SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

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PLAN COMPENSATION SCHEDULE (" Il ATTACHMENT MEDICAID For purposes of determining the Wellpoint Rate, the total reimbursement amount that Provider and Wellpoint have agreed upon for the applicable provider type(s) for Covered Services provided under this Agreement in effect on the date of service shall be as set forth below. The parties acknowledge and agree that the Medicaid Fee Schedule is subject to modification by Wellpoint at any time during the term of this Agreement and will be applied on a prospective basis. Program: WellipointMedicaid Network Behavioral Health Services Service Description Billing Code Rate/ Methodolo Rate Description Eligible Outpatient Services Codes with applicable CPT/HCPCS NDC Code(s) 100 o of the Washington State Medicaid Fee Schedule Per Service Provider agrees to reference SERI coding guidelines, available through Wellpoint's Web portal, to ensure the proper billing and reimbursement. Medicaid Affiliate Services. Provider acknowledges that Wellpoint is affiliated with health plans that offer similar benefits under similar programs as the programs covered hereunder ("Medicaid Affiliates"). The parties acknowledge that Provider is not a Participating Provider in Medicaid Affiliate's Network for purposes of rendering services to Medicaid Members. However, in the event Provider treats a Medicaid Member of a Medicaid Affiliate, subject to Regulatory Requirements, Provider shall accept as payment in full the rates established by the Medicaid Affiliate's state program governing care to Medicaid Members. Such services must be Medicaid Covered Services under the Medicaid Affiliate's state program, and shall require prior authorization, except for Emergency Services and services for which a Medicaid Member is entitled to self -refer. Upon request, Wellpoint shall coordinate and provide information as necessary between Provider and Medicaid Affiliate for services rendered to Medicaid Member. Reimbursement Specific to Provider Tvpe The following will be reimbursed for facility services only: Acute Care Hospital, ASC, Behavioral Health Facility, Free Standing Birthing Center, Rehabilitation Facility and SNF. Professional services are excluded. Ambulance Provider Air and/or Ground shall be reimbursed in accordance with Regulatory Requirements for the applicable methodology based on the referenced fee schedule. If such reimbursement is based on an Wellpoint Rate, the applicable state methodology on which such fee schedule is based, shall be used to determine the appropriate level of reimbursement. Hospice reimbursement is inclusive of skilled nursing, home health aide, medical social worker services, dietary, pastoral, bereavement counseling, DME, medical supplies and administration of medication. Specialty Provider Individual and/or group (Non -MD or DO) shall be reimbursed in accordance with Regulatory Requirements for the applicable methodology based on the referenced fee schedule. If such reimbursement is based on an Wellpoint proprietary fee schedule, the applicable state methodology on which such fee schedule is based, shall be used to determine the appropriate level of reimbursement. Specialty Provider Individual and/or group (including Non -MD or DO) shall be reimbursed for anesthesiology services in accordance with the accumulation of base, modifier and time units multiplied by the Washington State Medicaid Anesthesia Conversion Factor. The services should be billed in minute increments. One time unit will be allowed for each fifteen (15) minute interval, or fraction thereof, starting from the time Provider begins to prepare the Member for induction and ending when the Member may safely be placed under post -operative supervision and Provider is no longer in personal attendance. "Ambulatory Patient Group" ("APG") means the Wellpoint Rate that is a fixed reimbursement to a facility for Outpatient Services and which incorporates data regarding the reason for the visit and patient data. "Ambulatory Payment Classification" ("APC") or its successor shall have the meaning set forth in the Medicare law and CMS regulations and guidance. Washington Enterprise Provider Agreement PCs Attachment 34 1183932156 Medicaid — Behavioral Health Facility 05/05/2025 02024 Sept— Wellpoint Washington, Inc.