SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

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5.25 Pharmacy Preauthorization and Emergency Fill Requirements. Provider and Wellpoint shall each comply with all applicable pharmacy preauthorization and emergency requirements of the Government Contract and WAC 284-170-470, including but not limited to compliance with the following: (a) Disclose if the provider or pharmacy has the right to make a prior authorization request; and (b) Provide that if Wellpoint or Provider requires the authorization number to be transmitted on a pharmaceutical claim, the issuing party will provide the authorization number to the billing pharmacy. The authorization number will be communicated to the billing pharmacy after approval of a prior authorization request and upon receipt of a claim for that authorized medication. (c) The prior authorization determination must be transmitted to the requesting party and must include the information about whether a request was approved and if the request was made by the pharmacy, notification will additionally be made to the prescriber. (d) Wellpoint and Provider acknowledge and agree that Wellpoint shall authorize an emergency fill by the dispensing pharmacist and approve the claim payment. An emergency fill is only applicable when: (1) The dispensing pharmacy cannot reach Wellpoint's prior authorization department by phone as it is outside of that department's business hours; or (2) Wellpoint is available to respond to phone calls from a dispensing pharmacy regarding a covered benefit, but Wellpoint cannot reach the prescriber for full consultation. (a) Drug Utilization Review Process Provider agrees to comply with Wellpoint's drug utilization review process, including but not limited to, the exception rule (ETR) process as outlined in the provider manual and on Wellpoint's website. 5.26 Potentially Preventable Readmissions. If applicable, to facilitate care transitions for Medicaid Members, Provider and Wellpoint shall comply with all Potentially Preventable Readmission ("PPR") requirements, as set forth in the Government Contract and WAC 182-550-2900 and 182-550-3000. Consistent with the PPR provisions of the Government Contract, Wellpoint and Provider shall work together to facilitate care transitions for Medicaid Members and Provider shall be responsible for ensuring completion of the following: (a) discharge screenings, (b) discharge/care plans, (c) discharge education, and (d) follow up care after discharge, including for mental health services, as applicable. In addition, for high risk members, Provider will allow Wellpoint or Wellpoint's designee to assist with the coordination of planning, including visiting the Medicaid Member. 5.27 Reporting. Provider shall submit to Wellpoint all reports and clinical information required by Regulatory Requirements or otherwise reasonably requested by Wellpoint. 5.27.1 If Provider is a Certified Behavioral Health Agency (BHA), Provider must comply with behavioral health reporting requirements, including Service Encounter Reporting Instructions ("SERI"). Provider must report behavioral health supplemental transactions to Wellpoint as set forth in the provider manual(s), or as required under applicable Regulatory Requirements. 5.28 Provider Insurance Coverage. In addition to the Provider Insurance provision in the Agreement, Provider, at all times during the term of this Agreement, shall: 5.28.1 Maintain professional liability insurance; including maintaining such tail or prior acts coverage necessary to avoid any gap in coverage for claims arising from incidents occurring during the term of this Agreement. Such insurance shall (1) be obtained from a carrier authorized to conduct business in the jurisdiction in which Provider operates; (11) maintain minimum policy limits equal to $5,000,000.00 per occurrence and $10,000,000.00 in the aggregate for acute care hospitals and $1,000,000.00 per occurrence and $3,000,000.00 in the aggregate for other providers; and (Ili) include coverage for the professional acts and omissions of Provider and any employee, agent or other person for whose acts or omissions Provider is responsible. 5.28.2 Maintain general comprehensive liability insurance from a carrier authorized to conduct business in the jurisdiction in which Provider operates, in amounts required under Regulatory Requirements. Said insurance shall cover Provider's premises, insuring Provider against any claim of loss, liability, or damage caused by or arising out of the condition or alleged condition of said premises, or the furniture, fixtures, appliances, or equipment located therein, together with the standard liability Washington Enterprise Provider Agreement Medicaid Attachment 25 1183932156 Washington, © 2024 July— Wellpoint Inc. 05/0512025