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2.5 Provider Manuat In performing its duties hereunder, Facility shall comply, and require its <br />Facility -Based Providers to comply, with applicable requirements of the Provider Manual that <br />CHPW may amend from time to time at its sole discretion, including the following. <br />2.5.1 As required in the Provider Manual, Facility shall (i) before rendering any service that <br />requires CHPW's prior authorization, obtain prior authorization, and (ii) timely notify <br />CHPW of Member inpatient admission. Failure to obtain authorization and/or provide timely <br />notification shall result in denial of claims for services rendered. <br />2.5.2 Facility shall verify each Member's eligibility before providing Covered Services other <br />than screening and treatment for emergency medical conditions by either calling CHPW's <br />Customer Service Department at the telephone number printed on the back of Member's <br />CHPW identification card, or electronically as set forth in the Provider Manual, <br />2.5.3 Facility shall comply with RCW 48.135 concerning Insurance Fraud Reporting and <br />notify CHPW's Director of Compliance of all incidents or occasions of suspected fraud, <br />waste or abuse involving Covered Services provided to any Member. Facility shall report a <br />suspected incident of fraud, waste or abuse within ten (10) business days of the date Facility <br />first becomes aware of, or is on notice of, such activity. The obligation to report suspected <br />fraud, waste or abuse shall apply whether the suspected conduct was perpetrated by Facility, <br />Facility's employee, agent, or subcontractor, or Member. Facility shall establish policies and <br />procedures for identifying, investigating, and taking appropriate corrective action against <br />suspected fraud, waste or abuse. Upon request by CHPW or the State, Facility shall confer <br />with the appropriate State agency prior to or during any investigation into suspected Fraud, <br />waste or abuse. For purposes of this section, the terms fraud and abuse shall have the same <br />meaning as provided for in 42 CFR §455.2. <br />2.5.3.1 CHPW shall not penalize Facility because Facility, in good faith, reports to state <br />or federal authorities any act or practice by the health carrier that jeopardizes patient <br />health or welfare or that may violate state or federal law. <br />2.5.3.2 Facility will maintain policies and procedures that require its managers, officers <br />and directors involved in work that relates to Members to sign a Conflict of Interest <br />Statement upon hiring or appoint and annually thereafter and to report potential conflicts <br />of interest that may arise.I <br />2.6 Utilization Review and Quality Assurance. <br />2.6.1 Facility shall comply with, cooperate and participate in utilization review, quality <br />improvement, quality assurance programs, necessity of care evaluation programs, <br />coordination of benefit activities, health care coding reviews and cost containment activities, <br />as set forth in the Provider Manual and as CHPW deems necessary, including post payment <br />reviews, audits and/or reviews by independent quality review and improvement organizations <br />and accreditation agencies. <br />A conflict of interest may arise if a person or a member of his/her family has an existing or potential interest or relationship that <br />impairs or appears to impair the person's independent judgment. <br />2020 Facility Agmt— Template Page 7 of 51 Contract #{Contract #}-1PRC Agreement IDl <br />