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payment. If Plan is the secondary payor, the three hundred sixty-five (365) day period will not begin until
<br />Provider receives notification of primary payor's responsibility.
<br />3.1.1 Provider agrees to submit Claims in a format consistent with industry standards and acceptable to
<br />Plan either (a) electronically through electronic data interchange ("EDI"), or (b) if electronic
<br />submission is not available, utilizing paperforms as defined bythe National Uniform Claim Committee
<br />("NUCC").
<br />3.1.2 Provider agrees to provide to Wellpoint, unless otherwise instructed, at no cost to Wellpoint, Plan or
<br />the Medicaid Member, all information necessary for Plan to determine its payment liability. Such
<br />information includes, without limitation, accurate and Clean Claims for Medicaid Covered Services.
<br />If Wellpoint or Plan asks foradditional information so that Plan may process the Claim, Provider must
<br />provide that information within sixty (60) days, or before the expiration of the three hundred sixty-five
<br />(365) day period referenced in section 3.1 above, whichever is longer.
<br />3.1.3 Once Wellpoint determines Plan has any payment liability, all Clean Claims will be adjudicated in
<br />accordance with the terms and conditions of a Medicaid Member's Health Benefit Plan, the PCS, the
<br />provider manual(s), and the Regulatory Requirements applicable to Plan's Medicaid Program(s).
<br />3.1.4 Wellpoint shall meet the timeliness of payment standards specified for Medicaid fee -for -service in
<br />Section 1902(a)(37)(A) of the Social Security Act, 42 C.F.R. § 447.46 and specified for health carriers
<br />in WAC 284-170-431. To be compliant with both payment standards, Wellpoint shall pay ninety-five
<br />percent (95%) of the monthly volume of Clean Claims within thirty (30) calendar days of receipt and
<br />shall pay or deny ninety-five percent (95%) of the monthly volume of all Claims within sixty (60) days
<br />of receipt. Notwithstanding the foregoing, Wellpoint and Provider may agree to a different payment
<br />requirement in writing on a claim by claim basis.
<br />3.1.5 Wellpoint shall pay Provider interest at the rate of one percent (1 %) per month, as set forth in WAC
<br />284-170-431(2)(d) which section may be amended or recodifed from time to time, on the unpaid or
<br />undenied portion of Clean Claims not adjudicated within the time periods discussed above, as
<br />required under applicable prompt pay requirements.
<br />3.1.6 Provider agrees to accept payments or appropriate denials made in accordance with this Agreement
<br />as payment in full for all Medicaid Covered Services provided to Medicaid Members. Provider shall
<br />be responsible for collecting co -payments from Medicaid Members to the extent required by
<br />Regulatory Requirements.
<br />3.2 This provision intentionally left blank.
<br />3.3 Audit for Compliance with CMS Guidelines. Notwithstanding any otherterms and conditions of the Agreement,
<br />this Attachment, or the PCS, Plan has the same rights as CMS, to review and/or Audit and, to the extent
<br />necessary recover payments on any claim for Medicaid Covered Services rendered pursuant to this
<br />Attachment and the Agreement to ensure compliance with CMS Regulatory Requirements.
<br />3.4 Records Retention. In addition to the Plan Access to and Requests for Provider Records provision of the
<br />Agreement, Provider shall maintain an adequate record system for recording services, charges, dates and all
<br />other commonly accepted information elements for Medicaid Covered Services in a manner that is current,
<br />detailed and organized, and that permits effective and confidential patient care and quality review,
<br />administrative, civil and/or criminal investigations and/or prosecutions. Provider shall maintain all medical
<br />records for Medicaid Members in accordance with applicable Regulatory Requirements.
<br />3.4.1 In addition to and without limiting any audit rights otherwise setforth in the Agreement and immediate
<br />access for Medicaid fraud investigators, Provider agrees that agents and employees of HCA and
<br />HHS shall have the right to inspect, evaluate and audit any pertinent books, financial records,
<br />documents, papers, and records of Provider involving financial transactions related to a Government
<br />Contract. HCA representatives and authorized federal and state personnel including, but not limited
<br />to the Office of the Inspector General (OIG), the Medicaid Fraud Control Unit (MFCU), HHS, the
<br />Department of Justice (DOJ), the Comptroller of the Treasury and any other duly authorized state or
<br />federal agency, shall have immediate and complete access to all records pertaining to services
<br />provided to Medicaid Members.
<br />Washington Enterprise Provider Agreement Medicaid Attachment 20 1183932156
<br />©2024 July— Wellpolnl Washington, Inc. 0932156
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