HomeMy WebLinkAboutCoordinated Care Corp 615 Sheridan Street
Port Townsend, WA 98368
69efehson www.JeffersonCountyPublicHealth.org
ePunbi Consent Agenda
Public Health
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: j\J 4'v v\ b 'r 2v2. `-1
SUBJECT: Agenda item — Provider Agreement for covered services with Coordinated Care
Corporation ("CCC") and Coordinated Care of Washington; effective date — until
terminated; fee for service
STATEMENT OF ISSUE:
Jefferson County Public Health (JCPH), Community Health Division, requests Board approval of the Provider
Agreement with CCC and Coordinated Care of Washington to provide health care service; effective date —
until terminated; fee for service
ANALYSIS/STRATEGIC GOALS/PROS and CONS:
CCC 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 CCC and collect for clinic services provided to WA Medicaid eligible
clients who have chosen CCC as their managed care organization. By participating in CCC'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.
RECOMMENDATION:
JCPH management requests approval of Provider Agreement with CCC to provide health care service;
effective date — until terminated; fee for service
REVIEWED BY:
Mark McCauley, ounty Administrator . Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 (f) 360-379-4487
360-385-9401 (f) Always working for a safer and healthier community
N-24-045
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: Coordinated Care Corporation Contract No: N-24-045
Contract For: Provider Agreement Term: Effective Date - until terminated
COUNTY DEPARTMENT: Public Health
Contact Person: Veronica Shaw
Contact Phone: x 409
Contact email: veronica@co.jefferson.wa.us
AMOUNT: fee for service PROCESS: ✓ Exempt from Bid Process
Revenue: Cooperative Purchase
Expenditure: Competitive Sealed Bid
Matching Funds Required: Small Works Roster
Sources(s) of Matching Funds Vendor List Bid
Fund # 127 RFP or RFQ
Munis Org/Obj 12756220 Other:
APPROVAL STEPS:
STEP 1: DEPARTMENT CERTIFIES COMP CE W ; .55.080 AND CHAPTER 42.23 RCW.
CERTIFIED: ■ N/A: ���y Sept. 23, 2024
tgnatut e Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEE DEBA ED 13- ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: 11 N/A: Sept. 23, 2024
Signature Date
STEP 3: RISK MANAGEMENT REVIEW(will be added electronically through Laserfiche):
Electronically approved by Risk Management on 11/21/2024.
Understand the marital communities issue however I believe it is a low risk
shortcoming.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through Laserfiche):
Electronically approved as to form by PAO on 11/8/2024.
Indemnity section missing "marital communities" language. PAO worked
with PH to negotiate this into the contract but contractor refused. Risk
Management decision whether to accept the risk.
STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY(IF REQUIRED).
STEP 6: CONTRACTOR SIGNS
STEP 7: SUBMIT TO BOCC FOR APPROVAL
1
PARTICIPATING PROVIDER AGREEMENT
This Participating Provider Agreement(together with all Attachments and amendments,this "Agreement")
is made and entered by and between Jefferson County Public Health("Provider"), Coordinated Care Corporation, a
health maintenance organization ("CCC')and Coordinated Care of Washington, Inc. ("CCW') (each a"Party" and
collectively the"Parties"). This Agreement is effective as of the date designated by Health Plan(as defined herein)
on the signature page of this Agreement("Effective Date").
WHEREAS,Provider desires to provide certain health care services to individuals in products offered by or
available from or through a Company or Payor (as hereafter defined), and Provider desires to participate in such
products as a Participating Provider(as defined herein), all as hereinafter set forth.
WHEREAS, Health Plan desires for Provider to provide such health care services to individuals in such
products,and Health Plan desires to have Provider participate in certain of such products as a Participating Provider,
all as hereinafter set forth.
NOW, THEREFORE, in consideration of the recitals and mutual promises herein stated, the Parties hereby
agree to the provisions set forth below.
ARTICLE I-DEFINITIONS
When appearing with initial capital letters in this Agreement(including an Attachment),the following quoted
and underlined terms (and the plural thereof, when appropriate) have the meanings set forth below. Citations to the
Revised Code of Washington (RCW) and other governmental authority requirements are provided herein for
convenience only and shall not affect the meaning or interpretation of the terms of the Agreement. Such citations
may become outdated as these requirements are amended from time to time.
1.1. "Affiliate" means a person or entity directly or indirectly controlling, controlled by, or under
common control with Health Plan.
1.2. "Attachment" means any document, including an addendum, schedule or exhibit, attached to this
Agreement as of the Effective Date or that becomes attached pursuant to Section 2.2 or Section 8.7, all of which are
incorporated herein by reference and may be amended from time to time as provided in this Agreement.
1.3. "Clean Claim" means a claim for payment that has no defect or impropriety, including any lack of
any required substantiating documentation, or particular circumstances requiring special treatment that prevents
timely payments from being made on the claim.
1.4. "Company" means (collectively or individually, as appropriate in the context) Health Plan and its
Affiliates, except those specifically excluded by Health Plan.
1.5. "Compensation Schedule"means at any given time the then effective schedule(s)of maximum rates
applicable to a particular Product under which Provider and Contracted Providers will be compensated for the
provision of Covered Services to Covered Persons. Such Compensation Schedule(s)will be set forth or described in
one or more Attachments to this Agreement, and may be included within a Product Attachment.
1.6. "Contracted Provider"means a physician,hospital,health care professional or any other provider of
items or services that is employed by or has a contractual relationship with Provider and that provides Covered
Services. The term "Contracted Provider" includes Provider for those Covered Services provided by Provider.
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N-24-045
1.7. "Coverage Agreement" means any agreement, program or certificate entered into, issued or agreed
to by Company or Payor, under which Company or Payor furnishes administrative services or other services in
support of a health care program for an individual or group of individuals, and which may include access to one or
more of Company's provider networks or vendor arrangements, except those excluded by Health Plan.
1.8. "Covered Person" means any individual entitled to receive Covered Services pursuant to the terms
of a Coverage Agreement.
1.9. "Covered Services" means those services and items for which benefits are available and payable
under the applicable Coverage Agreement and which are determined, if applicable,to be Medically Necessary under
the applicable Coverage Agreement.
1.10. "Health Plan"means either CCC or CCW with respect to each Product covered by this Agreement,
as specified in accordance with Schedule B to this Agreement or the applicable Product Attachment.
1.11. "Medically Necessary" or "Medical Necessity" shall have the meaning defined in the applicable
Coverage Agreement and applicable Regulatory Requirements.
1.12. "Participating Provider" means, with respect to a particular Product, any physician, hospital,
ancillary,or other health care provider that has contracted,directly or indirectly,with Health Plan to provide Covered
Services to Covered Persons, that has been approved for participation by Company, and that is designated by
Company as a"participating provider"in such Product.
1.13. "Payor" means the entity (including Company where applicable) that bears direct financial
responsibility for paying from its own funds,without reimbursement from another entity,the cost of Covered Services
rendered to Covered Persons under a Coverage Agreement and, if such entity is not Company, such entity contracts,
directly or indirectly,with Company for the provision of certain administrative or other services with respect to such
Coverage Agreement.
1.14. "Payor Contract" means the contract with a Payor, pursuant to which Company furnishes
administrative services or other services in support of the Coverage Agreements entered into, issued or agreed to by
a Payor,which services may include access to one or more of Company's provider networks or vendor arrangements,
except those excluded by Health Plan. The term "Payor Contract" includes Company's or other Payor's contract
with a governmental authority(also referred to herein as a"Governmental Contract")under which Company or Payor
arranges for the provision of Covered Services to Covered Persons.
1.15. "Product" means any program or health benefit arrangement designated as a "product" by Health
Plan(e.g.,Health Plan Product,Medicaid Product,PPO Product,Payor-specific Product,etc.)that is now or hereafter
offered by or available from or through Company(and includes the Coverage Agreements that access, or are issued
or entered into in connection with such product, except those excluded by Health Plan).
1.16. "Product Attachment"means an Attachment setting forth requirements,terms and conditions specific
or applicable to one or more Products, including certain provisions that must be included in a provider agreement
under the Regulatory Requirements, which may be alternatives to, or in addition to, the requirements, terms and
conditions set forth in this Agreement.
1.17. "Regulatory Requirements" means all applicable federal and state statutes, regulations, regulatory
guidance,judicial or administrative rulings,requirements of Governmental Contracts and standards and requirements
of any accrediting or certifying organization, including, but not limited to, the requirements set forth in a Product
Attachment.
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1.18. "State" is defined as the State of Washington.
ARTICLE II-PRODUCTS AND SERVICES
2.1. Contracted Providers. Provider shall, and shall cause each Contracted Provider to comply,with and
abide by the agreements, representations,warranties, acknowledgements, certifications,terms and conditions of this
Agreement (including the provisions of Schedule A that are applicable to Provider, a Contracted Provider, or their
services,and any other Attachments)and fulfill all of the duties,responsibilities and obligations imposed on Provider
and Contracted Providers under this Agreement(including each Attachment).
2.2. Products and Attachments. Subject to the other provisions of this Agreement, Provider and each
Contracted Provider is subject to and bound by all Attachments designated on Schedule B of this Agreement, and
may be identified as a Participating Provider in each Product identified in a Product Attachment designated on
Schedule B of this Agreement.
2.2.1. Provider shall,at all times during the term of this Agreement,require each of its Contracted
Providers to, subject to Company's approval, participate as Participating Providers in each Product identified in a
Product Attachment that is designated on Schedule B of this Agreement or added to this Agreement in accordance
with Section 2.2 hereof.
2.2.2. A Contracted Provider may only identify itself as a Participating Provider for those Products
in which the Contracted Provider actually participates as provided in this Agreement. Provider acknowledges that
Company or Payor may have,develop or contract to develop various Products or provider networks that have a variety
of provider panels, program components and other requirements.No Company or Payor warrants or guarantees that
any Contracted Provider: (i)will participate in all or a minimum number of provider panels, (ii)will be utilized by a
minimum number of Covered Persons, or (iii) will indefinitely remain a Participating Provider or member of the
provider panel for a particular network or Product.
2.2.3. Provider shall provide Health Plan with the information listed on Schedule C entitled
"Information for Contracted Providers" for itself and the Contracted Providers as of the Effective Date. Provider
shall provide Health Plan, from time to time or on a periodic basis as requested by Health Plan,with a complete and
accurate list of Information for Contracted Providers and such other information as mutually agreed upon by the
Parties, and shall provide Health Plan with a list of modifications to such list at least 30 days prior to the effective
date of such changes, when possible. Provider shall provide such lists in a manner and format mutually acceptable
to the Parties.
2.2.4. Provider may add new providers to this Agreement as Contracted Providers. In such case,
Provider shall provide written notice to Health Plan of the prospective addition(s)and shall use best efforts to provide
such notice at least 60 days in advance of such addition. Provider shall maintain written agreements with each of its
Contracted Providers(other than Provider)that require Contracted Providers to comply with the terms and conditions
of this Agreement and that address and comply with the Regulatory Requirements.
2.2.5. If Company desires to add an additional Product, Company or Payor, as applicable, will
provide at least 60 days' prior written notice (electronic or paper) thereof to Provider, along with the applicable
Product Attachment and the new Compensation Schedule, if any. Contracted Providers will not be designated as
Participating Providers in such additional Product until Provider agrees to participate in such additional Product by
giving Company or Payor, as applicable, written notice of its decision to participate in accordance with the process
specified in the notice to Provider. If Provider gives timely notice of agreement to participate in an additional Product,
then each Contracted Provider shall be a Participating Provider in such additional Product on the terms and conditions
set forth in this Agreement and the applicable Product Attachment.
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2.3. Covered Services.Each Contracted Provider shall provide Covered Services described or referenced
in the applicable Product Attachment(s)to Covered Persons in those Products in which the Contracted Provider is a
Participating Provider in accordance with this Agreement. Each Contracted Provider shall provide Covered Services
to Covered Persons with the same degree of care and skill as customarily provided to patients who are not Covered
Persons, within the scope of the Contracted Provider's license and in accordance with generally accepted standards
of the Contracted Provider's practice and business and in accordance with the provisions of this Agreement and
Regulatory Requirements.
2.4. Policies and Procedures. Provider warrants that Provider and Contracted Providers shall at all times
cooperate and comply with applicable administrative requirements, policies, programs and procedures of Company
and Payor, which may include, but are not limited to, the following: credentialing criteria and requirements;
confidentiality and notification requirements;medical management programs; claims and billing,quality assessment
and improvement, utilization review and management, disease management, case management, on-site reviews,
referral and prior authorization,and grievance and appeal procedures;coordination of benefits and third party liability
policies; carve-out and third party vendor programs; and data reporting requirements. The failure to comply with
such policies and procedures could result in a denial or reduction of payment to the Provider or Contracted Provider
or a denial or reduction of the Covered Person's benefits. Such policies and procedures do not in any way affect or
remove the obligation of Contracted Providers to render care. Health Plan shall make the applicable policies available
to Provider and Contracted Providers prior to contracting and throughout the term of the Agreement upon reasonable
request via one or more designated websites or alternative means. Company shall notify Provider at least 60 days in
advance of changes in administrative policies and procedures that affect Provider's compensation or health care
service delivery unless changes to federal or State law or regulations make such advance notice impossible, in which
case notice will be provided as soon as possible. Such notice may be given by Health Plan through an update to
information available to Provider online, or any other written method (electronic or paper). Provider shall notify
Contracted Providers of such changes.
2.5. Credentialing Criteria. Provider and each Contracted Provider shall complete Company's and/or
Payor's credentialing and/or recredentialing process as required by Company's and/or Payor's credentialing policies,
and shall at all times during the term of this Agreement meet all of Company's and/or Payor's credentialing criteria.
Provider and each Contracted Provider represents, warrants and agrees: (a)that it is currently, and for the duration
of this Agreement shall remain: (i) in compliance with all applicable Regulatory Requirements, including licensing
laws; (ii) if applicable, accredited by The Joint Commission or the American Osteopathic Association; and (iii) a
Medicare-certified provider under the federal Medicare program and a Medicaid participating provider under
applicable federal and State laws;and(b)that all Contracted Providers and all employees and contractors thereof will
perform their duties in accordance with all Regulatory Requirements, as well as applicable national, State and local
standards of professional ethics and practice. No Contracted Provider shall provide Covered Services to Covered
Persons or identify itself as a Participating Provider unless and until the Contracted Provider has been notified, in
writing,by Company that such Contracted Provider has successfully completed Company's credentialing process.
2.6. Eligibility Determinations. Provider or Contracted Provider shall timely verify whether an individual
seeking Covered Services is a Covered Person. Company or Payor, as applicable, will make available to Provider
and Contracted Providers a method whereby Provider and Contracted Providers can obtain, in a timely manner,
general information about eligibility and coverage. Company or Payor,as applicable,does not guarantee that persons
identified as Covered Persons are eligible for benefits or that all services or supplies are Covered Services. If
Company, Payor or its delegate determines that an individual was not a Covered Person at the time services were
rendered, such services shall not be eligible for payment under this Agreement, except to the extent such services
were expressly authorized by Company or Payor. For retrospective review, eligibility determinations will be made
solely on the medical information available to the Contracted Provider at the time the health service was provided.
Such retrospective review will be completed within 30 calendar days of receipt of the necessary information. In
addition,Company will use reasonable efforts to include or contractually require Payors to clearly display Company's
PPA WA-Jefferson County Public Health-08.23.2024-ICMProviderAgreement_334499 Page 4 of 27
name, logo or mailing address(or other identifier(s)designated from time to time by Company) on each membership
card.
2.7. Referral and Preauthorization Procedures. Provider and Contracted Providers shall comply with
referral and preauthorization procedures adopted by Company and/or Payor, as applicable, prior to referring a
Covered Person to any individual, institutional or ancillary health care provider. Unless otherwise expressly
authorized in writing by Company or Payor, Provider and Contracted Providers shall refer Covered Persons only to
Participating Providers to provide the Covered Service for which the Covered Person is referred. Except as required
by applicable law, failure of Provider and Contracted Providers to follow such procedures may result in denial of
payment for unauthorized treatment. Preauthorization is not required prior to provision of Covered Services in the
event of an emergency.
2.7.1. Prior Authorization: In accordance with RCW 48.43.016(2)(a), the Agreement does not
require utilization management or review of any kind for an initial evaluation and management visit, and up to six
treatment visits with a Contracted Provider in a new episode of care for each of the following:
• Chiropractic
• Physical therapy
• Occupational therapy
• Acupuncture and Eastern medicine
• Massage therapy
• Speech therapy
Visits where utilization management or review is prohibited are still subject to quantitative treatment limits
of the Health Plan. With the exception of RCW 48.43.515(5), the Health Plan can require a referral or prescription
for the therapists listed.
For visits where utilization management or review is prohibited,Health Plan will not deny or limit coverage
on the basis of medical necessity or appropriateness; or retroactively deny care or refuse payment for the visits in
accordance with RCW 48.43.016(2)(b).
2.7.2. Telemedicine Payment Parity. In accordance with RCW 48.43.735, providers for
telemedicine services shall be compensated at the same rate(to be defined by the Legislature)as in-person services.
Provider can negotiate a telemedicine reimbursement rate that differs from in-person services for:
• hospitals,
• hospital systems,
• telemedicine companies, and
• provider groups consisting of 11 or more providers.
Provider can negotiate payment of facility fees for telemedicine services that originate at:
• a hospital,
• a rural health clinic,
• a federally qualified health center(FQHC),
• a physician/health care provider's office,
• community mental health center, skilled nursing facility, or
• a renal dialysis center(except an internal renal dialysis center).
PPA WA-Jefferson County Public Health-08.23.2024-ICMProviderAgreement_334499 Page 5 of 27
Any other site may not charge a facility fee. Health Plan shall not distinguish between originating sites that are
rural and urban when providing coverage. Health Plan is not required to reimburse:
• an originating site for professional fees,
• services not covered under the plan, or
• an originating site or provider that is not contracted under the plan.
Audio-Only Telemedicine: In accordance with RCW 48.43.735(1)(a)(v) and WAC 284-170-433(1)(b), the
covered person must have an established relationship with the provider.
Pursuant to RCW 48.43.735(9)(d)(i)-(ii)"Established relationship"means the provider providing audio-only
telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services, and: (i)
for health care services included in the essential health benefits category of mental health and substance use disorder
services, including behavioral health treatment: (A)The Covered Person has had,within the past three years,at least
one in-person appointment, or at least one real-time interactive appointment using both audio and video technology,
with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the
same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46
RCW as the provider providing audio-only telemedicine; or (B) The Covered Person was referred to the provider
providing audio-only telemedicine by another provider who has had,within the past three years,at least one in-person
appointment, or at least one real-time interactive appointment using both audio and video technology, with the
Covered Person and has provided relevant medical information to the provider providing audio-only telemedicine;
(ii) For any other health care service: (A) The Covered Person has had, within the past two years, at least one in-
person appointment, or, until January 1, 2024, at least one real-time interactive appointment using both audio and
video technology, with the provider providing audio-only telemedicine or with a provider employed at the same
medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under
chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or (B) The Covered Person was
referred to the provider providing audio-only telemedicine by another provider who has had, within the past two
years, at least one in-person appointment, or, until January 1, 2024, at least one real-time interactive appointment
using both audio and video technology, with the covered person and has provided relevant medical information to
the provider providing audio-only telemedicine.
2.8. Treatment Decisions. No Company or Payor is liable for,nor will it exercise control over,the manner
or method by which a Contracted Provider provides items or services under this Agreement. Provider and Contracted
Providers understand that determinations of Company or Payor that certain items or services are not Covered Services
or have not been provided or billed in accordance with the requirements of this Agreement are administrative
decisions only. Such decisions do not absolve the Contracted Provider of its responsibility to exercise independent
judgment in treatment decisions relating to Covered Persons. Nothing in this Agreement(i) is intended to interfere
with Contracted Provider's relationship with Covered Persons,or(ii)prohibits or restricts a Contracted Provider from
disclosing to any Covered Person any information that the Contracted Provider deems appropriate regarding health
care quality, medical treatment decisions or alternatives.
2.8.1. Withdrawal Management Services: In accordance with RCW 48.43.761 and WAC 284-43-
2000, the Agreement may not specify timeframes for substance abuse disorder treatment less than what is specified
in RCW 48.43.761(12(a)(i), nor specify timeframes for withdrawal management services less than what is specified
in RCW 48.43.761(2)(a)(ii), nor contain language that prevents a seamless transfer to an appropriate level of care.
2.9. Drug Utilization Management Exceptions. Provider drug utilization management exceptions are
available on the Health Plan website: www.coordinatedcarehealth.com.
2.10. Carve-Out Vendors. Provider acknowledges that Company may,during the term of this Agreement,
carve-out certain Covered Services from its general provider contracts, including this Agreement, for one or more
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Products as Company deems necessary or appropriate. Provider and Contracted Providers shall cooperate with and,
when medically appropriate, utilize all third party vendors designated by Company for those Covered Services
identified by Company from time to time for a particular Product.
2.11. Disparagement Prohibition. Provider, each Contracted Provider and the officers of Company shall
not disparage the other during the term of this Agreement or in connection with any expiration, termination or non-
renewal of this Agreement. Neither Provider nor Contracted Provider shall interfere with Company's direct or
indirect contractual relationships including, but not limited to, those with Covered Persons or other Participating
Providers. Nothing in this Agreement should be construed as limiting the ability of Health Plan, Company,Provider
or a Contracted Provider to inform Covered Persons that this Agreement has been terminated or otherwise expired
or, with respect to Provider, to promote Provider to the general public, or to limit Contracted Providers from
participating in discussions with a patient or someone paying for their coverage regarding the comparative merits of
different health carriers, even if critical of a carrier, or to post information regarding other health plans consistent
with Provider's usual procedures,provided that no such promotion or advertisement is specifically directed at one or
more Covered Persons. In addition, nothing in this provision should be construed as limiting Company's ability to
use and disclose information and data obtained from or about Provider or Contracted Provider, including this
Agreement,to the extent determined reasonably necessary or appropriate by Company in connection with its efforts
to comply with Regulatory Requirements and to communicate with regulatory authorities.
2.12. Nondiscrimination. Provider and each Contracted Provider will provide Covered Services to
Covered Persons without discrimination on account of race, sex, sexual orientation, age, color, religion, national
origin,place of residence,health status,type of Payor,source of payment(e.g.,Medicaid generally or a State-specific
health care program), physical or mental disability or veteran status, and will ensure that its facilities are accessible
as required by Title III of the Americans With Disabilities Act of 1991. This requirement does not require a
Contracted Provider to render services that are not appropriate for the provider to render due to limitations arising
from lack of training, experience, skill, or licensing restrictions. Provider and Contracted Providers recognize that,
as a governmental contractor, Company or Payor may be subject to various federal laws, executive orders and
regulations regarding equal opportunity and affirmative action,which also may be applicable to subcontractors, and
Provider and each Contracted Provider agree to comply with such requirements as described in any applicable
Attachment.
2.13. Notice of Certain Events. Provider shall give written notice to Health Plan of: (i)any event of which
notice must be given to a licensing or accreditation agency or board; (ii) any change in the status of Provider's or a
Contracted Provider's license; (iii) termination, suspension, exclusion or voluntary withdrawal of Provider or a
Contracted Provider from any state or federal health care program, including but not limited to Medicaid; or(iv)any
settlements or judgments in connection with a lawsuit or claim filed or asserted against Provider or a Contracted
Provider alleging professional malpractice involving a Covered Person. In any instance described in subsection (i)-
(iii) above, Provider must notify Health Plan or Payor in writing within 10 days, and in any instance described in
subsection (iv) above, Provider must notify Health Plan or Payor in writing within 30 days, from the date it first
obtains knowledge of the pending of the same.
2.14. Use of Name. Provider and each Contracted Provider hereby authorizes each Company or Payor to
use their respective names,telephone numbers,addresses, specialties, certifications,hospital affiliations(if any),and
other descriptive characteristics of their facilities,practices and services for the purpose of identifying the Contracted
Providers as "Participating Providers" in the applicable Products. Provider and Contracted Providers may only use
the name of the applicable Company or Payor for purposes of identifying the Products in which they participate, and
may not use the registered trademark or service mark of Company or Payor without prior written consent.
2.15. Compliance with Regulatory Requirements. Provider,each Contracted Provider and Company agree
to carry out their respective obligations under this Agreement in accordance with all applicable Regulatory
Requirements,including,but not limited to,Chapter 284-43-0140 of the Washington Administrative Code,the Health
PPA WA-Jefferson County Public Health-08.23.2024-ICMProviderAgreement_334499 Page 7 of 27
Insurance Portability and Accountability Act, the Health Information Technology for Economic and Clinical Health
(HITECH) Act, and federal drug and alcohol confidentiality laws in 42 C.F.R. Part 2, each as amended, including
any regulations promulgated thereunder. If, due to Provider's or Contracted Provider's noncompliance with
applicable Regulatory Requirements or this Agreement, sanctions or penalties are imposed on Company, Company
may, in its sole discretion, offset such amounts against any amounts due Provider or Contracted Providers from any
Company or require Provider or the Contracted Provider to reimburse Company for such amounts. If Provider
subcontracts any services under this Agreement,then Provider is responsible for ensuring that its written agreements
with such subcontractors contain all applicable Regulatory Requirements and that its subcontractors comply with
such requirements.
2.16. Program Integrity Required Disclosures. Provider agrees to furnish to Health Plan complete and
accurate information necessary to permit Health Plan to comply with the collection of disclosures requirements
specified in 42 C.F.R. Part 455 Subpart B or any other applicable State or federal requirements, within such time
period as is necessary to permit Health Plan to comply with such requirements. Such requirements include but are
not limited to: (i)42 C.F.R. §455.105,relating to(a)the ownership of any subcontractor with whom Provider has had
business transactions totaling more than $25,000 during the 12-month period ending on the date of the request and
(b)any significant business transaction between Provider and any wholly owned supplier or subcontractor during the
five year period ending on the date of the request; (ii)42 C.F.R. §455.104,relating to individuals or entities with an
ownership or controlling interest in Provider; and(iii)42 C.F.R. §455.106,relating to individuals with an ownership
or controlling interest in Provider,or who are managing employees of Provider,who have been convicted of a crime.
ARTICLE III-CLAIMS SUBMISSION,PROCESSING,AND COMPENSATION
3.1. Claims or Encounter Data Submission. Contracted Providers shall submit to Payor or its delegate
claims for payment for Covered Services rendered to Covered Persons. Contracted Provider shall submit encounter
data to Payor or its delegate in a timely fashion, which must contain statistical and descriptive medical and patient
data and identifying information. Payor or its delegate reserves the right to deny payment to the Contracted Provider
if the Contracted Provider fails to submit claims for payment or encounter data in accordance with the applicable
policies and procedures.
3.2. Protection of Individual Right to Privacy & Confidential Services. In accordance with RCW
48.43.505,Health Plan does not require protected individuals to obtain permission from the policyholder, subscriber,
or another covered person to receive care,or submit a claim if they have the right to consent to care. Health Plan
recognizes the right of a protected individual or enrollee to exercise their rights regarding health information related
to care they receive. Health Plan directs all communications regarding a protected individual's receipt of sensitive
health services to the patient receiving care,or via postal mail,e-mail,or telephone number specified by the protected
individual. Health information may not be disclosed to anyone other than the protected individual without their
written or recorded verbal consent.
3.2.1. A protected individual may request communications regarding the receipt of sensitive health
care services be sent to another individual or provider for the purposes of appealing adverse benefit determinations.
Health Plan will limit disclosure of any information about a protected individual who is the subject of the information
and will direct communications directly to the protected individual,or via mail,e-mail or phone number specified by
the protected individual upon request. Protected individuals are not required to waive any right to limit disclosure as
a condition of eligibility or coverage. To protect patient confidentiality, Health Plan communications disclosing
protected health information or relating to sensitive services shall be provided in the form and format requested by
the patient receiving care.
3.3. Compensation. The compensation for Covered Services provided to a Covered Person
("Compensation Amount")will be the appropriate amount under the applicable Compensation Schedule in effect on
the date of service for the Product in which the Covered Person participates. Subject to the terms of this Agreement,
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Provider and Contracted Providers shall accept the Compensation Amount as payment in full for the provision of
Covered Services. Subject to the terms of this Agreement, Payor shall pay or arrange for payment of each Clean
Claim received from a Contracted Provider for Covered Services provided to a Covered Person in accordance with
the applicable Compensation Amount less any applicable copayments, cost-sharing or other amounts that are the
Covered Person's financial responsibility under the applicable Coverage Agreement.
3.4. Financial Incentives. The Parties acknowledge and agree that nothing in this Agreement shall be
construed to create any financial incentive for Provider or a Contracted Provider to withhold Covered Services.
3.5. Hold Harmless.
3.5.1. Provider and each Contracted Provider agree that in no event, including but not limited to
non-payment by a Payor, a Payor's insolvency, or breach of this Agreement, shall Provider or a Contracted Provider
bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse
against a Covered Person or person acting on the Covered Person's behalf, other than Payor, for Covered Services
provided under this Agreement. This provision shall not prohibit collection of any applicable copayments, cost-
sharing or other amounts,which have not otherwise been paid by a primary or secondary carrier in accordance with
regulatory standards for coordination of benefits, that are the Covered Person's financial responsibility under the
applicable Coverage Agreement.
3.5.2. Provider and each Contracted Provider agree, in the event of Payor's insolvency,to continue
to provide the services promised in the Coverage Agreement to Covered Persons for the duration of the period for
which premiums on behalf of the Covered Persons were paid to Company or Payor or until the Covered Person's
discharge from inpatient facilities,whichever time is greater.
3.5.3. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be
construed to modify the rights and benefits contained in the Covered Person's Coverage Agreement.
3.5.4. Provider and each Contracted Provider may not bill Covered Persons for Covered Services
(except for deductibles, copayments, or coinsurance)where Payor denies payment because Provider or a Contracted
Provider has failed to comply with the terms or conditions of this Agreement.
3.5.5. Provider and each Contracted Provider further agree (i) that the provisions of 3.5.1, 3.5.2,
3.5.3, 3.5.4 and 3.5.5 of this Section 3.5 shall survive termination of this Agreement regardless of the cause giving
rise to termination and shall be construed to be for the benefit of Covered Persons, and (ii) that these provisions
supersede any oral or written contrary agreement now existing or hereafter entered into between Contracted Provider
and Covered Persons or persons acting on their behalf.
3.5.6. If Provider or Contracted Provider contracts with other providers or facilities who agree to
provide Covered Services to Covered Persons with the expectation of receiving payment directly or indirectly from
Payor, such providers or facilities must agree to abide by the provisions of Subsections 3.5.1 through 3.5.7.
3.5.7. Provider acknowledges that willfully collecting or attempting to collect payment from a
Covered Person,knowing that collection to be in violation of this Section 3.5,constitutes a class C felony under RCW
48.80.030(5).
3.5.8. Mental/Behavioral Health Providers: In accordance with RCW 48.43.087 and RCW
48.43.087,nothing in this contract will prevent a mental/behavioral health practitioner and an enrollee from agreeing
to have services provided at the Covered Person's expense. If a mental/behavioral health practitioner provides
services to an enrollee during an appeal or adverse certification process, the practitioner must provide written
notification to the enrollee that payment for services is the enrollee's responsibility,unless Health Plan elects to pay.
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3.6. Terms and Conditions of Payment.
3.6.1. Payor shall pay Provider and each Contracted Provider for Covered Services in accordance
with the applicable Compensation Schedule as soon as practical but subject to the following minimum standards: (a)
95%of the monthly volume of Clean Claims shall be paid within 30 days of receipt by Payor;(b)95%of the monthly
volume of all claims shall be paid or denied within 60 days of receipt by Payor, except as agreed to in writing by the
Parties on a claim-by-claim basis. The date of receipt of a claim is the date the Payor or its agent receives either
written or electronic notice of the claim. Payor shall utilize a reasonable method for confirming receipt of claims and
responding to Provider or Contracted Provider inquiries thereof.
3.6.2. Failure to pay claims within these minimum standards will result in interest payments on
undenied and unpaid Clean Claims more than 61 days old until Payor meets the standards in this Section 3.6. Interest
shall be assessed at the rate of 1% per month, and shall be calculated monthly as simple interest prorated for any
portion of a month. Payor shall add the interest payable to the amount of the unpaid claim without the necessity of
the Provider or Contracted Provider submitting an additional claim. Any interest paid under this section shall not be
applied by the Payor to a Covered Person's deductible, copayment, coinsurance, or any similar obligation of the
Covered Person.
3.6.3. When Payor issues payment in Provider or Contracted Provider and Covered Person names,
Payor shall make claim checks payable in the name of Provider or Contracted Provider first and Covered Person
second.
3.6.4. Claim denials shall be communicated to Provider or Contracted Provider and shall include
the specific reason why the claim was denied. If the denial is based upon Medical Necessity or similar grounds,then
Payor upon request of Provider or Contracted Provider must also promptly disclose the supporting basis for the
decision.
3.6.5. Payor shall be responsible for ensuring that any person acting on behalf of or at the direction
of Payor or acting pursuant to Payor standards or requirements complies with these billing and claim payment
standards.
3.6.6. The standards in this Section 3.6 do not apply in the following circumstances:to claims about
which there is substantial evidence of fraud or misrepresentation by Provider, Contracted Providers or Covered
Persons; in instances where Payor or Company has not been granted reasonable access to information under
Contracted Provider's control; or if the failure to comply is occasioned by any act of God, bankruptcy, act of a
governmental authority responding to an act of God or other emergency, or the result of a strike, lockout, or other
labor dispute.
3.7. Recovery Rights -Payor. Payor or its delegate shall have the right to immediately offset or recoup
any and all amounts owed by Provider or a Contracted Provider to Payor or Company against amounts owed by the
Payor or Company to the Provider or Contracted Provider. Provider and Contracted Providers agree that all
recoupment and any offset rights under this Agreement will constitute rights of recoupment authorized under State
or federal law and that such rights will not be subject to any requirement of prior or other approval from any court or
other government authority that may now have or hereafter have jurisdiction over Provider or a Contracted Provider.
Notwithstanding the foregoing, except in the case of fraud, a Payor may not request (a) a refund of a payment
previously made to satisfy a claim unless Payor does so in writing within 24 months(or within 30 months for reasons
related to coordination of benefits) in accordance with RCW 48.43.600 or(b)payment of a contested refund sooner
than six months after receipt of the request. This section is not applicable to subrogation claims.
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3.8. Recovery Rights-Provider. Except in the case of fraud, Provider or a Contracted Provider may not
request payment from Company or Payor to satisfy a claim unless it does so in writing within 24 months after the
date the claim was denied or payment intended to satisfy the claim was made. In the case of coordination of benefits,
Provider or a Contracted Provider must request from Company or Payor within 30 months after original payment was
made, any additional balances owed. Additional payment cannot be requested any sooner than six months after
request is made. This section is not applicable to subrogation claims.
ARTICLE IV-RECORDS AND INSPECTIONS
4.1. Records. Each Contracted Provider shall maintain medical, financial and administrative records
related to items or services provided to Covered Persons, including but not limited to a complete and accurate
permanent medical record for each such Covered Person, in such form and detail as are required by applicable
Regulatory Requirements and consistent with generally accepted medical standards. Such records shall be maintained
for a minimum of 10 years after final payment is made under this Agreement. However,when an audit, litigation, or
other action involving records is initiated prior to the end of said period, records shall be maintained for a minimum
of 10 years following resolution of such action. Medical records must support claims submitted to Company for
payment in accordance with accepted standards for claims coding as interpreted and applied by the Payor and
regulatory authorities.
4.2. Access. Provider and each Contracted Provider shall provide access to their respective books and
records to each of the following, including any delegate or duly authorized agent thereof, subject to applicable
Regulatory Requirements: (i) Company and Payor, during regular business hours and upon prior notice; (ii)
appropriate State and federal authorities, to the extent such access is necessary to comply with Regulatory
Requirements; and (iii) accreditation organizations. Access to health information and other similar records by
Company or Payor shall be limited to records related to Covered Persons. Access to medical records for audit
purposes must be limited to only that necessary to perform the audit. Provider and each Contracted Provider shall
provide copies of such records at no expense to any of the foregoing that may make such request. Each Contracted
Provider also shall obtain any authorization or consent that may be required from a Covered Person in order to release
medical records and information to Company or Payor or any of their delegates. Provider and each Contracted
Provider shall cooperate in and allow on-site inspections of its, his or her facilities and records by any Company,
Payor, their delegates, any authorized government officials, and accreditation organizations. Provider and each
Contracted Provider shall compile information necessary for the expeditious completion of such on-site inspection in
a timely manner. Contracted Providers may audit or examine Company or Payor's books and records of account
related to transactions between Company or Payor and Contracted Provider during normal business hours and upon
reasonable prior notice.
4.3. Record Transfer. Subject to applicable Regulatory Requirements, each Contracted Provider shall
cooperate in the timely transfer of Covered Persons' medical records to any other health care provider, at no charge
and when required by Company.
ARTICLE V-INSURANCE AND INDEMNIFICATION
5.1. Insurance. During the term of this Agreement and for any applicable continuation period as set forth
in Section 7.3 of this Agreement, Provider and each Contracted Provider shall maintain policies of general and
professional liability insurance and other insurance necessary to insure Provider and each Contracted Provider,
respectively;their respective employees; and any other person providing services hereunder on behalf of Provider or
such Contracted Provider,as applicable,against any claim(s)of personal injuries or death alleged to have been caused
or caused by their performance under this Agreement. Such insurance shall include, but not be limited to, any"tail"
or prior acts coverage necessary to avoid any gap in coverage.Insurance shall be through a licensed carrier acceptable
to Health Plan, and in a minimum amount of$1,000,000 per occurrence, and $3,000,000 in the aggregate unless a
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lesser amount is accepted by Health Plan or where State law mandates otherwise. Provider and each Contracted
Provider will provide Health Plan with at least 15 days' prior written notice of cancellation, non-renewal, lapse, or
adverse material modification of such coverage.Upon Health Plan's request, Provider and each Contracted Provider
will furnish Health Plan with evidence of such insurance.
Provider certifies that it is self-insured, is a member of a risk pool, or maintains an equivalent program of self-
insurance, applicable to the work being performed and the Covered Services contractor provides under this
Agreement, and acceptable to Company. Company 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 5.1. Provider agrees to require all subcontractors to maintain insurance in types and with limits as may be
determined by Provider and/or its risk manager, unless Provider and Company agree otherwise.
5.2. Indemnification by Provider and Contracted Provider. Provider and each Contracted Provider shall
indemnify and hold harmless (and at Health Plan's request defend) Company and Payor and all of their respective
officers, directors, agents and employees from and against any and all third party claims for any loss, damages,
liability, costs, or expenses (including reasonable attorney's fees)judgments or obligations arising from or relating
to any negligence,wrongful act or omission, or breach of this Agreement by Provider,a Contracted Provider, or any
of their respective officers, directors, agents or employees.
5.3. Indemnification by Health Plan. Health Plan agrees to indemnify and hold harmless (and at
Provider's request defend)Provider, Contracted Providers, and their officers, directors, agents and employees from
and against any and all third party claims for any loss, damages, liability, costs, or expenses (including reasonable
attorney's fees),judgments, or obligations arising from or relating to any negligence, wrongful act or omission or
breach of this Agreement by Company or its directors,officers,agents or employee.
ARTICLE VI-DISPUTE RESOLUTION
6.1. Informal Dispute Resolution. Any dispute between Provider and/or a Contracted Provider, as
applicable(the"Provider Party"),and Health Plan and/or Company,as applicable(including any Company acting as
Payor) (the "Administrator Party"), with respect to or involving the performance under, termination of, or
interpretation of this Agreement, or any other claim or cause of action hereunder,whether sounding in tort, contract
or under statute(a"Dispute")shall first be addressed by exhausting the applicable policies and procedures pertaining
to claims payment,credentialing,utilization management,or other programs. If,at the conclusion of these applicable
procedures,the matter is not resolved to the satisfaction of the Provider Party and the Administrator Party,or if there
are no such policies, then the Provider Party and the Administrator Party agree that they will engage in a period of
good faith negotiations between their designated representatives who have authority to settle the Dispute, which
negotiations may be initiated by either the Provider Party or the Administrator Party upon written request to the other,
provided such request takes place within one year of the date on which the requesting party first had, or reasonably
should have had,knowledge of the event(s)giving rise to the Dispute.Administrator Party must render a decision on
a Provider Party complaint within a reasonable time for the type of dispute. In the case of billing disputes, the
Administrator Party must render a decision within 30 days of a complaint. If.a written complaint is submitted by the
Provider Party and the Administrator Party does not grant or reject such written complaint within 30 days, then the
Provider Party may,but is not required to,choose to proceed as if the complaint is rejected and submit the complaint
to nonbinding mediation. Alternatively,if the matter has not been resolved within 60 days of such request,either the
Provider Party or the Administrator Party may initiate arbitration pursuant to Section 6.2 below by providing a written
request to the other party. The other party may, but is not required to,consent to such binding arbitration process.
6.2. Arbitration. If mutually agreed upon by the Provider Party and the Administrator Party,either of the
Provider Party and the Administrator Party wishing to pursue the Dispute as provided in Section 6.1 may submit it to
binding arbitration conducted in accordance with the Commercial Arbitration Rules of the American Arbitration
Association("AAA"). In no event may any arbitration be initiated more than 1 year following, as applicable,the end
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of the 60 day negotiation period set forth in Section 6.1,or the date of notice of termination. Arbitration proceedings
shall be conducted by an arbitrator chosen from the National Healthcare Panel at a mutually agreed upon location
within the State. Any arbitration in which the total amount in controversy is less than$100,000 shall be conducted in
a single hearing day. Each of the Provider Party and the Administrator Party shall bear its own costs and attorneys'
fees related to the arbitration except that the AAA's administrative fees, all arbitrator compensation and travel and
other expenses,and all costs of any proof produced at the direct request of the arbitrator shall be borne equally by the
applicable parties, and the arbitrator shall not have the authority to order otherwise. The existence of a Dispute or
arbitration proceeding shall not in and of itself constitute cause for termination of this Agreement. Except as hereafter
provided, during an arbitration proceeding, each of the Provider Party and the Administrator Party shall continue to
perform its obligations under this Agreement pending the decision of the arbitrator. Nothing herein shall bar either
the Provider Party or the Administrator Party from seeking emergency injunctive relief to preclude any actual or
perceived breach of this Agreement.Nothing contained in this Article VI shall limit a Party's right to terminate this
Agreement with or without cause in accordance with Section 7.2. Nothing herein shall be construed to require
alternative dispute resolution to the exclusion of judicial remedies.
ARTICLE VII-TERM AND TERMINATION
7.1. Term. This Agreement is effective as of the Effective Date, and will remain in effect for an initial
term ("Initial Term")of 1 year, after which it will automatically renew for successive terms of one year each (each a
"Renewal Term"), unless this Agreement is sooner terminated as provided in this Agreement or either Party gives
the other Party written notice of non-renewal of this Agreement not less than 180 days prior to the end of the then-
current term.
7.2. Termination. This Agreement, or the participation of Provider or a Contracted Provider as a
Participating Provider in one or more Products,may be terminated or suspended as set forth below.
7.2.1. Upon Notice. This Agreement may be terminated by either Party giving the other Party at
least 180 days' prior written notice of such termination.
7.2.2. With Cause. This Agreement, or the participation of any Contracted Provider as a
Participating Provider in one or more Products under this Agreement, may be terminated by either Party giving at
least 90 days' prior written notice of termination to the other Party if such other Party(or the applicable Contracted
Provider) is in breach of any material term or condition of this Agreement and such other Party (or the Contracted
Provider)fails to cure the breach within the 60 day period immediately following the giving of written notice of such
breach. Any notice given pursuant to this Section 7.2.2 must describe the specific breach.In the case of a termination
of a Contracted Provider, Provider shall immediately notify the affected Contracted Provider of such termination.
7.2.3. Suspension of Participation. Unless expressly prohibited by applicable Regulatory
Requirements, Health Plan has the right to immediately suspend or terminate the participation of a Contracted
Provider in any or all Products by giving written notice thereof to Provider when Health Plan determines that (i)
based upon available information, the continued participation of the Contracted Provider appears to constitute an
immediate threat or risk to the health, safety or welfare of Covered Persons, or(ii)the Contracted Provider's fraud,
malfeasance or non-compliance with Regulatory Requirements is reasonably suspected. Provider shall immediately
notify the affected Contracted Provider of such suspension. During such suspension,the Contracted Provider shall,
as directed by Health Plan, discontinue the provision of all or a particular Covered Service to Covered Persons.
During the term of any suspension, the Contracted Provider shall notify Covered Persons that his or her status as a
Participating Provider has been suspended. Such suspension will continue until the Contracted Provider's
participation is reinstated or terminated.
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7.2.4. Insolvency. This Agreement may be terminated immediately by a Party giving written notice
thereof to the other Party if the other Party is insolvent or has bankruptcy proceedings initiated against it.
7.2.5. Credentialing. The status of a Contracted Provider as a Participating Provider in one or more
Products may be terminated immediately by Health Plan giving written notice thereof to Provider if the Contracted
Provider fails to adhere to Health Plan's credentialing criteria, including,but not limited to,if the Contracted Provider
(i) loses, relinquishes, or has materially affected its license to provide Covered Services in the State, (ii) fails to
comply with the insurance requirements set forth in this Agreement; or(iii)is convicted of a criminal offense related
to involvement in any state or federal health care program or has been terminated, suspended, barred, voluntarily
withdrawn as part of a settlement agreement, or otherwise excluded from any state or federal health care program.
Provider shall immediately notify the affected Contracted Provider of such termination.
7.3. Effect of Termination. After the effective date of termination of this Agreement or a Contracted
Provider's participation in a Product, this Agreement shall remain in effect for purposes of those obligations and
rights arising prior to the effective date of termination. Upon such a termination, each affected Contracted Provider
(including Provider,if applicable)shall(i)continue to provide Covered Services to Covered Persons in the applicable
Product(s)during the longer of the 90 day period following the date of such termination or such other period as may
be required under any Regulatory Requirements, and, if requested by Company, each affected Contracted Provider
(including Provider,if applicable)shall continue to provide,as a Participating Provider,Covered Services to Covered
Persons until such Covered Persons are assigned or transferred to another Participating Provider in the applicable
Product(s),and(ii)continue to comply with and abide by all of the applicable terms and conditions of this Agreement,
including, but not limited to, Section 3.5 (Hold Harmless)hereof, in connection with the provision of such Covered
Services during such continuation period. During such continuation period, each affected Contracted Provider
(including Provider, if applicable) will be compensated in accordance with this Agreement and shall accept such
compensation as payment in full. Company shall make a good faith effort to provide written notice of termination
within 15 working days of receipt or issuance of a notice of termination to all Covered Persons who are patients seen
on a regular basis by each affected Contracted Provider that is terminated, regardless of the cause for termination.
The Contracted Provider will inform any Covered Person that seeks the Contracted Provider's services that this
Agreement has been terminated.
7.4. Survival of Obligations. All provisions hereof that by their nature are to be performed or complied
with following the expiration or termination of this Agreement, including without limitation Sections 2.8, 2.11, 3.3,
3.5, 3.6, 3.7, 4.2, 4.3, 5.1, 5.2, 5.3, 7.3, and 7.4 and Article VIII, survive the expiration or termination of this
Agreement.
ARTICLE VIII-MISCELLANEOUS
8.1. Relationship of Parties. The relationship between or among Health Plan, Company,Provider,Payor
and any Contracted Provider hereunder is that of independent contractors. None of the provisions of this Agreement
will be construed as creating any agency, partnership, joint venture, employee-employer, or other relationship.
References herein to the rights and obligations of any Company under this Agreement are references to the rights and
obligations of each Company individually and not collectively. A Company is only responsible for performing its
respective obligations hereunder with respect to a particular Product,Coverage Agreement,Payor Contract, Covered
Service or Covered Person. A breach or default by an individual Company shall not constitute a breach or default by
any other Company, including but not limited to Health Plan.
8.2. Conflicts Between Certain Documents. If there is any conflict between this Agreement and any
policy or procedure of Company, this Agreement will control. In the event of any conflict between this Agreement
and any Product Attachment,the Product Attachment will control as to such Product.
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8.3. Assignment. This Agreement is intended to secure the services of and be personal to Provider and
may not be assigned, sublet,delegated or transferred by Provider without Health Plan's prior written consent. Health
Plan shall have the right, exercisable in its sole discretion, to assign or transfer all or any portion of its rights or to
delegate all or any portion of its interests under this Agreement or any Attachment to an Affiliate,successor of Health
Plan, or purchaser of the assets or stock of Health Plan, or the line of business or business unit primarily responsible
for carrying out Health Plan's obligations under this Agreement.
8.4. Headings. The headings of the sections of this Agreement are inserted merely for the purpose of
convenience and do not limit, define, or extend the specific terms of the section so designated.
8.5. Governing Law. The interpretation of this Agreement and the rights and obligations of Health Plan,
Company, Provider and any Contracted Providers hereunder will be governed by and construed in accordance with
applicable federal and State laws.
8.6. Third Party Beneficiary. This Agreement is entered into by the Parties signing it for their benefit, as
well as,in the case of Health Plan,the benefit of Company,and in the case of Provider,the benefit of each Contracted
Provider. Except as specifically provided in Section 3.5 hereof, no Covered Person or third party, other than
Company,will be considered a third party beneficiary of this Agreement.
8.7. Amendment. Except as otherwise provided in this Agreement,this Agreement may be amended only
by written agreement of duly authorized representatives of the Parties.
8.7.1. Health Plan may amend this Agreement by giving Provider written notice of the amendment
to the extent such amendment is deemed necessary or appropriate by Health Plan to comply with any Regulatory
Requirements. Any such amendment will be deemed accepted by Provider upon the giving of such notice.
8.7.2. Health Plan may amend this Agreement by giving Provider written notice (electronic or
paper) of the proposed amendment. Unless Provider notifies Health Plan in writing of its objection to such
amendment during the 30 day period following the giving of such notice by Health Plan, Provider shall be deemed
to have accepted the amendment. If Provider objects to any proposed amendment to either the base agreement or any
Attachment,Health Plan may exclude one or more of the Contracted Providers from being Participating Providers in
the applicable Product(or any component program of, or Coverage Agreement in connection with, such Product).
8.7.3. Notwithstanding the above, Health Plan will give Provider at least 60 days' prior written
notice of any amendment or new Attachment involving changes that affect health care service delivery or
compensation, unless changes to federal or State law or regulations make such advance notice impossible, in which
case notice shall be provided as soon as possible. In such case, if Provider notifies Health Plan in writing of its
objection to such amendment within 30 days following the giving of such notice by Health Plan, such amendment or
new Attachment shall not go into effect as to Provider;Health Plan may on 60 days' notice terminate this Agreement
or the participation of Provider and Contracted Providers in the Products affected by the proposed amendment (or
any component program of such Products).No change to this Agreement will be made retroactive without the express
consent of Provider.
8.8. Entire Agreement. All prior or concurrent agreements, promises, negotiations or representations
either oral or written, between Health Plan and Provider relating to a subject matter of this Agreement,which are not
expressly set forth in this Agreement, are of no force or effect.
8.9. Severability. The invalidity or unenforceability of any terms or provisions hereof will in no way
affect the validity or enforceability of any other terms or provisions.
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8.10. Waiver. The waiver by either Party of the violation of any provision or obligation of this Agreement
will not constitute the waiver of any subsequent violation of the same or other provision or obligation.
8.11. Notices. Except as otherwise provided in this Agreement, any notice required or permitted to be
given hereunder is deemed to have been given when such written notice has been personally delivered or deposited
in the United States mail, postage paid, or delivered by a service that provides written receipt of delivery, addressed
as follows:
To Health Plan at: To Provider at:
Attn: President Attn: Glenn Gilbert
Coordinated Care Corporation Jefferson County Public Health
1145 Broadway, Suite 300 615 Sheridan St
Tacoma, WA 98402 Port Townsend, WA 98368
ggilbert@co.jefferson.wa.us
or to such other address as such Party may designate in writing. Notwithstanding the previous sentence,Health
Plan may provide notices by electronic mail,through its provider newsletter or on its provider website.
8.12. Force Majeure. Neither Party shall be liable or deemed to be in default for any delay or failure to
perform any act under this Agreement resulting, directly or indirectly, from acts of God, civil or military authority,
acts of public enemy, war, accidents, fires, explosions, earthquake, flood, strikes or other work stoppages by either
Party's employees, or any other similar cause beyond the reasonable control of such Party.
8.13. Proprietary Information. Each Party is prohibited from, and shall prohibit its Affiliates and
Contracted Providers from, disclosing to a third party the substance of this Agreement, or any information of a
confidential nature acquired from the other Party (or Affiliate or Contracted Provider thereof) during the course of
this Agreement, except to agents of such Party as necessary for such Party's performance under this Agreement, or
as required by a Payor Contract or applicable Regulatory Requirements. Provider acknowledges and agrees that all
information relating to Company's programs, policies, protocols and procedures is proprietary information and
Provider shall not disclose such information to any person or entity without Health Plan's express written consent.
8.14. Out-of-Network Payments. In accordance with RCW 48.49.030 and RCW 48.49.040, Health Plan
will negotiate in good faith with out-of-network providers/facilities to determine a commercially reasonable payment
amount for services. Enrollees may not be held responsible for anything above their in-network cost share. Health
Plan and out-ofnetwork providers/facilities may pursue arbitration to determine a commercially reasonable payment
amount as a dispute resolution process if good faith negotiations do not yield successful results.
8.15. Authority. The individuals whose signatures are set forth below represent and warrant that they are
duly empowered to execute this Agreement. Provider represents and warrants that it has all legal authority to contract
on behalf of and to bind all Contracted Providers to the terms of the Agreement with Health Plan. Provider and each
Contracted Provider acknowledges that references herein to the rights and obligations of any"Company"or a"Payor"
under this Agreement are references to the rights and obligations of each Company and each Payor individually and
not of the Companies or Payors collectively. Notwithstanding anything herein to the contrary, all such rights and
obligations are individual and specific to each such Company and each such Payor and the reference to Company or
Payor herein in no way imposes any cross-guarantees or joint responsibility or liability by, between or among such
individual Companies or Payors. A breach or default by an individual Company or Payor shall not constitute a breach
or default by any other Company or Payor, including but not limited to Health Plan.
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[Signature Page Below]
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IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments
noted on Schedule B,effective as of the date set forth beneath on their respective signatures.
HEALTH PLAN: PROVIDER:
Coordinated Care Corporation Jefferson County Washington
(Legibly Print Name of Provider)
Authorized Signature: Authorized Signature:
Print Name: Beth Johnson Print Name: Kate Dean
Title: Plan President&CEO Title: Chair, Board of County Commissioners
Signature Date: Signature Date:
Tax Identification Number: 91-6001322
Medicare Number: 000200610
Attest:
Carolyn Gallaway, Date
Clerk of the Board
Approv as, only:
for 11/08/2024
Philip C.Hunsucker, Date
Chief Civil Deputy Prosecuting Attorney
Signature Block Continues on Next Page
PPA WA-Jefferson County Public Health-08.23.2024-1CMProviderAgreement_334499 Page 18 of 27
HEALTH PLAN:
Coordinated Care of Washington, Inc.
Authorized Signature:
Print Name: Beth Johnson
Title: Plan President& CEO
Signature Date:
1CM#: ICMProviderAgreement_334499
To be completed by Health Plan only:
Effective Date:
PPA WA-Jefferson County Public Health-08.23.2024-ICMProviderAgreement_334499 Page 19 of 27
PARTICIPATING PROVIDER AGREEMENT
SCHEDULE A
CONTRACTED PROVIDER-SPECIFIC PROVISIONS
Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A.
1. Hospitals. If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions
apply:
1.1 24 Hour Coverage.Each Hospital shall be available to provide Covered Services to Covered
Persons 24 hours per day, 7 days per week.
1.2 Emergency Care. Each Hospital shall provide Emergency Care (as hereafter defined) in
accordance with Regulatory Requirements. The Contracted Provider shall notify Company's medical management
department of any emergency room admissions by electronic file sent within 24 hours or by the next business day of
such admission. "Emergency Care"(or derivative thereof)has,as to each particular Product,the meaning set forth in
the applicable Coverage Agreement or Product Attachment. If there is no definition in such documents, "Emergency
Care" means inpatient and/or outpatient Covered Services furnished by a qualified provider that are needed to
evaluate or stabilize an Emergency Medical Condition. "Emergency Medical Condition"means a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who
possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in the following: (i)placing the health of the individual (or,with respect to a pregnant woman,the
health of the woman or her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions; or (iii)
serious dysfunction of any bodily organ or part.
1.3 Staff Privileges. Each Hospital shall assist in granting staff privileges or other appropriate
access to Company's Participating Providers who are qualified medical or osteopathic physicians,provided they meet
the reasonable standards of practice and credentialing standards established by the Hospital's medical staff and
bylaws,rules,and regulations.
1.4 Discharge Planning. Each Hospital agrees to cooperate with Company's system for the
coordinated discharge planning of Covered Persons, including the planning of any necessary continuing care.
1.5 Credentialing Criteria. Each Hospital shall (a) currently, and for the duration of this
Agreement,remain accredited by the Joint Commission or American Osteopathic Association,as applicable; and(b)
ensure that all employees of Hospital perform their duties in accordance with all applicable local, State and federal
licensing requirements and standards of professional ethics and practice.
1.6 National Committee for Quality Assurance ("NCQA") Accreditation of Health Plans
Standards. Each Hospital agrees to: i) cooperate with Quality Management and Improvement ("QI") activities; ii)
maintain the confidentiality of a Covered Persons information and records pursuant to the agreement; and iii) allow
the Company to use Hospital's performance data.
2. Practitioners. If Provider or Contracted Provider is a physician or other health care practitioner
(including physician extenders) ("Practitioner"),the following provisions apply:
2.1 Contracted Professional Qualifications. At all times during the term of this Agreement,
Practitioner shall,as applicable,maintain medical staff membership and admitting privileges with at least one hospital
that is a Participating Provider ("Participating Hospital") with respect to each Product in which the Practitioner
participates. Upon Company's request, Practitioner shall furnish evidence of the foregoing to Company. If
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Practitioner does not have such admitting privileges, Provider or the Practitioner shall provide Company with a
written statement from another Participating Provider who has such admitting privileges,in good standing,certifying
that such individual agrees to assume responsibility for providing inpatient Covered Services to Covered Persons
who are patients of the applicable Practitioner.
2.2 Acceptance of New Patients. To the extent that Practitioner is accepting new patients, such
Practitioner must also accept new patients who are Covered Persons with respect to the Products in which such
Practitioner participates. Practitioner shall notify Company in writing 45 days prior to such Practitioner's decision to
no longer accept Covered Persons with respect to a particular Product. In no event will an established patient of any
Practitioner be considered a new patient.
2.3 Preferred Drug List/Drug Formulary. If applicable to the Covered Person's coverage,
Practitioners shall use commercially reasonable efforts, when medically appropriate under the circumstances, to
comply with formulary or preferred drug list when prescribing medications for Covered Persons.
2.4 National Committee for Quality Assurance ("NCQA") Accreditation of Health Plans
Standards. Each Practitioner agrees to: i)cooperate with Quality Management and Improvement("QI")activities; ii)
maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement; and iii)allow
the Company to use Practitioner's performance data.
3. Ancillary Providers. If Provider or Contracted Provider is an ancillary provider (including but not
limited to a chemical dependency services provider, residential treatment facility/behavioral health agency, home
health agency, durable medical equipment provider, sleep center, pharmacy, ambulatory surgery center, nursing
facility, laboratory or urgent care center)("Ancillary Provider"),the following provisions apply:
3.1 Acceptance of New Patients.To the extent that Ancillary Provider is accepting new patients,
such Ancillary Provider must also accept new patients who are Covered Persons with respect to the Products in which
such Ancillary Provider participates. Ancillary Provider shall notify Company in writing 45 days prior to such
Ancillary Provider's decision to no longer accept Covered Persons with respect to a particular Product. In no event
will an established patient of any Ancillary Provider be considered a new patient.
3.2 National Committee for Quality Assurance ("NCQA") Accreditation of Health Plans
Standards. Each ancillary provider agrees to: i) cooperate with Quality Management and Improvement ("QI")
activities; ii)maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement;
and iii) allow the Company to use ancillary provider's performance data.
4. FQHC. If Provider or a Contracted Provider is a federally qualified health center ("FQHC"), the
following provision applies:
4.1 FQHC Insurance. To the extent FQHC's employees are deemed to be federal employees
qualified for protection under the Federal Tort Claims Act ("FTCA") and Health Plan has been provided with
documentation of such status issued by the U.S.Department of Health and Human Services(such status to be referred
to as "FTCA Coverage"), Section 5.1 of this Agreement will not apply to those Contracted Providers with FTCA
Coverage. FQHC shall provide evidence of such FTCA Coverage to Health Plan at any time upon request. FQHC
shall promptly notify Health Plan if,any time during the term of this Agreement,any Contracted Provider is no longer
eligible for,or if FQHC becomes aware of any fact or circumstance that would jeopardize,FTCA Coverage. Section
5.1 of this Agreement will apply to a Contracted Provider immediately upon such Contracted Provider's loss of FTCA
Coverage for any reason.
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5. Facility Providers. . If Provider or a Contracted Provider is a facility (including but not limited to
clinic,FQHC, long-term acute care(LTAC),nursing home,rehabilitation,rural health clinic(RHC), skilled nursing)
("Facility Provider")the following provision applies:
5.1 National Committee for Quality Assurance ("NCQA") Accreditation of Health Plans
Standards. Each facility agrees to: i) cooperate with Quality Management and Improvement ("QI") activities; ii)
maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement; and iii)allow
the Company to use facility's performance data.
6. Long Term Services and Supports ("LTSS") and Home and Community-Based Services ("HCBS")
Providers. If Provider or a Contracted Provider is a provider of LTSS,the following provisions apply:
6.1 Definition. LTSS generally includes assistance with daily self-care activities(e.g.,walking,
toileting, bathing, and dressing) and activities that support an independent lifestyle (e.g., food preparation,
transportation, and managing medications). The broad category of LTSS also includes care and service coordination
for people who live in their own home, a residential setting, a nursing facility, or other institutional setting. Home
and community-based services are a subset of LTSS that functions outside of institutional care to maximize
independence in the community.
6.2 HCBS Waiver Authorization. Provider shall not provide HCBS Covered Services to
Covered Person without the required HCBS waiver authorization.
6.3 Conditions for Reimbursement. No payment shall be made to the Provider unless the
Provider has strictly conformed to the policies and procedures of the HCBS Waiver Program, including but not
limited to not providing HCBS Covered Services without prior authorization of Health Plan. For the purposes of this
schedule, "HCBS Waiver Program"shall mean any special Medicaid program operated under a waiver approved by
the Centers for Medicare and Medicaid Services which allows the provision of a special package of approved services
to Covered Person.
6.4 Acknowledgement. Health Plan acknowledges that Provider is a provider of LTSS and is
not necessarily a provider of medical or health care services. Nothing in this Agreement is intended to require
Provider to provide medical or health care services that Provider does not routinely provide, but would not prohibit
providers from offering these services, as appropriate.
6.5 Notification Requirements. Provider or the applicable Contracted Provider shall provide the
following notifications to Health Plan, via written notice or via telephone contact at a number to be provided by
Health Plan,within the following time frames:
6.5.1 Provider or the applicable Contracted Provider shall notify Health Plan of a
Covered Person's visit to urgent care or the emergency department of any hospital, or of a Covered Person's
hospitalization,within 24 hours of becoming aware of such visit or hospitalization.
6.5.2 Provider or the applicable Contracted Provider shall notify Health Plan of any
change to the designated/assigned services being provided under a Covered Person's plan of care and/or service
plan,within 24 hours of becoming aware of such change.
6.5.3 Provider or the applicable Contracted Provider shall notify Health Plan if a
Covered Person misses an appointment with Provider,within 24 hours of becoming aware of such missed
appointment.
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6.5.4 Provider or the applicable Contracted Provider shall notify Health Plan of any
change in a Covered Person's medical or behavioral health condition,within 24 hours of becoming aware of such
change. (Examples of changes in condition are set forth in the Health Plan Policies and Procedures.)
6.5.5 Provider or the applicable Contracted Provider shall notify Health Plan of any
safety issue identified by Provider or Contracted Provider or its agent or subcontractor,within 24 hours of the
identification of such safety issue. (Examples of safety issues are set forth in.the Health Plan Policies and
Procedures.)
6.5.6 Provider or the applicable Contracted Provider shall notify Health Plan of any
change in Provider's or Contracted Provider's key personnel,within 24 hours of such change.
6.6 Minimum Data Set. If Contracted Provider is a nursing facility,Provider or such Contracted
Provider shall submit to Health Plan or its designee the Minimum Data Set as defined by CMS and required under
federal law and Health Plan policy as it relates to all Covered Persons who are residents in Contracted Provider's
facility. Such submission shall be via electronic mail,facsimile transmission, or other manner and format reasonably
requested by Health Plan.
6.7 Quality Improvement Plan. Each Contracted Provider shall participate in Health Plan's
LTSS quality improvement plan. Each Contracted Provider shall permit Health Plan to access such Contracted
Providers' assessment and quality data upon reasonable advance notice,which may be given by electronic mail.
6.8 Electronic Visit Verification. If Contracted Provider provides in-home services, Contracted
Provider shall comply with 21"Century Cures Act and Health Plan's electronic visit verification system requirements
where applicable and accessible.
6.9 Criminal Background Checks. Provider shall conduct a criminal background check on each
Contracted Provider prior to the commencement of services under this Agreement and as requested by Health Plan
thereafter. Provider shall provide the results of such background checks to Health Plan and member, if self-directed,
upon request. Provider agrees to immediately notify Health Plan of any criminal convictions of any Contracted or
sub-contracted Provider. Provider shall pay any costs associated with such criminal background checks.
7. Person-Centered Planning, Care/Service Plan, and Services ("PCSP"). Provider shall comply with
all state and federal regulatory requirements related to person-centered planning, care/service plans, and services
including, but not limited to:
7.1 Covered Persons shall lead the person-centered planning process and can elect to include,
and/or consult with, any of their LTSS providers in the care/service plan development process.
7.2 The care/service plan must be finalized and agreed to, with the informed consent of the
individual in writing, and signed by all individuals and providers responsible for its implementation through the
mechanism required by state and federal requirements. Non-medical service providers (such as meals or assistive
technology) can signify their agreement through this contract or written agreement in lieu of directly in the plan, if
permitted by the Covered Persons.
7.3 LTSS provider shall be aware of, respect, and adhere to a Covered Person's preferences for
the delivery of services and supports.
7.4 LTSS provider shall ensure services and supports are culturally appropriate, provided in
plain language (where applicable), and accessible to Covered Persons and the person(s) supporting them who have
disabilities and/or are limited English proficient.
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7.5 Health Plan agrees to complete the care/service plan in a timely manner(within at least 120
days of enrollment or annually,or less if state requirements differ)and provide a copy to LTSS provider(s)responsible
for implementation.
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PARTICIPATING PROVIDER AGREEMENT
SCHEDULE B
PRODUCT PARTICIPATION
Provider and Contracted Providers will be subject to and bound by the Attachments set forth below, and designated
as a"Participating Provider" in the Products set forth below as of the date of successful completion of credentialing
in accordance with this Agreement.
List of Product Attachments and Addenda:
Attachment A: Medicaid
Attachment A-1: [Reserved]
Addendum A: [Reserved]
Addendum B: [Reserved]
Addendum C: [Reserved]
Attachment B: [Reserved]
Attachment C: Commercial-Exchange
Attachment D: [Reserved]
Attachment E: [Reserved]
Attachment F: Cascade Care Select Public Option Program
Attachment G: [Reserved]
List of Schedules:
Schedule A Contracted Provider-Specific Provisions
Schedule B Product Participation
Schedule C Information For Contracted Providers
Schedule D-1 [Reserved]
Schedule D-2 [Reserved]
Health Plan to which Product Attachments Apply:
On at least 60 days' advance written notice (written or electronic), CCC and CCW may jointly notify Provider that
an Attachment shall no longer be a Product of CCC and shall be a Product of CCW on the date specified in the notice.
As of such date,the designated Attachment(s)shall terminate with respect to CCC as the Health Plan and commence
with respect to CCW as the Health Plan for such Product.
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PARTICIPATING PROVIDER AGREEMENT
SCHEDULE C
INFORMATION FOR CONTRACTED PROVIDERS
Provider shall provide Health Plan with the information set forth below with respect to: (i) Provider; (ii) each
Contracted Provider; and(iii)if applicable,each Contracted Provider's locations and/or professionals. To the extent
Provider provides the name of any Contracted Provider to Health Plan hereunder, such entity and/or individual will
be considered a Contracted Provider under this Agreement regardless of whether the complete list of information set
forth below relating to such Contracted Provider is provided by Provider.
1. Name
2. Address
3. E-mail address
4. Telephone and facsimile numbers
5. Professional license numbers
6. Medicare/Medicaid ID numbers
7. Federal tax ID numbers
8. Completed W-9 form
9. National Provider Identifier(NPI)numbers
10. Provider Taxonomy Codes
11. Area of medical specialty
12. Age restrictions(if any)
13. Area hospitals with admitting privileges (where applicable)
14. Whether Providers are employed or subcontracted with Contracted Provider using the designation "E" for
employed or"C"for subcontracted.
15. For a subcontracted Provider,whether its Providers are employed or contracted with the subcontracted Provider
using the designation "E"for employed or"C"for contracted.
16. Office contact person
17. Office hours
18. Billing office
19. Billing office address
20. Billing office telephone and facsimile numbers
21. Billing office e-mail address
22. Billing office contact person
23. Ownership Disclosure Form, as required to comply with Regulatory Requirements and Governmental Contract
NOTE: For a complete listing of the information and additional documentation required, please refer to the
enrollment application.
This following Schedule C-1 is intended to capture all groups,clinics and facilities participating under the Agreement
(i.e., are Contracted Providers under this Agreement)as of the Effective Date.
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PARTICIPATING PROVIDER AGREEMENT
SCHEDULE C-1
CONTRACTED PROVIDERS
Contracted Provider Name Contracted Provider TIN Contracted Provider NPI
Jefferson County Public Health 916001322 1841225208
Jefferson County Public Health 91-6001322 1871783753
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ATTACHMENT A: Medicaid
EXHIBIT A-1
APPLE HEALTH
PARTICIPATING PROVIDER AGREEMENT ATTACHMENT
This Apple Health Participating Provider Agreement Attachment (this "Attachment") is incorporated into the
participating provider agreement (the "Agreement") entered into by and between Jefferson County Public Health
("Provider"), an entity described more fully in the signature block of the Agreement, and Coordinated Care of
Washington Inc., a health care service contractor("Health Plan").
Note that this Attachment is based on the 2022 IMC Apple Health contract.
Network: All Contracted Providers under this Agreement will participate as Participating Providers in and become
part of the CCCWA network. "CCCWA network" refers to Health Plan's registered network name with the
Washington State Office of the Insurance Commissioner(OIC).
ARTICLE I
RECITALS
1.1. Health Plan has contracted with the State of Washington Health Care Authority (HCA) to arrange
for the provision of integrated physical and behavioral health care services to Covered Persons under the Apple Health
Program.
1.2. This Attachment is intended to supplement the Agreement by setting forth the parties' rights and
responsibilities related to the provision of Covered Services to Covered Persons as it pertains to the Apple Health
Program(defined herein). In the event of a conflict between the terms and conditions of the Agreement and the terms
and conditions of this Attachment,this Attachment shall govern as to the Apple Health Program.
1.3. Provider agrees and understands that Covered Services shall be provided in accordance with the State
Contract(s) (defined herein), Payor requirements, any applicable State handbooks or policy and procedure guides,
and all applicable State and federal laws and regulations. To the extent Provider is unclear about Provider's duties
and obligations, Provider shall request clarification from Health Plan.
ARTICLE II
DEFINITIONS
Capitalized terms used and not otherwise defined herein shall have the meanings given to them in the Agreement or
the State Contract. The definitions listed below will supersede any meanings contained elsewhere in the Agreement
with regard to this Attachment. Citations to the State Contract and other governmental authority requirements are
provided herein for convenience only and shall not affect the meaning or interpretation of the terms of the Agreement.
Such citations may become outdated as these requirements are amended from time to time.
2.1. Apple Health Program shall mean the Medicaid managed care program known as Apple Health,
including both integrated managed care and integrated foster care, as applicable based on service area.
2.2. Covered Person shall have the meaning set forth in the Agreement.
2.3. HCA means the State of Washington Health Care Authority and its employees and authorized agents.
2.4. Medically Necessary means health care services that: (a) are reasonably calculated to prevent,
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diagnose, correct, cure, alleviate or prevent worsening of conditions in the Covered Person that endanger life, or
cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause
physical deformity or malfunction; and(b)are not more costly than any other equally effective or more conservative
course of treatment available or suitable for the Covered Person requesting the service. Such services shall include
services related to the Covered Person's ability to achieve age-appropriate growth and development.
2.5. Physician's Orders for Life Sustaining Treatment ("POLST") means a set of guidelines and
protocols for how emergency medical personnel shall respond when summoned to the site of an injury or illness for
the treatment of a person who has signed a written directive or durable power of attorney requesting that he or she
not receive futile emergency medical treatment, in accordance with RCW 43.70.480.
2.6. Primary Care Provider or PCP means a Participating Provider who has the responsibility for
supervising, coordinating, and providing primary health care to Covered Persons, initiating referrals for specialist
care, and maintaining the continuity of Covered Person care. PCPs include, but are not limited to pediatricians,
family practitioners, general practitioners, internists, naturopathic physicians, medical residents (under the
supervision of a teaching physician), physician assistants (under the supervision of a physician), or advanced
registered nurse practitioners (nurse practitioners), as designated by Health Plan. The definition of PCP is inclusive
of primary care physician as it is used in 42 C.F.R. § 438. All Federal requirements applicable to primary care
physicians will also be applicable to PCPs as the term is used in this Attachment.
2.7. State means the state of Washington.
2.8. State Contract(s) means the applicable contract(s) between HCA and Health Plan under which
Health Plan agrees to provide or arrange for services related to the Apple Health Program, including any exhibits,
attachments, documents, or materials incorporated by reference.
ARTICLE III
PROVIDER CONTRACT REQUIREMENTS
3.1. Health Plan 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 Provider. [Source: §9.1 of the 2022 Apple Health IMCAgreement]
3.2. Compliance with Applicable Law. Provider shall comply with all Applicable Law. For purposes of
this Attachment, "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, The 21 st Century Cures Act, 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).
3.3. Compliance with State Contract. Provider 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 Contract and the prohibition on direct and/or indirect
door-to-door,telephonic, or other cold-call marketing.
3.4. Policies and Procedures. Provider shall comply with Health Plan's policies and procedures,
including, but not limited to, credentialing and recredentialing; utilization management; fraud, waste and abuse;
authorization of services; quality improvement activities; and provider payment suspensions. Provider shall comply
with the program integrity requirements of the State Contract,as well as Health Plan's program integrity policies and
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procedures. Without limiting the generality of the foregoing, Provider shall comply with the program integrity
requirements in Section 1902(a)(68) of the Social Security Act, 42 C.F.R. § 438.610, 42 C.F.R. § 455, 42 C.F.R.
§ 1000 through 1008, and Chapter 182-502A WAC. Further, Provider 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 Provider. To the extent that Provider is delegated authority for authorization of services, Provider
shall comply with all utilization management requirements described in the State Contract.
3.5. Debarment Certification. Provider 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. Provider shall immediately notify Health Plan in writing if, during the
term of the Agreement, (a) Provider becomes debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded, or (b) Provider or any of Provider's employees are subject to disciplinary action against
accreditation, certification, license and/or registration. Further, Provider shall not pay for goods and services
furnished by an excluded person, at the medical direction, or on the prescription of an excluded person.
3.6. Records. Provider 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 Provider related to the Agreement. All records and reports relating to the Agreement shall be retained by
Provider for a minimum of 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 10 years following resolution of such action.
3.7. Inspection. Provider shall fully cooperate with and permit State, including HCA, Medicaid Fraud
Control Units(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
Provider that pertain to any aspect of services and activities performed, including any computerized data stored by
Provider, 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. Provider shall make
staff available to assist in such inspection, review, audit, investigation, monitoring or evaluation, including the
provision of adequate space on the premises to reasonably accommodate HCA, MFCD or other state or federal
agency.Provider shall make copies of records and shall deliver them to the requestor,without cost,within 30 calendar
days of request. The right for the parties named above to audit, access and inspect under this section exists for 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 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.
3.8. Interpreter Services. Provider shall provide interpreter services, free of charge, for all interactions
with Covered Persons or potential Covered Persons, including but not limited to: (a) customer service, (b) all
appointments with any provider for any Covered Service, (c)emergency services, and (d) all steps necessary to file
grievances and appeals including requests for Independent Review of Health Plan decisions.
3.9. Marketing Materials. All information to be provided to Covered Persons, e.g. marketing materials,
must be accurate, not misleading, comprehensible to its intended audience, designed to provide the greatest degree
of understanding, and written at a sixth grade reading level, in addition to any other requirements imposed by Health
Plan based on the nature of the materials. Such materials must generally be approved by Health Plan prior to use,
and must comply with the State Contract.
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3.10. 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. Health Plan 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. Health Plan
shall provide prenatal care and preventive pediatric care and then seek reimbursement from third parties. Provider
shall comply with all applicable Third-Party Liability and Coordination of Benefits provisions of Section 17 of the
State Contract.
3.11. Care Coordination. Provider shall comply with Health Plan's policies and support Health Plan's
efforts regarding care coordination, transfers between levels of care and medication management. If applicable,
Provider shall ensure that discharge plans and facilitation to post-discharge services are documented in a Covered
Person's electronic health record. If Provider is an inpatient substance use disorder(SUD)treatment provider, then
Provider shall have policies in place for prompt exchange of Covered Person information between behavioral health
treatment agencies to facilitate continuity of care, consistent with the State Contract.
3.12. Subcontracting.Provider may not subcontract any services under the Apple Health Program without
the prior written consent of Health Plan. Any subcontract entered into by Provider must be in writing consistent with
42 C.F.R. § 434.6, and all Provider requirements contained in this Attachment must be propagated downward into
any other lower tiered subcontracts.
3.13. Reasonable Accommodations for Disabilities. Provider shall cooperate with Health Plan to make
reasonable accommodation for Covered Persons with disabilities, in accordance with the Americans with Disabilities
Act,for all Covered Services and shall assure physical and communication barriers shall not inhibit Covered Persons
with disabilities from obtaining Covered Services.
3.14. Surgical Health and Safety. If Provider is a hospital,ambulatory care surgery center, or office-based
surgery site, Provider shall endorse and adopt procedures for verifying the correct patient,the correct procedure and
the correct surgical site that meet or exceed those set forth in the Universal ProtocolTM development by the Joint
Commission or other similar standards.
3.15. Practice Guidelines. Provider shall comply with applicable physical and behavioral health practice
guidelines adopted by Health Plan.
3.16. Timely Access to Care. Provider shall offer access comparable to that offered to commercial
enrollees or if Provider serves only Medicaid enrollees,then comparable to Medicaid fee-for-service.
3.17. Hours of Operation.Provider's hours of operation for Covered Persons shall be no less than the hours
of operation offered to any other of Provider's patients.
3.18. Administrative Simplification. Unless otherwise directed by Health Plan, Provider 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-Span® Master Drug Data or any other nationally recognized drug
database with approval by HCA.
3.19. 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, Health Plan shall meet the following minimum standards
for timeliness of payment: 95% of Clean Claims shall be paid within 30 calendar days of receipt of the paper or
electronic claim;95%of all claims shall be paid or denied within 60 calendar days of receipt of the paper or electronic
claim; and 99% of Clean Claims shall be paid or denied within 90 calendar days of receipt.
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3.20. Appointment Wait Time Standards. As applicable, Provider shall meet the following appointment
wait time standards with respect to Covered Persons:
(a) Transitional healthcare services by a PCP shall be available for clinical assessment and care
planning within seven calendar days of discharge from inpatient or institutional care for physical or behavioral health
disorders or discharge from a SUD treatment program.
(b) Transitional healthcare services by a home care nurse, a home care mental health
professional or other behavioral health professional shall be available within seven calendar days of discharge from
inpatient or institutional care for physical or behavioral health care, if ordered by the Covered Person's PCP or as
part of the discharge plan;
(c) Non-symptomatic (i.e., preventive care) office visits shall be available from the Covered
Person's PCP or another provider within 30 calendar days. A non-symptomatic visit may include, but is not limited
to, well/preventive care such as physical examinations, annual gynecological examinations, or child and adult
immunizations.
(d) Non-urgent,symptomatic(i.e.,routine care)office visits,shall be available from the Covered
Person's PCP or another provider within 10 calendar days, including behavioral health services from a behavioral
health provider. A non-urgent, symptomatic visit is associated with the presentation of medical signs not requiring
immediate attention.
(e) Urgent,symptomatic office visits shall be available from the Covered Person's primary care,
behavioral health or another provider within 24 hours. An urgent, symptomatic visit is associated with the
presentation of medical or behavioral health signs that require immediate attention, but are not emergent.
(f) Emergency medical care shall be available 24 hours per day, 7 days per week; and
(g) Second opinion appointments described in Subsection 16.2.1 of the State Contract must
occur within 30 calendar days of the request, unless the Covered Person requests a postponement of the second
opinion to a date later than 30 calendar days.
Health Plan shall monitor Provider's compliance with this section. In the event Provider fails to comply with the
applicable appointment wait time standards set forth in this section, Provider shall comply with Health Plan's
procedures for corrective action.Nothing in this section prohibits Provider from conducting assessments in alternate
settings, such as the Covered Person's home or within an institutional setting. [Source: § 6.9 of the 2022 Apple
Health IMC Agreement]
3.21. 24/7 Availability. To the extent applicable, Provider shall make the following services available 24
hours per day, 7 days per week, 365 days a year by a toll-free telephone number:
(a) Medical and behavioral health advice for Covered Persons from licensed health care
professionals;
(b) Triage concerning the emergent, urgent or routine nature of medical and behavioral health
conditions by licensed health care professionals; and
(c) The toll-free line staff must be able to make a warm handoff to the regional crisis line.
3.22. Health Information Systems.Provider shall maintain a health information system that complies with
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the requirements of 42 C.F.R. §438.242 and provides the information necessary to meet Health Plan's obligations
under the State Contract. Provider shall:
(a) 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
(b) Ensure data provided to Health Plan 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.
3.23. Release of Necessary Information. Provider acknowledges and agrees to release to Health Plan any
information necessary to perform any of Health Plan's obligations under the State Contract.
3.24. Encounter Data Reporting. Provider shall submit complete, accurate and timely encounter data and
behavioral health supplemental transactions to Health Plan in accordance with current encounter submission
guidelines published by HCA or as otherwise specified by Health Plan. Provider represents and warrants that it has
the capacity to submit all data required by HCA to enable Health Plan to meet the reporting requirements in the
Encounter Data Reporting Guide and Service Encounter Data Reporting Guide (SERI) and Behavioral Health
Supplemental Transaction Data Guide published by HCA.
3.25. Potential Allegations of Fraud. Provider shall refer potential allegations of fraud to HCA and the
Medicaid Fraud Control Unit as described in Subsection 12.6 of the State Contract.
3.26. Fraud, Waste, and Abuse. Provider shall comply with Health Plan's policies regarding fraud,waste
and abuse. In addition, Provider shall comply with the following applicable provisions necessary to prevent fraud,
waste and abuse.
(a) If Provider is delegated responsibility for coverage of services and payment of claims under
the State Contract, then Provider shall implement and maintain administrative and management arrangements or
procedures designed to detect and prevent fraud,waste and abuse that are consistent with Health Plan's policies and
all requirements of applicable law and the State Contract, including without limitation those described in Section
12.5.1 of the State Contract.
(b) Provider shall (i)provide written disclosure of any prohibited affiliation in accordance with
42 C.F.R. § 438.610; 42 C.F.R. § 455.106; and 42 C.F.R§ 438.608(c)(1)to HCA; (ii)provide written disclosures of
information on ownership and control as indicated under Subsection 12.3 of the State Contract(42 C.F.R. §455.104;
42 C.F.R. § 455.105; and 42 C.F.R § 438.608(c)(2)); (iii) maintain internal policies and procedures for the
documentation, retention, and recovery of all overpayments, specifically for the recovery of overpayments due to
fraud,waste or abuse, consistent with the State Contract; and(iv)report to Health Plan and HCA within 60 calendar
days when it has identified capitation payments mother payment amounts received are in excess to the amounts
specified in the State Contract(42 C.F.R. § 438.608(c)(3)).
(c) Provider shall cooperate with Health Plan audits of Provider to detect and identify fraud,
waste and abuse.
3.27. Subrogation. Provider 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 Provider 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,
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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 Provider in the collection against a third party.
3.28. Limitations on Referrals. Provider 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 Covered Person 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, Provider shall cover Covered Persons for
all physical and/or behavioral health necessary services.
3.29. 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 Health Plan's policies
and procedures regarding credentialing and recredentialing. Such providers shall revalidate Medicare enrollment
every five years in compliance with 42 C.F.R. §424.515. Notwithstanding the foregoing,infant in-home phototherapy
providers that meet Health Plan's certification requirements are not required to be enrolled in Medicare.
3.30. HCA Approval Required. To the extent that the Agreement is considered a"Subcontract"requiring
HCA approval under the State Contract, the Agreement will not take effect prior to HCA's review and written
approval, or failure to approve or deny within 45 calendar days of filing.
3.31. HCA Approval for Assignment. Provider acknowledges and agrees that no assignment of the
Agreement shall take effect without the prior written agreement of HCA.
3.32. Quality Improvement System. Provider shall maintain a quality improvement system tailored to the
nature and type of Covered Services provided hereunder, which affords quality control for such services, including
but not limited to the accessibility of Medically Necessary services, and which provides for a free exchange of
information with Health Plan to assist Health Plan 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 Health
Plan.
3.33. Records of Delegated Activities. As applicable to services rendered under the Agreement, Provider
shall have a means to keep records necessary to adequately document services provided to Covered Persons for any
and all delegated activities including quality improvement, utilization management, Covered Person's rights and
responsibilities, health homes, and credentialing and re-credentialing.
3.34. Behavioral Health Provider Supervision. Provider agrees that, if applicable, it will receive payment
for the supervision of behavioral health providers whose license or certification restricts them to working under
supervision.
3.35. Payment in Full and Covered Person Charges. Provider agrees to accept payment from Health Plan
as payment in. full. Provider shall not request payment from HCA or any Covered Person for Covered Services
provided under the Agreement, and shall comply with WAC 182-502-0160 requirements applicable to providers.
Provider shall report to Health Plan any instance in which a Covered Person is charged for services. Provider shall
repay to a Covered Person any inappropriate charges paid by such Covered Person,or shall reimburse Health Plan to
the extent Health Plan repays such inappropriate charges to the Covered Person.
3.36. HCA and Covered Person Hold Harmless.Provider agrees to hold harmless HCA and its employees,
and all Covered Persons in the event of non-payment by Health Plan. Provider further agrees to indemnify and hold
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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 Provider, its agents, officers, employees or contractors,and(b)any damages
related to Provider's unauthorized use or release of Personal Information (PI) or Protected Health Information(PHI)
of Covered Persons.
3.37. Termination Provision.Either Party to this Attachment may terminate this Attachment upon 90 days
advance written notice to the other Party. Notwithstanding the foregoing, in the event that(a) Provider is excluded
from participation in the Medicaid program, Health Plan may immediately terminate the Agreement or this
Attachment upon written notice to Provider, and may immediately recover any payments for goods or services that
benefit excluded individuals or entities; or(b)HCA or Medicare has taken any action to revoke Provider's privileges
for cause, and Provider has exhausted all applicable appeal rights or the timeline for appeal has expired. "For cause"
may include but is not limited to reasons related to fraud, integrity or quality.
3.38. Provider Appeal Rights. If Provider provides physician services, Provider may exercise any appeal
rights pursuant to Chapters 284-43 and 284-170 WAC to challenge Health Plan's failure to cover a service.
3.39. Health Plan Oversight and Corrective Action. Provider acknowledges and agrees that Health Plan
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 years or more often if specified,and will identify any deficiencies or areas
of improvement and provide for corrective action of any such deficiencies. Such review shall include an evaluation
to ensure that services furnished by Provider to individuals with special health care needs are appropriate to the
Covered Person'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.
3.40. Covered Person Self-Referral.Provider acknowledges that Covered Persons have a right to self-refer
for:
(a) 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;
(b) 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;
(c) Immunizations, sexually transmitted disease screening, family planning and behavioral
health services through and if provided by a school-based health center;
(d) All services received by American Indian or Alaska Native Covered Persons under the
Special Provisions for American Indians and Alaska Natives subsection of the State Contract; and
(e) 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.
3.41. Delegated Administrative Services Agreement. In the event that the Agreement delegates
administrative functions to Provider, including essential behavioral health administrative functions,the Parties agree
that they shall enter into a delegated administrative services agreement that contains all provisions required pursuant
to the State Contract.
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3.42. Confidential Member Information. Provider shall keep information about Covered Persons,
including their medical records,confidential in a manner consistent with Applicable Law.
3.43. Medicaid NCCI Files.Provider may disclose only non-confidential information that is also available
to the general public about the Medicaid NCCI edit files on the Medicaid NCCI webpage.
3.44. Member Rights. Provider shall comply with any Applicable Law that pertain to Covered Persons'
rights and shall protect and promote those rights when furnishing services to Covered Persons. Provider shall
guarantee each Covered Person the rights set forth below. Each Covered Person must be free to exercise these rights
and the exercise of these rights must not adversely affect the way Health Plan or Provider treats the Covered Person.
These rights include:
(a) To be treated with respect and with consideration for Covered Person's dignity and privacy;
(b) To receive information on available treatment options and alternatives,presented in a manner
appropriate to the Covered Person's ability to understand;
(c) To participate in decisions regarding Covered Person's health care, including the right to
refuse treatment;
(d) To be free from any form of restraint or seclusion used as a means of coercion, discipline,
convenience, or retaliation;
(e) To request and receive a copy of their medical records, and to request that they be amended
or corrected in accordance with Applicable Law; and
(f) To choose a behavioral health care provider.
3.45. Background Checks. Provider shall require a criminal history background check through the
Washington State Patrol for employees and volunteers of Provider who may have unsupervised access to children,
people with developmental disabilities, or vulnerable adults. Further, Provider 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.
3.46. Cultural Considerations.If applicable,Provider shall participate in and cooperate with Health Plan's
efforts to promote the delivery of services in a culturally competent manner to all Covered Persons, including those
with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of gender,
sexual orientation or gender identity.
3.47. Member Self-Determination. Provider shall (a) obtain informed consent prior to treatment from all
Covered Persons,or from persons authorized to consent on behalf of Covered Persons as described in RCW 7.70.065,
(b) comply with the provisions of the Natural Death Act (Chapter 70.122 RCW) and Applicable Law and rules
concerning advance directives and POLST (e.g., WAC 182-501-0125 and 42 C.F.R. § 417.436), and (c) when
appropriate, inform Covered Persons of their right to make anatomical gifts pursuant to Chapter 68.64 RCW.
3.48. Advance Directives and POLST. Provider shall ensure that whether a Covered Person has executed
an advance directive or POLST shall be indicated in a prominent part of such Covered Person's medical records,and
Provider shall not provision care or otherwise discriminate against a Covered Person based on whether the Covered
Person has executed an advance directive or POLST.
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3.49. Mental Health Advance Directives. Provider shall comply with Chapter 71.32 RCW(Mental Health
Advance Directives).
3.50. Insurance. Provider shall have and maintain insurance appropriate to the services to be performed
under the Agreement. Provider shall make copies of certificates of insurance available to HCA upon request.
3.51. Health Home Surety Bond. If Provider is a home health agency, Provider represents and warrants
that it is in compliance with the surety bond requirements of federal law (Section 4708(d) of the Balanced Budget
Act of 1997 and 42 C.F.R. § 441.16).
3.52. Solvency Requirements. If Provider is at financial risk, as defined in the substantial financial risk or
risk provisions in the State Contract, Provider shall be subject to solvency requirements that provide assurance of
Provider's ability to meet its obligations. Such requirements shall be regularly monitored and enforced.
3.53. Physician Incentive Plans. If Provider makes payment to any physician under a physician incentive
plan,such plan shall meet all applicable requirements under the State Contract, including but not limited to disclosure
requirements and stop-loss protection. No payment to Provider, or by Provider 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 Covered Person.
3.54. Information on Ownership and Control.
(a) Provider shall disclose the following information to Health Plan upon Agreement execution,
upon request during the re-validation of enrollment process under 42 C.F.R. § 455.414, and within 35 business days
after any change in ownership of Provider:
(1) The name and address of any person (individual or corporation)with an ownership
or control interest in Provider;
(2) If Provider is a corporate entity, the primary business address, every business
location, and P.O. Box address;
(3) If Provider has corporate ownership, the tax identification number of the corporate
owner(s);
(4) If Provider is an individual, date of birth and Social Security Number;
(5) If Provider has a five percent ownership interest in any of its subcontractors,the tax
identification number of the subcontractor(s);
(6) Whether any person with an ownership or control interest in Provider is related by
marriage or blood as a spouse, parent, child, or sibling to any other person with an ownership or control interest in
Provider;
(7) If Provider has a five percent ownership interest in any of its subcontractors,whether
any person with an ownership or control interest in such subcontractor is related by marriage or blood as a spouse,
parent, child, or sibling to any other person with an ownership or control interest in Provider; and
(8) Whether any person with an ownership or control interest in Provider also has an
ownership or control interest in any managed care entity.
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(b) Upon the request of Health Plan or HCA,Provider shall furnish to HCA,within 35 calendar
days of a request, full and complete business transaction information as follows:
(1) The ownership of any subcontractor with whom Provider has had business
transactions totaling more than $25,000.00 during the previous 12 month period ending on the date of the request;
and
(2) Any significant business transaction between Provider and any wholly owned
supplier or any subcontractor during the previous five year period ending on the date of the request.
Provider shall provide any further information needed or reasonably requested by Health Plan for the purpose of
satisfying Health Plan's HCA reporting requirements under the State Contract, or for the purpose of verifying or
screening for exclusion from federal or state health care programs, or for conviction of various criminal or civil
offences, among the individuals or entities who have an ownership or control interest in, or who are a managing
employee of, Provider.
(c) Upon request, Provider 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 Provider and a party in interest (as defined in Section 1318(b) of the Public Health Service Act)within 35
calendar days of the request, including the following transactions:
(1) Any sale or exchange,or leasing of any property between Provider and such a party;
(2) Any furnishing for consideration of goods, services (including management
services), or facilities between Provider and such a party but not including salaries paid to employees for services
provided in the normal course of their employment; and
(3) Any lending of money or other extension of credit between Provider and such a
party.
3.55. Information on Persons Convicted of Crimes. If the Provider is not an individual practitioner or a
group of practitioners,Provider shall investigate and disclose to Health Plan,at Agreement execution or renewal,and
upon request by Health Plan 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:
(a) A person who has an ownership or control interest in Provider;
(b) An agent or person who has been delegated the authority to obligate or act on behalf of
Provider; and
(c) An agent,managing employee, general manager, business manager, administrator, director,
or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the
day-to-day operation of, Provider.
3.56. 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. All sterilizations and
hysterectomies provided under the Agreement shall be in compliance with 42 C.F.R. § 441 Subpart F, and Provider
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).
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3.57. Grievance and Appeals. Health Plan shall maintain a grievance and appeals system in accordance
with the requirements of the State Contract,and Health Plan shall provide the following information regarding Health
Plan's grievance and appeal system to Provider:
(a) The toll-free numbers to file oral grievances and appeals;
(b) The availability of assistance in filing a grievance or appeal;
(c) The Covered Person's right to request continuation of Medicaid benefits during an appeal or
hearing and, if the Health Plan's adverse benefit determination is upheld,that the Covered Person may be responsible
to pay for the continued benefits;
(d) The Covered Person's right to file grievances and appeals and their requirements and
timeframes for filing;
(e) The Covered Person's right to a hearing, how to obtain a hearing and representation rules at
a hearing; and
(f) Provider may file a grievance or request an adjudicative proceeding on behalf of a Covered
Person in accordance with the State Contract.
3.58. Integrated Patient Record/Clinical Data Repository. If Provider has a certified electronic health
record (EHR) system, Provider shall submit automated exports of standard Continuity of Care Document (CCD)/
Consolidated Clinical Document Architecture (CCDA), or subsequent ONC-specified standard healthcare
transactions, as specified by HCA and consistent with the design of the integrated patient record, from their EHR to
the call detail record(CDR)via the health information exchange(HIE)each time a Covered Person is seen.
3.59. Training. If Provider is a behavioral health network provider, Provider must participate in training
when requested by HCA,unless Provider receives an exception from the HCA after submitting to the HCA a written
exception request along with a plan for how the required information will be provided to the Provider's staff.
3.60. WISe Service Providers. If Provider provides Wraparound with Intensive Services ("WISe")
services, Provider shall adhere to the most current version of the WISe Manual and participate in all WISe-related
activities. Without limiting the generally of the foregoing, Provider shall participate in a review of WISe services
conducted using the WISe Quality Improvement Review Tool(QIRT)at least once during the contract period.
3.61. GAIN-SS. Provider shall use GAIN-SS and assessment process that includes use of the quadrant
placement. Provider shall be subject to corrective action if the Integrated Co-Occurring Disorder Screening and
Assessment process is not implemented and maintained throughout the term of the Agreement.
3.62. Disaster Recovery Plan. If applicable,Provider shall develop and maintain a business continuity and
disaster recovery plan that ensures timely reestablishment of the Covered Person information system following total
loss of the primary system or a substantial loss of functionalist. Provider's plan shall comply with all relevant
requirements in the State Contract and Provider shall cooperate with Health Plan to comply with all related reporting
requirements.
3.63. Indian Health Care Provider. If Provider is an Indian Health Care Provider(IHCP),then it shall be
subject to the "Medicaid and Children's Health Insurance Program (CHIP) Managed Care Addendum for Indian
Health Care Providers(IHCPs)"schedule set forth in the Agreement.
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ATTACHMENT A: Medicaid
Network: CCCWA
EXHIBIT A-3
APPLE HEALTH
COMPENSATION SCHEDULE
PRACTITIONER SERVICES
Jefferson County Public Health
This Compensation Schedule sets forth the maximum reimbursement amounts for the provision of Covered Services
to Covered Persons in a Medicaid Product offered through Health Plan and referred to as Apple Health. For Covered
Services rendered to a Covered Person and billed under a Contracted Provider's tax identification number("TIN")
that has been designated by the Payor as subject to this Compensation Schedule, Payor shall pay or arrange for
payment of a Clean Claim for Covered Services rendered by the Contracted Provider according to the terms of the
Agreement and this Compensation Schedule. Payment under this Compensation Schedule is subject to the
requirements set forth in the Agreement.
For Behavioral Health Agency Covered Services provided to Covered Persons, Contracted Provider's maximum
compensation shall be the Allowed Amount. Except as otherwise provided in this Compensation Schedule the
Allowed Amount is the lesser of: (i) the Contracted Provider's Allowable Charges; or(ii) 100% of the Coordinated
Care Behavioral Health Agency fee schedule in effect on the date of service.
For Covered Services not covered above provided to Covered Persons, Contracted Provider's maximum
compensation shall be the Allowed Amount. Except as otherwise provided in this Compensation Schedule the
Allowed Amount is the lesser of: (i) the Contracted Provider's Allowable Charges; or (ii) 100% of the State's
Medicaid fee schedule in effect on the date of service.
If there is no established payment amount on the State's Medicaid fee schedule for a Covered Service provided to a
Covered Person, Payor may establish a payment amount to apply in determining the Allowed Amount. Until such
time as Payor establishes such a payment amount, Contracted Provider's Allowed Amount shall be 25% of the
Contracted Provider's Allowable Charge.
Additional Provisions:
1. Code Change Updates. Payor utilizes nationally recognized coding structures (including, without limitation,
revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or their
successors) for basic coding and descriptions of the services rendered. Updates to billing-related codes shall
become effective on the date ("Code Change Effective Date")that is the later of: (i)the first day of the month
following 60 days after publication by the governmental agency having authority over the applicable product of
such governmental agency's acceptance of such code updates, (ii) the effective date of such code updates as
determined by such governmental agency or(iii)if a date is not established by such governmental agency or the
product is not regulated by such governmental agency,the date that changes are made to nationally recognized
codes. Such updates may include changes to service groupings. Claims processed prior to the Code Change
Effective Date shall not be reprocessed to reflect any such code updates.
2. Fee Change Updates. Updates to the fee schedule shall become effective on the effective date of such fee
schedule updates, as determined by the Payor ("Fee Change Effective Date"). However, the date of
implementation of any fee schedule updates, i.e. the date beginning on which such fee change is used for
reimbursement ("Fee Change Implementation Date") shall be the later of: (i) the date on which Payor is
reasonably able to implement the update in the claims payment system; or (ii) the Fee Change Effective Date.
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Claims processed prior to the Fee Change Implementation Date shall not be reprocessed to reflect any updates to
such fee schedule, even if service was provided after the Code Change Effective Date.
Definitions:
l. Allowed Amount means the amount designated as the maximum amount payable to a Contracted Provider for
any particular Covered Service provided to any particular Covered Person, pursuant to this Agreement or its
Attachments for Covered Services.
2. Allowable Charges means a Contracted Provider's billed charges for services that qualify as Covered Services
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Attachment C: Commercial-Exchange
AMBETTER
PRODUCT ATTACHMENT
This COMMERCIAL-EXCHANGE PRODUCT ATTACHMENT (this "Product Attachment") is
incorporated into the participating provider agreement(the "Agreement") entered into by and between Health Plan
and Provider(as such entities are defined in the Agreement).
RECITALS
WHEREAS,Health Plan and Provider entered into the Agreement,as the same may have been amended and
supplemented from time to time, pursuant to which Provider and its Contracted Providers or other Downstream
Entities(defined herein)participate in certain Products offered by or available from or through a Company; and
WHEREAS, pursuant to the provisions of the Agreement, Contracted Providers will be designated and
participate as Participating Providers in the Product described in this Product Attachment, and will be considered to
be and will be governed under this Product Attachment as Downstream Entities, as defined in this Product
Attachment; and
WHEREAS,the Agreement is modified or supplemented as hereafter provided.
NOW THEREFORE, in consideration of the recitals, the mutual promises herein stated, the parties hereby
agree to the provisions set forth below.
TERMS
1. Defined Terms. For purposes of the Commercial-Exchange Product, the following terms have the
meanings set forth below. All capitalized terms not specifically defined in this Product Attachment will have the
meanings given to such terms in the Agreement. Citations to governmental authority requirements are being provided
herein for convenience only and shall not affect the meaning or interpretation of the terms of this Attachment. Such
citations may become outdated as these requirements are amended from time to time.
1.1. "Commercial-Exchange Product", also referred to as"Ambetter",refers to those programs
and health benefit arrangements offered by a Company that provide incentives to Covered Persons to utilize the
services of certain contracted providers. The Commercial-Exchange Product includes those Coverage Agreements
entered into,issued or agreed to by a Payor under which a Company furnishes administrative services or other services
in support of a health care program for an individual or group of individuals, which may include access to one or
more of the Company's provider networks or vendor arrangements, and which may be provided in connection with
a state or governmental-sponsored, employer-sponsored or other private health insurance exchange, except those
excluded by Health Plan. The Commercial-Exchange Product does not apply to any Coverage Agreements that are
specifically covered by another Product Attachment to the Agreement.
1.2. "Delegated Entity" means any party, including an agent or broker, that enters into an
agreement with Health Plan to provide administrative services or health care services to qualified individuals,
qualified employers or qualified employees and their dependents(as such terms are defined in 45 C.F.R. §156.20).
1.3. "Downstream Entity" means any party, including an agent or broker, that enters into an
agreement with a Delegated Entity or with another Downstream Entity for purposes of providing administrative or
health care services related to the agreement between the Delegated Entity and Health Plan. The term "Downstream
Entity"is intended to reach the entity that directly provides administrative services or health care services to qualified
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individuals,qualified employers,or qualified employees and their dependents(as such terms are defined in 45 C.F.R.
§156.20).
1.4. "Emergency" or "Emergency Care" has the meaning set forth in the Covered Person's
Coverage Agreement.
1.5. "Emergency Medical Condition" has the meaning set forth in the Covered Person's
Coverage Agreement.
1.6. "State" means the State of Washington, or such other state to the extent that a Coverage
Agreement or Covered Person is subject to such other state's law.
2. Commercial-Exchange Product. This Product Attachment constitutes the "Commercial-Exchange
Product (Ambetter) Attachment" and is incorporated into the Agreement. It supplements the Agreement by setting
forth specific terms and conditions that apply to the Commercial-Exchange Product with respect to which a
Participating Provider has agreed to participate, and with which a Participating Provider must comply in order to
maintain such participation. This Product Attachment applies with respect to the provision of health care services,
supplies or accommodations (including Covered Services) to Covered Persons enrolled in or covered by a
Commercial-Exchange Product.
3. Participation. Except as otherwise provided in this Product Attachment or the Agreement, all
Contracted Providers under the Agreement will participate as Participating Providers in this Commercial-Exchange
Product, and will provide to Covered Persons enrolled in or covered by a Commercial-Exchange Product,upon the
same terms and conditions contained in the Agreement, as supplemented or modified by this Product Attachment,
those Covered Services that are provided by Contracted Providers pursuant to the Agreement. In providing such
services, Provider shall, and shall cause Contracted Providers, to comply with and abide by the provisions of this
Product Attachment and the Agreement(including the Company's policies and procedures).
3.1. Network Name. All Contracted Providers under the Agreement will participate as
Participating Providers in and become part of the CCCWA Exchange network.
4. Attachments. This Product Attachment includes the Compensation Schedules for the Commercial-
Exchange Product,which are incorporated herein by reference.
5. Construction. This Product Attachment supplements and forms a part of the Agreement. Except as
otherwise provided herein or in the terms of the Agreement, the terms and conditions of the Agreement will remain
unchanged and in full force and effect as a result of this Product Attachment. In the event of a conflict between the
provisions of the Agreement and the provisions of this Product Attachment,this Product Attachment will govern with
respect to health care services, supplies or accommodations (including Covered Services) rendered to Covered
Persons enrolled in or covered by a Commercial-Exchange Product. To the extent Provider or any Contracted
Provider is unclear about its, his or her respective duties and obligations, Provider or the applicable Contracted
Provider shall request clarification from the Company.
6. Term. This Product Attachment will be coterminous with the Agreement unless a Party terminates
the participation of the Contracted Provider in this Commercial-Exchange Product in accordance with the applicable
provisions of the Agreement or this Product Attachment.
7. Federal Requirements. The following requirements apply to Delegated and Downstream Entities
under this Product Attachment,which includes but is not limited to Provider and all Contracted Providers.
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7.1. Provider's delegated activities and reporting responsibilities, if any, are specified in the
Agreement or applicable attachment to the Agreement(e.g.,Delegated Credentialing Agreement,Delegated Services
Agreement, Statement or Work,or other scope of services attachment)attached to this Agreement.If such attachment
is not executed, no administrative functions shall be deemed as delegated.
7.2. CMS, Health Plan and Payor reserve the right to revoke the delegation activities and
reporting requirements or to specify other remedies in instances where CMS,Health Plan or the Payor determine that
Provider or any Downstream Entity has not performed satisfactorily.
7.3. Provider and all Downstream Entities must comply with all applicable laws and regulations
relating to the standards specified under 45 CFR §156.340(a);
7.4. Provider and all Downstream Entities must permit access by the Secretary and OIG or their
designees in connection with their right to evaluate through audit, inspection or other means, to the Provider's or
Downstream Entities' books, contracts, computers, or any other electronic systems including medical records and
documentation,relating to Health Plan's obligations in accordance with federal standards under 45 CFR§156.340(a)
until 10 years from the termination date of this Product Attachment.
8. Other Terms and Conditions. Except as modified or supplemented by this Product Attachment, the
compensation hereunder for the provision of Covered Services by Contracted Providers to Covered Persons enrolled
in or covered by the Commercial-Exchange Product is subject to all of the other provisions in the Agreement
(including the Company's policies and procedures) that affect or relate to compensation for Covered Services
provided to Covered Persons.
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I __
Attachment C: Commercial-Exchange
Network: CCCWA Exchange
EXHIBIT C-27
COMPENSATION SCHEDULE
PROFESSIONAL SERVICES
Jefferson County Public Health
This compensation schedule ("Compensation Schedule") sets forth the maximum reimbursement amounts for
Covered Services provided by Contracted Providers to Covered Persons enrolled in a Commercial-Exchange Product.
Where the Contracted Provider's tax identification number ("TIN") has been designated by the Payor as subject to
this Compensation Schedule,Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered
by the Contracted Provider according to the terms of,and subject to the requirements set forth in,the Agreement and
this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as
set forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule
shall have the meanings set forth in the Agreement,the applicable Product Attachment, or the Definitions section set
forth at the end of this Compensation Schedule.
The maximum compensation for professional Covered Services rendered to a Covered Person shall be the"Allowed
Amount." Except as otherwise provided in this Compensation Schedule, the Allowed Amount for professional
Covered Services is the lesser of: (i)Allowable Charges; or(ii) 100%of the Medicare Fee Schedule in effect on the
date of service.
Additional Provisions:
1. Code Change Updates. Payor utilizes nationally recognized coding structures (including, without limitation,
revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or their
successors) for basic coding and descriptions of the services rendered. Updates to billing-related codes shall
become effective on the date ("Code Change Effective Date") that is the later of: (i) the first day of the month
following 60 days after publication by the governmental agency having authority over the applicable Product of
such governmental agency's acceptance of such code updates, (ii) the effective date of such code updates as
determined by such governmental agency or(iii) if a date is not established by such governmental agency or the
applicable Product is not regulated by such governmental agency, the date that changes are made to nationally
recognized codes. Such updates may include changes to service groupings. Claims processed prior to the Code
Change Effective Date shall not be reprocessed to reflect any such code updates.
2. Fee Change Updates. Updates to the fee schedule shall become effective on the effective date of such fee
schedule updates,as determined by the Payor("Fee Change Effective Date"). The date of implementation of any
fee schedule updates, i.e. the date on which such fee change is first used for reimbursement ("Fee Change
Implementation Date"), shall be the later of: (i)the first date on which Payor is reasonably able to implement the
update in the claims payment system; or(ii)the Fee Change Effective Date. Claims processed prior to the Fee
Change Implementation Date shall not be reprocessed to reflect any updates to such fee schedule, even if service
was provided after the Fee Change Effective Date.
3. Fee Sources. In the event CMS contains no published fee amount, alternate (or"gap fill") fee sources may be
used to supply the fee basis amount for deriving fee amount(the"Alternative Fee Source Amount"). Health Plan
will utilize such Alternative Fee Source Amount until such time that CMS publishes its own resource-based
relative value scale(RBRVS)value. At such time in the future as CMS publishes its own RBRVS value for that
CPT/HCPCS code,Payor will use the CMS fee amount for that code and no longer use the Alternate Fee Source
Amount. If CMS has no published fee amount or a gap fill fee source is not available for a Covered Service
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provided to a Covered Person, Payor may establish a payment amount to apply in determining the Allowed
Amount. Until such time as Payor establishes such a payment amount,the maximum compensation shall be 30%
of Allowable Charges.
4. Modifier. Unless specifically indicated otherwise, fee amounts listed in the fee schedule represent global fees
and may be subject to reductions based on appropriate Modifier (for example, professional and technical
modifiers).As used in the previous sentence,"global fees"refers to services billed without a Modifier,for which
the fee amount includes both the professional component and the technical component. Any Cost-Sharing
Amounts that the Covered Person is responsible to pay under the Coverage Agreement will be subtracted from
the Allowed Amount in determining the amount to be paid.
5. Anesthesia Modifier Pricing Rules. The dollar amount that will be used in the calculation of time-based and non-
time based anesthesia management fees in accordance with the anesthesia payment policy. Unless specifically
stated otherwise, the anesthesia conversion factor indicated is fixed and will not change. The anesthesia
conversion factor is based on an anesthesia time unit value of 15 minutes.
6. Place of Service Pricing Rules. This fee schedule follows CMS guidelines for determining when services are
priced at the facility or non-facility fee schedule(with the exception of services performed at Ambulatory Surgery
Centers,POS 24,which will be priced at the facility fee schedule).
7. Carve-Out Services. With respect to any"Carve-Out"Covered Services as contemplated in this Agreement,any
payment arrangement entered into between Provider and a third party vendor of such services shall supersede
compensation hereunder.
8. Payment under this Compensation Schedule. Claims should be coded appropriately according to industry
standard coding guidelines (including but not limited to UB Editor, AMA, CPT, CPT Assistant, HCPCS, DRG
guidelines, CMS' National Correct Coding Initiative (CCI) Policy Manual, CCI table edits and other CMS
guidelines). All payments under this Compensation Schedule are subject to the terms and conditions set forth in
the Agreement and applicable policies and procedures.
Definitions:
1. Allowable Charges means a Contracted Provider's billed charges for services that qualify as Covered Services.
2. Allowed Amount means the amount designated in this Compensation Schedule as the maximum amount payable
to a Contracted Provider for any particular Covered Service provided to any particular Covered Person,pursuant
to this Agreement or its Attachments.
3. Cost-Sharing Amounts means any amounts payable by a Covered Person, such as copayments, cost-sharing,
coinsurance, deductibles or other amounts that are the Covered Person's financial responsibility under the
applicable Coverage Agreement, if applicable.
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Attachment F: Cascade Care Select Public Option
EXHIBIT F-0
CASCADE CARE SELECT PUBLIC OPTION
PRODUCT ATTACHMENT
This CASCADE CARE SELECT PRODUCT ATTACHMENT(this"Product Attachment")is incorporated
into the participating provider agreement(the "Agreement") entered into by and between Health Plan and Provider
(as such entities are defined in the Agreement).
RECITALS
WHEREAS,Health Plan and Provider entered into the Agreement,as the same may have been amended and
supplemented from time to time, pursuant to which Provider and its Contracted Providers or other Downstream
Entities(defined herein)participate in certain Products offered by or available from or through Health Plan; and
WHEREAS, Health Plan has contracted with HCA to arrange for the provision of health care service to
Covered Persons enrolled in a Public Option Plan(defined herein), and
WHEREAS, this Product Attachment is intended to supplement the Agreement by setting for the parties'
rights and responsibilities related to the provision of Covered Services as it pertains to the Cascade Care Select Public
Option Product; and
WHEREAS, pursuant to the provisions of the Agreement, Contracted Providers will be designated and
participate as Participating Providers in the Product described in this Product Attachment, and will be considered to
be and will be governed under this Product Attachment as Downstream Entities, as defined in this Product
Attachment; and
WHEREAS,the Agreement is modified or supplemented as hereafter provided.
NOW THEREFORE, in consideration of the recitals, the mutual promises herein stated, the parties hereby
agree to the provisions set forth below.
TERMS
1. Defined Terms. For purposes of the Cascade Care Select Product, the following terms have the
meanings set forth below. All capitalized terms not specifically defined in this Product Attachment will have the
meanings given to such terms in the Agreement. Citations to the PO HCA Contract or other governmental authority
requirements are being provided herein for convenience only and shall not affect the meaning or interpretation of the
terms of this Attachment. Such citations may become outdated as these requirements are amended from time to time.
1.1. "Breach" means the unauthorized acquisition, access, use, or disclosure of Confidential
Information that compromises the security, confidentiality, or integrity of the Confidential Information.
1.2. "Cascade Care Select Product",also referred to as"Cascade Care Select",refers the Public
Option Plan offered by Health Plan that provide incentives to Covered Persons to utilize the services of certain
contracted providers and which are subject to the terms and conditions specified in Engrossed Substitute Senate Bill
5526 (2019)and the rules promulgated thereunder, as they may be amended or repealed.
1.3. "Carrier"means a disability insurer regulated under chapter 48.20 or 48.21 RCW, a health
care service contractor as defined in RCW 48.44.010, or a health maintenance organization as defined in RCW
48.46.020.
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1.4. "Confidential Information" means information that may be exempt from disclosure to the
public or other unauthorized persons under chapter 42.56 RCW or chapter 70.02 RCW or other state or federal statutes
or regulations. Confidential Information includes, but is not limited to, any information identifiable to an individual
that relates to a natural person's health (see also Protected Health Information), finances, education, business,use or
receipt of governmental services, names, addresses, telephone numbers, social security numbers, driver license
numbers, financial profiles, credit card numbers, financial identifiers and any other identifying numbers, law
enforcement records, HCA source code or object code, or HCA or State security information.
1.5. "Delegated Entity" means any party, including an agent or broker, that enters into an
agreement with Health Plan to provide administrative services or health care services to qualified individuals,
qualified employers or qualified employees and their dependents(as such terms are defined in 45 C.F.R. §156.20).
1.6. "Downstream Entity" means any party, including an agent or broker, that enters into an
agreement with a Delegated Entity or with another Downstream Entity for purposes of providing administrative or
health care services related to the agreement between the Delegated Entity and Health Plan. The term "Downstream
Entity"is intended to reach the entity that directly provides administrative services or health care services to qualified
individuals,qualified employers,or qualified employees and their dependents(as such terms are defined in 45 C.F.R.
§156.20).
1.7. "HCA" means the State of Washington Health Care Authority and its employees and
authorized agents.
1.8. "Medicare" means the health insurance program for the aged and disabled under title XVIII
of the Social Security Act.
1.9. "PO HCA Contract" means the Contract for Cascade Care Select Public Option Plans on
the Washington Healthplanfinder entered into by and between HCA and Health Plan.
1.10. "Protected Health Information"or"PHI"means individually identifiable information that
relates to the provision of health care to an individual; the past, present, or future physical or mental health or
condition of an individual; or past,present,or future payment for provision of health care to an individual,as defined
in 45 CFR 160.103. Individually identifiable information is information that identifies the individual or about which
there is a reasonable basis to believe it can be used to identify the individual, and includes demographic information.
PHI is information transmitted,maintained,or stored in any form or medium.45 CFR 164.501. PHI does not include
education records covered by the Family Educational Rights and Privacy Act, as amended, 20 USC
1232g(a)(4)(b)(iv).
1.11. "Public Option Participating Provider" means a Participating Provider who provides
Covered Services to Covered Persons pursuant to Health Plan's Public Option Plan.
1.12. "Public Option Plan" means a qualified health plan procured by HCA and offered on the
Health Benefit Exchange as described in RCW 41.05.410 that meets the standard plan design and additional
affordability and quality metrics required by applicable law.
1.13. "Standard Plan" means a standardized health benefit plan design developed by the Health
Benefit Exchange to provide consistent cost-sharing and benefit design across all Carriers; allows consumers the
ability to compare plans across Carriers.
1.14. "State" means the State of Washington, or such other state to the extent that a Coverage
Agreement or Covered Person is subject to such other state's law.
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2. Cascade Care Select Product. This Product Attachment constitutes the"Cascade Care Select Product
(Cascade Complete Care) Attachment" and is incorporated into the Agreement. It supplements the Agreement by
setting forth specific terms and conditions that apply to the Cascade Care Select Product with respect to which a
Participating Provider has agreed to participate, and with which a Participating Provider must comply in order to
maintain such participation. This Product Attachment applies with respect to the provision of health care services,
supplies or accommodations (including Covered Services)to Covered Persons enrolled in or covered by a Cascade
Care Select Product.
3. Compliance with PO HCA Contract. Provider shall comply with any term or condition of the PO
HCA Contract that is applicable to the services to be performed under the Agreement.
4. Public Option Plan Reimbursement. Provider acknowledges that the following reimbursement
obligations govern the Health Plan's overall administration of the Cascade Care Select Product's Public Option Plan
and Provider agrees that its reimbursement is subject to the obligations described herein.
4.1. Participating Provider. The total amount of reimbursement provided by Health Plan to all
Public Option Participating Providers for the provision of Covered Services in the statewide aggregate to Covered
Persons will not exceed 160%of the total amount that would have been reimbursed under the Medicare program for
provision of same or similar services in the statewide aggregate.
4.2. Rural Provider. The reimbursement rate provided by Health Plan to Public Option
Participating Providers that are certified as rural hospitals by CMS,such as critical access hospitals or sole community
hospitals,for the provision of Covered Services to Covered Persons will not be less than 101%of allowable costs,as
defined by CMS for purposes of Medicare cost reporting.
4.3. Primary Care Services. The reimbursement provided by Provider to a Public Option
Participating Provider who is a physician with a primary specialty designation of family medicine, general internal
medicine, or pediatric medicine for the provision of primary care services, as defined by HCA, to Covered Persons
will not be less than 135%of the amount that would have been reimbursed under the Medicare program for provision
of the same or similar services.
4.4. Compensation Schedule Override. In the event that Health Plan is obligated to modify
compensation to Participating Providers in order to comply with the requirements described in this Section 12.4,
Health Plan shall provide 60 day notice of such change to the extent commercially reasonable. Provider may choose
not to accept the terms of any change in compensation by giving 60 day notice of intent to terminate this Product
Attachment.
5. Participation. Except as otherwise provided in this Product Attachment or the Agreement, all
Contracted Providers under the Agreement will participate as Participating Providers in this Cascade Care Product,
and will provide to Covered Persons enrolled in or covered by a Cascade Care Product, upon the same terms and
conditions contained in the Agreement, as supplemented or modified by this Product Attachment, those Covered
Services that are provided by Contracted Providers pursuant to the Agreement. In providing such services, Provider
shall, and shall cause Contracted Providers, to comply with and abide by the provisions of this Product Attachment
and the Agreement(including the Company's policies and procedures).
5.1. Network Name. All Contracted Providers under the Agreement will participate as
Participating Providers in and become part of the Cascade Complete Care network.
6. Attachments. This Product Attachment includes the Compensation Schedule(s)for the Cascade Care
Select Product,which are incorporated herein by reference.
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7. Construction. This Product Attachment supplements and forms a part of the Agreement. Except as
otherwise provided herein or in the terms of the Agreement,the terms and conditions of the Agreement will remain
unchanged and in full force and effect as a result of this Product Attachment. In the event of a conflict between the
provisions of the Agreement and the provisions of this Product Attachment,this Product Attachment will govern with
respect to health care services, supplies or accommodations (including Covered Services) rendered to Covered
Persons enrolled in or covered by a Cascade Care Select Product. To the extent Provider or any Contracted Provider
is unclear about its,his or her respective duties and obligations,Provider or the applicable Contracted Provider shall
request clarification from Health Plan.
8. Term. This Product Attachment will be coterminous with the Agreement unless a Party terminates
the participation of the Contracted Provider in this Cascade Care Product in accordance with the applicable provisions
of the Agreement or this Product Attachment.
9. Confidential Information. If HCA Confidential Information provided to Health Plan under the PO
HCA Contract is to be shared with Provider,then the following provisions will apply:
9.1. All Confidential Information Security Requirements("Security Requirements")described in
"Attachment 1"to the PO HCA Contract are incorporated herein by reference in their entirety. Provider will comply
with all applicable laws, regulations and Security Requirements while acquiring, accessing, using, disclosing or
otherwise maintaining HCA Confidential Information.
9.2. Provider will comply with all applicable requirements of the PO HCA Contract in the event
of any Breach or suspected Breach of Confidential Information. Provider agrees to indemnify and hold harmless
Health Plan for any damages related to unauthorized use or disclosure of Confidential Information by Provider, its
officers, directors, employees, subcontractors or agents. This obligation shall survive termination of this Product
Attachment and the Agreement.
10. Debarment Certification. Provider 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. Provider shall immediately notify Health Plan in writing if, during the
term of the Agreement, (a) Provider becomes debarred, suspended, proposed for debarment, declared ineligible or
voluntarily excluded, or (b) Provider or any of Provider's employees are subject to disciplinary action against
accreditation, certification, license and/or registration. Further, Provider shall not pay for goods and services
furnished by an excluded person, at the medical direction, or on the prescription of an excluded person.
11. Work Product Rights. All data and work products produced pursuant to PO HCA Contract
(collectively"Work Product")will be considered work for hire under the U.S.Copyright Act, 17 U.S.C. §101 et seq,
and will be owned by HCA.Provider will not copy or disclose,transmit or perform any Work Product or any portion
thereof, in any form,to any third party.
12. Site Security. While on HCA premises, Provider will conform in all respects with physical, fire or
other security policies or regulations.
13. Subcontracting and Assignment.
13.1. Provider will not enter into subcontracts for any work contemplated under the PO HCA
Agreement without obtaining prior written approval of HCA. Provider will not enter into subcontracts for the
provision of Covered Services to Covered Persons or any other work contemplated under this Product Attachment
without obtaining prior written approval from Health Plan.
13.2. To the extent that the Agreement is considered a "Subcontract" requiring HCA approval
under the PO HCA Contract,the Agreement will not take effect prior to HCA's review and written approval.
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13.3. Provider acknowledges and agrees that no assignment of the Agreement shall take effect
without the prior written agreement of HCA.
14. Federal Requirements. The following requirements apply to Delegated and Downstream Entities
under this Product Attachment.
14.1. Provider's delegated activities and reporting responsibilities, if any, are specified in the
Agreement or applicable attachment to the Agreement(e.g.,Delegated Credentialing Agreement,Delegated Services
Agreement,Statement of Work,or other scope of services attachment)attached to this Agreement.If such attachment
is not executed, no administrative functions shall be deemed as delegated.
14.2. CMS, Health Plan and Payor reserve the right to revoke the delegation activities and
reporting requirements or to specify other remedies in instances where CMS,Health Plan or the Payor determine that
Provider or any Downstream Entity has not performed satisfactorily.
14.3. Provider and all Downstream Entities must comply with all applicable laws and regulations
relating to the standards specified under 45 CFR §156.340(a);
14.4. Provider and all Downstream Entities must permit access by the Secretary and OIG or their
designees in connection with their right to evaluate through audit, inspection or other means, to the Provider's or
Downstream Entities' books, contracts, computers, or any other electronic systems including medical records and
documentation,relating to Health Plan's obligations in accordance with federal standards under 45 CFR§156.340(a)
until 10 years from the termination date of this Product Attachment.
15. Termination. If at any time HCA determines that Provider is incompetent or undesirable and notifies
the Health Plan of such determination, then Health Plan will immediately terminate this Product Attachment and
notify Provider of the termination. Upon receiving a notice of termination, Provider must immediately cease
performance of all Covered Services and other work under this Product Attachment.
16. Other Terms and Conditions. Except as modified or supplemented by this Product Attachment,the
compensation hereunder for the provision of Covered Services by Contracted Providers to Covered Persons enrolled
in or covered by the Cascade Care Product is subject to all of the other provisions in the Agreement(including Health
Plan's policies and procedures) that affect or relate to compensation for Covered Services provided to Covered
Persons.
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ATTACHMENT F: Cascade Care Select Public Option
Network: Cascade Complete Care
EXHIBIT F-2
CASCADE CARE SELECT PUBLIC OPTION
COMPENSATION SCHEDULE
PRACTITIONER SERVICES
Jefferson County Public Health
This Compensation Schedule sets forth the maximum reimbursement amounts for the provision of Covered Services
to Covered Persons in a Cascade Care Select Product offered through Health Plan. For Covered Services rendered
to a Covered Person and billed under a Contracted Provider's tax identification number ("TIN") that has been
designated by the Payor as subject to this Compensation Schedule,Payor shall pay or arrange for payment of a Clean
Claim for Covered Services rendered by the Contracted Provider according to the terms of the Agreement and this
Compensation Schedule. Payment under this Compensation Schedule is subject to the requirements set forth in the
Agreement, which include reducing the Allowed Amount by the applicable Cost-Sharing Amounts and the Public
Option Plan Reimbursement obligations described in the Cascade Care Select Product Attachment.
For Practitioner Covered Services provided to Covered Persons,Contracted Provider's maximum compensation shall
be the Allowed Amount. Except as otherwise provided in this Compensation Schedule, the Allowed Amount is the
lesser of: (i) the Contracted Provider's Allowable Charges; or (ii) 100% of the Medicare Fee Schedule in effect on
the date of service.
For Primary Care Practitioner Covered Services provided to Covered Persons, Contracted Provider's maximum
compensation shall be the Allowed Amount. Except as otherwise provided in this Compensation Schedule, the
Allowed Amount is the lesser of: (i)the Contracted Provider's Allowable Charges; or(ii) 135%of the Medicare Fee
Schedule in effect on the date of service.
Multiple Procedure Pricing Rules. Multiple procedures performed during the same day will be reimbursed at 100%
for the primary procedure, 50% for the second procedure, and 50% for the third procedure, subsequent procedures
shall not be eligible for reimbursement.
Additional Provisions:
1. Code Change Updates. Payor utilizes nationally recognized coding structures (including, without limitation,
revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or their
successors) for basic coding and descriptions of the services rendered. Updates to billing-related codes shall
become effective on the date ("Code Change Effective Date") that is the later of: (i)the first day of the month
following 60 days after publication by the governmental agency having authority over the applicable product of
such governmental agency's acceptance of such code updates, (ii) the effective date of such code updates as
determined by such governmental agency or(iii) if a date is not established by such governmental agency or the
product is not regulated by such governmental agency, the date that changes are made to nationally recognized
codes. Such updates may include changes to service groupings. Claims processed prior to the Code Change
Effective Date shall not be reprocessed to reflect any such code updates.
2. Fee Change Updates. Updates to the fee schedule shall become effective on the effective date of such fee
schedule updates, as determined by the Payor ("Fee Change Effective Date"). However, the date of
implementation of any fee schedule updates, i.e. the date beginning on which such fee change is used for
reimbursement ("Fee Change Implementation Date") shall be the later of: (i) the date on which Payor is
reasonably able to implement the update in the claims payment system; or (ii) the Fee Change Effective Date.
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Claims processed prior to the Fee Change Implementation Date shall not be reprocessed to reflect any updates to
such fee schedule, even if service was provided after the Code Change Effective Date.
3. Modifier. Unless specifically indicated otherwise,the Allowed Amount represents global fees and may be subject
to reductions based on appropriate modifiers(for example,professional and technical modifiers). As used in the
previous sentence, "global fees" refers to services billed without a modifier, for which the Allowed Amount
includes both the professional component and the technical component.
4. Anesthesia Modifier Pricing Rules. The dollar amounts that will be used in the calculation of Anesthesia
Management fees are in accordance with the Anesthesia Payment Policy. Unless specifically stated otherwise,
the Anesthesia Conversion Factor indicated is fixed and will not change. The Anesthesia Conversion Factor is
based on an anesthesia time unit value of 15 minutes.
5. Place of Service Pricing Rules. Payor will follow CMS guidelines for determining when services are priced at
the facility or non-facility fee schedule(with the exception of services performed at Ambulatory Surgery Centers,
POS 24,which will be priced at the facility fee schedule).
Definitions:
1. Allowed Amount means the amount designated as the maximum amount payable to a Contracted Provider for
any particular Covered Service provided to any particular Covered Person, pursuant to this Agreement or its
Attachments for Covered Services.
2. Allowable Charges means a Contracted Provider's billed charges for services that qualify as Covered Services.
3. Cost-Sharing Amounts means any amounts payable by a Covered Person, such as copayments, cost-sharing,
coinsurance, deductibles or other amounts that are the Covered Person's financial responsibility under the
applicable Coverage Agreement, if applicable.
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