|
disclosure or transfer of proprietary or confidential information by Provider or Wellpoint will be in accordance
<br />with applicable Regulatory Requirements. Provider shall immediately notify Wellpoint if Provider is required
<br />to disclose any proprietary or confidential information at the request of an Agency or pursuant to any federal
<br />or state freedom of information act request.
<br />3.2 Confidentiality of Member Information. Both parties agree to comply with the Health Insurance Portability and
<br />Accountability Act of 1996 ("HIPAA") and the Health Information Technology for Economic and Clinical Health
<br />Act ("HITECH Act"), and as both may be amended, as well as any other applicable Regulatory Requirements
<br />regarding confidentiality, use, disclosure, security and access of the Member's personally identifiable
<br />information ("PII") and protected health information ("PHI"), (collectively "Member Information"). Provider shall
<br />review all Member Information received from Wellpoint to ensure no misrouted Member Information is
<br />included. Misrouted Member Information includes but is not limited to, information about a Member that
<br />Provider is not currently treating. Provider shall immediately destroy any misrouted Member Information or
<br />safeguard the Member Information for as long as it is retained. In no event shall Provider be permitted to
<br />misuse or re -disclose misrouted Member Information. If Provider cannot destroy or safeguard misrouted
<br />Member Information, Provider must contact Wellpoint to report receipt of misrouted Member Information.
<br />3.3 Network Provider/Patient Discussions. Notwithstanding any other provision in this Agreement and regardless
<br />of any benefit or coverage exclusions or limitations associated with a Health Benefit Plan, Provider shall not
<br />be prohibited from discussing fully with a Member any issues related to the Member's health including
<br />recommended treatments, treatment alternatives, treatment risks and the consequences of any benefit
<br />coverage or payment decisions made by Plan or any other party. In addition, nothing in this Agreement shall
<br />be construed to, create any financial incentive for Provider to withhold Covered Services, or prohibit Provider
<br />from disclosing to the Member the general methodology by which Provider is compensated under this
<br />Agreement, such as for example, whether Provider is paid on a fee for service, capitation or Percentage Rate
<br />basis. Plan shall not refuse to allow or to continue the participation of any otherwise eligible provider, or
<br />refuse to compensate Provider in connection with services rendered, solely because Provider has in good
<br />faith communicated with one or more of his/her/its current, former or prospective patients regarding the
<br />provisions, terms or requirements of a Health Benefit Plan as they relate to the health needs of such patient.
<br />Nothing in this section shall be construed to permit Provider to disclose Wellpoint Rates or specific terms of
<br />the compensation arrangement under this Agreement.
<br />3.4 Plan Access to and Requests for Provider Records. Provider and its designees shall comply with all applicable
<br />state and federal record keeping and retention requirements, and, as set forth in the provider manual(s) and/or
<br />Participation Attachment(s), shall permit Plan or its designees to have, with appropriate working space and
<br />without charge, on -site access to and the right to perform an Audit, examine, copy, excerpt and transcribe any
<br />books, documents, papers, and records related to Member's medical and billing information within the
<br />possession of Provider and inspect Provider's operations, which involve transactions relating to Members and
<br />as may be reasonably required by Plan in carrying out its responsibilities and programs including, but not
<br />limited to, assessing quality of care, complying with quality initiatives/measures, Medical Necessity, concurrent
<br />review, appropriateness of care, accuracy of Claims coding and payment, risk adjustment assessment as
<br />described in the provider manual(s), including but not limited to completion of the Encounter Facilitation Form
<br />(also called the "SOAP" note), compliance with this Agreement, and for research. In lieu of on -site access, at
<br />Plan's request, Provider or its designees shall submit records to Plan, or its designees via photocopy or
<br />electronic transmittal, within thirty (30) days, at no charge to Plan from either Provider or its designee. Provider
<br />shall make such records available to the state and federal authorities involved in assessing quality of care or
<br />investigating Member grievances or complaints in compliance with Regulatory Requirements. Provider
<br />acknowledges that failure to submit records to Plan in accordance with this provision and/or the provider
<br />manual(s), and/or Participation Attachment(s) may result in a denial of a Claim under review, whether on pre-
<br />payment or post -payment review, or a payment retraction on a paid Claim, and Provider is prohibited from
<br />balance billing the Member in any of the foregoing circumstances.
<br />3.5 Transfer of Medical Records. Following a request, Provider shall transfer a Member's medical records in a
<br />timely manner, or within such other time period required under applicable Regulatory Requirements, to other
<br />health care providers treating a Member at no cost to Wellpoint, Plan, the Member, or other treating health
<br />care providers.
<br />3.6 Clinical Data Sharing. Wellpoint and Provider desire to collaborate by sharing data, including Member
<br />Information, to enhance certain health care operations activities, primarily to help improve quality and
<br />efficiency of health care. Each party's access to better clinical and administrative data is critical to the mutual
<br />goal of Wellpoint and Provider improving health care quality as it relates to their respective Members and
<br />patients. Therefore and upon request, Provider agrees to provide data to Wellpoint for treatment purposes,
<br />Washington Enterprise ProNder Agreement PCs 7 1183932156
<br />0 2024 July— Wellpoint Washington, Inc. 05/05/2025
<br />
|