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5.25 5.26 5.27 5.28 (a) (b) Pharmacy Preguthorization and Eme-roencv Fill Requirements. Provider and Wellpoint shall each complywith all applicable pharmacy preauthorization and emergency requirements of the Government Contract and WAC 284-170-470, including but not limited lo compliance with the following: (c) (d) Disclose if the provider or pharmacy has the right to make a prior authorization request; and Provlde that if Wellpoint or Provider requires the authorization number to be transmitted on a pharmaceutical claim, the lssulng party wlll provide the authorlzation number to the bitling pharmacy. The authorization number will be communicated to the billing pharmacy after approval of a prior auftorization request and upon receipt of a claim for that authorized medication, The prlor authorization determinaton must be transmitted to the requestlng party and must lnclude the information aboutwhethera requestwas approved and if the requestwas made bythe pharmacy, notification will additionally be made to the prescriber. Wellpoint and Provider acknowledge and agree that Wellpolnt shall authorize an emergency fill by the dlspensing pharmacist and approve the claim payment. An emergency flll is only applicable when: (1) The dispensing pharmacy cannot reach Wellpoint's prior authorizatlon department by phone as it is outside of that department's business hours; or (21 Wellpolnt ls available to respond to phone calls from a dispensing pharmacy regarding a covered beneflt, but Wellpoint cannot reach the prescriber for full consultation. (e) Druo Utillzation Review Process. Provider agrees to comply with Wellpoint's drug utilization revlew procoss, including but not limited to, the exceplion rute (ETR) process as outlined ln the provider manual and on Wellpoint's webslte. Potentiallv Preventable Refffmission$. lf applicable, to facilitate care transltions for Medicaid Members, Provider and Wellpoint shall comply with all Potentially Preventable Readmission ('PPR") requirements, as set forth in the Government Contract and WAC 182-550-2900 and 182-550-3000. Consistent wlth the PPR provisions of the Government Contract, Wellpoint and Provlder shall worlt together to facilitate care transltions for Medicaid Members and Provider shall be responslble for ensuring completlon of the followlng: (a) discharge screenings, (b) discharge/care plan$, (c) discharge education, and (d) follow up care after discharge, including for mental health services, as applicable. ln addition, for high risk members, Provider will allow Wellpoint oi Wellpoint's designee to assist with the coordination of plannlng, including visiting the Medicaid Member. Reportino. Provider shall submit to Wellpolnt all reports and clinical information requlred by Regulatory Requirements or otherwise reasonably requested by Wellpoint, 5.27.1 lf Provider is a Certlfled Behavioral Health Agency (BHA), Provider must comply with behavioral health reporting requirements, including Service Encounter Reporting lnstructlons ("SERl"). Provider must report behavloral health supplemental transactions to Wellpolnt as set forth in the provlder manual(s), or as required under applicable Regulatory Requirements. Provider lnsurance Qoveraqe. ln addllion to the Provider lnsurance provision ln the Agreement, Provider, at all times during the term of this Agreement, shall: 5.28.1 Malntain professional liability insurance; includlng maintalning such tail or prior acts coverage nece$sary to avoid any gap in covenage for claims arising from incidents occurring during the term of this Agreement. Such lnsurance shall (i) be obtained from a carrlerauthorized to conduct businessin the jurisdiction in which Provider operates; (ii) maintaln mlnlmum policy limits equal to $5,000,000.00 per occur€nce and 910,000,000.00 in the aggregate for acute care hospitrils and $1,000,000.00 per occurrence and $3,000,000.00 ln the aggregate for other providers; and (iii) include coverage for the professional acts and omissions of Provider and any employee, agent or other person forwhose acts or omisslons Provider is responsible. 5.28.2 Maintain general comprehonslve liability insurance fom a carier authorized to conduct business in the jurisdictlon in which Provlder operates, ln amounts requlred under Regulatory Requirements. Said insurance shall cover Provider's premises, insuring Provider against any claim of loss, llablllty, or damage caused by or arising out of the condition or allegod condltlon of said premises, or the furniture, fixtures, appliances, or equipment located thorein, iogether wlth the standard liabllity Washington Er{elprlse Provlder Agrsment Medlcald Attachment O 2024 July- Wollpolnl Washlngton, lnc.1183932156 05105/2025 25