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manual(s), notices and communications related to this Agreement, the term "Member" may be used interchangeably
<br />with the terms Insured, Covered Person, Covered Individual, Enrollee, Subscriber, Dependent Spouse/Domestic
<br />Partner, Child, Beneficiary or Contract Holder, and the meaning of each is synonymous with any such other.
<br />"Network" means a group of providers that support, through a direct or indirect contractual relationship, one or more
<br />product(s) and/or program(s) in which Members are enrolled.
<br />"Other Payors" means persons orentities, pursuant to an agreement with Wellpoint or an Affiliate, that access the rates,
<br />terms or conditions of this Agreement with respect to certain Network(s), excluding Government Programs unless
<br />otherwise set forth in any Participation Attachment(s) for Government Programs. Other Payors include, without
<br />limitation, employers or insurers providing Health Benefit Plans pursuant to partially or wholly insured, self-administered
<br />or self -insured programs.
<br />"Participating Provider" means a person, including but not limited to, a physician or other health care professional or
<br />entity, including but not limited to a hospital, health care facility, a partnership of such professionals, or a professional
<br />corporation, or an employee or subcontractor of such person or entity, that is party to an agreement to provide Covered
<br />Services to Members that has met all applicable required Plan credentialing requirements, standards of participation
<br />and accreditation requirements for the services the Participating Provider provides, and that is designated by Plan to
<br />participate in one or more Network(s). Unless otherwise specifically delineated, all references herein to "Provider" may
<br />also mean and refer to "Participating Provider".
<br />"Participation Attachment(s)" means the document(s) attached hereto and incorporated herein by reference, and which
<br />identifies the additional duties and/or obligations related to Network(s), Government Programs Health Benefit Plan(s),
<br />and/or Plan programs such as quality and/or incentive programs.
<br />"Plan" means Wellpoint, an Affiliate, and/or an Other Payor. For purposes of this Agreement, when the term "Plan"
<br />applies to an entity other than Wellpoint, "Plan" shall be construed to only mean such entity (i.e., the financially
<br />responsible Affiliate or Other Payor under the Member's Health Benefit Plan).
<br />"Plan Compensation Schedule" and "Plan Compensation Schedule Attachment" (collectively "PCS") means the
<br />document(s) attached hereto and incorporated herein by reference, and which set forth the Wellpoint Rate(s) and
<br />compensation related terms for the Network(s) in which Provider participates. The PCS may include provider type,
<br />additional Provider obligations and specific Wellpoint compensation related terms and requirements.
<br />"Regulatory Requirements" means any requirements, as amended from time to time, imposed by applicable federal,
<br />state or local laws, rules, regulations, guidelines, instructions, Government Contract, or otherwise imposed by an
<br />Agency or government regulator in connection with the procurement, development or operation of a Health Benefit
<br />Plan, or the performance required by either party under this Agreement. The omission from this Agreement of an
<br />express reference to a Regulatory Requirement applicable to either party in connection with their duties and
<br />responsibilities shall in no way limit such party's obligation to comply with such Regulatory Requirement.
<br />"Wellpoint Rate" means the lesser of one hundred percent (100%) of Eligible Charges for Covered Services, or the
<br />total reimbursement amount that Provider and Wellpoint have agreed upon as set forth in the Plan Compensation
<br />Schedule ("PCS"). The Wellpoint Rate includes applicable Cost Shares, and shall represent payment in full to Provider
<br />for Covered Services.
<br />ARTICLE II
<br />S E R V I C E SIO B LI GAT I O N S
<br />2.1 Member Identification. Wellpoint shall ensure that Plan provides a means of identifying Member either by
<br />issuing a paper, plastic, electronic, or other identification document to Member or by a telephonic, paper or
<br />electronic communication to Provider. This identification need not include all information necessary to
<br />determine Member's eligibility at the time a Health Service is rendered, but shall include information necessary
<br />to contact Plan to determine Member's participation in the applicable Health Benefit Plan. Provider
<br />acknowledges and agrees that possession of such identification document or ability to access eligibility
<br />information telephonically or electronically, in and of itself, does not qualify the holder thereof as a Member,
<br />nor does the lack thereof mean that the person is not a Member. Wellpoint shall ensure that Provider furnish
<br />Health Services to each Medicaid Member without regard to the Medicaid Member's enrollment in the plan as
<br />a private purchaser of the plan or as a participant in publicly financed programs of health care services. This
<br />requirement does not apply to circumstances when the provider should not render services due to limitations
<br />arising from lack of training, experience, skill, or licensing restrictions."
<br />Washington Enterprise Provider Agreement PCs 2 1183932156
<br />02024 July— Wellpoint Washington, Inc. OW0512025
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