SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

Home Browse Search

Members on evenings and weekends. Provider agrees that it will provide for regular monitoring of timely access and corrective action by Wellpoint if Provider fails to comply with the appointment wait time standards as stated in 42 CFR 438.206(c)(1). Provider shall comply with 42 CFR §438.206(c)(1). Provider shall comply with appointment standards that are no longer than the following: (a) Transitional healthcare services by a primary care provider shall be available for clinical assessment and care planning within seven (7) calendar days of discharge from inpatient or institutional care for physical or behavioral health disorders or discharge from a substance use disorder treatment program; (b) Transitional healthcare services by a home care nurse or home care registered counselor within seven (7) calendar days of discharge from inpatient or institutional care for physical or behavioral health disorders or discharge from a substance use disorder treatment program, if ordered by the enrollee's primary care provider or as part of the discharge plan; (c) Non -symptomatic (i.e., preventive care) office visits shall be available from the Medicaid Member's PCP or another provider within thirty (30) calendar days. A non -symptomatic office visit may include, but is not limited to, well/preventive care such as physical examinations, annual gynecological examinations, or child and adult immunizations; (d) Non - urgent, symptomatic (i.e., routine care) office visits shall be available from the Medicaid Member's PCP or another provider within ten (10) calendar days. A non -urgent, symptomatic office visit is associated with the presentation of medical signs not requiring immediate attention; (a) Urgent, symptomatic office visits shall be available from the Medicaid Member's PCP or another provider within twenty-four (24) hours. An urgent, symptomatic visit is associated with the presentation of medical signs that require immediate attention, but are not life threatening; and (f) Emergency medical care shall be available twenty-four (24) hours per day, seven (7) days per week. 5.11 Prohibited Practices. Nothing in this Agreement shall be construed as prohibiting any Participating Provider from: 5.11.1 Discussing treatment or non -treatment options with Medicaid Members irrespective of Wellpoint's position on such treatment or non -treatment options or whether such treatment options are Medicaid Covered Services; 5.11.2 Acting within the lawful scope of such provider's practice, advising or advocating on behalf of a Medicaid Member for such Medicaid Member's health status, medical care, or treatment or non - treatment options, including any alternative treatments that might be self-administered by the Medicaid Member; 5.11.3 Advocating on behalf of a Medicaid Member within the utilization review or grievance processes established by Wellpoint or individual authorization process to obtain Medically Necessary Medicaid Covered Services; or 5.11.4 Discouraging Medicaid Members or those paying for their coverage from discussing the comparative merits of different health carriers with their providers. This prohibition specifically includes prohibiting or limiting providers participating in those discussions even if critical of a carrier. 5.12 Cultural Comoetencv Plan. Provider shall participate with the State of Washington's efforts to promote the delivery of services in a culturally competent manner to all Medicaid Members, including those with limited English proficiency and diverse cultural ethnic backgrounds. To that end, Provider agrees to comply with all Wellpoint policies and procedures designed to ensure that culturally competent services, including but not limited to effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs, are provided by Wellpoint both directly and through its health care providers and subcontractors. 5.13 Authorizations. Provider shall comply with Wellpoint's preauthorization and authorization processes and procedures applicable to Provider as more fully set forth in the provider manual(s). 5.14 Prohibited Referrals. In accordance with federal and state law, Provider is prohibited from referring any Medicaid Members for designated health services to any entity in which Provider, or a member of Provider's immediate family, has a financial relationship. 5.15 Transfers of Members. Without otherwise limiting Wellpoint's rights pursuant to this Agreement, upon Wellpoint's determination made in good faith and with reasonable belief that a Medicaid Member's health or safety is in jeopardy, Wellpoint may require that such Medicaid Member be transferred immediately for care to another provider at Wellpoint's direction, and Provider shall fully cooperate with any such transfer requirement. Additionally, Provider shall cooperate in all respects with provider of other health plans to assure maximum health outcomes with regard to transitioning Medicaid Members. Washington Enterprise Provider Agreement Medicaid Attachment 23 1183932156 02024 July— Wellpoint Washington, Inc. 05/05/2025