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PLAN COMPENSATTON SCHEDULE ('pCS,') ATTAGHMENT MEDICAID For purposes of determining the Wellpoint Rate, the tolal relmbursement amount that Provider and Wellpolnt have !9peq upon for.the appllcable provider type(s) for Covered Servlcee provlded under this Agreement in efiect on he date of service shall be as set forth below. The parties acknowledge and agree that the Medicald Fee Schedule is subject to modlfication by Wellpoint at any 1me during the term of this Agreement and will be applied on a prospective basis_ Provider agrees to reference SERI coding guidelines, available through Wellpolnt's Web portal, to ensurc the proper billing and reimbursement, Medlcail Affiliate Services. Provlder acknowledges that Wellpoint is affillated with health plans that offer similar beneflts under.similar programs as the programs covered hereunder ("Medicaid Afflllates"). The partles acknowledge that Provider is not a Participatlng Provider in Medicaid Affillate's Network for purposes of rendering servlces to M6dicaiO Members. However, in the event Provider treats a Medicaid Member of a Medlcaid Affiliate, subject to Regulatory Roqulrements, Provlder shall accepl as payment in full the rates establlshsd by the Medicaid Affiliaie's state firograrirgoverning care to Medicaid Members, Such services must be Medicaid Covered Services under the Medicaid AmLte's state program' and shall require prior authorizallon, except for Emergency Services and services forwhich a Medicaid Member is entitled to self*efer.- _-Upon request, Wellpoint shall coordinate and provide information as nec€ssary between Provider and Medicaid Affiliate for services rendered to Medicald Member.' Reimbursement Specific to Provider Tvpe The following will be reimbur.sef.for facllity servlces only: Acute Care Hospital, ASC, Behavioral Health Facility, Free $tanding Birthing Center, Rehabllltation Faclllty and SNF, Professional services are excluded. Ambulance Provider Alr and/or Ground shall be reimbursed in accordance with Regulatory Requirements for the applicable methodology based on the referenced fee schedule. lf such reimbursementis basdO on an Wellpoint Rate, the applicable state methodology on whlch such fee schedule is based, shall be used to determine the appropriaie level of reimbursement. Hospice reimbursement is inclusive of skilled nursing, home health aide, medlcal social worker services, dietary, pastoral, bereavement counseling, DME, medical supplies and administration of medication, Specialty Provider lndivid_ual .and/or group (Non-MD or DO) shall be reimbursed In accordance with Regulatory Requirements for the applicable methodology based on the referenced fee schedule. lf such reimbursement ii nasei on an Wellpoint proprietary fee schedule, the appllcable state methodology on whlch such fee schedule js based, shall be used to determine the appropriate level of reimbursement. Specialty Provider lndlvldual and/or group (including Non-MD or DO) shall be reimbursed for anestheslology services in accordance with the accumulation of base, modifler and time units multiplied by the Washinglon Stat6'Medicaid Anesthesia Conversion Factor. The services should be billed in minute increments. One tlme unit will be allowed for each fifteen (15) minute interval, or fractlon thereof, starting from the time Provider begins to prepare the Member for induction and endlng when the Member may safely be placed under post-operative iupervibion and provlder is no longer ln personal attendance. "Ambulatory Patient Group" ('APG") means the Wellpoint Rate that ls a lixed reimbursoment to a facility for Outpatient Services and which incorporates data regardlng the reason for the vislt and patient data, "Ambulatory Payment Classification" ("APC") or its successor shall have the meaning set forth ln the Medicare law and CMS regulations and guidance. Washlnglon En[elpdse Provlder Agreement PCS Atlachment Medlcald - Bohevloral Hoallh Facility 1 1 83932156 Bit Rate/ ServicesEligible CPT/HCPCS NDC Code(s)State Medicaid Fes 100%Per Service @ 2024 Sept - Wellpoint Washhglon, lnc, 34 o610512025