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Docusign Envelope lD: CEBC6B3C-DFA1-486C-AFE8-6A4A63440080 <br />Outpatient Services:N/A% of Medicare Fee Schedule <br />for all Covered Services described therein; and <br />NiA% of the Washington State Health Care <br />Authority's ("HCA's") Apple Health (Medicaid) <br />Fee Schedule for all Covered Services for which no <br />Medicare fee exists. <br />Professional Services :N/A% of Medicare Fee Schedule <br />for all Covered Services described therein; and <br />N/A% of the Washington State Health Care <br />Authority's ("HCA's") Apple Health (Medicaid) <br />Fee Schedule for all Covered Services for which no <br />Medicare fee exists. <br />2. Payment. <br />A. CHPW will adjust payments to Facility consistent with adjustments that CMS <br />and/or HCA applies to their respective fee schedule(s). 1 CHPW will pay, or <br />require the applicable third party plan sponsor to pay, Facility for Covered <br />Services rendered to Members in accordance with the terms of this Agreement, <br />the Provider Manual, the applicable Benefit Plan, and billing instructions and <br />policy guidelines published and periodically updated by applicable state and <br />federal agencies. <br />B. Facility shall seek and accept payment from CHPW, or the applicable plan <br />sponsor, for Covered Services in accordance with the terms of this Agreement, the <br />Provider Manual, the applicable Benefit Plan, and billing instructions and policy <br />guidelines published and periodically updated by applicable state and federal <br />agencies. Facility shall have the right to bill, charge, or collect a deposit directly <br />from a Member for any applicable deductible, co-payment, or coinsurance, or for <br />any services that is not a Covered Service. In no event may Facility bill or collect <br />form a Member any difference between Facility's charges and the amount <br />described in this Exhibit B-4-A for Covered Services. <br />Effective Date: 7 11 12025 <br />(cHPtr ro CoMPLETE) <br />I Medicare Managed Care GME, IME, and Allied Health payments are paid through the Medicare cost reporting process, and are <br />therefore excluded from these referred payment rates. In addition, Sole Community Hospitals (SCH) and Medicare Dependent <br />Hospitals (MDH) receive a supplemental payment if their inflated and case mix adjusted base-year cost, referred to as their Hospital <br />Specific Rate (HSR) exceed the Medicare Operating MSDRG and Outlier payments under traditional Medicare Part A fee for <br />service. SCH and MDH special payment adjustrnents are excluded from these referred payment rates. <br />2021Facility Exh B4A - 3PHBERates Page 49 of51 Conhact #5908-662684