|
Name Aocordlng lo W-9 Form with d/b/ai County ot Ktttltss dba Kllllas County
<br />*'?f3iT,'=Ht'JillgilgNf '"
<br />This Provider Agroement (heroinafter 'Agreement") is made and entered into by and between Wellpoint Washlngton,
<br />lnc. (herelnafter "Wellpoint") and the undersigned Provider (hereinafter "Provider"), and shall be effective as of the date
<br />set forth immedlately above Wellpoinfs signature (the "Effectlve Date"). ln consideration of the mutual promlses and
<br />covenants herein contained, the sufficiency of which is acknowledged by the parties, the partles agree as follows:
<br />ARTICLE I
<br />DEFINITIONS
<br />'Affiliate" means any entity that ls: (i) owned or controlled, either dlrectly or through a parent or subsidiary entity, by
<br />Wellpoint, or any entity which controls or is under common control with Wellpolnt and/or (ii) that is ldentified as an
<br />Affiliate on a deeignated web site as referenced in the provider manual(s). Unless othenrvise set forth in this Agreemsnt,
<br />an Aftiliate may access the rates, terms and condftions of thls Agreement,
<br />'Agency" means a federal, state or local agency, administratlon, board or oth€r governing body with jurlsdictlon over
<br />tho govemance or administnation of a Health Benefit Plan.
<br />"Audlt" means a post-payment review of the Claim(s) and supporting cllnlcal informatlon reviewed by Wellpoint to
<br />onsure payment accuracy. The review onaures Claim(s) comply wlth all pertinent aspects of submission and payment
<br />including, but not limited to, contractual terms, Regulatory Requirements, Coded Service ldentifiers (as defined in the
<br />PCS) guidellnes and instructions, Wellpolnt medical policies and clinical utilization management guldelines,
<br />reimbursement policies, and generally accepted medlcal practices. Audlt does not include medlcal record review for
<br />quality and risk adJustment initiatives, or actlvities conducted by Wellpoinfs Spedal lnvestlgation Unlt ("SlU").
<br />"Claim" means either the uniform bill claim form or electronic claim form in tho format prescribed by Plan submitted by
<br />a provider for payment by a Plan for Health Servlces rendered to a Member.
<br />"CMS" means the Centers for Medicare & Medicaid Services, an adminlstrative agency within the United States
<br />Department of Health & Human Sorvicos ("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 referrod to as an allowance, coinsurance, copayment,
<br />deductible, penalty or othor Member payment responsibillty, and may be a fixed amount or a percentage of applicable
<br />payment for Covered Servlces rendered to the Member.
<br />"Covered Service$" means Medically Necossary Health Services, as determined by Plan and describod ln the
<br />applicable Health Benefit Plan, for which a Member is eligible for coverage.
<br />"Government Contracf' means the contract between Wellpoint and an applicable party, such as an Agency, which
<br />governs the delivery of Health Servlces by Wellpoint to Membe(s) pursuant to a Government Program.
<br />"Government Program" means any federal or state funded program under the Social Security Act, and any other
<br />federal, or state, county or other municipally funded program or product in which Wellpoint maintains a contract to
<br />furnish services as designated by Wellpoint. For purposes of this Agreement, Government Program does not include
<br />the Federal Employees Health Benefits Program ("FEHBP"), or any state or local government employer program.
<br />"Health Benefit Plan" means the document(s) that set forth Covered Services, rules, excluslon$, terms and conditions
<br />of coverage. Such document(s) may lnclude but are not limited to a Member handbook, a health certificate of coverage,
<br />or evidence of coverage.
<br />"Health Service" rneans those services, supplles or items lhat a health care provider is licensed, equipped and staffed
<br />to provide and which heishe/it customarlly provides to or arangos for individuals.
<br />"Medically Necessary" or "Medical Necessity" means the definition as set forth in the appllcable Participation
<br />Attachment(s).
<br />"Membern means any lndividual who is ellgible, as determined by Plan, to receive Covered Servlces under a Health
<br />Benefit Plan, For all purposos related to this Agreement, including all schedules, aftachments, exhibits, provider
<br />Washinglon Entorpdso Plovider Agrernenl Pcs
<br />@2024 July - Wellpolnt WashlrEton, hc.1'183S321561
<br />06h5t2026
|