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not limitedto: (i) 42 C.F.R. $455.105, relating to (a) the ownership of any suboontractor with whom Providerhas had business fansactiors totaling more than $25,000 during the l2-month period ending on the date of the request and (b) any significant business transaction between Provider and any wholly owned supplier or subcontractor during the five year period ending on the date of the request; (ii) 42 C.F.R. $455.104, relating to individuals or entities with an ownership or controlling interest in Plovicler; and (iii) 42 C.F,R, $455,106, relating to individuals with an ownership or controlling interest in Provider, or who are rnanaging employees of Provider, who have been convicted of a orime. ARTTCLE m - CLATMS SUBMISSION, PROCESSTNG, AND COMPENSATION 3.1. Claims or Encormter Data Submission, Contracted Providers shall submit to Payor or its delegate claims for payment for Covered Service.s rendered to Covered Persons. Contracted Provider shall submit encounter data to Payor or its delegate in a timely fashion, whioh must coniain statistical and descriptive medical and patient data and iderrtifying infomtation. Payor or its delegate reserves the right to deny payme,nt to the Contracted hovider if the Contnoted Provider fails to submit ciaims for payment or encounter da+a in accnrdance with the applicable policies and procedures. 3.2. Protection of Individual Right to hivacy & Confidential Servioes. In accordance with RCttr/ 48,43.505, Health Plan does not require protected individuals to obtain permission from the polieyholder, subsoriber, or another covered person to receive care or submit a claim if they have the right to conse,nt to care. Health Plan recognizes the right of a protected individual or enrollee to e>rercise their riglrts regarcling health information related to care they receive. Health Plan directs all comrnunications rcgarding a protected individual's receipt of sensitive health serviees to the patient receiving care, or via postal mail, +mail, or telephone number specified by the protected individual. Health information may not be disclosed to anyone other than the protected individual without their written or recorded verbal consent. 3 -2.1 . A protected individual may request communications regarding the receipt of sensitive health care seryices be sent to another individual or provider for the purpos€s of appealing adverse benefit deterrninations. Health Plan will limit clisclosure of any information about a protected individual who is the subject of the information and will direct comnunications directly to the protected individual, or via mail, e-mail or phone number specifi.ed by the protected individual upon request. Protected individuals are not required to waive any right to limit disclosure as a condition of eligibility or coverage. To protect patient confidentiality, Health Plan comrnunications disolosing protected health information or relating to sensitive services shail be provided in the form and fomrat requested by the patient receiving care, 3.3. Compensation, 'llre compensation for Covered Services provided to a Covered Person ('Compensation Amount') will be the appropriate amount under the applicable Compensation Schedule in effect on the date of service for the Product in which the Covered Person participates. Subject to the terms of this Agreemento Provider and Contracted Providers shall accept the Compensation Amount as payment in fulI for the provision of Covered Services. Subject to the terms of this Agreernent, Payor shall pay or arrange for payment of each Clean Claim reoeived from a Conhacted Provider for Covered Services provided to a Covered Person in accordance with the applicable Compensation Amount less any applicable copalmrents, cost-sharing or other amounts that are the Covered Person's financial resporsibility under the applicable Covoage Agreement. 3.4. Financi.al Incentives. The Parties acknowledge and agree that nothing in this Agreement shall be construed to create any financial incontive for Provider or a Contracted Provider to withhold Covered Services. 3.5. HoldHannless. 3.5.1. Pt'ovicler and each Contracted Provider agree that in no event, including but not limited to non-payment by a Payor, a Payor's insolvency, or breach of this Agreement, shall Provider or a Contracted Provider bill, charge, collect a deposit from, seek compensatioq remunemtion or reimbursement from, or have any recourse against a Covered Person or person actrng on the Covered Person's behalf, other than Payor, for Covered Services provided rnder this Agreement. This provision shall not prohibit collection of any applicable copayments, cost- PPA WA - Ifittitas County Public Health - 05.07.2Q25 - ICMProviderAgteernent_360268 page B of 24