SHJ25-008 COORDINATED CARE CONTRACT - PARTIALLY EXECUTED

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3.23. Release of Necessary Information. Provider acknowledges and agrees to release to Health Plan any information necessary to perform any of Health Plan's obligations under the State Contract. 3.24. Encounter Data Reporting. Provider shall submit complete, accurate and timely encounter data and behavioral health supplemental transactions to Health Plan in accordance with current encounter submission guidelines published by HCA or as otherwise specified by Health Plan. Provider represents and warrants that it has the capacity to submit all data required by HCA to enable Health Plan to meet the reporting requirements in the Encounter Data Reporting Guide and Service Encounter Data Reporting Guide (SERI) and Behavioral Health Supplemental Transaction Data Guide published by HCA. 3.25. Potential Allegations of Fraud. Provider shall refer potential allegations of fraud to HCA and the Medicaid Fraud Control Unit as described in Subsection 12.6 of the State Contract. 3.26. Fraud, Waste, and Abuse. Provider shall comply with Health Plan's policies regarding fraud, waste and abuse. In addition, Provider shall comply with the following applicable provisions necessary to prevent fraud, waste and abuse. (a) If Provider is delegated responsibility for coverage of services and payment of claims under the State Contract, then Provider shall implement and maintain administrative and management arrangements or procedures designed to detect and prevent fraud, waste and abuse that are consistent with Health Plan's policies and all requirements of applicable law and the State Contract, including without limitation those described in Section 12.5.1 of the State Contract. (b) Provider shall (i) provide written disclosure of any prohibited affiliation in accordance with 42 C.P.R. § 438.610; 42 C.F.R. § 455.106; and 42 C.F.R § 438.608(c)(1) to HCA; (ii) provide written disclosures of information on ownership and control as indicated under Subsection 12.3 of the State Contract (42 C.P.R. § 455.104; 42 C.F.R. § 455.105; and 42 C.F.R § 438.608(c)(2)); (iii) maintain internal policies and procedures for the documentation, retention, and recovery of all overpayments, specifically for the recovery of overpayments due to fraud, waste or abuse, consistent with the State Contract; and (iv) report to Health Plan and HCA within 60 calendar days when it has identified capitation payments or other payment amounts received are in excess to the amounts specified in the State Contract (42 C.F.R. § 438.608(c)(3)). (c) Provider shall cooperate with Health Plan audits of Provider to detect and identify fraud, waste and abuse. 3.27. Subro ag tion. Provider agrees to subrogate to the State for all criminal, civil and administrative action recoveries undertaken by any government entity, including, but not limited to, all claims Provider has or may have against any entity or individual that directly or indirectly receives funds under the State Contract including, but not limited to, any health care provider, manufacturer, wholesale or retail supplier, sales representative, laboratory, or other provider in the design, manufacture, marketing, pricing, or quality of drugs, pharmaceuticals, medical supplies, medical devices, durable medical equipment, or other health care related products or services. For the purposes of this section, "subrogation" means the right of any State government entity or local law enforcement to stand in the place of Provider in the collection against a third party. 3.28. Limitations on Referrals. Provider referrals may be limited to Participating Providers except in the following circumstances: (a) emergency services; (b) services provided outside the Service Areas as necessary to provide Medically Necessary services; (c) when a Covered Person has other primary comparable physical and/or behavioral health coverage, as necessary to coordinate benefits; and (d) within the Service Areas, as defined in the Service Areas provisions of the Enrollment Section of the State Contract, Provider shall cover Covered Persons for all physical and/or behavioral health necessary services. 3.29. High Categorical Risk Providers. Providers that are deemed to be "high categorical risk," including PPA WA - Kittitas County Public Health - 05.07.2025 - ICMProviderAgreement_360268 Page 6 of 12