|
2.2 Provider Non-discrimination. Provider shall provide Health Services to Members in a manner similar to and
<br />within the same time availability in which Provider provides Health Services to any other individual. Provider
<br />will not differentiate, or discriminate against any Member as a result of his/her enrollment in a Health Benefit
<br />Plan, or because of race, color, creed, national origin, ancestry, religion, sex, marital status, age, disability,
<br />payment source, state of health, need for Health Services, status as a litigant, status as a Medicare or Medicaid
<br />beneficiary, sexual orientation, gender identity, or any other basis prohibited by law. Provider shall not be
<br />required to provide any type, or kind of Health Service to Members that he/she/it does not customarily provide
<br />to others. Additional requirements may be set forth in the applicable Participation Attachment(s).
<br />2.3 Publication and Use of Provider Information. Provider agrees that Wellpoint, Plans or their designees may
<br />use, publish, disclose, and display, for commercially reasonable general business purposes, either directly or
<br />through a third party, information related to Provider, including but not limited to demographic information,
<br />information regarding credentialing, affiliations, performance data, Wellpoint Rates, and information related to
<br />Provider for transparency initiatives.
<br />2.4 Use of Symbols and Marks. Neither party to this Agreement shall publish, copy, reproduce, or use in any way
<br />the other party's symbols, service mark(s) or trademark(s) without the priorwritten consent of such other party.
<br />Notwithstanding the foregoing, the parties agree that they may identify Provider as a participant in the
<br />Network(s) in which he/she/it participates.
<br />2.5 Submission and Adjudication of Claims. Provider shall submit, and Plan shall adjudicate, Claims in accordance
<br />with the applicable Participation Attachment(s), the PCS, the provider manual(s) and Regulatory
<br />Requirements. If Provider submits Claims prior to receiving notice of Wellpoint's approval pursuant to section
<br />2.13, then such Claims must be submitted in accordance with prior authorization requirements, and shall be
<br />processed as out of network. Wellpoint shall not make retroactive adjustments with respect to such Claims.
<br />2.6 Payment in Full and Hold Harmless
<br />2.6.1 Provider agrees to accept as payment in full, in all circumstances, the applicable Wellpoint Rate
<br />whether such payment is in the form of a Cost Share, a payment by Plan, or a payment by another
<br />source, such as through coordination of benefits or subrogation. Provider shall bill, collect, and
<br />accept compensation for Cost Shares. Provider agrees to make reasonable efforts to verify Cost
<br />Shares prior to billing for such Cost Shares. In no event shall Plan be obligated to pay Provider or
<br />any person acting on behalf of Provider for services that are not Covered Services, or any amounts
<br />in excess of the Wellpoint Rate less Cost Shares or payment by another source, as set forth above.
<br />Consistent with the foregoing, Provider agrees to accept the Wellpoint Rate as payment in full if the
<br />Member has not yet satisfied his/her deductible.
<br />2.6.2 Except as expressly permitted under Regulatory Requirements, Provider agrees that in no event,
<br />including, but not limited to non-payment by Wellpoint, Wellpoint insolvency, or breach of this
<br />Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration, or
<br />reimbursement from or have any recourse against a Member, any person acting on behalf of a
<br />Member, or HCA for services provided pursuant to this Agreement. This provision shall not prohibit
<br />collection of deductibles, copayments, coinsurance and/or payment for noncovered services, which
<br />have not otherwise been paid by a primary or secondary issuer in accordance with the terms of
<br />regulatory standards for coordination of benefits, from a Member in accordance with applicable
<br />Government Contracts or Agency requirements. This provision supersedes any oral or written
<br />contrary agreement now existing or hereafter entered into between Provider and a Member or
<br />persons acting on such Member's behalf. Provider agrees, in the event of Wellpoint's insolvency, to
<br />continue to provide the services promised in this Agreement to Members of Wellpoint for the duration
<br />of the period for which premiums on behalf of the Member were paid to provider or until the Member's
<br />discharge from inpatient facilities, whichever time is greater. Provider shall not hold Member liable
<br />for payment of any fees that are the legal obligation of Wellpoint. Notwithstanding any other provision
<br />of this Agreement, nothing in this Agreement shall be construed to modify the rights and benefits
<br />contained in the Member's health plan. Provider may not bill the Member for Covered Services
<br />(except for deductibles, copayments, or coinsurance) where Wellpoint denies payments because the
<br />provider has failed to comply with the terms or conditions of this Agreement. Provider further agrees
<br />that the provisions of WAC 284-170-421 (3)(a), (b), (c), and (d) shall survive termination of this
<br />contract regardless of the cause giving rise to termination and shall be construed to be for the benefit
<br />of Provider's Members. If Provider enters into agreements with other providers who agree to provide
<br />Covered Services to Members of Wellpoint, with the expectation of receiving payment directly or
<br />indirectly from Wellpoint, then such providers must agree to abide by the provisions of WAC 284-
<br />Washington Enterprise Provider Agreement PCS 3 1183932156
<br />© 2024 July— Wellpoint Washington, Inc. 05/05/2025
<br />
|