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Claim Submissions for Pharmaceuticals. Each Claim submitted for a pharmaceutical product must include standard
<br />Coded Service Identifier(s), a National Drug Code ("NDC") number of the covered medication, a description of the
<br />product, and dosage and units administered.
<br />Coding Updates. Coded Service Identifier(s) used to define specific rates are updated from time to time to reflect new,
<br />deleted or replacement codes. Wellpoint shall use commercially reasonable efforts to update all applicable Coded
<br />Service Identifiers within sixty (60) days of release by CMS or other applicable authority. When billing codes are
<br />updated, Provider is required to use appropriate replacement codes for Claims for Covered Services, regardless of
<br />whether this Agreement has been amended to reflect changes to standard billing codes. If Provider bills a revised code
<br />prior to the effective date of the revised code, the Claim will be rejected or denied and Provider shall resubmit Claim
<br />with correct code. In addition, Claims with codes which have been deleted will be rejected or denied.
<br />Coding Software. Updates to Wellpoint's Claims processing filters, code editing software, pricers, and any edits related
<br />thereto, as a result of changes in Coded Service Identifier(s) reporting guidelines and instructions, shall take place
<br />automatically and do not require any notice, disclosure or amendment to Provider. Wellpoint reserves the right to use
<br />a code editing software as reasonably required by Wellpoint to ensure Claims adjudication in accordance with industry
<br />standards, including, but not limited to, determining which services are considered part of, incidental to, or inclusive of
<br />the primary procedure and ensuring medically appropriate age, gender, diagnosis, frequency, and units billed.
<br />Modifiers. All appropriate modifiers must be submitted in accordance with Regulatory Requirements, industry standard
<br />billing guidelines and Policies. If appropriate modifiers are not submitted, Claims may be rejected or denied.
<br />New/Expanded Service or New/Expanded Technology. In accordance with the Scope/Change in Status section of the
<br />Agreement, as of the Effective Date of this Agreement, any New/Expanded Service or New/Expanded Technology
<br />(defined below) is not reimbursable under this Agreement. Notwithstanding the foregoing, Provider may submit the
<br />following documentation to Wellpoint at least sixty (60) days prior to the implementation of any New/Expanded Service
<br />or New/Expanded Technology for consideration as a reimbursable service: (1) a description of the New/Expanded
<br />Service or New/Expanded Technology; (2) Provider's proposed charge for the New/Expanded Service or
<br />New/Expanded Technology; (3) such other reasonable data and information required by Wellpoint to evaluate the
<br />New/Expanded Service or New/Expanded Technology. In addition, Wellpoint may also need to obtain approval from
<br />applicable Agency prior to Wellpoint making determination that New/Expanded Service or New/Expanded Technology
<br />can be considered a reimbursable service. If Wellpoint agrees that the New/Expanded Service or New/Expanded
<br />Technology may be reimbursable under this Agreement, then Wellpoint shall notify Provider, and both parties agree to
<br />negotiate in good faith, a new Wellpoint Rate for the New/Expanded Service or New/Expanded Technology within sixty
<br />(60) days of Wellpoint's notice to Provider. If the parties are unable to reach an agreement on a new Wellpoint Rate
<br />for the New/Expanded Service or New/Expanded Technology before the end of the sixty (60) day period, then such
<br />New/Expanded Service or New/Expanded Technology shall not be reimbursed by Wellpoint, and the Payment in Full
<br />and Hold Harmless provision of this Agreement shall apply.
<br />a. "New/Expanded Service" shall be defined as a Health Service: (a) that Provider was not providing to Members
<br />as of the Effective Date of this Agreement and; (b) for which there is not a specific Wellpoint Rate as set forth
<br />in this PCS.
<br />b. "New/Expanded Technology" shall be defined as a technological advancement in the delivery of a Covered
<br />Service which results in a material increase to the cost of such service. New/Expanded Technology shall not
<br />include a new device, or implant that merely represents a new model or an improved model of a device or
<br />implant used in connection with a service provided by Provider as of the Effective Date of this Agreement.
<br />Non -Priced Codes for Covered Services. Wellpoint reserves the right to establish a rate for codes that are not priced
<br />in this PCS or in the Fee Schedule(s), including but not limited to, Not Otherwise Classified Codes ("NOC"), Not
<br />Otherwise Specified ("NOS"), Miscellaneous, Individual Consideration Codes ("IC"), and By Report ("BR") (collectively
<br />"Non -Priced Codes"). Wellpoint shall only reimburse Non -Priced Codes for Covered Services in the following
<br />situations: (i) the Non -Priced Code does not have a published dollar amount on the then current applicable Plan, State
<br />or CMS Fee Schedule, (ii) the Non -Priced Code has a zero dollar amount listed, or (iii) the Non -Priced Code requires
<br />manual pricing. In such situations, such Non -Priced Code shall be reimbursed at a rate established by Wellpoint for
<br />such Covered Service. Notwithstanding the foregoing, Wellpoint shall not price Non -Priced Codes that are not Covered
<br />Services under the Members Health Benefit Plan. Wellpoint may require the submission of medical records, invoices,
<br />or other documentation for Claims payment consideration.
<br />Reimbursement for Wellpoint Rate Based on Eligible Charles. Notwithstanding any reimbursement amount set forth
<br />herein, Provider shall only be allowed to receive such reimbursement if such reimbursement is for an Eligible Charge.
<br />In addition, if Provider reimbursement is under one or more of the following methodologies: Capitation, Case Rate,
<br />Washington Enterprise Provider Agreement PCS 32 1183932156
<br />92024 July— Wellpoint Washington, Inc. 05/05/2025
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