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5.16 Monitoring. Provider agrees to Wellpoint monitoring Provider's performance on an ongoing basis and subject
<br />to formal review, which review shall be accordance with a periodic schedule established by HCA consistent
<br />with industry standards and Regulatory Requirements. Formal review must be completed no less than once
<br />every three years and must identify deficiencies or areas for improvement and provide for corrective action in
<br />accordance with 42 CFR 438.230(b).
<br />5.17 Provider to Monitor Quality. Provider shall maintain a quality assurance system to monitor the quality of
<br />services delivered under this Attachment and initiate corrective action where necessary to improve quality of
<br />care, in accordance with that level of care which is recognized as acceptable professional practice in the
<br />respective community in which the Provider practices and/or the standards established by the Medicaid
<br />Program or its designee.
<br />5.18 Medicaid Member Rights. Notwithstanding anything to the contrary in this Agreement, Provider agrees to
<br />observe, protect and promote all rights of Medicaid Members as patients in accordance with all applicable
<br />laws, Government Contract and Agency requirements. Provider shall provide any information that a Medicaid
<br />Member needs in order to decide among all relevant treatment options.
<br />5.19 Program Integrity Requirements. Provider shall comply with Wellpoinfs HCA approved program integrity
<br />policies and procedures and the program integrity requirements of the Government Contract, including but not
<br />limited to compliance with section 1902(a)(68) of the Social Security Act, 42 C.F.R. § 438.610, 42 C.F.R. §455,
<br />42 C.F.R. §1000 through 1008 and Chapter 182-502A WAC. If Provider is defined as a subcontractor under
<br />the Government Contract, Provider shall verify that services billed by Provider were actually provided to
<br />Medicaid Members and shall conduct ongoing analysis of utilization, claims, billing and/or encounter data to
<br />detect overpayments and including audits and investigations of Provider's subcontractors and downstream
<br />entities.
<br />5.20 Enrollee Self Determination. Provider shall obtain informed consent prior to treatment from Medicaid
<br />Members, or persons authorized to consent on behalf of a Medicaid Member, and shall comply with the
<br />provisions of the Natural Death Act (RCW 70.122) and state and federal Medicaid rules concerning advance
<br />directives, and, when appropriate, inform Medicaid Members of their right to make anatomical gifts.
<br />5.21 Enrollee Self -Referral. Provider understands and agrees that Medicaid Members have the right to self -refer
<br />for certain services to participating or non -participating local health departments and participating or non-
<br />participating family planning clinics paid through separate arrangements with the State of Washington. The
<br />services to which a Medicaid Member may self refer include: (i) including family planning services and
<br />sexually -transmitted disease screening and treatment services provided at participating or nonparticipating
<br />providers, including but not limited to family planning agencies, such as Planned Parenthood; (ii)
<br />immunizations, sexually -transmitted disease screening and follow-up, immunodeficiency virus (HIV)
<br />screening, tuberculosis screening and follow-up, and family planning services through and if provided by a
<br />local health department; (iii) immunizations, sexually transmitted disease screening, family planning and
<br />mental health services through and if provided by a school -based health center; and (iv) all services received
<br />by American Indian or Alaska Native enrollees under the Special Provisions for American Indians and Alaska
<br />Natives subsection as set forth in the Government Contract.
<br />5.22 Solvency Requirements. If Provider is at financial risk, as defined in the Government Contract, Wellpoint shall
<br />establish, enforce and monitor solvency requirements that provide assurance of Provider's ability to meet its
<br />obligations. Furthermore, Provider acknowledges that Wellpoint shall annually conduct surveys of Medicaid
<br />Members' satisfaction with Provider in accordance with Government Contract requirements, which surveys
<br />shall to be provided to HCA or Medicaid Members upon request.
<br />5.23 Subrogation. Provider acknowledges and agrees that it shall subrogate to the State of Washington for all
<br />criminal, civil and administrative action recoveries undertaken by any government entity, including, but not
<br />limited to, all claims Wellpoint or Provider have or may have against any entity that directly or indirectly
<br />receives funds under the Government Contract including, but not limited to, any health care provider,
<br />manufacturer, wholesale or retail supplier, sales representative, laboratory, or other provider in the design,
<br />manufacture, marketing, pricing, or quality of drugs, pharmaceuticals, medical supplies, medical devices,
<br />durable medical equipment, or other health care related products or services.
<br />5.24 Assignment. Notwithstanding Section 9.2 of the Agreement, this Agreement may not be assigned by either
<br />party without the consent of HCA.
<br />Washington Enterprise Provider Agreement Mediceld Attachment 24 1183932156
<br />82024 July— Wellpoint Washington, Inc. 05/05/2025
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