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MEDICAID PARTICIPATION ATTAGHMENT TO THE WELLPOINT WASHINGTON, INC. FROVIDER AGREEMENT Aftachment ("Attachment") to the Wellpolnt Provlder Agreement ('Agreement'), entered and Provider and is incorporated into the Agreement. This is a Medicaid Participatlon into by and between Wellpoint Washlngton Entorprlse Ptovider Agr€ement Modlcald Atlaclm6nt 920?4 July- Wellpolnl Washington, lnc. ARTICLE I DEFIN!TIONS The followlng definitions shall apply to this Attachment. Terms not othenryise defined in this Attachment shall carry the meaning set forth in the Agreement. "Clean Claim" means a claim that can be processed without obtaining additional informatlon from the provider of the service or flom a third party and has no defect or impropriety, lncluding any lack of any required substantiating documentation, or partlcularclrcumstances requiring special treatment that prevents timely payments from being made on the claim. "Medicaid Program(s)" means, for purposes of thls Attachment, a medical asslstance program provided under a Health Benefit Plan approved underTitle XVl, (Supplemental Security lncome), Title XIX (Medicaid) and/orTitle XXI (Children's Health lnsurance Prognam "CHIP Program(s)") of the Social $ecurity Act or any otherfederat or state funded program or product as designated by Wellpoint. "Medicaid Covered Services" means, for purposes of thio Attachment, only those Covered SeMces provided under Plan's Medicaid Program(s); health care services that HCA determines are covered for onrollees, those health care servlces (including Behavioral Health Care Servlces)that a Medicaid Member is entitled to recelve through Wellpoint pursuant to Regulatory Requirements, and for whlch a PGS is attached horeto setting forth the Providers' roimbursement under one or more Programs. Medicaid Covered Services do not include the preventable adverse events as set forth in the provider manual(s). "Medicaid Membe/' means, for purposes of this Attachment, a Membor who is enrolled in Plan's Medicaid Progmm(s). "Medically NecessaryiMedical Necessity" means services that are "medically necessary" as is defined in WAC 182- 500-0070, a requested service which is reasonably calculaled to prevent, diagnose, conect, cure, alleviate, or prevent worsening of condltions in the Medicald Member lhat endanger life, or cause sufferlng of pain, or result in an lllness or lnfinnity, or threaten to cause or aggravate a handicap, or cause physical deformity, or malfunction. There is no other egually effective, more conservative or substantially less costly couftie of treatnent available or suitable for the Medicaid Member requesting the service. For the purpose of this Attachment, "course of treatment" may include mere observation or, where appropriate, no medical treatment at all. "Slate Agency" means the Washington Health Care Authority ("HCA') or other duly authorized state agency. ARTIGLE II SERVICES/OBLIGATIONS 2.1 Partlcipation:Medicaid Netwg-r.k, As a participant in Wellpoint's Medicaid Network, Provider will render Medlcald Covered SeMces to Medlcaid Members in accordance with the terms and conditions of the Agreement and this Attachment consistent with the provlsions of 42 CFR 434.6. Such Medicaid Coverod Services provided shall be within the scope of Providefs licensure, expertl$e, and usual and customary range of services pursuant to the terms and condltions of the Agreement and this Aftachment, and Provider shall be responsible to Wellpoint for his/her/its performance hereunder. Provlder shall release to Wellpoint any information necessary for Wellpoint to perform any of its obllgations under the Agreement or under the Government Contract. Except as set forth ln this Attachment or the Plan Compensation Schedule ("PCS"), all terms and conditions of the Agreement will apply to Provider's participation in Wellpoint's Medicaid Network. The terms and conditions set forth in this Attachment are limited to the provision of and payment for Health Services provided to Medicaid Members. WellPoint shall ensure that Provider furnlshes Health Servlces to each Medlcaid Memberwlthout regard to the Medicaid Member's enrollment in the plan as a prlvate purchaser of the plan or as a participant in publicly financed programs of health care services. This requirement does not apply to clrcumstances when the Provider should not render services due to limitations arising from lack of tralning, experience, skill, or licensing rostrlctlons." I 1 839321 56 05i05t2026 17