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Name According to W-9 Form with ftla: County of Kittilas ribs Kitties County
<br />WELLPOINT WASHINGTON, INC.
<br />PROVIDER AGREEMENT
<br />This Provider Agreement (hereinafter "Agreement") is made and entered into by and between Wellpoint Washington,
<br />Inc. (hereinafter "Wellpoint") and the undersigned Provider (hereinafter "Provider"), and shall be effective as of the date
<br />set forth immediately above Wellpoint's signature (the "Effective Date"). In consideration of the mutual promises and
<br />covenants herein contained, the sufficiency of which is acknowledged by the parties, the parties agree as follows:
<br />ARTICLE I
<br />DEFINITIONS
<br />"Affiliate" means any entity that is: (i) owned or controlled, either directly or through a parent or subsidiary entity, by
<br />Wellpoint, or any entity which controls or is under common control with Wellpoint, and/or (ii) that is identified as an
<br />Affiliate on a designated web site as referenced in the provider manual(s). Unless otherwise set forth in this Agreement,
<br />an Affiliate may access the rates, terms and conditions of this Agreement.
<br />"Agency" means a federal, state or local agency, administration, board or other governing body with jurisdiction over
<br />the governance or administration of a Health Benefit Plan.
<br />"Audit" means a post -payment review of the Claim(s) and supporting clinical information reviewed by Wellpoint to
<br />ensure payment accuracy. The review ensures Claim(s) comply with all pertinent aspects of submission and payment
<br />including, but not limited to, contractual terms, Regulatory Requirements, Coded Service Identifiers (as defined in the
<br />PCS) guidelines and instructions, Wellpoint medical policies and clinical utilization management guidelines,
<br />reimbursement policies, and generally accepted medical practices. Audit does not include medical record review for
<br />quality and risk adjustment initiatives, or activities conducted by Wellpoint's Special Investigation Unit ("SIU").
<br />"Claim" means either the uniform bill claim form or electronic claim form in the format prescribed by Plan submitted by
<br />a provider for payment by a Plan for Health Services rendered to a Member.
<br />"CMS" means the Centers for Medicare & Medicaid Services, an administrative agency within the United States
<br />Department of Health & Human Services ("HHS").
<br />"Cost Share" means, with respect to Covered Services, an amount which a Member is required to pay underthe terms
<br />of the applicable Health Benefit Plan. Such payment may be referred to as an allowance, coinsurance, copayment,
<br />deductible, penalty or other Member payment responsibility, and may be a fixed amount or a percentage of applicable
<br />payment for Covered Services rendered to the Member.
<br />"Covered Services" means Medically Necessary Health Services, as determined by Plan and described in the
<br />applicable Health Benefit Plan, for which a Member is eligible for coverage.
<br />"Government Contract" means the contract between Wellpoint and an applicable party, such as an Agency, which
<br />governs the delivery of Health Services by Wellpoint to Member(s) pursuant to a Government Program.
<br />"Government Program" means any federal or state funded program under the Social Security Act, and any other
<br />federal, or state, county or other municipally funded program or product in which Wellpoint maintains a contract to
<br />furnish services as designated by Wellpoint. For purposes of this Agreement, Government Program does not include
<br />the Federal Employees Health Benefits Program ("FEHBP"), or any state or local government employer program.
<br />"Health Benefit Plan" means the document(s) that set forth Covered Services, rules, exclusions, terms and conditions
<br />of coverage. Such document(s) may include but are not limited to a Member handbook, a health certificate of coverage,
<br />or evidence of coverage.
<br />"Health Service" means those services, supplies or items that a health care provider is licensed, equipped and staffed
<br />to provide and which he/shelit customarily provides to or arranges for individuals.
<br />"Medically Necessary" or "Medical Necessity" means the definition as set forth in the applicable Participation
<br />Attachment(s).
<br />"Member" means any individual who is eligible, as determined by Plan, to receive Covered Services under a Health
<br />Benefit Plan. For all purposes related to this Agreement, including all schedules, attachments, exhibits, provider
<br />Washington Enterprise Provider Agreement PCS 1 1183932156
<br />0 2024 July— Wellpoint Washington, Inc. 05/05/2025
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