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Washlngton Enterpalse Provldor Agreement PCS @2024 July* Wellpolnl Wa6hlngton, lnc, PLAN COMPENSATTON SCHEDULE ('pCS") ARTICLE I DEFINITIONS The definitions set forth below shall apply with respect to all of the terms outlined ln this PCS, Terms not othenruise defined in this PCS and deflned elsewhero ln the Agreement shall carry the meanings set forth in lhe Agreement. "Capitation" means the amount paid by Wellpoint to a provider or management services organization on a per member per month basis for either specific services or the total cost of care for Covered Services. - "Case Rate" means the all-incluslve Wellpoint Rate for an entire admission or one outpatlent encounter for Covered Services. "Chargemaster" or "Charge Master" means facility's listlng of facility cfiarges for products, servlces and supplies. "Coded Service ldentlfler{s)" means a llsting of descriptive terms and identi$ing codes, updaled from time to 1me by CMS or other lndustry source, for reporting Health Services on the CMS 1500 or GMS 1450/UB-04 claim form or its successor as appllcable based on the services provided. The codes include but are not limited to, Amerlcan Medical Association Current Procedural Terminology ("CPT@4"), CMS Healthcare Common Procedure Godlng System ("HCPCS"),-lnternational Classiflcation of Dsea$es, 1Oth Revislon ("lCD-10"), National Uniform Billing Committee ("Revenue Code") and National Drug Code ("NDC") or their sucsessors. "999t t9. Charge Ratio" ("CCR") means the quotient of cost (total operating expenses minus other oporating revenue) divided by charges (gross patlent revenue) expressed as a decimal, as doflned by Regulatory Requiremenis "Diagnosis-Related Group" ("DRG") means Diagnosls Related Group or its successor as established by CMS or other grouper, including but not limited to, a state mandated grouper or other lndustry standard grouper. "DRG Rate" means the all-inclusive dollar amount which is multiplied by the appropriate DRG Weight to determine the Wellpoint Rate for Covered Services, "DRG Weight" me€ns the weight appticable to the specific DRG methodology set forth in this PGS, includlng but not limited to, CMS DRG welghts as published in the Foderal Register, state agency weights, or other industry itandard weights. "Eligible Charges" means those Provider Charges that meet Wellpolnt's condltions and reguirements for a Health Service to be eligiblo for roimbursement. Theso condltions and requirements include but ars not llmited to: Memberproglm eligibility, ProMder program eligibllity, benefit coverage, authorization requirements, provider manual speclfications, Wellpolnt administrative, clinical and reimbursement policies and methodologles, cdde editing logic, coordination of benefits, Regulatory Requirements, and this Agreement. Ellglble Charges do not include P:rovider Gharges for any items or services that Provider receives and/or provides free oi charge. "Emergency.Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (lncluding severe pain) such that a prudont layperson, with an average knowledge of health and medicine, could reasonabl! expect the absence of immediate medical attention to result in serious jeopardy to the health of the individual, or in the case of a pregnant woman! the health of the woman or her unborn child; serious impalrment to bodily functions; or serious dysfunctlon of any bodily organ or part. oEmergency Services" rnsans those Covsred Services furnished by a provider qualified to furnlsh emergsncy services, and which are needed to evaluate or treat an Emergency Condltion. "Encounter Data" means Claim informatlon and any additional information submitted by a provlder under capitated or risk-sharing arrangements for Health Services rendered to Members, "Encounter Rate" means the Wellpoint Rate that is all-inclusivo of professional, technical and facility charges including evaluatlon and management, pharmaceuticals, routine surglcal and therapeutic procedures, and dlagnostic testing (including laboratory and radiology) capable of belng performed on site. "Fee Schedule(s)" means the complete llsting of Wellpoint Rate(s) for specific services that is payment for each unit of seMce allowed based on applicable Coded Service ldontilie(s) for Covered Services. 1 1 839321 56 05/05/2025 30