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

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suspended if Carrier provides notice that a credible allegation of fraud exists and there is a pending investigation. Carrier performs coding edit procedures based primarily on National Correct Coding Initiative (NCCI) policies and other nationally recognized and validated policies. Provider agrees that it will provide medical records to Carrier upon its request in order to determine appropriateness of coding. Claims payments may be temporarily suspended or adjusted if the Provider bills a claim with a code that does not match the service provided. Provider may dispute any temporarily suspended or adjusted payment consistent with the terms of the Agreement. 3.25 Claims Information. Provider shall promptly submit to Carrier information needed to make payment. Provider must submit a Clean Claim no more than twelve (12) months after the calendar month in which the Covered Service is performed. Provider shall identify third party liability coverage, including Medicare and other insurance, and if applicable seek such third party liability payment before submitting Claims to Carrier. 3.26 Data; Reports. Provider shall cooperate with and release to Carrier any information necessary for Carrier to perform its obligations under the State Contract to the extent applicable to Provider in performance of the Agreement, including the timely submission of reports and information required by Carrier. Such reports shall include child health check-up reporting, if applicable, as well as complete and accurate encounter data in accordance with the requirements of Carrier and the State Contract. Data and reports must be provided within the timeframes specified and in a form that meets Carrier and State requirements. By submitting data to Carrier, Provider represents to Carrier that the data is accurate, and upon Carrier's request Provider shall certify in writing, that the data is accurate, complete, and truthful, based on Provider's best knowledge, information and belief. 3.27 Insurance Requirements. As applicable, Provider shall secure and maintain during the term of the Agreement insurance appropriate to the services to be performed under the Agreement. If Provider is a home health agency, Provider shall comply with the surety bond requirements in accordance with 42 CPR 441.16. Upon request, Provider shall make available to Carrier copies of its Certificate(s) of Insurance. 3.28 Licensure. Provider represents that it is currently licensed and/or certified under applicable State and federal statutes and regulations and by the appropriate State licensing body or standard - setting agency, as applicable. Provider represents that it is in compliance with all applicable State and federal statutory and regulatory requirements of the State Program and that it is eligible to participate in the State Program. Provider represents that it does not have a State Program provider agreement with HCA that is terminated, suspended, denied, or not renewed as a result of any action of the HCA, CMS, HHS, or the MFCD of the State's Attorney General. Provider shall maintain at all times throughout the term of the Agreement all necessary licenses, certifications, registrations and permits as are required to provide the health care services and/or other related activities delegated to Provider by Carrier under the Agreement. If at any time during the term of the Agreement, Provider is not properly licensed as described in this Section, Provider shall discontinue providing services to Covered Persons. 3.29 Quality; Utilization Management. Pursuant to any applicable provider manuals and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Carrier's quality assessment, performance improvement and utilization review and management activities, which shall be tailored to the nature and type of services subcontracted. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Carrier or as required under the State Contract to ensure quality control for the health care provided, including but not limited to the accessibility of Medically Necessary health care, and Covered Persons have due UFIC/STATE PROGRAMS REGAPX, WA.02.25 37