SHJ25-007 Kittitas County and Wellpoint Agreement - PARTIALLY EXECUTED

Home Browse Search

PLAN COMPENSATION SCHEDULE ("PCS") 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: Wellpoint Medicaid Network Specialty Ph sician Group Service Description Billing Code Rate/ Methodology Rate Description Professional Services Applicable CPT/HCPCS 100% of the Washington Per Service Code State Medicaid Fee Schedule Laboratory Services Applicable CPT/HCPCS 39% of the Wellpoint Per Service Code Reference Laboratory Fee Schedule Wellpoint shall not compensate Provider for collection of specimens (including venipuncture), lab handling, or stat services, which Wellpoint considers components of the laboratory test. In addition, Wellpoint shall not compensate Provider for services not described by codes contained in the Wellpoint Reference Laboratory Fee Schedule. Wellpoint shall update rates for codes from the Medicare schedules according to the provisions of the "Updates to Wellpoint Rates Based on External Sources" provision of the PCS. Wellpoint shall notify Provider in writing at least sixty (60) days before significant Wellpoint initiated changes to the Wellpoint Reference Laboratory Fee Schedule. Provider shall notify Wellpoint in writing within thirty (30) days of receiving the notice and if Provider objects to such changes both parties agree to discuss the objections. In any event, Wellpoint may implement the changes sixty (60) days after notifying Provider. Notwithstanding the foregoing, all Wellpoint Rate updates made pursuant to an External Source shall be governed by the "Updates to Wellpoint Rate(s) Based on External Sources" provision of the PCS. 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 Type 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. Washington Enterprise Provider Agreement PCS Attachment 36 1183932156 Medicaid — Specialist Physician Grp OS/05l2025 0 2024 Sept— Wellpoint Washington, Inc.