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Persons, within the scope of the Contraoted Providgr's license and in accordance with generally accepted standards of the Contracted Provider's practice and business and in accordanoe with the provisions of this Agreement and Regulatory Requirements, 2.4. Policies and Procedures. Provider warrants that Provider and Contracted Providers shall at all times ooopelate and comply with applicable administrative requirements, policies, progralns and procedures of Company and Payor, which may includq but are not limited to, the following: credentialing criteria and requirements; confidenrtiality and notification requireinents; medical management programs; claims and billing quality assessment and improvement, utilization review and managernent, disease management, case managemont, on-site reviews, referral and prior authorization, and grievance and appeal procedures; coordination ofbenefits and third party liability policies; carve-out and third parly vendor programs; and data reporting requirements. The failr.re to comply with zuch policies and procedures sould result in a denial or reduction of payment to the Provider or Contracted Provider or a denial or reduction of the Covered Person's benefits. Such policies and procedures do not in any way affeot or remove the obligation of Contracted Providers to render care. Health Plan shall make the applicable policies available to Provicler and Contracted Providers prior to conffacting and throughout the term of the Agreement upon reasonable rocluest via one or more designated websites or alternative means. Company shall notifu Provider at least 60 days in advance of changes in administrative policies and procedures that affect Provider's compensation or health care service deliveryunless changes to fEderal or State law or regulations make such advance notice impossible, in which case notice will be provided as soon as possiblo. Such notice may be grven by Health Plan through an update to information available to Provider online, or any other written method {elechonic or paper). Provider shali notify C;ontracted Providers of such changes. 2,5, Credentialing Criteria. Provider and each Contracted Provider shal1 complete Company's and/or Payor's credentialing arid/or recredentialing process as required by Company's and/or Payor's oredentialing policies, and shall at all times during the term of this Agreement meet all of Company's and/or Payor's credentialing criteria. Provider and each Contracted Provider represents, warrants and agrees: (a) that it is currently, and for the duration of this Agreement shall rernain: (i) in complianoe with all applicable Regulatory Requirernents, including licensing laws; (ii) if applicable, accredited by The Joint Commission or the American Osteopathic Associatioq and (iii) a Medicare-certified provider under the federal Medicare program and a Medicaid participating provider under applicable federal and State laws; and (b) that all Contracted Providers and all employoos and contractors thereof will perform their duties in accordance with all Regulatory Requirements, as well as applicable national, State and local standards of professional ethics and practice. No Contracted Provider shall provide Covered Services to Covered Persons or iclentiff itself as a Participating Provider rrnless and until the Contracted Provider has been notified, in writing, by Company that such Contracted Provider has successfully cnmpleted Company's credentialing process. 2.6. EligibilituDeterminations. ProviderorContraotedProvidershalltimelyverifywhetheranindividual seeking Covered Services is a Covered Person. Company or Payor, as applicable, will make available to Provider and Contracted Providers a method whereby Provider and Conhacted Providers can obtain, in a timety manner, general information about eligibility and coverage. Company or Payor, as applicable, does not guarantee that persons identified as Covered Persons are eligible for benefits or that all services or srpplies are Covered Services. If Company, Payor or its delegate determine that an indiviclual was not a Covered Person at the time services were rendered, such services shall not be eligible for payment under this Agreement, except to the extent zuch services were expressly authorized by Company or Payor. For retroqpective review, eligibility deteflrinations will be made solely on the meclical information available to the Contracted Provider at the time the health service was provided. Such retrospective review will be completed within 30 calendar days of receipt of the necessary inforrnation, In addition, Company will use reasonable efforts to include or contractuallyrequire Payors to clearly display Company's name, logo ormailing address (or other identifier(s) desipated from time to timeby Company) on each mernbership card. 2,7, Referral and Preauthorization Procedures. Provider and Contracted Providers shall comply with referral and preauthofization procedures adopted by Company and/or Payor, as applicable, prior to referring a Covered Person to any individual, institutional or ancillary health care provider. Unless otlrerwise expressly authorized in writing by Company or Payor, Provider and Contraoted Proviclers shall refer Coverecl Persons only to PPA WA - Kittitas County Public Hcalth - 05.07.2025 - ICMProviderAgreement_360268 Page4 of 24