SHJ25-014 MOLINA HEALTHCARE RENEWAL - PARTIALLY EXECUTED

Home Browse Search

X. Member(s) means a person(s) enrolled in one of Health Plan's benefit Products or a Health Plan affiliate's benefit Product and who is eligible to receive Covered Services. y. Molina Fee Schedule means the Health Plan's fee schedule, inclusive of all reimbursement rates Health Plan is required to reimburse Provider within this Agreement. The Molina Fee Schedule is available upon request. Z. Molina Marketplace means the health benefit program offered and sold by Health Plan to individuals or employers who obtain health coverage through the Washington Health Benefit Exchange. aa. Participating Provider means a healthcare facility or practitioner contracted with and, as applicable, credentialed by Health Plan or Health Plan's designee. bb. Product means the various health insurance programs offered by Health Plan to Members in which Provider agrees to be a Participating Provider, identified in the compensation exhibit(s), and which will include any successors to such Products. cc. Prior Authorization means the requirement that a provider must request, on behalf of a Member and when required by rule or state and government billing instructions, the state or governments designee's approval to provide a health care service before the Member receives the health care service, prescribed drug, device, or drug -related supply. dd. Provider means the entity identified on the Signature Page of this Agreement and includes any person or entity performing Covered Services on behalf of Provider and for which: (i) an entity of the Provider bills under an owned tax identification number; and (ii), when applicable, such person or entity has been approved by Health Plan as a Participating Provider. Where Provider is a Group/IPA or Hospital, Provider means and includes all constituent physicians, allied health professionals and staff persons who provide health care services to Members by and/or through the Group/IPA or Hospital. All of said persons are bound by the terms of this Agreement. cc. Provider Manual means the compilation of Health Plan policies, procedures, standards and specimen documents, as may be unilaterally amended or modified from time to time by Health Plan, that have been compiled by Health Plan for the use and instruction of Provider, and to which Provider must adhere. ff. Quality Improvement Program means the policies, procedures and systems developed by Health Plan for monitoring, assessing and improving the accessibility, quality and continuity of care provided to Members. gg. Subcontract means any separate agreement or contract between Health Plan and an individual or entity ("Subcontractor") to perform all or a portion of the duties and obligations that the Health Plan is obligated to perform pursuant to Health Plan's contract with the State or CMS. hh. Subcontractor means an individual or organization, including Downstream Entity, with which Provider contracts for the provision of Covered Services or administrative functions related to the performance of this Agreement, including delegation activities. For the avoidance of doubt, a Subcontractor does not include individual providers. ii. Utilization Review and Management Program means the policies, procedures and systems developed by Health Plan for monitoring the utilization of Covered Services by Members, including but not limited to under -utilization and over -utilization. ARTICLE TWO - PROVIDER OBLIGATIONS 2.1 Serving as a Panel Provider. Provider shall serve on Health Plan's panel of providers for the Products specified in Exhibit 1 and its applicable sub -exhibits. Provider agrees that its practice information may be used in Health Plan's provider directories, promotional materials, advertising, and other informational material made available to the public and Members. Practice information includes, but is not limited to, name, address, telephone number, hours of operation, type of practice, and ability to accept new patients. Provider shall promptly notify Health Plan of any changes in this practice information. MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 4 of25