SHJ25-011 UNITED HEALTHCARE & KCJ Carceral 2025 Medicaid Contract - PARTIALLY EXECUTED

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2.7 HCA: Washington State Health Care Authority, any division, section, office, unit or other entity of HCA, or any of the officers or other officials lawfully representing HCA. 2.8 Primary Care Provider or PCP: A participating provider who has the responsibility for supervising, coordinating, and providing primary health care to Enrollees, initiating referrals for specialist care, and maintaining the continuity of Enrollee care. PCPs include, but are not limited to Pediatricians, Family Practitioners, General Practitioners, Internists, Naturopathic physicians, medical residents (under the supervision of a teaching physician), Physician Assistants (under the supervision of a physician), or Advanced Registered Nurse Practitioners (ARNP), as designated by the Contractor. The definition of PCP is inclusive of primary care physician as it is used in 42 C.P.R. § 438.2. All Federal requirements applicable to primary care physicians will also be applicable to primary care providers as the term is used in this Contract. 2.9 Provider: Any individual or entity engaged in the delivery of services, or ordering or referring for those services, and is legally authorized to do so by the State in which it delivers the services. 2.10 State: The State of Washington or its designated regulatory agencies. 2.11 State Contract: Carrier's contract with the HCA for the purpose of providing and paying for Covered Services to Covered Persons enrolled in one or more State Programs. 2.12 State Program(s): The State of Washington Apple Health, Apple Health for Kids, Integrated Managed Care or other similar program(s) where Carrier provides services to Washington residents through a contract with the State. For purposes of this Appendix, State Program may refer to the State agency(ies) responsible for administering the applicable State Program. SECTION 3 PROVIDER REQUIREMENTS The State Programs, through contractual requirements and federal and State statutes and regulations, requires the Agreement to contain certain conditions that Carrier and Provider agree to undertake, which include the following: 3.1 Definitions Related to the Provision of Covered Services. Provider shall follow the State Contract's requirements for the provision of Covered Services. Provider's decisions affecting the delivery of acute or chronic care services to Covered Persons shall be made on an individualized basis and in accordance with the following definitions: Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average lurowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: i) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; ii) serious impairment to bodily functions; or iii) serious dysfunction of any bodily organ or part. ii) Emergency Services: Inpatient and outpatient contracted services furnished by a provider qualified to furnish the services needed to evaluate or stabilize an Emergency Medical Condition. iii) Medically Necessary or Medical Necessity: Services that are "Medically Necessary" as defined in WAC 182-500-0070. In addition, Medically Necessary services shall include UHUSTATE PROGRAMS REGAPX WA.02.25 29