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PLAN COMPENSA,T|ON SCHEDULE ("pCS"l ATTACHMENT MEDIGAID For purposes of determining the Wellpoint Rate, the total reimbursement amount that Provider and Wellpoint have agreed upon for the applicable provider type(s) for Covered Servlces provided under this Agreement in effect on the date of service shall be as set forth below. The parties acknowledge and agree that the Medicaid Fee Schedule is subject to modlfication by Wellpoint at any time during the term of thls Agreement and wilf be applled on a prospective basis. Wellpoint shall not compensate Provlder for collectlon of specimens (including venipuncture), lab handllng, or stat services, which Wellpoint considers components of the laboratory test, ln addltion, Wellpoint shall not compensate Provider for services not described by codes contained in the Wellpoint Reference Laboratory Fee Schedule. Wellpoint shall updato rates for codes from the Medicare schedules according to the provisions of the "Updates to Wellpoint Rates Based on External Sources" provlslon of the PCS. Wellpoint shall notifl7 Provider in wrlting at least sixty (60) days before significant Wellpoint initiated changes to the Wellpoint Reference Laboratory Fee Schedule. Providor shall notlff Wellpoint in writing wiftln thirty (30) days of receiving the notice and lf Provlder obJects to such changes both parties agree to dlscuss the objections. ln any evonl, Wellpoint may implement the changes sixty (60) days after notiffing Provider. Notwithstanding the foregoing, all Wellpoint Rate updates made pursuant lo an Extemal Source shall be governed by the "Updatos to Wellpolnt Rate(s) Based on External Sources" provislon of the PCS. Medicaid Affiliate Services. Provlder acknowledges that Wellpoint is affiliated with health plans that offer similar beneflts under similar programs as the programs covered hereunder ("Medicald Affiliates"). The perties acknowledge that Provider is not a Partlclpating Provlder in Medicaid Afflliate's Network for purposes of rendering services to Medicaid Members. However, in the event Provider treats a Medlcaid Member of a Medicaid Affiliate, $ubject to Regulatory Requirements, Provider shall accept as payment ln full the rates established by the Medicald Afflliate's state program governing care to Medicaid Members. Such services must be Medicaid Covered Services underthe Medicaid Afflllate's state program, and shall require prior authorization, except for Emergency Servlces and servicos for which a Medicaid Member is entltled to self-refer. Upon request, Wellpoint shall coordinate and provide information as necessary between Provider and Medicaid Affiliate for services rendered to Medicaid Member, Reimburqement Specific tg Provlder Tvpe The following will be reimbursed for faclllty services only: Acute Care Hospital, ASC, Behavloral Health Facility, Free Standing Birthing Center, Rehabilitatlon Facility and SNF. Professlonal sollces are excluded. Ambulance Provider Air and/or Ground shall be reimbursed ln accordance with Regulatory Requirements for the appllcable methodology based on the referenced fee schedule. lf such relmbursement ls based on an Wellpoint Rate, the applicable state methodology on whlch such fee schedule is based, shall be used to determine the appropriate level of reimbursement. Hosplce reimbursement is inclusive of skilled nursing, home health aide, medical social worker services, dietary, pastoral, bereavement counseling, DME, medical supplies and administration of medicatlon. Specialty Provider lndividual andior group (Non-MD or DO) shall be relmbursed in accordance wlth Regulatory Requirements for tho appllcable methodology based on the referenced fee schedule, lf such relmbursement is based on an Wellpoint proprietary fee schedule, the applicable state methodology on whlch such fee schedulo is based, shall be used to determine the appropriate level of reimbursement. w.oshln$on Enterpdse Provlder Agreement Pcs Attachment 36 1 I 939321 56 4gd_llald - sp€clallst fh.ygl.dal.clp- __ oaostz[26 @ 2024 Sept- Wollpolnt Washington, hc. Group $ervice Description Billing Gode Rate/ Methodoloov Rate Descrlption Professional Services Applicable CPT/HCPCS Code 100% of the Washington State Medicaid Fee Schedule Per Seruice Laboratory $ervices Applicable CPT/HCPCS Code 39% of the Wellpoint Reference Laboratory Feo Schedule Per Service