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"Global Case Rate" means the all-inclusive Wellpoint Rate which includes faclllty, probssional and physician services for specific Coded Service ldentifier(s) for Covered Services. nlnpatient Servlces" means Covered Seruices provided by a facility to a Member who ls admitted and treated as a registered inpatient, is assigned a licensed bed within the facility, remains assigned to such bed and for whom a room and board charge is made. "Observstion" means the services furnished on the facilifu's premlses, including use of a bed and perlodic monitoring by nursing or other staff, which are Medically Necessary to evaluate a Member's condltion and determlne if the Membei requires an inpatlent admission to the faclllty. Such determlnation shall be ln compliance with Policies or Regulatory Requirements. "Outlier Rate" means the payment applied to an admission whlch exceeds the outlier threshold as set forth ln the PCS or in compliance wlth Policies or Regulatory Requirements "Outpatient Services" means Covered Services provided by a facillty to a Member who is admitted and treated as a registerod outpatient wlthln the facility. "Patlent Day" means each approved calendar day of care that a Member receives ln the facility, to the extent such day of care is a Covered Service under the terms of the Member's Health Benefit Plan, but oxcluding the day of discharge, "Percentage Rate" means the Wellpolnt Rate that ls a percentage of Eligible Charges billed by a provlder for Covered Services. "Per Diem Rate" means the Wellpoint Rate that ls the all-inclusive flxed paymsnt for Covered Services rendered on a eingle date of service. "Per Hour Rate" means the Wellpoint Rate that is payment based on an increment of time for Coverod Services. "Per Relative Value Unif' ("RVU") means tho Wellpoint Rate for each unll of service based on the CMS, State Agency or other (e.9., American Soclety of Anesthesiologists (ASA)) defined Relative Value Unit (RVU). "Por Service Rate" means the Wellpoint Rate that is payment for each service allowed based on appllcable Coded Seruice ldentifier(s) for Covered Services. "Per Unit Rate' msans tho Wellpolnt Rate that is payment for each unit of service allowed based on applicable Coded Service ldentifie(s) for Covered Services. "PerVislt Rate" means the Wellpoint Rate that is the alFincluslve fixed payment for one encounterfor Covered Services. "Provider Charge$" msans the regular, unlform rate or price Providor determines and submits to Wellpoint as charges for Health Services provided to Members. Such Provlder Charges shall be no greater than the mte or price Provider submits to any porson or other health care benefit payor for the same Health Servlces provlded, regardless of whether Provlder agrees with such person or other payor to accept a different rate or price as payment in full for such servlces. "Short Stay" means an inpatient hospital stay that ls less than a specified number of calendar days in compliance with Policies and/or Regulatory Requirements, ARTICLE II GENERAL PROVISIONS BillinLForyt and Claims Rgnortinq Requlrements. Provider shall submit all Clalms on a CMS 1500 or CMS 1450/UB- 04 claim form or its successor form(s) as applicable based on the Health Services provided ln accordance with Policies or appllcable Regulatory Re quirements. Provlder shall report all Health Servicos ln accordance with the Coded Servlce ldentifle(s) reporting guidelinos and instructions using HIPAA compliant billing codes, [n addition, Plan shall not pay any Claim(s) nor accept any Encounler Data submitted uslng non-compliant codes. Plan audits that result in identification of Health Services that are not reported in accordance with the Coded Service ldentlfler(s) guidelines and instructions, will be subject to recovery through remittance adjustment or other recovery action as may be set forth in the provider manual(s). 1 183932156Washlngton Enterprlso Provder Agreement PCS @ 2024 July- Wollpolnl Washington, lnc.31 0510512025