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SHJ25-008 COORDINATED CARE CONTRACT - PARTIALLY EXECUTED
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2025-06-17 10:00 AM - Commissioners' Agenda
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SHJ25-008 COORDINATED CARE CONTRACT - PARTIALLY EXECUTED
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Last modified
6/12/2025 12:53:41 PM
Creation date
6/12/2025 12:49:58 PM
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Meeting
Date
6/17/2025
Meeting title
Commissioners' Agenda
Location
Commissioners' Auditorium
Address
205 West 5th Room 109 - Ellensburg
Meeting type
Regular
Meeting document type
Supporting documentation
Supplemental fields
Item
Request to Approve Agreement SHJ25-008 Coordinated Care - 1115 Medicaid Re-Entry Initiative
Order
15
Placement
Consent Agenda
Row ID
132242
Type
Contract
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PARTICIPATING PROVIDER AGREEMENT <br />SCHEDULE A <br />CONTRACTED PROVIDER -SPECIFIC PROVISIONS <br />Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A. <br />1. Hospitalc. If Provider or a Contracted Provider is a hospital ("Hospital"), the following provisions <br />apply <br />1.1 24 Hour Coverage. Each Hospital shall be available to provide Covered Services to Covered <br />Persons 24 hours per day, 7 days per week. <br />1.2 Emergency. Each Hospital shall provide Emergency Care (as hereafter defined) in <br />accordance with Regulatory Requirements. The Contracted Provider shall notify Company's medical management <br />department of any emergency room admissions by electronic file sent within 24 hours or by the next business day of <br />such admission. "Emergency Care" (or derivative thereof) has, as to each particular Product, the meaning set forth in <br />the applicable Coverage Agreement or Product Attachment. If there is no definition in such documents, "Emergency <br />Care" means inpatient and/or outpatient Covered Services furnished by a qualified provider that are needed to <br />evaluate or stabilize an Emergency Medical Condition. "Emergency Medical Condition" means a medical condition <br />manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who <br />possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical <br />attention to result in the following: (i) placing the health of the individual (or, with respect to a pregnant woman, the <br />health of the woman or her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions; or (iii) <br />serious dysfunction of any bodily organ or part. <br />1.3 Staff Privileges. Each Hospital shall assist in granting staff privileges or other appropriate <br />access to Company's Participating Providers who are qualified medical or osteopathic physicians, provided they meet <br />the reasonable standards of practice and credentialing standards established by the Hospital's medical staff and <br />bylaws, rules, and regulations. <br />1.4 Discharge Planning. Each Hospital agrees to cooperate with Company's system for the <br />coordinated discharge planning of Covered Persons, including the planning of any necessary continuing care. <br />1.5 Credentialing Criteria. Each Hospital shall (a) currently, and for the duration of this <br />Agreement, remain accredited by the Joint Commission or American Osteopathic Association, as applicable; and (b) <br />ensure that all employees of Hospital perform their duties in accordance with all applicable local, State and federal <br />licensing requirements and standards of professional ethics and practice. <br />1.6 National Committee for Quality Assurance ("NCQA") Accreditation of Health Plans <br />Standards. Each Hospital agrees to: i) cooperate with Quality Management and Improvement ("QI") activities; ii) <br />maintain the confidentiality of a Covered Persons information and records pursuant to the agreement; and iii) allow <br />the Company to use Hospital's performance data. <br />2. Practitioners, If Provider or Contracted Provider is a physician or other health care practitioner <br />(including physician extenders) ("Practitioner"), the following provisions apply: <br />2.1 Contracted Professional Qualifications. At all times during the term of this Agreement, <br />Practitioner shall, as applicable, maintain medical staff membership and admitting privileges with at least one hospital <br />that is a Participating Provider ("Participating Hospital") with respect to each Product in which the Practitioner <br />participates. Upon Company's request, Practitioner shall furnish evidence of the foregoing to Company. If <br />Practitioner does not have such admitting privileges, Provider or the Practitioner shall provide Company with a <br />written statement from another Participating Provider who has such admitting privileges, in good standing, certifying <br />PPA WA - Kittitas County Public Health - 05.07.2025 - ICMProviderAgreement_360268 Page 19 of 24 <br />
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