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EXHIBIT D PROVIDER DISPUTE RESOLUTION PROCESSES Glossary Adverse Determination: For purpose of the appeal process means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of any of the following: • application of utilization review; • determination that a treatment is not Medically Necessary; or • Billing Dispute. Appeal Record: Includes all information which was relied upon in making the payment determination; or was submitted, considered, or generated in the course of making the payment determination, whether or not such document, record, or other information was relied upon in making the payment determination; or demonstrates compliance with the Company's Claims procedures, administrative processes and safeguards; or constitutes a statement of policy or guidance with respect to the payment determination. Billing Dispute: A dispute with a Provider arising from Covered Services provided to Members by such Provider concerning: • the Company's application of coding and payment rules and methodologies for fee for service claims (including bundling and downcoding), • application of a Current Procedural Terminology (CPT°) modifier, and/or other reassignment of a code by the Company to patient specific factual situations, including the appropriate payment when two or more CPT Codes are billed together, or whether a payment enhancing modifier is appropriate. Claims: A Provider's request for payment submitted in the usual course of business between the Provider and the Company. External Review: Review of a Billing Dispute Appeal or a Medical Necessity Procedure Appeal submitted to the External Review Organization with which the Company has contracted to provide these review services by a Provider in compliance with the terms of the Adverse Determination Appeal Process. External Review Organization ("ERO"): An independent organization employing physicians and other medically qualified individuals or experts, which acts as the decision maker for External Reviews, through an independent contractor relationship with the Company. Provider: Provider means practitioner, clinic, provider, or other health care provider as defined in the Agreement. "Our" or "We": References to our or we mean Asuris Northwest Health or the Company. "You" or "Your": References to you or your mean Medical Group as defined in the Agreement Asuris Standard MGA Exhibit D Dispute Resolution Process A18816854AA Page 1 of 9