SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

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abuse, or misconduct to Wellpoint. Provider shall also refer all potential allegations of fraud to HCA and the Medicaid Fraud Control Division (MFCD) as described in 42 C.F.R § 455.23. 2.5 Plan Marketinq/Information Requirements. Provider agrees to abide by Plan's marketing/information requirements. Provider shall forward to Plan for prior approval all flyers, brochures, letters and pamphlets Provider intends to distribute to Wellpoint's Medicaid Members concerning its payor affiliations, or changes in affiliation or relating directly to the Medicaid population. Provider will not distribute any marketing or recipient informing materials without the consent of Plan or the applicable State Agency. 2.6 Schedule of Benefits and Determination of Medicaid Covered Services. Wellpoint shall make available upon Provider's request schedules of Medicaid Covered Services for applicable Medicaid Program(s), and will notify Provider in a timely manner of any material amendments or modifications to such schedules. 2.7 Medicaid Member Verification. Provider shall establish a Medicaid Member's eligibility for Medicaid Covered Services prior to rendering services, except in the case of an Emergency Condition, as defined in the PCS, where such verification may not be possible. In the case of an Emergency Condition, Provider shall establish a Medicaid Member's eligibility as soon as reasonably practical. Plan shall provide a system for Providers to contact Plan to verify a Medicaid Member's eligibility twenty-four (24) hours a day, seven (7) days per week. Nothing contained in this Attachment orthe Agreement shall, or shall be construed to, require advance notice, coverage verification, or pre -authorization for Emergency Services, as defined in the PCS, provided in accordance with the federal Emergency Medical Treatment and Labor Act ("EMTALA") prior to Provider's rendering such Emergency Services. 2.8 Hospital Affiliation and Privileges. To the extent required under Plan's credentialing requirements, Provider or any Participating Providers employed by or under contract or subcontract with Provider shall maintain privileges to practice at one or more of Wellpoint's participating hospitals orfurnish documentation to Wellpoint that referral arrangements have been made with another Wellpoint contracted provider to assume the Participating Provider admission responsibilities of Provider. In addition, in accordance with the Change in Provider Information Section of the Agreement, Provider shall immediately notify Wellpoint in the event any such hospital privileges are revoked, limited, surrendered, or suspended at any hospital or health care facility. 2.9 Participating Provider Requirements. If Provider is a group provider, Provider shall require that all Participating Providers employed by or under contract or subcontract with Provider comply with all terms and conditions of the Agreement and this Attachment. Notwithstanding the foregoing, Provider acknowledges and agrees that Wellpoint is not obligated to accept as Participating Providers all providers employed by or under contract or subcontract with Provider. 2.10 Coordinated and Managed Care. Provider shall participate in utilization management and care management programs designed to facilitate the coordination of services as referenced in the applicable provider manual(s). 2.11 Representations and Warranties. Provider represents and warrants that all information provided to Wellpoint is true and correct as of the date such information is furnished, and that Provider is unaware of any undisclosed facts or circumstances that would make such information inaccurate or misleading. Provider further represents and warrants that Provider: (i) is legally authorized to provide the services contemplated hereunder; (it) is qualified to participate in all applicable Medicaid Program(s); (!it) is not in violation of any licensure or accreditation requirement applicable to Provider under Regulatory Requirements; (iv) has not been convicted of bribery or attempted bribery of any official or employee of the jurisdiction in which Provider operates, nor made an admission of guilt of such conduct which is a matter of record; (v) is capable of providing all data related to the services provided hereunder in a timely manner as reasonably required by Wellpoint to satisfy its internal requirements and Regulatory Requirements, including, without limitation, data required under the Healthcare Effectiveness Data and Information Set ("HEDIS") and National Committee for Quality Assurance ("NCQA") requirements; and (vi) is not, to Provider's best knowledge, the subject of an inquiry or investigation that could foreseeably result in Provider failing to comply with the representations set forth herein. In accordance with the Change in Provider Information Section of the Agreement, Provider shall immediately provide Wellpoint with written notice of any material changes to such information. ARTICLE III COMPENSATION AND AUDIT 3.1 Submission and Adjudication of Medicaid Claims. Unless otherwise instructed, or required by Regulatory Requirements, Providershall submit Claims to Plan, using appropriate and current Coded Service Identifer(s), within three hundred sixty-five (365) days from the date the Health Services are rendered or Plan may refuse Washington Enterprise Provider Agreement Medicaid Attachment 19 1183932156 ©2024 July— Welipoint Washington, Inc. 05/05/2025