SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

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"Global Case Rate" means the all-inclusive Wellpoint Rate which includes facility, professional and physician services for specific Coded Service Identifier(s) for Covered Services. "Inpatient Services" means Covered Services provided by a facility to a Member who is admitted and treated as a registered inpatient, is assigned a licensed bed within the facility, remains assigned to such bed and for whom a room and board charge is made. "Observation" means the services furnished on the facility's premises, including use of a bed and periodic monitoring by nursing or other staff, which are Medically Necessary to evaluate a Member's condition and determine if the Member requires an inpatient admission to the facility. Such determination shall be in compliance with Policies or Regulatory Requirements. "Outlier Rate" means the payment applied to an admission which exceeds the outlier threshold as set forth in the PCS or in compliance with Policies or Regulatory Requirements. "Outpatient Services" means Covered Services provided by a facility to a Member who is admitted and treated as a registered outpatient within the facility. "Patient Day" means each approved calendar day of care that a Member receives in the facility, to the extent such day of care is a Covered Service under the terms of the Member's Health Benefit Plan, but excluding the day of discharge. "Percentage Rate" means the Wellpoint Rate that is a percentage of Eligible Charges billed by a provider for Covered Services. "Per Diem Rate" means the Wellpoint Rate that is the all-inclusive fixed payment for Covered Services rendered on a single date of service. "Per Hour Rate" means the Wellpoint Rate that is payment based on an increment of time for Covered Services. "Per Relative Value Unit" ("RVU") means the Wellpoint Rate for each unit of service based on the CMS, State Agency or other (e.g., American Society of Anesthesiologists (ASA)) defined Relative Value Unit (RVU). "Per Service Rate" means the Wellpoint Rate that is payment for each service allowed based on applicable Coded Service Identifiers) for Covered Services. "Per Unit Rate" means the Wellpoint Rate that is payment for each unit of service allowed based on applicable Coded Service Identifiers) for Covered Services. "Per Visit Rate" means the Wellpoint Rate that is the all-inclusive fixed payment for one encounter for Covered Services. "Provider Charges" means the regular, uniform rate or price Provider determines and submits to Wellpoint as charges for Health Services provided to Members. Such Provider Charges shall be no greater than the rate or price Provider submits to any person or other health care benefit payer for the same Health Services provided, regardless of whether Provider agrees with such person or other payer to accept a different rate or price as payment in full for such services. "Short Stay" means an inpatient hospital stay that is less than a specified number of calendar days in compliance with Policies and/or Regulatory Requirements. ARTICLE II GENERAL PROVISIONS Billing Form and Claims Reporting Requirements. Provider shall submit all Claims on a CMS 1500 or CMS 1450/UB- 04 claim form or its successor forms) as applicable based on the Health Services provided in accordance with Policies or applicable Regulatory Requirements. Provider shall report all Health Services in accordance with the Coded Service dentifier(s) reporting guidelines and instructions using HIPAA compliant billing codes. In addition, Plan shall not pay any Claims) nor accept any Encounter Data submitted using non -compliant codes. Plan audits that result in identification of Health Services that are not reported in accordance with the Coded Service Identifiers) guidelines and instructions, will be subject to recovery through remittance adjustment or other recovery action as may be set forth in the provider manual(s). Washington Enterprise Provlder Agreement PCs 31 1183932156 0 2024 July— Well Washington, Inc. 05/05/2025