SHJ25-014 MOLINA HEALTHCARE RENEWAL - PARTIALLY EXECUTED

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arrangement between Health Plan (or applicant) and Provider. These written arrangements continue down to the level of the ultimate provider for health and administrative services, j. Emergency Services are Covered Services necessary to evaluate or stabilize the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. For Health Plan's Medicaid Members, Emergency Services also includes any services defined as emergency services under 42 C.F.R. §438.114. Health Plan reserves the right to investigate certain emergency care Claims to determine if a Claim meets the definition of Emergency Services. If Health Plan denies a Claim on the basis that a reasonably prudent layperson would not have believed that an emergency health condition existed, the Member may exercise the right of appeal under the Grievance Program. k. Encounter Data means all data captured during the course of a single health care encounter that specifies: (i) the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative) pharmaceuticals, medical devices, and equipment associated with a Member receiving services during the encounter; (ii) the identification of the Member receiving and the provider providing the health care services during the single encounter; and (iii) a unique and unduplicated identifier for the single encounter. 1. Government Contracts means the contract between Health Plan and a governmental agency for a Product. in. Government Program Requirements mean the requirements of governmental agencies for a Product, which includes, but are not limited to, the requirements set forth in the Government Contract. n. Grievance Program means the procedures established by Health Plan to timely address Member and Provider complaints or grievances. o. HCA means The Washington State Health Care Authority. p. Health Benefit Exchange means the Washington health benefit exchange established in RCW 43.71.020, et seq., the Health Benefit Exchange Act. q. Health Plan means Molina Healthcare of Washington, Inc. r. HEDIS Studies mean Healthcare Effectiveness Data and Information Set. S. IPA means Independent Practice Association. t. Law means, without limitation, federal, state/commonwealth, tribal, or local statutes, codes, orders, ordinances, and regulations applicable to this Agreement. U. Medicaid means the joint federal -state program provided for under Title XIX of the Social Security Act, as amended. V. Medicare Advantage (04MA") means a program in which private health plans provide health care and related services through a Government Contract with CMS, which is authorized under Title XVIII of the Social Security Act, as amended (otherwise known as "Medicare"). Medicare Advantage also includes Medicare Advantage Special Needs Plans ("MA -SNP"). W. Medically Necessary means those medical services and supplies which are provided in accordance with professionally recognized standards of practice which are determined to be: (a) appropriate and necessary for the symptoms, diagnosis or treatment of the Member's medical condition; (b) provided for the diagnosis and direct care and treatment of such condition; (c) not furnished primarily for the convenience of the Member, the Member's family, the treating provider, or other provider; (d) furnished at the most appropriate level which can be provided consistent with generally accepted medical standards of care; and (e) consistent with Health Plan policy. MIIWPROV22.3 MHWPSA/Revised Jan 2024 Page 3 of25