SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

Home Browse Search

PLAN COMPENSATION SCHEDULE ("PCS") ARTICLE I DEFINITIONS The definitions set forth below shall apply with respect to all of the terms outlined in this PCS. Terms not otherwise defined in this PCS and defined elsewhere in the Agreement shall carry the meanings set forth in the Agreement. "Capitation" means the amount paid by Wellpoint to a provider or management services organization on a per member per month basis for either specific services or the total cost of care for Covered Services. "Case Rate" means the all-inclusive Wellpoint Rate for an entire admission or one outpatient encounter for Covered Services. "Chargemaster" or "Charge Master" means facility's listing of facility charges for products, services and supplies. "Coded Service Identifier(s)" means a listing of descriptive terms and identifying codes, updated from time to time by CMS or other industry source, for reporting Health Services on the CMS 1500 or CMS 1450/UB-04 claim form or its successor as applicable based on the services provided. The codes include but are not limited to, American Medical Association Current Procedural Terminology ("CPT&4"), CMS Healthcare Common Procedure Coding System ("HCPCS"), International Classification of Diseases, 10th Revision ("ICD-10"), National Uniform Billing Committee ("Revenue Code") and National Drug Code ("NDC") or their successors. "Cost to Charge Ratio" ("CCR") means the quotient of cost (total operating expenses minus other operating revenue) divided by charges (gross patient revenue) expressed as a decimal, as defined by Regulatory Requirements. "Diagnosis -Related Group" ("DRG") means Diagnosis Related Group or its successor as established by CMS or other grouper, including but not limited to, a state mandated grouper or other industry standard grouper. "DRG Rate" means the all-inclusive dollar amount which is multiplied by the appropriate DRG Weight to determine the Wellpoint Rate for Covered Services. "DRG Weight" means the weight applicable to the specific DRG methodology set forth in this PCS, including but not limited to, CMS DRG weights as published in the Federal Register, state agency weights, or other industry standard weights. "Eligible Charges" means those Provider Charges that meet Wellpoint's conditions and requirements for a Health Service to be eligible for reimbursement. These conditions and requirements include but are not limited to: Member program eligibility, Provider program eligibility, benefit coverage, authorization requirements, provider manual specifications, Wellpoint administrative, clinical and reimbursement policies and methodologies, code editing logic, coordination of benefits, Regulatory Requirements, and this Agreement. Eligible Charges do not include Provider Charges for any items or services that Provider receives and/or provides free of charge. "Emergency Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the health of the individual, or in the case of a pregnant woman, the health of the woman or her unborn child; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. "Emergency Services" means those Covered Services furnished by a provider qualified to furnish emergency services, and which are needed to evaluate or treat an Emergency Condition. "Encounter Data" means Claim information and any additional information submitted by a provider under capitated or risk -sharing arrangements for Health Services rendered to Members. "Encounter Rate" means the Wellpoint Rate that is all-inclusive of professional, technical and facility charges including evaluation and management, pharmaceuticals, routine surgical and therapeutic procedures, and diagnostic testing (including laboratory and radiology) capable of being performed on site. "Fee Schedule(s)" means the complete listing of Wellpoint Rate(s) for specific services that is payment for each unit of service allowed based on applicable Coded Service Identifier(s) for Covered Services. Washington Enterprise Provider Agreement PCS 30 1183932156 02024 July— Wellpolnt Washington, Inc. 05/05/2025