|
Pursuant to RCW 48.43.735(9)(dxi)-(ii) "Established relationship" means the provider providing audio-only
<br />telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services, and: (i)
<br />for health care services included in the essential health benefits category of mental health and substance use disorder
<br />services, including behavioral health treatment: (A) The Covered Person has had, within the past three years, at least
<br />one in-person appointment, or at least one real-time interactive appointrnent using both audio and video technology,
<br />with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the
<br />same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46
<br />RCW as the provider providing audio-only telernedicine; or (B) The Covered Person was referred to the provider
<br />providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person
<br />appointment, or at least one real-time interactive appointment using both audio and video technology, with the
<br />Covered Person and has provided relevant medical information to the provider providing audio-only telemedicine;
<br />(ii) For any other health care service: (A) Tlie Covered Person has had, within the past two years, at least one in-
<br />person appointment, or, until January l, 2024, at least one real-time interactive appointment using both audio and
<br />video technology, with the provider providing audio-only telemedicine or with a provider employed at the same
<br />medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under
<br />chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or (B) The Covered Person was
<br />referred to the provider providing audio-only telemedicine by another provider who has had, within the past two
<br />years, at least one in-person appointment, or, until January 1,2024, at least one real-time interactive appointment
<br />using both audio and video technology, with the covered person and has provided relevant medical information to
<br />the provider providing audio-only telemedicine.
<br />2.8. Treatment Decisions. No Company or Payor is liable for, nor will it exercise control over, tlle marmer
<br />or method by which a Contracted Provider provides items or services under this Agreement. Provider and Contracted
<br />Providers understand that detemrinations of Company or Payor that certain items or services are not Covered Services
<br />or have not been provided or billed in accordance with the requirements of this Agreement are administrative
<br />decisions only. Such decisions do not absolve the Contracted Provider of its responsibitity to exercise independent
<br />judgment in treatment decisions relating to Covered Persons. Nothing in this Agreement (i) is intended to interfere
<br />rvith Contracted Provider's relationship with Covered Persons, or (ii) prohibits or restricts a Contracted Provider fiom
<br />disclosing to any Covered Person any information that the Contracted Provider deems appropriate regarding health
<br />care quality, medical treatment decisions or alternatives.
<br />2.8.1. Withdrawal Manasement Services: In accordance with RCW 48.43.761 and WAC 28443-
<br />2000, the Agrcement may not specify timeframes for substance abuse disorder treatment less than what is specified
<br />in RCW 48.43.761(12(a)(i), nor speciff timeframes for withdrawal management services less than rvhat is specified
<br />in RCW 48.43.76I(2)(a)(ii), nor contain language that prevents a seamless transfer to an appropriate level of care.
<br />2.9. Drus Utilization Management Exceptions. Provider drug utilization management exceptions are
<br />available on the Health Plan website: rvww.coordinatedcarehealth.com.
<br />2.10. Carve-Out Vendors. Provider acknowledges that Company may, during the term of this Agreement,
<br />carve-out certain Covered Services from its general provider contracts, including this Agreement, for one or more
<br />Ptoducts as Company deems necessary or appropriate. Provider and Contracted Providers shall cooperate with and,
<br />when medically appropriate, utilize all third party vendors designated by Company for those Covered Services
<br />identified by Company from time to time for a particular Product.
<br />2.1 L Disparagement Prohibition. Provider, each Contracted Provider and the officers of Company shall
<br />not disparage the other during the term of this Agreement or in connection with any expiration, termination or non-
<br />renewal of this Agreement. Neither Provider nor Contracted Provider shall interfere with Cornpany's direct or
<br />indirect contractual relationships including, but not limited to, those with Covered Persons or other Participating
<br />Providers. Nothing in this Agreement should be construed as limiting the ability of Health Plan, Company, provider
<br />or a Contracted Provider to infomr Covered Persons that this Agreement has been terminated or otherwise expired
<br />or, with respect to Provider, to promote Provider to the general public, or to limit Contracted Providers from
<br />participating in discussions with a patient or someone paying for their coverage regardilg the comparative merits of
<br />PPA wA - Kinitas county Public Health - 05.07.2025 - ICMproviderAgreemcnt_36026g page 6 of 24
|