SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

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MEDICAID PARTICIPATION ATTACHMENT TO THE WELLPOINT WASHINGTON, INC. PROVIDER AGREEMENT This is a Medicaid Participation Attachment ("Attachment") to the Wellpoint Provider Agreement ("Agreement"), entered into by and between Wellpoint and Provider and is incorporated into the Agreement. ARTICLE I DEFINITIONS The following definitions shall apply to this Attachment. Terms not otherwise defined in this Attachment shall carry the meaning set forth in the Agreement. "Clean Claim" means a claim that can be processed without obtaining additional information from the provider of the service or from a third party and 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. "Medicaid Program(s)" means, for purposes of this Attachment, a medical assistance program provided under a Health Benefit Plan approved under Title XVI, (Supplemental Security Income), Title XIX (Medicaid) and/orTitle XXI (Children's Health Insurance Program "CHIP Program(s)") of the Social Security Act or any other federal or state funded program or product as designated by Wellpoint. "Medicaid Covered Services" means, for purposes of this Attachment, only those Covered Services provided under Plan's Medicaid Program(s); health care services that HCA determines are covered for enrollees, those health care services (including Behavioral Health Care Services) that a Medicaid Member is entitled to receive through Wellpoint pursuant to Regulatory Requirements, and for which a PCS is attached hereto setting forth the Providers' reimbursement under one or more Programs. Medicaid Covered Services do not include the preventable adverse events as set forth in the provider manual(s). "Medicaid Member" means, for purposes of this Attachment, a Member who is enrolled in Plan's Medicaid Program(s) "Medically Necessary/Medical Necessity" means services that are "medically necessary" as is defined in WAC 182- 500-0070, a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions in the Medicaid Member that endanger life, or cause suffering of pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity, or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the Medicaid Member requesting the service. For the purpose of this Attachment, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all. "State Agency" means the Washington Health Care Authority ("HCA") or other duly authorized state agency ARTICLE II SERVICES/OBLIGATIONS 2.1 Participation -Medicaid Network. As a participant in Wellpoint's Medicaid Network, Provider will render Medicaid Covered Services to Medicaid Members in accordance with the terms and conditions of the Agreement and this Attachment consistent with the provisions of 42 CFR 434.6. Such Medicaid Covered Services provided shall be within the scope of Provider's licensure, expertise, and usual and customary range of services pursuant to the tenns and conditions of the Agreement and this Attachment, and Provider shall be responsible to Wellpoint for his/her/its performance hereunder. Provider shall release to Wellpoint any information necessary for Wellpoint to perform any of its obligations under the Agreement or under the Government Contract. Except as set forth in this Attachment or the Plan Compensation Schedule ("PCS"), all terms and conditions of the Agreement will apply to Provider's participation in Wellpoint's Medicaid Network. The terms and conditions set forth in this Attachment are limited to the provision of and payment for Health Services provided to Medicaid Members. WellPoint shall ensure that Provider furnishes Health Services to each Medicaid Member without regard to the Medicaid Member's enrollment in the plan as a private purchaser of the plan or as a participant in publicly financed programs of health care services. This requirement does not apply to circumstances when the Provider should not render services due to limitations arising from lack of training, experience, skill, or licensing restrictions." Washington Enterprise Prodder Agreement Medicaid Attachment 17 1183932156 0 2024 July— Wellpoint Washington, Inc. 05/05/2025