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9laim-S=ubmisslons fg,r Pharm.qpeUticals. Each Claim submltted for a pharmaceuticat product must include standard
<br />Coded Service ldentifier{s), a National Drug Code ('NDC') numbor of lhe covered medication, a description of theproduct, and dosage and units administered.
<br />Coding. Uodatqq. Coded Service ldentifie(s) used to define specific rates are updated from time to time to reflect new,
<br />doleted or rePlacement codes. Wellpoint shall use commercially reasonable efforts to update all applicable Coded
<br />Service ldentifiers within eixty (60) days of releaso by CMS or other applicable authorit!. Wnen 6iiting codes are
<br />updated, Provider is req.uirod to use appropriate replacement codes for Claims for Covered $ervlces, regardless of
<br />whetherthis Agreement has been amended to reflect changes to stahdard billing codes. lf Provider bllls a re-vised code
<br />prior to the effective date of the revlsed code, the Claim will be rejected or denied and Provider shatl resubmlt Glaim
<br />with conect code. ln addltion, Claims with codes whlch have been deleted will bo reJecied or denied.
<br />9odino Software. lpdatgs to WeJlpolnt's Claims processing flltors, code editing softrruare, pricers, and any edits related
<br />thereto, as a result of changes in Coded Seruice ldentifie(s) reporting guidellnes and instructions, sh-all take place
<br />automatically and do not require any notice, disclosure or amendment to Provider. Wellpoint reserves the right to use
<br />a.code editing software as reasonafly required by Wellpoint to ensuro Claims adJudlcation ln accordance with industry
<br />standards, including, but not llmlted to, determlning which services are considered part of, incidental to, or inclusive of
<br />the primary procedure and ensuring medically appropriate age, gender, diagnosls, ftequency, and units bllled.
<br />Modifigrs. All appropriate modifiers must be submitted ln accordanco wlth Regulatory Requirements, indusfuy standard
<br />billlng guidelines and Policiss. lf appropriate modifiers are not submitted, Claims may be iejected or denied.
<br />NeWFxpanded Sgrvice or NeWExpanded Technoloqy. ln accordance with the Scope/Change ln Status section of the
<br />Agreemont, as of the Eff.ecllve Date of this. Agreement, any New/Expandod Servlce or NeWExpanded Technology
<br />(defined below) is nol reimbursable under this Agreement, Notwithstandlng the foregoing, Provider may submit t66
<br />followlng documentatlon to.Wellpoint at least sixty (60) days prior to the implementation of iny NedExparided Service
<br />or New/Expanded Technology for consideration as a relmbursable service: (1) a descripti6n of the NedExpanded
<br />9"t ,-q" or New/Expanded Technology; (2) Provider's proposed charga for the NewlExpanded Service or
<br />NeMExpanded Technology; (3) such other reasonable data and information required by Wellpoint to evaluate the
<br />NewlExpanded Service or NewlExpanded Technology. ln addition, Wellpolnt may also n6ed to obtain approval from
<br />applicable Agency prior to Wellpoint making determination that NeWExpanded Service or New/Expanded iechnotogy
<br />can be considered a reimbursable service. lf Wellpoint agroes that the New/Expanded Service or NeWExpanddi
<br />Technology may be reimbursable.underlhis Agreement, then Wellpoint shall notiff Provider, and both parties agree to
<br />leqoliate in good faith, a new Wellpoint Rate for the New/Expanded Seruice or NewlExpanded Technoiogy wlthin sixty
<br />(60).days of Wellpoint's notice to Provider, lf the parties are unable to reach an agreement on a new Wfulpoint nat6
<br />for lhe New/Expanded Service cr NeWExpanded Technology before the end of tlie sixty (60) day period, ihen such
<br />NeMExpanded Service or NedExpanded Technology shall not be reimbursed by Wettpolrit, dnO inb payment in Full
<br />and Hold Harmless provision of this Agreement shall apply.
<br />a' "NeWExpanded Service" shall be defined as a Health Service: (a) that Providerwas not providing to Members
<br />as of the Effective Date of this Agreement and; (b) for which there is not a specific Wellpoint Raie as set forth
<br />in this PCS.
<br />b. "NedExpanded Technology" shall be deflned as a technologlcal advancement in the delivery of a Covered
<br />Service which results in a material increase to the cost of such service. New/Expanded Technology shall not
<br />lnclude a new device, or implant that merely represents a new model or an improved model of i-device or
<br />implant used in connection with a service provided by Providor as of the Effectlve Date of this Agreement.
<br />Non-Priced Codes for Coveled Services, Wellpoint reserves the right to establish a rate for sodes that are not priced
<br />in this PCS or in the Fee Schedule(s), including but not limited to, Not Otherwise Classified Codes ("NOC'), Not
<br />Otherwise Specifled ("NOS"), Miscellaneous, lndividual Consideration Codes ("1C"), and By Report ("BR'i (colb6lively
<br />"Non-Frlced Codes"). Wellp-oint shall only reimburse Non-Priced Codes ior Covered Seiricei in [n'e toltowing
<br />situations: (i)the Non-Priced Code does not have a published dollar amount on the lhen current applicable plan, Stai6
<br />or CMS Fee Schedule, (ii) the Non-Priced Code has a zero dollar amount listed, or (iii)the Non-Priced Code requires
<br />manual pricing. ln such situatlons, such Non-Prlced Code shall be reimbursed at a rate established by Wellpolht for
<br />such Covered Service. Notwithstanding the foregoing, Wellpoint shall not price Non-Priced Godes that aie not bovered
<br />Servlces under the Members Health Beneflt Plan. Wellpoint may require the submission of medlcal rscords, invoices,
<br />or other documentation for Clalms payment consideration.
<br />Reimbursement for Wsllpoint Rate Based on Ellgible Charges. Notwithstandlng any relmbursement amount sot forth
<br />herein, Provlder shall only be allowed to receive such reimbursement if such reimbursement is for an Eligible Charge.
<br />ln addition, if Provider reimbursement is under one or more of the following methodologles: Capltation] Case Raie,
<br />Washlngton Enterpriso Provider Agreomsnt PCS
<br />@2024 July- Wellpoinl Washlngton, lnD,1 183932156
<br />05/06/2025
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