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Docusign Envelope lD: 7 4E827C5-FAB8-8084-827C-41 4AD59920A6
<br />arrangement between Health Plan (or applicant) and Provider. These written affangements continue
<br />down to the level of the ultimate provider for health and administrative seruices,
<br />i, Emergency Services are Covered Services neces$ary to evaluate or stabilize the emergent and
<br />acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson
<br />acting reasonably to believe that a health condition exists that requires immediate medical attention,
<br />if failure to provide medical attention would result in serious impairment to bodily functions or
<br />serious dysfunction of a bodily ofgan or patt, or would place the person's health in seriotrs
<br />jeopardy. For Health Plan's Medicaid Members, Emergency Services also includes any services
<br />defined as emergengy services under42 C,F.R. $438,114, Health Plan reserves the rightto
<br />investigate certain ernergency care Claims to determine if a Claim meets the definition of
<br />Emergency Services. If Health Plan denies a Claim on the basis that a reasonably prudent layperson
<br />would not have believed that an emergency health condition existed, the Member may exercise the
<br />right of appeal under the Grievance Program.
<br />k, Encounter Data means all data captured during the course of a single health care encounter that
<br />specifies: (i) the diagnoses, comorbidities, procedures (fterapeutic, rehabilitative, maintenance, ol'
<br />palliative) pharmaceuticals, medical devices, and equipment associated with a Member receiving
<br />services during the encounter; (ii) the identification of the Member receiving and the provider
<br />providing the health care services during the single encounter; and (iii) a unique and unduplicated
<br />identifrer for the single encounter.
<br />l, Government Contracts means the contract between Health Plan and a govemmental agency for a
<br />Product.
<br />m, Government Program Requirements mean the requirements of governmental agencies for a
<br />Product, which includes, but are not limited to, the requirements set forth in the Government
<br />Contract.
<br />n. Grievance Program means the procedures established by Health Plan to timely address Member
<br />and Provider complaints or grievances.
<br />o. HCA means The Washington State Health Care Autholity.
<br />p. Ilealth Benefit Exchange means the Washington health benefit exchange ostablished in RCW
<br />43.77,020, et seq., the Health Benefit Exchange Act,
<br />q. Health Plan means MolinaHealthcare of Washington, Inc.
<br />r, TIEDIS Studies mean Healthcare Effectiveness Data and Information Set,
<br />s. IPA means Independent Practice Association.
<br />t, Law means, without limitation, federal, state/commonwealth, tribal, or local statutes, codes, orders,
<br />ordinances, and regulations applicable to this Agreement.
<br />u. Medicaid means the joint federal-state program provided for under Title XIX of the Social Security
<br />Act, as amencled.
<br />v. Mcdicare Advantage ("MA') means a ptogram in which private health plans provicle health care
<br />and related services through a Government Conhac.t with CMS, which is authorized under Title
<br />XVIII of the Social Security Act, as amended (otherwise known as "Medicare"). Medicare
<br />Advantage also includes Medicare Advantage Special Needs Plans ("MA-SNP").
<br />w, Medically Necessary means those medical services and supplies which are provided in accordance
<br />with professionally recognized standards of practice which are determined to be: (a) appropriate
<br />and necessary for the symptoms, diagnosis or treatment of the Member's medical condition; (b)
<br />provided for the diagnosis and direct care and treatment ofsuch condition; (c) not furnished
<br />primarily foL the convenience of tlre Member, the Member's family, the treating provider, or other
<br />provider; (d) furnished at the most appropriate level which can be provided consistent with
<br />generally accepted medical standards of care; and (e) consistent with Health Plan policy.
<br />MI-IWPRoV22.3 MHWPSA"/Revised Jan 2024 Page 3 of25
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