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EXHIBIT C ASURIS NORTHWEST HEALTH PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT REIMBURSEMENT METHODOLOGY AND FEE SCHEDULE THIS EXHIBIT TO THE PARTICIPATING PROVIDER MEDICAL GROUP AGREEMENT (the "Agreement") is effective for dates of service on or after the effective date of the Agreement and replaces and supersedes any prior payment and/or rate exhibits. Any term not defined herein shall have the meaning set forth in the Agreement. DEFINITIONS 1.1 Billed Charges —charges submitted by Medical Group for Covered Services. 1.2 Maximum Allowable — the amount that Company agrees to pay, subject to standard Company administrative guidelines, reimbursement policies and payment methodologies, including but not limited to reimbursement for CPT® code modifiers. 1.3 Anesthesia Services — services described by CPT® codes to which the American Society of Anesthesiologists has assigned a base unit. 1.4 Total Anesthesia Units — ASA base unit for a CPT® code plus time units, which are defined as total time for a service in 15 -minute increments. Sixty minutes is 4 time units. Per the Company's reimbursement policy, after one minute, Company rounds units up to the next 15 -minute increment. 1.5 CMS RVUs — the Centers for Medicare and Medicaid Services (CMS) site -of -service based (facility or non -facility), non-GPCI adjusted Relative Value Units (RVUs), which are updated annually in the Federal Register. The Company shall provide notice as described in Article V below of the CMS RVUs in effect for a particular date of service. 1.6 Ingenix RVUs — (formerly known as St. Anthony's RVU's) the site -of -service based (facility or non -facility), non-GPCI adjusted Relative Value Units in The Essential RBRVS - A Comprehensive Listing of RBRVS Values for CPT® and HCPCS Codes, published by Ingenix. The Company shall provide notice as described in Article V below of the Ingenix RVUs in effect for a particular date of service. II. FEE SCHEDULE/PAYMENT METHODOLOGY Applies to Participating and Preferred Plan Provider Networks when applicable by appropriate network participation. 2.1 Medical Group agrees to accept as payment in full the lesser of Billed Charges or the Maximum Allowable for Covered Services provided to Members. 2.2 The Maximum Allowable for covered Anesthesia Services shall be calculated by multiplying the anesthesia conversion factor established by the Company for the date of service, times the Total Anesthesia Units for the service. 2.3 The Maximum Allowable for Covered Services provided by MDs and DOs shall be calculated by multiplying the MD/DO conversion factor established by the Company for the date of service times the CMS RVU, except as noted below. The Maximum Allowable for Covered Services provided by ARNPs and PAs shall be calculated by multiplying the ARNP/PA conversion factor established by the Company for the date of service times the CMS RVU, except as noted below: 2.3.1 For services with professional and technical components, the associated global Maximum Allowable for Covered Services will equal the sum of these components. 2.3.2 The Maximum Allowable for Covered Services included in Medicare's Clinical Diagnostic laboratory fee schedule shall be a percentage, as established by the Company for the date of service, of the most current version of that fee schedule. 2.3.3 The Maximum Allowable for Covered Services for the following shall be the amount set forth on the Company's fee schedule: Asuris Medical Standard MGA Exhibit C Al8816854AA Page 1 of 2