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physical defonnity or malfirnction; and O) are not more costly than any other equally effective or more conservative
<br />course of treatment available or suitable for the Covered Person requesting the service. Such services shall include
<br />services related to the Covered Person's abilify to achieve age-appropriate growth and deveiopment.
<br />2.5. Physfuian's Orderc for Ltfe Sustaining Treatment ((POI^|T) means a set of guidelines and
<br />ptotocols for how emergency medical personnel shall respond when summoned to the site of an iqjury or illness for
<br />the treatment of a person who has signed a written directive or durable power of attorney requesting lhat he or she
<br />not receive futile emergency medioal treatment, in accordance with RCW 43.70.480.
<br />2.6. Prirnary Care Provlder or PCP moans a Parlicipating Provider who has the responsibility for
<br />supervising coordinating, and providing primary health care to Covered Persons, initiating referrals for qpecialist
<br />care, and maintaining the continuity of Covered Person care. PCPs include, but are not limited to pediatricians,
<br />family practitioners, ganeral practitioners, intemists, naturopathic physicians, medical residents (under the
<br />supervision of a teaching physician), physician assistants (under the supervision of a physician), or advanced
<br />registered nurse practitioners (nurse practitioners), as designated by Flealth Plan. The definition of PCP is inclusive
<br />of primary care physician as it is used in 42 C.F.R. $ 438. A1l Federai requirernents applioable to primary oare
<br />physicians will also be applioable to PCPs as the term is used in this Attachment.
<br />2.7. Statemans the state of Washington.
<br />2.8. State Con*acf(s,) means the applicable contract(s) between HCA and Health Plan under which
<br />Health Plan agrees to provide or affange for seryices related to the Apple Health Program, inclucling any exhibits,
<br />attachments, documenls, or materials incorporated by reference.
<br />ARTICLE III
<br />PROVIDER C ONTRACT REQUIREMENTS
<br />3.1. Health Plan Remahs Lqsally Responsible, Nothing herein shall be construed to delegate lega1
<br />responsibility to HCA for any work performed under the Agreement, nor for oversight of any functions and/or
<br />responsibilities delegated to Provider. lSouree: g 9.1 of the 2022 Apple hlealth IMC Agreementl
<br />3.2. Complianee with Applicable Lay. Provider shall comply with all Applicable Law. For purposes of
<br />this Attachment, "Applicable Lil.taf' shall specifically include thosE laws and regulations as set forth in the State
<br />Contract, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (TIIPAA"),
<br />the Mental Health Parity and Addiction Equity Act ("MIIPAEA') and final nrlq The 21$ Century Cures Act, state
<br />laws and regulations regarding mental and behavioral health and substance use disorder services, the Federal Drug
<br />and Alcohol Confidentiality Laws in 42 C.F.R.Part2,42 U.S.C. gg 1396a(a)( :) (ear$ and periodic screening,
<br />diagnostic, and treatment services ('EPSDT")), 1396d(r) (definition of EPSDT), and 42 C.F.R. $ 438.30) (choice of
<br />network provider).
<br />3.3. Compliance with State Contract. Provider shall comply with any term or condition of the State
<br />Conkaot that is applicable to the sewices to be perfoirned under the Agreement, inclu,ling but not limited to the
<br />Performance Improvernent Project requirements of the State Conhact and the prohibition on direct and/or indirect
<br />door-to-door, telephonic, or other cold-call marketing.
<br />3.4. Policies and Procedures. Provider shall comply with Health Plan's policies and procedures,
<br />including, but not limited to, credentialing and recredentialing; utilization managemen! fraud, waste ancl abuse;
<br />aulhorization of services; quality improvement activities; and provider payment suspensions. Provider shall comply
<br />with the program integrity requirernents of the State Contract, as well as l-Iealth Plan's program integrity policies and
<br />procedures. Withouf limiting the generality of the foregoing, Provider sha1l comply with the program integrity
<br />requirements in Section 1902(a)(68) of the Social Security }lct,42 C.F.R, $ 438.610, 42 C.F.R. g 455, 42 C.F.R.
<br />$ 1000 tbrough 1008, and Chapter t82-502A WAC. Further, Provider shall be subject to ongoing analysis of
<br />utilization, claims, billing and/or encounter data to detect overpayrnent, which analysis shall include audits and
<br />PPA WA - ICttitas County Public Health - 05.07.2025 - ICMProvirlerAgreement_360268 P age2 of lZ
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