SHJ25-008 COORDINATED CARE CONTRACT - PARTIALLY EXECUTED

Home Browse Search

not limited to: (i) 42 C.F.R. §455.105, relating to (a) the ownership of any subcontractor with whom Provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request and (b) any significant business transaction between Provider and any wholly owned supplier or subcontractor during the five year period ending on the date of the request; (ii) 42 C.F.R. §455.104, relating to individuals or entities with an ownership or controlling interest in Provider; and (iii) 42 C.F.R. §455,106, relating to individuals with an ownership or controlling interest in Provider, or who are managing employees of Provider, who have been convicted of a crime. ARTICLE III - CLAIMS SUBMISSION, PROCESSING, AND COMPENSATION 3.1. Claims or Encounter Data Submission, Contracted Providers shall submit to Payor or its delegate claims for payment for Covered Services rendered to Covered Persons. Contracted Provider shall submit encounter data to Payor or its delegate in a timely fashion, which must contain statistical and descriptive medical and patient data and identifying information. Payor or its delegate reserves the right to deny payment to the Contracted Provider if the Contracted Provider fails to submit claims for payment or encounter data in accordance with the applicable policies and procedures. 3.2. Protection of Individual Right to Privacy & Confidential Services. In accordance with RCW 48.43.505, Health Plan does not require protected individuals to obtain permission from the policyholder, subscriber, or another covered person to receive care or submit a claim if they have the right to consent to care. Health Plan recognizes the right of a protected individual or enrollee to exercise their rights regarding health information related to care they receive. Health Plan directs all communications regarding a protected individual's receipt of sensitive health services to the patient receiving care, or via postal mail, e-mail, or telephone number specified by the protected individual. Health information may not be disclosed to anyone other than the protected individual without their written or recorded verbal consent. 3.2.1. A protected individual may request communications regarding the receipt of sensitive health care services be sent to another individual or provider for the purposes of appealing adverse benefit determinations. Health Plan will limit disclosure of any information about a protected individual who is the subject of the information and will direct communications directly to the protected individual, or via mail, e-mail or phone number specified by the protected individual upon request. Protected individuals are not required to waive any right to limit disclosure as a condition of eligibility or coverage. To protect patient confidentiality, Health Plan communications disclosing protected health information or relating to sensitive services shall be provided in the form and format requested by the patient receiving care. 3.3. Compensation. The compensation for Covered Services provided to a Covered Person ("Compensation Amount") will be the appropriate amount under the applicable Compensation Schedule in effect on the date of service for the Product in which the Covered Person participates. Subject to the terms of this Agreement, Provider and Contracted Providers shall accept the Compensation Amount as payment in fall for the provision of Covered Services. Subject to the terms of this Agreement, Payor shall pay or arrange for payment of each Clean Claim received from a Contracted Provider for Covered Services provided to a Covered Person in accordance with the applicable Compensation Amount less any applicable copayments, cost -sharing or other amounts that are the Covered Person's financial responsibility under the applicable Coverage Agreement. 3.4. Financial Incentives. The Parties acknowledge and agree that nothing in this Agreement shall be construed to create any financial incentive for Provider or a Contracted Provider to withhold Covered Services. 3.5. Hold Harmless. 3.5.1. Provider and each Contracted Provider agree that in no event, including but not limited to non-payment by a Payor, a Payor's insolvency, or breach of this Agreement, shall Provider or a Contracted Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Covered Person or person acting on the Covered Person's behalf, other than Payor, for Covered Services provided tinder this Agreement. This provision shall not prohibit collection of any applicable copayments, cost- PPA WA - Kittitas County Public Health - 05.07.2025-1CMProviderAgreement_360268 Page 8 of 24