor.
Contractor's failure to object in writing within sixty (60) days of receipt of such amendment shall
constitute Contractor's acceptance thereof. If Contractor gives timely notice that it objects to such
amendment, it may terminate the Agreement without penalty pursuant to Section 6.3 and such
amendment shall not go into effect as to Contractor.
7.4.3 CHPW may immediately amend this Agreement by written notice as necessary to
maintain consistency and/or compliance with any state or federal law, policy, directive or state and
federal sponsored Benefit Plan.
7.5 Third -Party Beneficiaries. Notwithstanding that benefits arising from. this Agreement
may inure to a Member or other third party, the parties hereto intend that no third -party
shall be a Third -Party Beneficiary of the obligations assumed by either party to this
Agreement and no such person shall have the right to enforce any such obligation.
2023_CSNegAgmt JeffersonCounty Page 26 of 55 Contract #300090-232143
7.6 Notice*
7.6.1 All notices or other communications, except notice of termination, required or
permitted to be given hereunder shall be in writing and deemed to have been delivered to a party
upon: (i) personal delivery to that party; (ii) electronically confirmed delivery by facsimile to the
telephone number provided by the party for such purposes; (1*1*1) electronic mail transmission to the
electronic mailbox provided by the party for such purposes; (iv) upon deposit for overnight
delivery with a bonded courier holding itself out to the public as providing such services, with
charges prepaid; or (v) four (4) business days following deposit with the United States Postal
Service, postage prepaid, and in any case addressed to the party as set forth below, or to another
address that the party provides by notice to the other party.
7.6.2 Notice of termination shall be in writing and deemed to have been delivered to a
party upon deposit for overnight delivery with a bonded courier holding itself out to the public as
4.
providing such services, with charges prepaid and signature receipt required; or deposit with the
United States Postal Service, postage prepaid and certified mail or return receipt requested, and in
any case addressed to the person set forth below, or to another address that the party provides by
notice to the other party.
Community Health Plan of Washington I Jefferson County DBA
Jefferson County Public Health
ATTN: Director, Network Management & Strategy ATTN: Glenn Gilbert
1111 Third Avenue, Suite 400 615 Sheridan Street
Seattle, WA 98101-3292 Port Townsend, WA 98368
FAX: (206) 613-5018 FAX:
Email: Cath .Neiman CHPW.or Email: g i-lbert@co. rson.wa.us
7.7 Force Majeure. Neither party shall be considered to be in breach of this Agreement if its
failure to comply is occasioned by an act of God, declared local or national emergency,
public health crisis including without limitation a WHO- or CDC -designated pandemic, act
of a governmental authority responding to an act of God or other declared emergency or
public health crisis, or the result of a strike, lockout or other labor dispute.
7.8 Payment of Federal Funds.
7.8.1 Neither party shall make any specific payment, directly or indirectly, to a physician
or physician group, or other health care provider, as an incentive to reduce or limit Medically
Necessary Services furnished to a particular Member. Indirect payments may include offerings of
monetary value (e.g. stock options, or waivers of debt) measured in the present or future.
7.8.2 Each party shall remain in good standing with applicable regulatory agencies and
shall comply with applicable federal and state laws and regulations. Each party, in fulfilling its
obligations hereunder, acknowledges that it is subject to certain laws that are applicable to
individuals and entities receiving federal funds. Each party agrees to inform all related entities,
2023_CSNegAgmt JeffersonCounty Page 27 of 55 Contract #300090-232143
contractors, and subcontractors that payments that they receive are, in whole or in part, from
federal funds.
7.9 Construction,
7.9.1 Entire Agreement. This Agreement, with exhibits attached hereto, constitutes the
entire agreement between the parties with respect to its subject matter and supersedes any and all
previous or contemporaneous agreements and understandings regarding such subject matter.
7.9.2 Construction and Applicability of Certain Laws and Regulations.
7.9.2.1 Nothing in this Agreement modifies any benefits, terms, or conditions
contained in a Member's Benefit Plan. In the event of a conflict between this Agreement
and the benefits, terms, and conditions of a Member's Benefit Plan, the benefits, terms or
conditions contained in the Member's Benefit Plan shall govern.
7.9.2.2In addition to the applicable terms of this Agreement, as to the state
sponsored Benefits Plans offered by CHPW through its contracts with HCA, and listed in
Exhibit B. the contract between the HCA and CHP W, as well as applicable laws and
regulations, shall govern construction.
7.9.2.3 In addition to the applicable terms of this Agreement, as to Medicare
Advantage Plans listed on Exhibit B, applicable laws and regulations as well as the CMS-
CHPW Contract, CMS guidance and instructions shall govern construction.
7.9:2.4 In addition to the applicable terms of this Agreement, as to the Health
Benefit Exchange Products listed on Exhibit B, applicable laws and regulations including
those from the Washington Health Benefit Exchange, the Health Benefit Exchange Act
including the 2012 regular session laws, chapter 87, Affordable Care Act Implementation
and regulations adopted pursuant to RCW 43.71 and the OIC shall govern construction.
7.9.2.5 With regard to this Agreement in general, ambiguities shall be reasonably
construed in accordance with all relevant circumstances and shall not be construed against
either party, irrespective of which party is deemed to have authored the ambiguous
provision. The captions and headings appearing herein are for reference only and will not
be considered in construing this Agreement. As used herein, "including" means "including
without limitation". If any provision hereof is held invalid or unenforceable, such provision
will be amended to achieve as nearly as possible the same economic and operational effect
as the original provision, and the remainder of this Agreement will remain in full force and
effect. Waiver by either party of the breach of any provision hereof by the other party will
not operate or be construed as a waiver of any subsequent, similar or other breach by the
breaching party. The rights of each party granted herein are in addition to any others that a
party may be entitled to by law, shall be construed as cumulative, and no such right is
exclusive of any others or of any right or priority allowed by law. Whether specifically
identified or not, obligations of the parties hereunder, that, by their nature or content would
continue beyond the expiration or termination of this Agreement, shall survive such
expiration or termination, and the statute of limitations shall not begin to run until the time
such obligations have been fulfilled. This Agreement may be executed in any number of
2023_CSNegAgmt JeffersonCounty Page 28 of 55 Contract #300090-232143
counterparts, each of which will be an original and all of which together will constitute one
and the same instrument.
H signature page follows H
2023_CSNegAgmt—JeffersonCounty Page 29 of 55 Contract #300090-232143
The undersigned have executed this Agreement as of the date and year written below.,
Community Health Flan of Washington Jefferson County DBA
Jefferson County Public Health
I I I I Third Avenue, Suite 400 615 Sheridan Street
Seattle, WA 98101-3292 Port Townsend, WA. 98368
Phone: (206) 521-8 83 3 Phone: (360) 3 8 5 -9400
Sign:
Sign:
Name: Stacy Kessel Name: Greg Brotherton
Title: Chief Finance and Strate officer Title: Chair, Board of Coun!y Commissioners
Date: Date:
ATTEST
Carolyn Gallaway,
Clerk of the Board
Date
APPROVED AS TO FORM ONLY:
May 12, 2023
Philip C. Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
11 the remainder of this page is left intentionally blank//
2423_g gmt CSNe A JeffersonCounty Page 30 of 55 Contract #300090-232143
.�
EXHIBIT A
CONTRACT LOCATIONS AND PARTICIPATING PROVIDERS
GROUP CONTRACT INFORMATION
Group Legal Name
Jefferson County
Group DBA Name
Jefferson County Public Health
Group TIN/(EIN)
916001322
Group NPI
1841225208
1. Please complete the following Location Roster for all locations to be covered under this Agreement:
LOCATION to be LINKED to CONTRACT
Location Name
Jefferson County Public Health
Street Address 1
615 Sheridan Street
Street Address 2
0
'p"
City
Port Townsend
State
WA
Zip
98368
Q
a
Office Phone
360-385-9400
office Fax
TIN: Same as above?
Same
NPI: Same as above?
Same
LOCATION to be LINKED to CONTRACT
Location Name
Street Address 1
Street Address 2
v
0
City
State
Zip
office Phone
office Fax
TIN: Same as above?
NPI: Same as above?
LOCATIONN to be LINKED to CONTRACT
Location Name
Street Address 1
Street Address 2
City
State
Zip
a
Office Phone
office Fax
TIN: Same as above?
NPI: Same as above?
2023_CSNegAgmt_JeffersonCoun.ty Page 31 of 55 Contract #300090-232143
2. Please complete the following Provider Roster as requested below for all Contracted Participating
Providers at each Contractor Location.
INDIVIDUAL PROVIDERS to be LINKED to CONTRACT
Provider Name First Last
Accreditation
NPI
A
B
C
Active w/CHPW
Cred App
1
Locke, Thomas
1750342770
Yes
2
Berry, Allison
1982973400
In process
3
O'Brien, Susan
1487712188
Yes
4
Bower, Melinda
1275976490
In process
5
d
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
3. whenever there are changes to any of the information on this Exhibit A, Contractor may submit
changes online via webforms as hyperlinked below, to have information accurately updated
across all CHPW systems and applications -- as well as our Provider Directory:
a. Clinic & Qroup Chanvs Fq rn
b. individual Prodder Add, C'%an,e 'rerin Form
2023_CSNegAgmt_JeffersonCounty Page 32 of 55 Contract #300090-232143
EXHIBIT B
BENEFIT PLANS
Benefit Plan Controls. Nothing in this Exhibit B, or the Agreement, will have the effect of
modifying any benefit, term, or condition of a Benefit Plan. In the event of a conflict between the
Agreement and a Benefit Plan, the benefits, terms, and condition of the Benefit Plan will govern
with respect to Covered Services provided to Members enrolled in the Benefit Plan.
Amendments. Consistent with Section 7.4 of the Agreement, Amendments, CHPW may add
Benefit Plans, or otherwise make changes to this Exhibit B (e.g. termination of a Benefit Plan),
by notifying Facility in writing of such addition(s) or change(s), and Facility shall not
unreasonably withhold its consent to participate in additional Benefit Plan(s) or accept such
changes). If Facility fails to object in writing within sixty days of its receipt of such notice,
Facility will be deemed to have agreed to inclusion of the additional Benefit Plans). The
following Benefit Plans are designated as either "Included" or "Not Included" for purposes of
this Agreement.
CHPW Benefit Plans. The following are the Benefit Plans offered by Community Health Plan
of Washington that may be subject to this Agreement. The following Benefit Plans are
designated as either "Included" or "Not Included" for purposes of this Agreement, and any
Benefit Plan that is "Included" is accompanied by one or more Plan Exhibits, as indicated, that
will control with regard to services delivered to Members of that Benefit Plan.
1. Medicaid Plans Included
Washington Apple Health Integrated Managed Care Plans
Includes Behavioral Health Services Only, where applicable
Network Name: CHPW A.H Network
Exhibit BW 1-A
— Medicaid Reimbursement Rates
®
Exhibit B-1-B —Medicaid
Required Provisions
❑
Exhibit B-1-C —Medicaid
Value Based Payment Arrangement
❑
Exhibit B-1-D
—Medicaid CHIP Managed Care Addendum for IHCP's
2. Medicare Advantage (MA) Plans
Medicare Advantage and Medicare Advantage Not Included
Prescription Drug Plans offered by CHPW.
Network Name: CHPW MA Network
2023-CSNegAgmt_JeffersonCounty Page 33 of 55 Contract #300090-232143
Medicare Advantage (MA) Plans (Continued)
Medicare Advantage Special Needs Plans Not Included
offered by CHPW.
Network Name: CHPW SNP Network
❑ Exhibit B-2-A — Medicare Advantage Reimbursement Rates
❑ Exhibit B-2-B — Medicare Advantage Required Provisions
❑ Exhibit B-2-C — Medicare Advantage Value Based Payment Arrangement
2. CHPW Health Benefit Exchange Products
"Cascade Care" Public option Plans Included
offered by CHPW.
Network Name: CHPW Cascade Care Affiliate Network
0 Exhibit B-3-A — CHPW Health Benefit Exchange Reimbursement Rates
❑ Exhibit B-3-B — CHPW Health Benefit Exchange Required Provisions
❑ Exhibit B-3-C — CHPW Health Benefit Exchange Value Based Payment Arrangement
❑ Exhibit B-3-D — CHPW Health Benefit Exchange QHP Addendum for IHCP's
Third Partv Benefit Plans. The following Benefit Plans are offered by third party plan
sponsors that (i) have an obligation to administer and pay for Covered Services provided to a
Member enrolled in the applicable Benefit Plan, and (ii) have entered or is subject to a written
agreement with CHPW for provider network management services for the applicable Benefit
Plan, and which may be subject to this Agreement. The following Benefit Plans are designated as
either "Included" or "Not Included" for purposes of this Agreement, and any Benefit Plan that is
"Included" is accompanied by one or more Plan Exhibits, as indicated, that will control with
regard to services delivered to Members of that Benefit Plan.
For each Benefit Plan designated as "Included" below, Facility authorizes the applicable plan
sponsor to offer Facility's services to individuals in accordance with the provisions of the
"Included" Benefit Plan(s). Notwithstanding anything in the Agreement to the contrary, for Third
Party Benefit Plans listed as "Included" below, Facility shall accept payment as outlined in the
applicable Plan Exhibits.
3. Third -Party Health Benefit Exchange Products
Affiliated "Cascade Care" Public Option Plans
Public Option Plans offered by a CHPW affiliate, including
Community Health Network of Washington.
Network Name: CHPW Cascade Care Affiliate Network
Included
2023—CSNegAgmt_JeffersonCounty Page 34 of 55 Contract #300090-232143
4. Third Party Health Benefit Exchange Products (Continued)
Non -Affiliated "Cascade Care" Public Option Plans Included
Public Option .,Flans offered by a thud party who is not a
CHPW affiliate.
Network Name: CHPw Cascade Care Non -Affiliate Network
M Exhibit B-4-A —Third Party Health Benefit Exchange Reimbursement Rates
❑ Exhibit B-4-B —Third Party Health Benefit Exchange Required Provisions
❑ Exhibit B-4-C —Third Party Health Benefit Exchange Value Based Payment Arrangement
❑ Exhibit B-4-D —Third Party Health Benefit Exchange QHP Addendum for IHCP's
Effective Date:
(CHPW To COMPLETE)
2023—CSNegAgmt—JeffersonCounty Page 35 of 55 Contract #300090-232143
EXHIBIT B-l-A
MEDICAID
REIMBURSEMENT RATES
1. Rates. Subject to the terms and conditions of the Agreement, reimbursement rates for
Covered Services billed under Facility's tax ID number for the Apple Health program
shall be the lesser of billed charges or the following and will be less any applicable Cost
Sharing Amounts:
Network Name: CHPW .A.H Network
0 100% of HCA's Fee Schedule.
❑ The Rates set forth in Schedule(s) [A] [B] for the Covered Services described therein.
❑ The Rates set forth in Schedule(s) [A] [B] for the Covered Services described therein;
for all other Covered Services:
of CHPW's [IMC Mental Health][IMC Substance Use Disorder] Fee Schedule.
❑ The Rates set forth in Schedule(s) [A] [B] for the Covered Services described therein;
for all other Covered Services:
% of HCA's Fee Schedule.
2. P y All payments under this Agreement shall be made in accordance with the
terms of this Agreement, the Provider Manual and the applicable billing instructions and
policy guidelines published and periodically updated by applicable state and federal
agencies as set forth in Section 4 of the Agreement.
Effective Date:
(CHPW TO COMPLETE)
2023_CSNegComp_JeffersonCounty Page 36 of 55 Contract #300090-232143
EXHIBIT B-1-B
MEDICAID
REQUIRED PROVISIONS
Community Health Plan of Washington ("CHPW") has contracted with the Washington State
Health Care Authority ("HCA") to arrange for the provision of fully integrated physical and
behavioral health care services to Members under the Apple Health Medicaid Program. The
Contract between CHPW and HCA (the "State Contract") requires that specific terms and
conditions be incorporated into agreements between CHPW and its participating providers and
subcontractors.
This Exhibit B-1-B ("this Exhibit") is intended to supplement the Agreement by setting forth the
parties' rights and responsibilities related to the provision of Covered Services to Members as it
pertains to the Apple Health Program. In the event of a conflict between the terms and conditions
of the Agreement and the terms and conditions of this Exhibit, this Exhibit shall govern as to the
Apple Health Program.
Contractor agrees and understands that Covered Services shall be provided in accordance with the
State Contracts), Payor requirements, any applicable State handbooks or policy and procedure
guides, and all applicable State and federal laws and regulations. To the extent Contractor is
unclear about Contractor's duties and obligations, Contractor shall request clarification from
CHPW.
Definitions. The following definitions apply to this Exhibit 13-1-B:
Capitalized terms used and not otherwise defined herein shall have the meanings given to them
in the Agreement or the State Contract. The definitions listed below will supersede any
meanings contained elsewhere in the Agreement with regard to this Exhibit.
Apple Health Program: the Medicaid integrated managed care program known as Apple Health.
Behavioral Health Supplemental Transaction ("BHST")., non -encounter data submissions
outlined in the HCA's Behavioral Health Supplemental Transaction Data Guide, which include
supplemental data, including additional demographic and social determinant data, as well as
service episode and outcome data necessary for federal Substance Abuse and Mental Services
Administration (SAMHSA) block grant reporting and other state reporting needs.
HCA: the State of Washington Health Care Authority and its employees and authorized agents.
Medically Necessary: health care services that: (a) are reasonably calculated to prevent, diagnose,
correct, cure, alleviate or prevent worsening of conditions in the Member that endanger life, or
cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a
handicap, or cause physical deformity or malfunction; and (b) are not more costly than any other
equally effective or more conservative course of treatment available or suitable for the Member
requesting the service. Such services shall include services related to the Member's ability to
achieve age -appropriate growth and development.
2023—CSNegAgmt_JeffersonCounty Page 37 of 55 Contract #300090-232143
Member: an individual enrolled in Apple Health and entitled to receive Covered Services pursuant
to that Benefit Plan.
Physician's Orders for Life Sustaining Treatment ("POLST"): a set of guidelines and protocols for
how emergency medical personnel shall respond when summoned to the site of an injury or illness
for the treatment of a person who has signed a written directive or durable power of attorney
requesting that he or she not receive futile emergency medical treatment, in accordance with RCW
43.70.480.
Primary Care Provider or PCP: a Participating Provider who has the responsibility for supervising,
coordinating, and providing primary health care to Members, initiating referrals for specialist care,
and maintaining the continuity of Member care. PCPs include, but are not limited to pediatricians,
family practitioners, general practitioners, internists, naturopathic physicians, medical residents
(under the supervision of a teaching physician), physician assistants (under the supervision of a
physician), or advanced registered nurse practitioners (nurse practitioners), as designated by
CHPW. The definition of PCP is inclusive of primary care physician as it is used in 42 C.F.R. §
438. All Federal requirements applicable to primary care physicians will also be applicable to
PCPs as the term is used in this Exhibit.
State: the state of Washington.
State Contract(s): the applicable contract(s) between HCA and CHPW under which CHPW agrees
to provide or arrange for services related to the Apple Health Program, including any exhibits,
attachments, documents, or materials incorporated by reference.
Contractor A reement Re uirements. The parties agree to the following terms and
conditions:
1. CHPW Remains Legally Responsible. Nothing herein shall be construed to delegate
legal responsibility to HCA for any work performed under the Agreement, nor for oversight of
any functions and/or responsibilities delegated to Contractor.
2. Compliance with Applicable Law. Contractor shall comply with all Applicable Law. For
purposes of this Exhibit, Applicable Law shall specifically include those laws and regulations as
set forth in the State Contract, including but not limited to the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA"), the Mental Health Parity and Addiction Equity Act
("MHPAEA") and final rule, state laws and regulations regarding mental and behavioral health
and substance use disorder services, the Federal Drug and Alcohol Confidentiality Laws in 42
C.F.R. Part 2, 42 U.S.C. § § 1396a(a)(43) (early and periodic screening, diagnostic, and treatment
services ("EPSDT")), 1396d(r) (definition of EPSDT), and 42 C.F.R. § 438.3(1) (choice of
network provider).
3. Compliance with State Contract. Contractor shall comply with any term or condition of
the State Contract that is applicable to the services to be performed under the Agreement,
including but not limited to the Performance Improvement Project requirements of the State
2023—CSNegAgmt_JeffersonCounty Page 38 of 55 Contract #300090-232143
Contract and the prohibition on direct and/or indirect door-to-door, telephonic, or other cold -call
marketing.
4. Policies and Procedures. Contractor shall comply with CHPW's policies and procedures,
including, but not limited to, credentialing and recredentialing, utilization management, fraud
and abuse, authorization of services, quality improvement activities and provider payment
suspensions. Contractor shall comply with the Program Integrity requirements of the State
Contract, as well as CHPW's program integrity policies and procedures. Without limiting the
generality of the foregoing, Contractor shall comply with the Program Integrity requirements in
Section 1902(a)(68) of the Social Security Act, 42 C.F.R. § 43 8.610, 42 C.F.R. § 455, 42 C.F.R.
1000 through 1008, and Chapter 182-502A WAC. Further, Contractor shall be subject to
ongoing analysis of utilization, claims, billing and/or encounter data to detect overpayment,
which analysis shall include audits and investigations of Contractor. To the extent that
Contractor is delegated authority for authorization of services, Contractor shall comply with all
Utilization Management requirements described in the State Contract.
5, Debarment Certification. Contractor represents and warrants that it is not presently
debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any
State or federal department or agency from participating in transactions. Contractor shall
immediately notify CHP W in writing if, during the term of the Agreement, (a) Contractor
becomes debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded, or (b) Contractor or any of Contractor's employees are subject to disciplinary action
against accreditation, certification, license and/or registration.
6. Records. Contractor shall maintain all financial, billing, medical and other records
pertinent to the Agreement, including but not limited to records related to services rendered,
quality, appropriateness, and timeliness of service, any administrative, civil or criminal
investigation or prosecution. All financial records shall follow generally accepted accounting
principles. other records shall be maintained as necessary to clearly reflect all actions taken by
Contractor related to the Agreement.
All records and reports relating to the Agreement shall be retained by Contractor for a minimum
of ten (10) years after final payment is made under the Agreement. However, when an inspection,
audit, litigation, or other action involving records is initiated prior to the end of said period, records
shall be maintained for a minimum of ten (10) years following resolution of such action.
7. Inspection. Contractor shall fully cooperate with and permit State, including HCA,
MFCU and state auditor, CMS, auditors from the federal Government Accountability office,
federal Office of the Inspector General, federal Office of Management and Budget, the Office of
the Inspector General, the Comptroller General, and their designees, to access, inspect and audit
any books, records, contracts, or documents of Contractor that pertain to any aspect of services
and activities performed, including any computerized data stored by Contractor, and shall permit
inspection of the premises, physical facilities, and equipment where Medicaid -related activities
or work is conducted, at any time whether such visit is announced or unannounced. Contractor
shall make copies of records and shall deliver them to the requestor, without cost, within thirty
(30) calendar days of request. The right for the parties named above to audit, access and inspect
under this Section exists for ten (10) years from the final date of the contract period or from the
date of completion of any audit, whichever is later. If the State, CMS or the federal Office of the
2023_CSNegAgmt_JeffersonCounty Page 39 of 55 Contract 4300090-232143
Inspector General determines that there is a reasonable possibility of fraud or similar risk, the
State, CMS, or the federal office of the Inspector General may inspect, evaluate, and audit the
subcontractor at any time.
8. Interpreter Services. Contractor shall provide interpreter services, free of charge, for all
interactions with Members or potential Members, including but not limited to: (a) customer
service, (b) all appointments with any provider for any Covered Service, (c) emergency services,
and (d) all steps necessary to file grievances and appeals including requests for Independent
Review of CHPw decisions.
9. Marketing Materials. All information to be provided to Members, e.g. marketing
materials, must be accurate, not misleading, comprehensible to its intended audience, designed to
provide the greatest degree of understanding, and written at a sixth (6th) grade reading level, in
addition to any other requirements imposed by CHPw based on the nature of the materials.
Such materials must generally be approved by CHPw prior to use and must comply with the
State Contract.
10. Coordination of Benefits. Services and benefits available under the Agreement shall be
secondary to any other medical coverage, except in accordance with Chapter 284-51 WAC, as
applicable. CHPw shall not refuse or reduce services provided under the Agreement solely due
to the existence of similar benefits under any other health care contract, except in accord with
applicable coordination of benefits rules in wAC 284-51. CHPW shall provide prenatal care and
preventive pediatric care and then seek reimbursement from third parties.
11. Subcontracting. Contractor may not subcontract any services under the Apple health
Program without the prior written consent of CHPw. Any subcontract entered into by
Contractor must be in writing consistent with 42 C.F.R. § 434.6, and all Contractor requirements
contained in this Exhibit must be propagated downward into any other lower tiered subcontracts.
12. Reasonable Accommodations for Disabilities. Contractor shall cooperate with CHPw to
make reasonable accommodation for Members with disabilities, in accordance with the
Americans with Disabilities Act, for all Covered Services and shall assure physical and
communication barriers shall not inhibit Members with disabilities from obtaining Covered
Services.
13, Surgical Health and Safety. If Contractor is a hospital, ambulatory care surgery center,
or office -based surgery site, Contractor shall endorse and adopt procedures for verifying the
correct patient, the correct procedure and the correct surgical site that meet or exceed those set
forth in the Universal ProtocolTM development by the Joint Commission or other similar
standards.
14. , Practice Guidelines. Contractor shall comply with applicable physical and behavioral
health practice guidelines adopted by CHPw.
15. Supervision of Behavioral Health Care Providers. If applicable under the behavioral
health practice guidelines, Contractor will receive payment for the supervision of behavioral
health providers whose license or certification restricts them to working under supervision,
effective as of the first day of the term following August 2019.
2023—CSNegAgmt JeffersonCounty Page 40 of 55 Contract #300090-232 1 43
16. Timely Access to Care. Contractor shall offer access to care comparable to that offered to
commercial enrollees or if Contractor serves only Medicaid enrollees, then comparable to
Medicaid fee -for -service.
17. Hours of operation. Contractor's hours of operation for Members shall be no less than
the hours of operation offered to any other of Contractor's patients.
18. Administrative Simplification. Unless otherwise directed by CHPW, Contractor shall use
and follow the most recent updated versions of: Current Procedural Terminology ("CPT");
International Classification of Diseases ("ICD"); Healthcare Common Procedure Coding System
("HCPCS"); CMS Relative Value Units"RVUs"); CMS billing instructions and rules; The
Diagnostic and Statistical Manual of Mental Disorders; NCPDP Telecommunication Standard
D.o.; and Medi-Spang Master Drug Data or any other nationally recognized drug database with
approval by HCA.
19. Claims .Payment Standards. Except as otherwise allowed under Applicable Law, or
unless otherwise agreed by the Parties in writing on a claim -by -claim basis, CHPW shall meet
the following minimum standards for timeliness of payment: ninety-five percent (95%) of Clean
Claims shall be paid or denied within thirty (30) calendar days of receipt of the paper or
electronic claim; ninety-five percent (95%) of all claims shall be paid or denied within sixty (60)
calendar days of receipt of the paper or electronic claim; and ninety-nine percent (99%) of Clean
Claims shall be paid or denied within ninety (90) calendar days of receipt.
20. Appointment bait Time Standards. As applicable, Contractor shall meet the following
appointment wait time standards with respect to Members:
20.1 Transitional healthcare services by a PCP shall be available for clinical
assessment and care planning within seven (7) calendar days of discharge from inpatient or
institutional care for physical or behavioral health disorders or discharge from a Substance Use
Disorder treatment program.
20.2 Transitional healthcare services by a home care nurse, a home care Mental Health
Professional or other Behavioral Health Professional shall be available within seven (7) calendar
days of discharge from inpatient or institutional care for physical or behavioral health care, if
ordered by the Member's PCP or as part of the discharge plan;
20.3 Preventive care office visits shall be available from the Member's PCP within
thirty (30) calendar days; available
20.4 Routine care office visits shall be available from the Member's PCP within ten
(10) calendar days, including behavioral health services from a behavioral health provider;
20.5 Urgent, symptomatic office visits shall be available from the Member's primary
care, behavioral health or another provider within twenty-four (24) hours,
20.6 Emergency medical care shall be available twenty-four (24) hours per day, seven
(7) days per week; and
2023—CSNegAgmt_SeffersonCounty Page 41 of 55 Contract #300090-232143
20.7 Second opinion appointments specifically described in the State Contract must
occur within thirty (30) calendar days of the request, unless the Member requests a postponement
of the second opinion to a date later than thirty (30) calendar days.
CHPW shall monitor Contractor's compliance with this Section. In the event Contractor fails to
comply with the applicable appointment wait time standards set forth in this Section, Contractor
shall comply with CHPW's procedures for corrective action. Nothing in this Section prohibits
Contractor from conducting assessments in alternate settings, such as the Member's home or
within an institutional setting.
21. 24/7Availability. To the extent applicable, Contractor shall make the following services
available twenty-four (24) hours per day, seven (7) days per week, three hundred sixty-five (365)
days a year by a toll -free telephone number:
21.1 Medical and behavioral health advice for Members from licensed health care
professionals;
21.2 Triage concerning the emergent, urgent or routine nature of medical and
behavioral health conditions by licensed health care professionals; and
21.3 The toll -free line staff must be able to make a warm handoff to the regional crisis
one.
22, Health Information Systems. Contractor shall maintain a health information system that
complies with the requirements of 42 C.F.R. § 43 8.242 and provides the information necessary
to meet CHPW's obligations under the State Contract. Contractor shall:
22.1 Collect, analyze, integrate, and report data. The system must provide information
on areas that include but are not limited to utilization, grievance and appeals, and terminations of
enrollment for other than loss of Medicaid eligibility; and
22.2 Ensure data provided to CHPW is accurate and complete by: (a) verifying the
accuracy and timeliness of reported data; (b) Screening the data for completeness, logic, and
consistency; and (c) Collecting service information on standardized formats to the extent feasible
and appropriate.
23. Release of Necessary Information. Contractor acknowledges and agrees to release to
CHPW any information necessary to perform any of CHPW's obligations under the State
Contract.
24. Encounter Data .Deporting. Contractor shall submit complete, accurate and timely
encounter data to CHPW in accordance with current encounter submission guidelines published
by HCA or as otherwise specified by CHPW. Contractor represents and warrants that it has the
capacity to submit all data required by HCA to enable CHPW to meet the reporting requirements
in the Encounter Data Reporting Guide published by HCA,
25. Behavioral Health Supplemental Transaction Deporting. If Contractor is a behavioral
health agency, Contractor shall submit complete, accurate and timely BHST data to CHPW or its
2023—CSNegAgmt—JeffersonCounty Page 42 of 55 Contract #300090-232143
designee in accordance with the current guidelines published by HCA or as otherwise specified
by CHPW. Contractor represents and warrants that is has the capacity to submit all data required
by HCA to enable CHPW to meet the reporting requirements in the Behavioral Health
Supplemental Transaction Data Guide published by HCA.
26, Clinical Data Repository. If Contractor utilizes a certified electronic health record system
(EHR), Contractor is required to submit automated exports of standard CCD/CODA, or
subsequent ONCWspecified standard healthcare transactions, from Contractor's EHR to HCA's
Clinical Data Repository (CDR) via the State Health Information Exchange (HIE), as specified
by HCA.
27. Credible Allegations of Fraud. Contractor shall refer credible allegations of fraud to
HCA and the Medicaid Fraud Control Unit as described in Subsection 12.6 of the State Contract,
or its successor.
28. Subrogation. Contractor agrees to subrogate to the State for all criminal, civil and
administrative action recoveries undertaken by any government entity, including, but not limited
to, all claims Contractor has or may have against any entity or individual that directly or
indirectly receives funds under the State Contract including, but not limited to, any Health Care
Provider, manufacturer, wholesale or retail supplier, sales representative, laboratory, or other
provider in the design, manufacture, marketing, pricing, or quality of drugs, pharmaceuticals,
medical supplies, medical devices, durable medical equipment, or other health care related
products or services. For the purposes of this Section, "subrogation" means the right of any State
government entity or local law enforcement to stand in the place of Contractor in the collection
against a third party.
29. Limitations on Referrals. Contractor referrals may be limited to Participating Providers
except in the following circumstances: (a) Emergency services; (b) Services provided outside the
Service Areas as necessary to provide Medically Necessary services; (c) when a Member has
other primary comparable physical and/or behavioral health coverage, as necessary to coordinate
benefits; and (d) Within the Service Areas, as defined in the Service Areas provisions of the
Enrollment Section of the State Contract, Contractor shall cover Members for all physical and/or
behavioral health necessary services.
30. High Categorical Risk Providers. Providers that are deemed to be "high categorical
risk," including prospective (newly enrolling) home health agencies and prospective (newly
enrolling) durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) suppliers
or such other categories of providers as defined under 42 C.F.R. § 424.518, shall be enrolled in
and screened by Medicare, in addition to complying with CHPW's policies and procedures
regarding credentialing and recredentialing. Such providers shall revalidate Medicare enrollment
every three (3) years in compliance with 42 C.F.R. § 424.515. Notwithstanding the foregoing,
Infant In -Home Phototherapy Providers that meet CHPW's certification requirements are not
required to be enrolled in Medicare.
31. HCA Approval for Assignment. Contractor acknowledges and agrees that no assignment
of the Agreement shall take effect without the prior written agreement of HCA.
2023—CSNegAgmt_JeffersonCounty Page 43 of 55 Contract #300090-232143
32. Quality Improvement System. Contractor shall maintain a quality improvement system
tailored to the nature and type of Covered Services provided hereunder, which affords quality
control for such services, including but not limited to the accessibility of Medically Necessary
services, and which provides for a free exchange of information with CHPW to assist CHPW in
complying with the requirements of the State Contract. Providers that are PCPs or specialty care
providers shall comply with all quality improvement activities of the CHPW.
33. .Records of Delegated Activities. As applicable to services rendered under the Agreement,
Contractor shall have a means to keep records necessary to adequately document services
provided to Members for any and all delegated activities including quality improvement,
utilization management, Member's rights and responsibilities, Health Homes, and credentialing
and re-credentialing.
34, Payment in .Full and Member Charges. Contractor agrees to accept payment from
CHPW as payment in full. Contractor shall not request payment from HCA or any Member for
Covered Services provided under the Agreement, and shall comply with WAC 182-502-01 60
requirements applicable to providers. Contractor shall report to CHPW any instance in which a
Member is charged for services. Contractor shall repay to a Member any inappropriate charges
paid by such Member, or shall reimburse CHPW to the extent CHPW repays such inappropriate
charges to the Member.
35. HCA and .Member Hold Harmless. Contractor agrees to hold harmless HCA and its
employees, and all Members in the event of non-payment by CHPW. Contractor further agrees
to indemnify and hold harmless HCA and its employees against (a) all injuries, deaths, losses,
damages, claims, suits, liabilities, judgments, costs and expenses which may in any manner
accrue against HCA or its employees through the intentional misconduct, negligence, or
omission of Contractor, its agents, officers, employees or contractors, and (b) any damages
related to Contractor's unauthorized use or release of Personal Information or PHI of Members.
35, Termination Provision. Either Party to this Exhibit may terminate this Exhibit upon
ninety (90) days advance written notice to the other Party. Notwithstanding the foregoing, in the
event that (a) Contractor is excluded from participation in the Medicaid program, CHPW may
immediately terminate the Agreement or this Exhibit upon written notice to Contractor, and may
immediately recover any payments for goods or services that benefit excluded individuals or
entities; or (b) HCA or Medicare has taken any action to revoke Contractor's privileges for
cause, and Contractor has exhausted all applicable appeal rights or the timeline for appeal has
expired. "For cause" may include but is not limited to reasons related to fraud, integrity or
quality.
37. Provider Appeal Rights. If Contractor provides physician services, Contractor may
exercise any appeal rights pursuant to Chapter 284-170 WAC to challenge CHPW's failure to
cover a service.
38. CHPW oversight and Corrective Action. Contractor acknowledges and agrees that
CHPW shall conduct ongoing monitoring and periodic formal review that is consistent with
applicable industry standards and the regulations of the Washington State Office of the Insurance
Commissioner, if any. Such formal review shall be completed no less than once every three (3)
years or more often if specified, and will identify any deficiencies or areas of improvement and
2023-CSNegAgmt_JeffersonCounty Page 44 of 55 Contract #300090-232143
provide for corrective action of any such deficiencies. Such review shall include an evaluation to
ensure that services furnished by Contractor to individuals with special health care needs are
appropriate to the Member's needs. Inadequate performance under the Agreement will be
subject to the revocation of delegation or imposition of sanctions in accordance with the dispute
resolution process detailed in the Agreement.
39., Member Self -Referral. Contractor acknowledges that Members have a right to self -refer
for:
39.1 Family planning services and supplies, and sexually -transmitted disease screening
and treatment services provided at participating or non -Participating Providers, including but not
limited to family planning agencies;
39.2 Immunizations, sexually -transmitted disease screening and follow-up,
immunodeficiency virus (HIV) screening, tuberculosis screening and follow-up, and family
planning services through and if provided by a local health department;
39.3 Immunizations, sexually transmitted disease screening, family planning and
behavioral health services through and if provided by a school -based health center;
39.4 All services received by American Indian or Alaska Native Members under the
Special Provisions for American Indians and Alaska Natives Subsection of the State Contract;
and
39.5 Crisis Response Services, including crisis intervention; crisis respite;
investigation and detention services; and, evaluation and treatment services. Self -referrals can
also be made for assessment and intake for behavioral health services.
40. Delegated Administrative Services Agreement. In the event that the Agreement delegates
administrative functions to Contractor, the Parties agree that they shall enter into a delegated
administrative services agreement that contains all provisions required pursuant to the State
Contract.
41, Confidential Member Information. Contractor shall beep information about Members,
including their medical records, confidential in a manner consistent with Applicable Law.
42. Member Rights. Contractor shall comply with any Applicable Law that pertain to
Members' rights and shall protect and promote those rights when furnishing services to
Members. Contractor shall guarantee each Member the rights set forth below. Each Member
must be free to exercise these rights and the exercise of these rights must not adversely affect the
way CHPW or Contractor treats the Member. These rights include:
42.1 To be treated with respect and with consideration for Member's dignity and
privacy;
42.2 To receive information on available treatment options and alternatives, presented
in a manner appropriate to the Member's ability to understand;
2023_CSNegAgmt_JeffersonCounty Page 45 of 55 Contract #300090-232143
42.3 To participate in decisions regarding Member's health care, including the right to
refuse treatment;
42.4 To be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience, or retaliation;
42.5 To request and receive a copy of their medical records, and to request that they be
amended or corrected in accordance with Applicable Law; and
42.6 To choose a behavioral Health Care Provider.
43. Background Checks. Contractor shall require a criminal history background check
through the Washington State Patrol for employees and volunteers of Contractor who may have
unsupervised access to children, people with developmental disabilities, or vulnerable adults.
Further, Contractor shall maintain related policies and procedures and personnel files consistent
with requirements in Chapter 43.43 RCW, Chapters 388-877 WAC and Chapter 388-06A WAC.
44, Cultural Considerations. If applicable, Contractor shall participate in and cooperate with
CHPW's efforts to promote the delivery of services in a culturally competent manner to all
Members, including those with limited English proficiency and diverse cultural and ethnic
backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity.
45. Member Set( -Determination. Contractor shall (a) obtain informed consent prior to
treatment from all Members, or from persons authorized to consent on behalf of Members as
described in RCW 7.70.065, (b) comply with the provisions of the Natural Death Act (Chapter
70.122 RCW) and Applicable Law and rules concerning advance directives and POLST (eg.,
WAC 182-501-0125 and 42 C.F.R. § 417.436), and (c) when appropriate, inform Members of
their right to make anatomical gifts pursuant to Chapter 68.64 RCW.
46. Advance Directives and POLST. Contractor shall ensure that whether a Member has
executed an advance directive or POLST shall be indicated in a prominent part of such
Member's medical records, and Contractor shall not provision care or otherwise discriminate
against a Member based on whether the Member has executed an advance directive or POLST.
47, Mental Health Advance Directives. Contractor shall comply with Chapter 71.32 RCW
(Mental Health Advance Directives).
48. Behavioral Health Services. If Contractor provides behavioral health services,
Contractor must use GAIN -SS and assessment process that includes use of the quadrant
placement. Failure to implement and maintain the Integrated Co-occurring Disorder Screening
and Assessment process will result in corrective action.
49. Behavioral Health Organization (BHO) Coordination. Contractor shall coordinate with
BHO providers in accordance with the State Contract and as required by CHPW.
50, Health Home Surety Bond. If Contractor is a home health agency, Contractor represents
and warrants that it is in compliance with the surety bond requirements of federal law (Section
4708(d) of the Balanced Budget Act of 1997 and 42 C.F.R. § 441.16).
2023—CSNegAgmt_JeffersonCounty Page 46 of 55 Contract #3 00090-232 1 43
51, Physician Incentive Plan. If Contractor is at financial risk, as defined in the Substantial
Financial Risk or Risk provisions in the State Contract, Contractor shall be subject to solvency
requirements that provide assurance of Contractor's ability to meet its obligations. Such
requirements shall be regularly monitored and enforced.
If Contractor makes payment to any physician under a Physician Incentive Plan, such plan shall
meet all applicable requirements under the State Contract, including but not limited to disclosure
requirements and stop -loss protection. No payment to Contractor, or by Contractor to a provider,
under a Physician Incentive Plan shall, directly or indirectly, be an inducement to reduce or limit
Medically Necessary Services provided to an individual Member.
52. Information on ownership and Control. Failure to comply with the terms of this
Section shall be deemed a material breach of the Agreement.
52.1 If Contractor is not an individual practitioner or a group of practitioners,
Contractor shall disclose the following information to CHPw upon Agreement execution, upon
request during the re -validation of enrollment process under 42 C.F.R. § 45 5.414, and within
thirty-five (35) business days after any change in ownership of Contractor:
52.1.1 The name and address of any person (individual or corporation) with an
ownership or control interest in Contractor;
52.1.2 If Contractor is a corporate entity, the primary business address, every
business location, and P.O. Box address;
52.1.3 If Contractor has corporate ownership, the tax identification number of the
corporate owner(s);
52.1.4 If Contractor is an individual, date of birth and Social Security Number;
52.1.5 If Contractor has a five percent (5%) ownership interest in any of its
subcontractors, the tax identification number of the subcontractor(s);
52.1.E whether any person with an ownership or control interest in Contractor is
related by marriage or blood as a spouse, parent, child, or sibling to any other person with an
ownership or control interest in Contractor;
52.1.7 If Contractor has a five percent (5%) ownership interest in any of its
subcontractors, whether any person with an ownership or control interest in such subcontractor is
related by marriage or blood as a spouse, parent, child, or sibling to any other person with an
ownership or control interest in Contractor, and
52.1.8 whether any person with an ownership or control interest in Contractor
also has an ownership or control interest in any other Medicaid provider, in the State's fiscal
provider or in any Managed Care entity.
52.2 Upon the request of CHPw or HCA, Contractor shall furnish to HCA, within
thirty-five (35) calendar days of a request, full and complete business transaction information as
follows:
2023—CSNegAgmt_JeffersonCounty Page 47 of 55 Contract #300090-232143
52.2.1 The ownership of any subcontractor with whom Contractor has had
business transactions totaling more than twenty-five thousand dollars ($25,000.00) during the
previous twelve (12) month period ending on the date of the request; and
52.2.2 Any significant business transaction between Contractor and any wholly
owned supplier or any subcontractor during the previous five (5) year period ending on the date
of the request.
Contractor shall provide any further information needed or reasonably requested by CHPW for
the purpose of satisfying CHPW's HCA reporting requirements under the State Contract, or for
the purpose of verifying or screening for exclusion from federal or state health care programs, or
for conviction of various criminal or civil offences, among the individuals or entities who have
an ownership or control interest in, or who are a managing employee of, Contractor.
52.3 Upon request, Contractor shall furnish to the Washington Secretary of State, the
Secretary of the US Department of Health and Human Services, the Inspector General of the US
Department of Health and Human Services, the Washington State Auditor, the Comptroller of
the Currency, and HCA a description of the transaction between Contractor and a party in
interest (as defined in Section 131 S (b) of the Public Health Service Act) within thirty-five (35)
calendar days of the request, including the following transactions:
52.3.1 Any sale or exchange, or leasing of any property between Contractor and
such a party;
52.3.2 Any furnishing for consideration of goods, services (including
management services), or facilities between Contractor and such a party but not including
salaries paid to employees for services provided in the normal course of their employment; and
52.3.3 Any lending of money or other extension of credit between Contractor and
such a party.
53. Information on Persons Convicted of Crimes. Contractor shall investigate and disclose
to CHPW, at Agreement execution or renewal, and upon request by CHPW of the identified
person who has been convicted of a criminal offense related to that person's involvement in any
program under Medicare, Medicaid, or the title xX services program since the inception of those
programs and who is:
53.1 A person who has an ownership or control interest in Contractor;
53.2 An agent or person who has been delegated the authority to obligate or act on
behalf of Contractor; and
53.3 An agent, managing employee, general manager, business manager,
administrator, director, or other individual who exercises operational or managerial control over,
or who directly or indirectly conducts the day-to-day operation of, Contractor.
54. Maternity Newborn Length of Stay; ►Sterilizations and .Hysterectomies. All hospital
delivery maternity care provided under the Agreement shall be in accord with RCW 48.43.115.
2023_CSNegAgmt_JeffersonCounty Page 48 of 55 Contract #300090-232143
All sterilizations and hysterectomies provided under the Agreement shall be in compliance with
42 C.F.R. § 441 Subpart F, and Contractor shall use a Consent for Sterilization form (HHS-687)
or its equivalent in connection therewith. A hysterectomy requires the Hysterectomy Consent
and Patient Information form (HCA 13-365).
55, Grievance and Appeals. CHPW shall maintain a grievance and appeals system in
accordance with the requirements of the State Contract, and CHPw shall provide the following
information regarding CHPw's grievance and appeal system to Contractor:
55.1 The toll -free numbers to file oral grievances and appeals;
55.2 The availability of assistance in filing a grievance or appeal, including informing
the Member about ombuds services and how to access those services,
55.3 The Member's right to request continuation of Medicaid benefits during an appeal
or hearing and, if the CHPw's Adverse Benefit Determination is upheld, that the Member may
be responsible to pay for the continued benefits;
55.4 The Member's right to file grievances and appeals and their requirements and
timeframes for filing;
55.5 The Member's right to a hearing, how to obtain a hearing and representation rules
at a hearing; and
55.6 Contractor may file a grievance or request an adjudicative proceeding on behalf of
a Member in accordance with the State Contract.
2023_CSNegAgmt_ieffersonCounty Page 49 of 55 Contract #300090-232143
EXHIBIT B-2-A
MEDICARE ADVANTAGE
REIMBURSEMENT RATES
1e Rates. Subject to the terms of the Agreement, reimbursement rates for Covered
Services billed under Facility's tax ID number for the Medicare Advantage benefit
plans listed below shall be the lesser of billed charges or the following and will be less
any applicable Cost Sharing Amounts:
As CHPW Medicare Advantage and Medicare .Advantage Prescription Drug Plans
Network Name: CHPW MA Network
NIA of Medicare Fee Schedule.
Be CHPW Medicare Advantage Special Needs Plan
Network Name: CHPW SNP Network
NIA of Medicare Fee Schedule.
2e Pa3ment. This Exhibit B-2-A reflects the CMS "Medicare Advantage" rates.2 CHPW
will adjust payments to Facility consistent with any adjustment that CMS applies to
CHPW as a Medicare Advantage Organization. All payments under this Agreement
shall be made in accordance with the terms of this Agreement, the Provider .Manual
and the applicable billing instructions and policy guidelines published and periodically
updated by applicable state and federal agencies as set forth in Section 4 of the
Agreement.
Effective Date:
(CHPW TO COMPLETE)
1 Medicare Managed Care GME, iME, and Allied Health payments are paid through the Medicare cost reporting process, and are
therefore excluded from these referred payment rates. In addition, Sole Community Hospitals (SCH) and Medicare Dependent
Hospitals (MDH) receive a supplemental payment if their inflated and case mix adjusted base -year cost, referred to as their
Hospital Specific Rate (HSR) exceed the Medicare Operating MSDRG and Outlier payments under traditional Medicare Part A
fee for service. SCH and MDH special payment adjustments are excluded from these referred payment rates.
2023_CSNegComp—JeffersonCounty Page 50 of 55 Contract #300090-232143
EXHIBIT B-3-A
CHPw HEALTH BENEFIT EXCHANGE
REIMBURSEMENT RATES
1. Rates. Subject to the terms of the Agreement, reimbursement rates for Covered
Services billed under Facility's federal tax ID number for the Third -Party Benefit
Plans listed below shall be the lesser of billed charges or the following, and will be
less any applicable Cost Sharing Amounts.
A. CHPW -Affiliated `Cascade Care" Public Option Plans:
Network Name: C]H[Pw Cascade Care Affiliate Network
120% of HCA's Fee Schedule for all Covered Services described
therein; and
NLof HCA's Fee Schedule for all Covered Services for which
no Medicare fee exists
2. Payments CHPw will adjust payments to Provider consistent with adjustments that
CMS and/or HCA applies to their respective fee schedule(s).' All payments under
this Agreement shall be made in accordance with the terms of this Agreement, the
Provider Manual and the applicable billing instructions and policy guidelines
published and periodically updated by applicable state and federal agencies as set
forth in Section 4 of the Agreement.
Effective Date:
(CHPW TO COMPLETE)
Medicare Managed Care GME, IME, and Allied Health payments are paid through the Medicare cost reporting process, and are
therefore excluded from these referred payment rates. In addition, Sole Community Hospitals (SCH) and Medicare Dependent
Hospitals (MDH) receive a supplemental payment if their inflated and case mix adjusted base -year cost, referred to as their
Hospital Specific Rate (HSR) exceed the Medicare Operating MSDRG and Outlier payments under traditional Medicare Part A
fee for service. SCH and MDH special payment adjustments are excluded from these referred payment rates.
2023_CSNegComp_JeffersonCounty Page 51 of 55 Contract #300090-232143
EXHIBIT B-4-A
THIRD PARTY HEALTH BENEFIT EXCHANGE
REIMBURSEMENT RATES
1. Rates. Subject to the terms of the Agreement, reimbursement rates for Covered
Services billed under Provider's federal tax III number for the Third -Party Benefit
Plans listed below shall be the lesser of billed charges or the following, and will be less
any applicable Cost Sharing Amounts.
A. CHPW Affiliated "Cascade are" Public Option Plans
Network Name: CHPw Cascade Care Affiliate Network
120% of HCA's Fee Schedule for all Covered Services described therein;
and
NIA of HCA's Fee Schedule for all Covered Services for which no
Medicare fee exists.
B. Non -Affiliated `Cascade Care" Public Option Plans:
Network Name: CHPw Cascade Care Non -Affiliate Network
120% of HCA's Fee Schedule for all Covered Services described therein;
and
NIA of HCA's Fee Schedule for all Covered Services for which no
Medicare fee exists.
2. Payment:
A. CHPw will adjust payments to Provider consistent with adjustments that CMS
and/or HCA applies to their respective fee schedule(s). 1 CHPw will pay, or
require the applicable third party plan sponsor to pay, Provider for Covered
Services rendered to Members in accordance with the terms of this .Agreement,
the Provider Manual, the applicableBenefit Plan, and billing instructions and
policy guidelines published and periodically updated by applicable state and
federal agencies.
B. Provider shall seek and accept payment from CHPw, or the applicable plan
sponsor,for Covered Services in accordance with the terms of this Agreement, the
ProviderManual, the applicable Benefit Plan, and billing instructions and policy
guidelinespublished and periodically updated by applicable state and federal
agencies. Provider shall have the right to bill, charge, or collect a deposit directly
from. a Member for any applicable deductible, co -payment, or coinsurance, or for
2023_CSNegComp_JeffersonCounty Page 52 of 55 Contract #300090-232143
any services that is not a Covered Service. In no event may Provider bill or collect
from a Member any difference between Provider's charges and the amount
described in this Exhibit Bm4-A for Covered Services
Effective Date:
(CHPW TO COMPLETE)
1 Medicare Managed Care GME, IME, and Allied Health payments are paid through the Medicare cost reporting process,
and aretherefore excluded from these referred payment rates. In addition, Sole Community Hospitals (SCH) and Medicare
Dependent Hospitals (MDH) receive a supplemental payment if their inflated and case mix adjusted base -year cost,
referred to as their Hospital Specific Rate (HSR) exceed the Medicare Operating MSDRG and Outlier payments under
traditional Medicare Part A fee for service. SCH and MDH special payment adjustments are excluded from these referred
payment rates.
2023—CSNegComp_JeffersonCounty Page 53 of 55 Contract #300090-232143
EXHIBIT D
ACKNOWLEDGEMENT OF REVIEw OF PROVIDER MANUAL
Contractor hereby acknowledges review of CHPw's Provider .Manual and acknowledges that the
Provider .Manual was made available to Contractor for review prior to Contractor's decision to
enter into this Agreement. The Provider Manual is available at CHPW's website at
www.CHPW.org.
Effective Date:
_. { dew.. M.. -, •�
Date of Review:
Initials of Contractor's Authorized Representative:
(CHPW TO COMPLETE)
2023—CSNegAgmt—JeffersonCounty Page 54 of 55 Contract 4300090-232143
EXHIBIT E
CONTRACT REPRESENTATIVES AND CONTACT INFORMATION
Jefferson County DBA Jefferson County Public Health
Contact Name
Glenn Gilbert
Contact Title
Public Health Assistant
Mailing Address 1
615 Sheridan Street
Mailing Address 2
City
Port Townsend State WA Zip
98368
Phone
360-385-9421 Fax
Email
ggilbert ageo.jefferson.wa.us
COMMUNITY HEALTH PLAN of WASHINGTON (CHPW)
ATTN: Provider Contracting Department
Mailing Address
1111 Third Avenue, Suite 400
City
Seattle State WA Zip
98101-3292
Email
Provider. Contra41C1-4PW_ 0r
ATTN: Provider Relations Department
Mailing Address
1111 Third Avenue, Suite 400
City
Seattle State WA. Zip
98101-3292
Phone
(206) 521-8833 Fax (206) 613
- 5018
Email
Provider. Relatiops C CHPW.org
---------
ATTN: Contract Administrator
Name
Rhonda Edminster
Mailing Address
1111 Third Avenue, Suite 400
City
Seattle I State WA Zip
98101-3292
Phone
(206) 515 -7994 Fax (206) 613
- 5 018
Email
Rhonda.Edminster@chpw.org
2023_CSNegAgmt_JeffersonCounty Page 55 of 55 Contract #300090-232143