SHJ25-008 COORDINATED CARE CONTRACT - PARTIALLY EXECUTED

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Participating Providers to provide the Covered Service for which the Covered Person is referred. Except as required by applicable law, failure of Provider and Contracted Providers to follow such procedures may result in denial of payment for unauthorized treatment. Preauthorization is not required prior to provision of Covered Services in the event of an emergency. 2.7.1. Prior Authorization: In accordance with RCW 48.43.016(2)(a), the Agreement does not require utilization management or review of any kind for an initial evaluation and management visit, and up to six treatment visits with a Contracted Provider in a new episode of care for each of the following: • Chiropractic • Physical therapy • Occupational therapy • Acupuncture and Eastern medicine • Massage therapy • Speech therapy Visits where utilization management or review is prohibited are still subject to quantitative treatment limits of the Health Plan. With the exception of RCW 48.43.515(5), the Health Plan can require a referral or prescription for the therapists listed. For visits where utilization management or review is prohibited, Health Plan will not deny or limit coverage on the basis of medical necessity or appropriateness; or retroactively deny care or refuse payment for the visits in accordance with RCW 48.43.016(2)(b). 2.7.2. Telemedicine Payment Paris. In accordance with RCW 48.43.735, providers for telemedicine services shall be compensated at the same rate (to be defined by the Legislature) as in -person services. Provider can negotiate a telemedicine reimbursement rate that differs from in -person services for: • hospitals, • hospital systems, • telemedicine companies, and • provider groups consisting of 11 or more providers. Provider can negotiate payment of facility fees for telemedicine services that originate at: • a hospital, • a rural health clinic, • a federally qualified health center (FQHC), • a physician/health care provider's office, • community mental health center, skilled nursing facility, or • a renal dialysis center (except an internal renal dialysis center). Any other site may not charge a facility fee. Health Plan shall not distinguish between originating sites that are rural and urban when providing coverage. Health Plan is not required to reimburse: an originating site for professional fees, services not covered under the plan, or an originating site or provider that is not contracted under the plan. Audio -Only Telemedicine: In accordance with RCW 48.43.735(1)(a)(v) and WAC 284-170-433(1)(b), the covered person must have an established relationship with the provider. PPA WA - Kittitas County Public Health - 05.07.2025 - ICMProviderAgreement_360268 Pago 5 of 24