SHJ25-008 COORDINATED CARE CONTRACT - PARTIALLY EXECUTED

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ATTACHMENT A: Medicaid Network: CCCWA EXHIBIT A-6 APPLE HEALTH COMPENSATION SCHEDULE ANCILLARY SERVICES CORRECTIONAL FACILITY Kittitas County Public Health This Compensation Schedule sets forth the maximum reimbursement amounts for the provision of Covered Services to Covered Persons in a Medicaid Product offered through Health Plan and referred to as Apple Health. For Covered Services rendered to a Covered Person and billed under a Contracted Provider's tax identification number ("TIN") that has been designated by the Payor as subject to this Compensation Schedule, Payer shall pay or arrange for payment of a Clean Claim for Covered Services rendered by the Contracted Provider according to the terms of the Agreement and this Compensation Schedule. Payment under this Compensation Schedule is subject to the requirements set forth in the Agreement. For correctional facility Covered Services provided to Covered Persons, Contracted Provider's maximum compensation shall be the Allowed Amount. Except as otherwise provided in this Compensation Schedule the Allowed Amount is the lesser of: (i) the Contracted Provider's Allowable Charges; or (ii) 100% of the State's Medicaid fee schedule in effect on the date of service. If there is no established payment amount on the Payer's Medicaid fee schedule for a Covered Service provided to a Covered Person, Payer may establish a payment amount to apply in determining the Allowed Amount. Until such time as Payer establishes such a payment amount, Contracted Provider's Allowed Amount shall be 25% of the Contracted Provider's Allowable Charge. Additional Provisions: Code Change Updates. Payor utilizes nationally recognized coding structures (including, without limitation, revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or their successors) for basic coding and descriptions of the services rendered. Updates to billing -related codes shall become effective on the date ("Code Change Effective Date") that is the later of: (i) the first day of the month following 60 days after publication by the governmental agency having authority over the applicable product of such governmental agency's acceptance of such code updates, (ii) the effective date of such code updates as determined by such governmental agency or (iii) if a date is not established by such governmental agency or the product is not regulated by such governmental agency, the date that changes are made to nationally recognized codes. Such updates may include changes to service groupings. Claims processed prior to the Code Change Effective Date shall not be reprocessed to reflect any such code updates. 2. Fee Change Updates. Updates to the fee schedule shall become effective on the effective date of such fee schedule updates, as determined by the Payer ("Fee Change Effective Date"). However, the date of implementation of any fee schedule updates, i.e. the date beginning on which such fee change is used for reimbursement ("Fee Change Implementation Date") shall be the later of: (i) the date on which Payer is reasonably able to implement the update in the claims payment system; or (ii) the Fee Change Effective Date. Claims processed prior to the Fee Change Implementation Date shall not be reprocessed to reflect any updates to such fee schedule, even if service was provided after the Code Change Effective Date. Billing Requirements. Contracted Provider must bill HCPCS codes in addition to revenue code for services specified within this Exhibit. Failure to submit a HCPCS code may result in a claim denial. PPA WA - Kittitas County Public Health - 05.07.2025 - ICMProviderAgreement 360268 Page I of 2