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physical deformity or malfunction; and (b) are not more costly than any other equally effective or more conservative
<br />course of treatment available or suitable for the Covered Person requesting the service. Such services shall include
<br />services related to the Covered Person's ability to achieve age -appropriate growth and development.
<br />2.5. Physician's Orders for Life Sustaining Treatment ("POLST") means a set of guidelines and
<br />protocols for how emergency medical personnel shall respond when summoned to the site of an injury or illness for
<br />the treatment of a person who has signed a written directive or durable power of attorney requesting that he or she
<br />not receive futile emergency medical treatment, in accordance with RCW 43.70.480.
<br />2.6. Primary Care Provider or PCP means a Participating Provider who has the responsibility for
<br />supervising, coordinating, and providing primary health care to Covered Persons, initiating referrals for specialist
<br />care, and maintaining the continuity of Covered Person care. PCPs include, but are not limited to pediatricians,
<br />family practitioners, general practitioners, internists, naturopathic physicians, medical residents (under the
<br />supervision of a teaching physician), physician assistants (under the supervision of a physician), or advanced
<br />registered nurse practitioners (nurse practitioners), as designated by Health Plan. The definition of PCP is inclusive
<br />of primary care physician as it is used in 42 C.F.R. § 438. All Federal requirements applicable to primary care
<br />physicians will also be applicable to PCPs as the term is used in this Attachment.
<br />2.7. State means the state of Washington.
<br />2.8. State Contract(s) means the applicable contract(s) between HCA and Health Plan under which
<br />Health Plan agrees to provide or arrange for services related to the Apple Health Program, including any exhibits,
<br />attachments, documents, or materials incorporated by reference.
<br />ARTICLE III
<br />PROVIDER CONTRACT REQUIREMENTS
<br />3.1. Health Plan Remains Legally Res oy nsible. Nothing herein shall be construed to delegate legal
<br />responsibility to HCA for any work performed under the Agreement, nor for oversight of any functions and/or
<br />responsibilities delegated to Provider. [Source: § 9.1 of the 2022 Apple Flealth IMCAgreement]
<br />3.2. Compliance with Applicable Law. Provider shall comply with all Applicable Law. For purposes of
<br />this Attachment, "Applicable Law" shall specifically include those laws and regulations as set forth in the State
<br />Contract, including but not limited to the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"),
<br />the Mental Health Parity and Addiction Equity Act ("MHPAEA") and final rule, The 21" Century Cures Act, state
<br />laws and regulations regarding mental and behavioral health and substance use disorder services, the Federal Drug
<br />and Alcohol Confidentiality Laws in 42 C.F.R. Part 2, 42 U.S.C. §§ 1396a(a)(43) (early and periodic screening,
<br />diagnostic, and treatment services ("EPSDT")), 1396d(r) (definition of EPSDT), and 42 C.F.R. § 438.3(l) (choice of
<br />network provider).
<br />3.3. Compliance with State Contract. Provider shall comply with any term or condition of the State
<br />Contract that is applicable to the services to be performed under the Agreement, including but not limited to the
<br />Performance Improvement Project requirements of the State Contract and the prohibition on direct and/or indirect
<br />door-to-door, telephonic, or other cold -call marketing.
<br />3.4. Policies and Procedures. Provider shall comply with IIealth Plan's policies and procedures,
<br />including, but not limited to, credentialing and recredentialing; utilization management; fraud, waste and abuse;
<br />authorization of services; quality improvement activities; and provider payment suspensions. Provider shall comply
<br />with the program integrity requirements of the State Contract, as well as IIealth Plan's program integrity policies and
<br />procedures. Without limiting the generality of the foregoing, Provider shall comply with the program integrity
<br />requirements in Section 1902(a)(68) of the Social Security Act, 42 C.F.R. § 438.610, 42 C.F.R. § 455, 42 C.F.R.
<br />§ 1000 through 1008, and Chapter 182-502A WAC. Further, Provider shall be subject to ongoing analysis of
<br />utilization, claims, billing and/or encounter data to detect overpayment, which analysis shall include audits and
<br />PPA WA - Kittitas County Public Health - 05.07.2025 - ICMProviderAgreement_360268 Page 2 of 12
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