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3.2
<br />3.3
<br />3.4
<br />payment. lf Plan is the s_econdary payor, the three hundred slxty-flve (365) day period will not begin until
<br />Provider recelves notification of primary payor's responslbility.
<br />3,1.1 Provider agrees to submit Clalms in a format conslstent with lndustry standards and acceptable to
<br />Plan either (a) electronlcally through electronic data interchange ("EDl'), or (b) if electronic
<br />submission is not available, utilizing paperforms as defined by the National Uniform Claim Committee
<br />("NUCC").
<br />3'1'2 Provider agree to provide to Wellpoint, unless othenryise instructed, at no cost lo Wellpoint, Plan or
<br />the Medicaid Membor, all informatlon necessary for Plan to determine ib payment liability, Such
<br />information includes, without limitation, accurate and Cloan Clalms for Medicaid Govered Services.
<br />lf Wellpoint or Plan asks foradditional lnformation so that Plan may process the Clalm, Provider must
<br />provide that informatlon within slxty (60) days, or before the expiration of the three hundred sixty-five
<br />(365) day perlod referenced in section 3,1 above, whichever ls longer.
<br />3.1.3 Once Wellpoint determines Plan has any payment liability, all Clean Claims will be adjudicated in
<br />accordance with the terms and conditions dt a UeOIcaiO M6mbe/s Health Benefit plan, tie FCS, tnu
<br />provlder manual(s), and tho Regulatory Requirements applicable to Plan's Medicaid Program(s).
<br />3.1'4 Wellpoint shall meet the timeliness of payment standards specifled for Medicald fee-for-servics in
<br />$ection 1902(a)(37)(A) of the Social Security Act, 42 C,F.R, S 447 .46 and specifled for heatth carriers
<br />in WAC 284'170-431, To be compliant with both payment standards, Wellpolnt shall pay ninety-five
<br />percent (95%) of the monthly volume of Clean Claims within thirty (30) calendar days of receipt and
<br />shall pay or deny.ninety-five percent (95o/o) of the monthly volums of all Claims wlthl-n sixty (OO) days
<br />of receipt. Notwithstanding the foregolng, Wellpolnt and Provider may agree to a different'paiment
<br />requirement in wrlting on a claim by claim basis.
<br />3.1.5 Wellpoint shall pay Provider Interest at the rate of one percent (1%) per month, as set forth in WAC
<br />284-17O-431(2)(d)which section may be amended or recodifled from time to time, on the unpaid or
<br />undenied portion of Clean Claims not adjudicated within the time periods discussed above, as
<br />required under applicable prompt pay requlrements.
<br />3.1.6 Provider agrees to accept payments or approprlate denlals made in accordanco with this Agreement
<br />as payment in full for all Modlcaid Covered Services provided to Medicaid Members. Provlder shall
<br />be responshle for collecting co-payments from Medicaid Members to the extent required by
<br />Regulatory Requirements.
<br />Thls provision intentionally left blank.
<br />Audit for Compliance with QMS Guidelines. Notwithstanding any other terms and conditions of the Agreement,
<br />this Attachment, or the PGS, Plan has the same rights as CMS, to review and/or Audit and, to [he extsnt
<br />necessary r€cover payments on any claim for Medicaid Covered Servlces rendered pursuant to this
<br />Attachment and the Agreement to ensure compliance with GMS Regulatory Requirements. '
<br />Fecords Relentign. ln addltion to the Plan Access to and Requests for Provlder Records provision of the
<br />Agreement, Provider shall malntain an adequate record system for recording services, charges, dates and all
<br />other commonly accepted information elements for Medlcaid Covered Services in a manner that is cunent,
<br />detailed and organlzed, and that pormits effective and confidential patient care and quality revlew,
<br />administrative, civil andlor criminal investigations and/or prosecutions. Provider shall maintaln all medical
<br />records for Medicaid Members in accordance with applicable Regulatory Requirements.
<br />3.4.1 ln additlon to and wllhout limiting any audii rlghts otherwise setforth in the Agreement and immediate
<br />access for Medicaid fraud investigators, Provider agrees that agents and employees of HCA and
<br />HHS shall have the right to inspect, ovaluate and audit any pertinent books, flnancial records,
<br />documents, paperc, and records of Provider invotving financial'transactions related to a Government
<br />Contract. HCA representatives and authorized federal and state personnel including, but not limited
<br />to the Office of the lnspector General (OlG), the Medlcald Fraud Control Unit (MFCU), HHS, the
<br />Department of Justice (DOJ), the Comptroller of the Treasury and any other duly buthori2ed state or
<br />federal agency, shall have immediate and complete access to all records pertaining to servlces
<br />provided to Modicaid Members.
<br />Washlngton Enlerprlse ProviderAg€emenl Medlcstd Attachmenl.
<br />@2024 July- Wellpolnt Washhglon, lne.20 1 183932156
<br />0sl05l2025
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