HomeMy WebLinkAboutSHJ25-014 MOLINA HEALTHCARE RENEWAL - PARTIALLY EXECUTEDMOLINA HEALTHCARE OF WASHINGTON, INC.
PROVIDER SERVICES AGREEMENT
SIGNATURE PAGE
In consideration of the promises, covenants, and warranties stated, the Parties agree as set forth in this Agreement.
The Authorized Representative acknowledges, warrants, and represents that the Authorized Representative has the
authority and authorization to act on behalf of its party. The Authorized Representative further acknowledges
he/she received and reviewed this Agreement in its entirety.
The parties hereby acknowledge that Health Plan's Provider Manual was made available to Provider for review
prior to Provider's decision to enter into this Agreement. Health Plan's Provider Manual is available at the Health
Plan's website.
The Authorized Representative for each party executes this Agreement with the intent to bind the Parties in
accordance with this Agreement.
Effective Date of Agreement ("Effective Date"): Upon Health Plan Signature
Provider Signature and Information.
Provider's Legal Name ("Provider") — as listed on applicable tax form (i.e. W-9):
County of Kittitas DBA Kittitas County
Name — Printed:
Authorized Signature:
CA4 Y A,)' 5
Title: LJ ('
�"
Signature Date: S_ d
Telephone Number:
Fax Number — Official Correspondence:
(509) 962-7527
Mailing Address — Official Correspondence:
Payment Address — If different than Mailing Address:
205 W 5th Ave Suite 1
Ellensburg, WA 98926
Email Address — Official Correspondence:
Tax ID Number — As listed on corresponding tax form:
Britta.Cantu.sh@co.kittitas.wa.us co.kittitas.wa.us
916001349
NPI — That corresponds to the above Tax ID Number:
Specialty:
1063226272
Prison Health
Health Plan Signature and Information.
Molina Healthcare of Washington, Inc., a Washington Corporation ("Health Plan")
Name — Printed:
Authorized Signature:
Emily Leigh
Title: VP, Network Mgmt. & Ops
Countersignature Date:
Mailing Address — Official Correspondence:
Email Address — Official Correspondence:
Molina Healthcare of Washington, Inc.
MHWProviderContracting@MolinaHealthcare.com
Attention: President
22522 29 h Dr SE Ste 210 & 212
Bothell, WA 98021
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page l of 25
PROVIDER SERVICES AGREEMENT
This Provider Services Agreement ("Agreement") is entered by and between Molina Healthcare of Washington,
Inc., a Washington corporation ("Health Plan"), and County of Kittitas DBA Kittitas County ("Provider"). The
purpose of this Agreement is to make available Covered Services to Members according to the terms and
conditions set forth below.
RECITALS
A. Health Plan arranges for the provision of certain health care services to Members pursuant to contracts
with various government sponsored health programs. Health Plan intends to participate in additional
government sponsored health programs and offer other health Products as the opportunities become
available.
B. Health Plan arranges for the provision of certain health care services to Members by entering into
provider service agreements with individual physicians, groups of physicians, individual practice
associations, hospitals, clinics, ancillary health providers, and other health providers.
C. Provider is licensed to render certain health care services and desires to provide such services to Health
Plan's Members in connection with Health Plan's contractual obligations to provide and/or arrange for
Covered Services for Health Plan's Members.
Now, therefore, in consideration of the promises, covenants and warranties stated herein, Health Plan and
Provider agree as follows:
ARTICLE ONE - DEFINITIONS
1.1 Capitalized words or phrases in this Agreement shall have the meaning set forth below.
a. Advance Directive is a Member's written instructions, recognized under state law, relating to the
provision of health care when the Member is not competent to make a health care decision as
determined under state law. Examples of Advance Directives are living wills and durable powers of
attorney for health care.
b. Affiliate means an entity owned or controlled by Health Plan or Molina Healthcare, Inc.
C. Agreement means this Provider Services Agreement, all attachments and incorporated documents
or materials.
d. Capitated Provider is a Provider who receives a monthly premium from Health Plan for each
Member assigned to Provider. Capitated Provider may be responsible for payment of some or all
covered health services (professional, institutional, pharmacy) incurred by Member.
e. Centers for Medicare and Medicaid Services ("CMS") is the Centers for Medicare and Medicaid
Services, an administrative agency of the United States Government, responsible for administering
the Medicare program and certain parts of the Medicaid, CHIP, Medicare -Medicaid Program, and
the Health Insurance Marketplace.
f. Claim means an invoice for services rendered to a Member by Provider, submitted in a format
approved by Health Plan and with all service and encounter information required by Health Plan.
g. Clean Claim means a Claim for Covered Services that has no defect, impropriety, lack of any
required substantiating documentation, or particular circumstance requiring special treatment that
prevents timely payment from being made on the Claim.
h. Covered Services mean those health care services that are Medically Necessary, are within the
normal scope of practice and licensure of Provider and are benefits of the Health Plan Product or a
Health Plan affiliate's Product which covers the Member.
i. Downstream Entity means any party that enters into a written arrangement, acceptable to CMS,
with persons or entities involved with Medicare or, Medicaid Products, below the level of the
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 2 of 25
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
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
2.2 Standards for Provision of Care.
a. Provision of Covered Services. Provider shall provide Covered Services to Members, within the
scope of Provider's business and practice, in accordance with this Agreement, Health Plan's policies
and procedures, the terms and conditions of the Health Plan Product which covers the Member, and
the requirements of any applicable government sponsored program.
b. Standard of Care. Provider shall provide Covered Services to Members at a level of care and
competence that equals or exceeds the generally accepted and professionally recognized standard of
practice at the time of treatment, all applicable rules and/or standards of professional conduct, and any
controlling governmental licensing requirements.
c. Facilities, Equipment, and Personnel. Provider's facilities, equipment, personnel and administrative
services shall be at a level and quality as necessary to perform Provider's duties and responsibilities
under this Agreement and to meet all applicable legal requirements, including the accessibility
requirements of the Americans with Disabilities Act.
d. Prior Authorization. If Provider determines that it is Medically Necessary to consult or obtain
services from other health professionals that are Medically Necessary, Provider shall obtain the prior
authorization of Health Plan in accordance with Health Plan's Provider Manual unless the situation is
one involving the delivery of Emergency Services. Upon and following such referral, Provider shall
coordinate the provision of such Covered Services to Members and ensure continuity of care. The
approval is based on medical necessity. Receipt of prior authorization does not guarantee payment.
Expedited prior authorization and limitation extension are types of prior authorization (WAC 182-
500-0085).
e. Contracted Providers. Except in the case of Emergency Services or upon prior authorization of
Health Plan, Provider shall use only those health professionals, hospitals, laboratories, skilled nursing
and other facilities and providers which have contracted with Health Plan ("participating providers").
f. Member Eligibility Verification. Provider shall verify eligibility of Members prior to rendering
services.
g. Admissions. Provider shall cooperate with and comply with Health Plan's hospital admission and
prior authorization procedures.
h. Prescriptions. Except with respect to prescriptions and pharmaceuticals ordered for in -patient
hospital services, Provider shall abide by Health Plan's drug formularies and prescription policies,
including those regarding the prescription of generic or lowest cost alternative brand name
pharmaceuticals. Provider shall obtain prior authorization from Health Plan if Provider believes a
generic equivalent or formulary drug should not be dispensed. Provider acknowledges the authority of
Health Plan contracting pharmacists to substitute generics for brand name pharmaceuticals unless
counter indicated on the prescription by the Provider.
i. Subcontract Arrangements. Any subcontract arrangement entered into by Provider for the delivery
of Covered Services to Members shall be in writing, consistent with the provisions of 42 CFR 434.6,
and shall bind Provider's subcontractors to the terms and conditions of this Agreement including, but
not limited to, terms relating to licensure, insurance, and billing of Members for Covered Services.
j. Availability of Services. Provider shall make necessary and appropriate arrangements to ensure the
availability of Covered Services to Members on twenty-four (24) hours a day, seven (7) days a week
basis, including arrangement to ensure coverage of Member patient visits after hours. Provider shall
meet the applicable standards for timely access to care and services, taking into account the urgency
of the need for the services. Provider will make necessary and appropriate arrangements to ensure the
availability of non -emergent Covered Services during Provider's normal business hours, unless
otherwise required by Laws or Government Program Requirements.
k. Treatment Alternatives. Health Plan encourages open Provider -Member communication regarding
appropriate treatment alternatives. Health Plan promotes open discussion between Provider and
Members regarding Medically Necessary or appropriate patient care, regardless of Covered Services
MFIWPROV22.3 MHWHA/Revised Jan 2024 Page 5 of25
limitations. Provider is free to communicate any and all treatment options to Members regardless of
benefit coverage limitations.
2.3 Promotional and Marketing Activities. At the request of Health Plan, Provider shall (1) display Health
Plan promotional materials in its offices and facilities as practical, and (2) shall cooperate with and
participate in all reasonable Health Plan's marketing efforts. Provider shall not use Health Plan's name in
any advertising or promotional materials without the prior written permission of Health Plan.
As applicable, Provider shall not directly or indirectly conduct door-to-door telephonic, or other cold -call
marketing of enrollment (42 CFR 438.104(b)(1)(v)).
2.4 Nondiscrimination.
a. Enrollment. Provider shall not differentiate or discriminate in providing Covered Services to
Members because of race, color, religion, national origin, ancestry, age, sex, marital status, sexual
orientation, physical, sensory, or mental handicap, socioeconomic status, or participation in publicly
financed programs of health care services. Provider shall render Covered Services to Members in the
same location, in the same manner, in accordance with the same standards, and within the same time
availability regardless of payer.
b. Employment. Provider shall not differentiate or discriminate against any employee or applicant for
employment, with respect to their hire, tenure, terms, conditions or privileges of employment, or any
matter directly or indirectly related to employment, because of race, color, religion, national origin,
ancestry, age, sex, height, weight, marital status, physical, sensory, or mental disability unrelated to
the individual's ability to perform the duties of the particular job or position.
2.5 Recordlceeping.
a. Maintaining Member Medical Record. Provider shall maintain a medical record for each Member
to whom Provider renders health care services. Provider shall open each Member's medical record
upon the Member's first encounter with Provider. The Member's medical record shall contain all
information required by Laws, generally accepted and prevailing professional practice, applicable
government sponsored health programs, and all Health Plan policies and procedures. Provider shall
retain all such records for at least ten (10) years.
b. Confidentiality of Member Health Information. Provider shall comply with all Laws, Health
Plan's policies and procedures, and government sponsored program requirements regarding privacy
and confidentiality of Members' health information and medical records, including mental health
records. Provider shall not disclose or use Member names, addresses, social security numbers,
identities, other personal information, treatment modalities, or medical records without obtaining
appropriate authorization to do so. This provision shall not affect or limit Provider's obligation to
make available medical records, encounter data and information concerning Member care to Health
Plan, any authorized state or federal agency, or other Providers of health care upon authorized
referral.
c. HIPAA. To the extent Provider is considered a covered entity under the Health Insurance Portability
and Accountability Act of 1996 ("HIPAA"), Provider shall comply with all provisions of HIPAA
including, but not limited to, provisions addressing privacy, security, and confidentiality.
d. Delivery of Patient Care Information. Provider shall promptly deliver to Health Plan, upon request
and/or as may be required by Laws, Health Plan's policies and procedures, applicable government
sponsored health programs, Health Plan's contracts with the government agencies or third party
payers, any information, statistical data, encounter data, or patient treatment information pertaining to
Members served by Provider, including but not limited to, any and all information requested by
Health Plan in conjunction with utilization review and management, grievances, peer review, HEDIS
Studies, Health Plan's Quality Improvement Program, Consumer Assessment of Health Plans
("CAHPS"), or Claims payment. Health Plan will not pay copying fees when records are requested
for any of the above listed programs. Provider shall further provide direct access to said patient care
MH WPROV22.3 MHWPSA/Revised Jan 2024 Page 6 of 25
information as requested by Health Plan and/or as required by any governmental agency or any
appropriate state and federal authority having jurisdiction over Health Plan.
e. Member Access to Health Information. Provider shall give Health Plan and Members access to
Members' health information including, but not limited to, medical records and billing records, in
accordance with Laws, applicable government sponsored health programs, and Health Plan's policies
and procedures.
f. National Provider Identifier ("NPI"). In accordance with applicable statutes and regulations of
HIPAA Provider will comply with the Standard Unique Identifier for Health Care Provider
regulations promulgated under HIPAA (45 CFR Section 162.402, et seq.) and use only the NPI to
identify HIPAA covered health care providers in standard transactions. Provider will utilize an NPI
from the National Plan and Provider Enumeration System ("NPPES") for itself or for any subpart of
the Provider. Provider will make best efforts to report its NPI and any subparts to Health Plan.
Provider will report any changes in its NPI or subparts to Health Plan within thirty (30) days of the
change. Provider will use its NPI to identify itself on all Claims and encounters (both electronic and
paper formats) submitted to Health Plan.
2.6 Program Participation.
a. Participation in Grievance Program. Provider shall participate in Health Plan's Grievance Program
and shall cooperate with Health Plan in identifying, processing, and promptly resolving all Member
complaints, grievances, or inquiries.
b. Participation in Quality Improvement Program. Provider shall participate in Health Plan's Quality
Improvement Program and shall cooperate with Health Plan in conducting peer review and audits of
care rendered by Provider.
c. Participation in Utilization Review and Management Program. Provider shall participate in and
comply with Health Plan's Utilization Review and Management Program or the utilization review and
management program of Health Plan's designee, including all policies and procedures regarding prior
authorizations, and shall cooperate with Health Plan or Health Plan's designee in audits to identify,
confirm, and/or assess utilization levels of Covered Services. If Provider is a medical group or IPA,
Provider shall accept delegation of utilization management responsibilities from Health Plan at Health
Plan's request.
d. Participation in Credentialing. Provider shall participate in Health Plan's credentialing and re-
credentialing process and shall satisfy, throughout the term of this Agreement, all credentialing and
re-credentialing criteria established by the Health Plan. Provider shall immediately notify Health Plan
of any change in the information submitted or relied upon by Provider to achieve credentialed status.
If Provider's credentialed status is revoked, suspended, or limited by Health Plan, Health Plan may at
its discretion terminate this Agreement and/or reassign Members to another provider. If Provider is a
medical group or IPA, Provider shall accept delegation of credentialing responsibilities at Health
Plan's request and shall cooperate with Health Plan in establishing and maintaining appropriate
credentialing mechanisms within Provider's organization.
e. Provider Manual. Provider will follow the terms set forth in Health Plan's Provider Manual, which
may be amended from time to time at Health Plan's sole discretion. Provider shall comply and render
Covered Services in accordance with the contents, instructions and procedures set forth in Health
Plan's Provider Manual and any additional operating procedures and policies for Providers which are
communicated to Provider in writing by Health Plan. Provider acknowledges it received Health
Plan's Provider Manual.
f. Government Contracts. Provider acknowledges that Health Plan has entered into contracts with
state and federal agencies for the arrangement of health care services for Members through
government sponsored programs. Provider shall comply with any term or condition of those
government sponsored program contracts that are applicable to the services to be performed under
this Agreement.
MIIWPROV22.3 MHWPSA/Revised Jan 2024 Page 7 or25
g. Health Education/Training. Provider shall participate in and cooperate with Health Plan's Provider
education and training efforts as well as Member education efforts. Provider shall also comply with
all Health Plan health education, cultural and linguistic standards, policies, and procedures, and such
standards, policies, and procedures as may be necessary for Health Plan to comply with its contracts
with employers, the state, or federal government. Provider shall promptly deliver to Provider's
constituent providers, if any, all informational, promotional, educational, or instructional materials
prepared by Health Plan regarding any aspect of providing Covered Services to Members.
h. Supplemental Materials. Health Plan may periodically issue bulletins or other written materials in
order to supplement the Provider Manual or to give additional instruction, guidance, or information
("Supplemental Materials"). Health Plan may issue Supplemental Materials in an electronic format,
which includes, but is not limited to, posting on Health Plan's interactive web -portal, with a physical
copy available upon request. Supplemental Materials become binding upon Provider as of the
Effective Date indicated on the Supplemental Materials or, if applicable, the Effective Date will be
determined in accordance with this Agreement.
i. Health Plan's Electronic Processes and Initiatives. Provider will participate in and comply with
Health Plan's electronic processes and initiatives, including, but not limited to, electronic submission
of prior authorization, access to electronic medical records, electronic claims filing, electronic data
interchange ("EDI"), electronic remittance advice, electronic fund transfers, and registration and use
of Health Plan's interactive web -portal.
2.7 Licensure and Standing.
a. Licensure. Provider warrants and represents that it is appropriately licensed to render health care
services within the scope of Provider's practice, including having and maintaining a current narcotics
number, where appropriate, issued by all proper authorities. Provider shall provide evidence of
licensure to Health Plan upon request. Provider shall maintain its licensure in good standing, free of
disciplinary action, and in unrestricted status throughout the term of this Agreement. Provider shall
immediately notify Health Plan of any change in Provider's licensure status, including any
disciplinary action taken or proposed by any licensing agency responsible for oversight of Provider.
b. Unrestricted Status. Provider represents to its best knowledge, information, and belief„ neither it, nor
any of its owners, employees, temporary employees, volunteers, consultants, members of its board of
directors, officers, or contractors (collectively, "Personnel") have been excluded from participation in
the Medicare Program, any state, commonwealth or the District of Columbia's Medicaid Program, or
any other federal health care program (collectively "Federal Health Care Program"). Provider agrees
that it must check the Department of Health and Human Services Office of Inspector General List of
Excluded Individuals and Entities, the System for Award Management, any other list maintained by a
state, commonwealth, or federal government and every state, commonwealth, and the District of
Columbia's Medicaid exclusion lists to determine whether Provider or any of its Personnel have been
excluded from participation in any Federal Health Care Program. These databases must be checked
for any new Personnel and thereafter not less than monthly. Provider will notify Health Plan
immediately in writing if Provider determines that Provider or any of its Personnel are suspended or
excluded, or could be suspended or excluded, from any Federal Health Care Program. Provider agrees
that it is subject to 2 CFR Part 376 and will require its Personnel to agree that they are subject to 2
CFR Part 376. If a governmental agency imposes a penalty, sanction, or other monetary adjustment or
withhold due to Provider's non-compliance with this provision or any payments were made to
Provider while under non-compliance with this provision, Health Plan may collect the amount by: (i)
offsetting from amounts due to Provider; or (ii) issuing a recoupment letter to Provider. If required,
such offset or recoupment will be done in a manner that is compliant with Laws and Government
Program Requirements. This section will survive any termination.
c. Malpractice and Other Actions. Provider shall give immediate notice to Health Plan of: (a) any
malpractice claim asserted against it by a Member, any payment made by or on behalf of Provider in
settlement or compromise of such a claim, or any payment made by or on behalf of Provider pursuant
to ajudgment rendered upon such a claim; (b) any criminal investigations or proceedings against
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 8 of25
Provider; (c) any convictions of Provider for crimes involving moral turpitude or felonies; and (d) any
civil claim asserted against Provider that may jeopardize Provider's financial soundness.
d. Staffing Privileges for Providers. Consistent with community standards, every physician Provider
shall have staff privileges with at least one Health Plan contracted hospital as necessary to provide
services to members under this Agreement and shall authorize each hospital at which he/she
maintains staff privileges to notify Health Plan should any disciplinary or other action of any kind be
initiated against such provider which could result in any suspension, reduction or modification of
his/her hospital privileges.
e. Liability Insurance. Provider shall maintain premises and professional liability insurance in
coverage amounts appropriate for the size and nature of Provider's facility and the nature of
Provider's health care activities. Every physician Provider shall maintain, at a minimum, professional
liability insurance with limits of not less than $1 million per occurrence and $3 million in the
aggregate for the policy year and for each physician comprising Provider. If the coverage is claims
made or reporting, Provider agrees to purchase similar "tail" coverage upon termination of the
Provider's present or subsequent policy. Provider shall deliver copies of such insurance policies to
Health Plan within five (5) business days of a written request by Health Plan.
2.8 Claims Payment.
a. Submitting Claims. Provider shall promptly submit to Health Plan Claims for Covered Services
rendered to Members. All Claims shall be submitted in a form acceptable to and approved by Health
Plan and shall include any and all medical records pertaining to the Claim if requested by Health Plan
or otherwise required by Health Plan's policies and procedures. Claims must be submitted by
Provider to Health Plan within three hundred sixty-five (365) days of providing the Covered Services
that are the subject of the Claim. If Health Plan is not the primary payer under coordination of
benefits, Provider must submit Claims to Health Plan within three hundred sixty-five (365) days from
the primary payer's date of payment or date of contest, denial or notice. Except as otherwise provided
by law or provided by government sponsored program requirements, any Claims that are not
submitted by Provider to Health Plan within the timelines stated above shall not be eligible for
payment, and Provider hereby waives any right to payment, therefore.
b. Compensation. Health Plan shall pay Provider for Clean Claims for Covered Services provided to
Members, including Emergency Services, in accordance with applicable law and regulations and in
accordance with the compensation schedule set forth in Exhibit 1 and its applicable sub -exhibits.
Provider shall accept such payment, applicable co -payments, deductibles, and coordination of
benefits collections as payment in full for services provided under this Agreement. Provider shall not
balance bill Members for any Covered Services.
c. Co -payment, Deductibles and Co-insurances. Provider is responsible for collection of co -
payments, deductibles and co-insurances, if any, provided for in the Member's Health Plan Product.
d. Member Hold Harmless.
i. Provider hereby agrees that in no event, including, but not limited to nonpayment by Health Plan,
Health Plan's insolvency, or breach of this contract will Provider bill, charge, collect a deposit
from, seek compensation, remuneration, or reimbursement from, or have any recourse against a
Member or person acting on their behalf, other than Health Plan, for services provided pursuant
to this Agreement. This provision does not prohibit collection of deductibles, copayments,
coinsurance, and/or payment for noncovered services, which have not otherwise been paid by a
primary or secondary issuer in accordance with regulatory standards for coordination of benefits,
from Members in accordance with the terms of the Member's health plan.
ii. Provider agrees in the event of Health Plan's insolvency to continue to provide the services
promised in this Agreement to Members of Health Plan for the duration of the period for which
premiums on behalf of the Member were paid to Health Plan or until the Member's discharge
from inpatient facilities, whichever time is greater.
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 9 of25
iii. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be
construed to modify the rights and benefits contained in the Member's Health Plan.
iv. Provider may not bill the Member for Covered Services except for deductibles, copayments, or
coinsurance where Health Plan denies payments because Provider has failed to comply with the
terns of this Agreement.
v. Provider further agrees i) that the provisions of paragraphs i, ii, iii, iv of this section shall survive
termination of this Agreement regardless of the cause giving rise to termination and shall be
construed to be for the benefit of Health Plan's Members; and ii) that this provision supersedes
any oral or written contrary agreement not existing or hereafter entered into between Provider and
Member or persons acting on their behalf.
vi. If Provider contracts with other providers or facilities who agree to provide Covered Services to
Members of Health Plan with expectation of receiving payment directly or indirectly from Health
Plan, such providers or facilities must agree to abide by paragraphs i, ii, iii, iv, v, of this section.
e. Coordination of Benefits. Health Plan is a secondary payer in any situation where there is another
payer as primary carrier. Provider shall make reasonable inquiry of Members to learn whether
Member has health insurance or health benefits other than from Health Plan or is entitled to payment
by a third party under any other insurance or plan of any type, and Provider shall immediately notify
Health Plan of said entitlement. In the event that coordination of benefits occurs, Provider shall be
compensated in an amount equal to the allowable Clean Claim less the amount paid by other health
plans, insurance carriers and payers, not to exceed the amount specified in Exhibit 1 and its applicable
sub -exhibits.
f. Offset. In the event that Health Plan determines that a Claim has been overpaid or paid in duplicate,
or that funds were paid which were not provided for under this Agreement, Health Plan may make a
written request for repayment: (1) within twenty-four (24) months after the date that the payment was
made; (2) within thirty (30) months after the date that the payment was made if the request is related
to coordination of benefits with another carrier or entity responsible for payment of the Claim; or (3)
at any time if a third party is found responsible for satisfaction of the Claim as a consequence of
liability imposed by law and Health Plan is unable to recover directly from the third party because the
third party has either already paid or will pay Provider the health care services covered by the Claim.
Provider may contest Health Plan's request in writing by participating in the Claims dispute process
as outlined in Section 2.8g. Overpayment and duplicate payment disputes must be submitted in
writing within thirty (30) days of receipt of request. If it is decided that Health Plan will recover the
contested payment, such refund may be recovered by way of offset or recoupment from current or
future amounts due Provider after six (6) months have passed from the date Health Plan received
Provider's written notice contesting the repayment. In addition to any other contractual or legal
remedy, if Provider fails to contest Health Plan's request for a refund in writing within thirty (30)
days of receipt of the request or if Provider contested the request and six (6) months has passed from
the date Provider received Health Plan's refund request, Health Plan may recover the amounts owed
by way of offset or recoupment from current or future amounts due Provider. As a material condition
to Health Plan's obligations under this Agreement, Provider agrees that the offset and recoupment
rights set forth herein shall be deemed to be and to constitute rights of offset and recoupment
authorized in state and federal law or in equity to the maximum extent legally permissible, and that
such rights shall not be subject to any requirement of prior or other approval from any court or other
governmental authority that may now or hereafter have jurisdiction over Health Plan and/or Provider.
Nothing in this section prohibits Provider from choosing at any time to refund to Health Plan any
payment previously made by Health Plan to satisfy a Claim either by way of repayment by Provider
or a request that Health Plan offset or recoup the money from current or future amounts due Provider.
g. Claims Dispute Process. In the event that Provider determines that a Claim has been improperly
denied or underpaid, Provider may make a written request for payment: (1) within twenty-four (24)
months after the date the Claim was denied or payment intended to satisfy the Claim was made; (2)
within thirty (30) months after the date the Claim was denied or payment intended to satisfy the
MHWPROV22.3 MHWPSA/2evised Jan 2024 Page 10 of 25
Claim was made if the request is related to coordination of benefits with another carrier or entity
responsible for payment of the Claim. Provider may not request that payment be made any sooner
than six (6) months after Health Plan's receipt of the request. Any request for review of denied or
underpaid Claims must be submitted to Health Plan in accordance with the requirements stated in this
section and conform to the following instructions:
i. The request must specify why the Provider believes Health Plan owes the payment.
ii. In the case of coordination of benefits, the request must include the name and mailing address of
any entity that has disclaimed responsibility for payment.
iii. The request must be addressed to the attention of Health Plan's Provider Services Department.
iv. The request must clearly indicate "Denied Claims Review Request" or "Adjustment Request";
and,
v. The request must include all pertinent information, including, but not limited to, Claim number,
Member identifier, denial letter, supporting medical records, and any new information pertinent
to the request.
vi. Health Plan will render a decision on all disputed Claims within sixty (60) days of receipt of the
Claim.
vii. Should Provider not be satisfied with Health Plan's decision, Provider may proceed to the
mediation steps outlined in the Provider Manual.
h. Claims Review and Audit. Provider acknowledges Health Plan's right to review Provider's Claims
prior to payment for appropriateness in accordance with industry standard billing rules, including, but
not limited to, current UB manual and editor, current CPT and HCPCS coding, CMS billing rules,
CMS bundling/unbundling rules, National Correct Coding Initiatives (NCCI) Edits, CMS multiple
procedure billing rules, and FDA definitions and determinations of designated implantable devices
and/or implantable orthopedic devices. Provider acknowledges Health Plan's right to conduct such
review and audit on a line -by-line basis or on such other basis as Health Plan deems appropriate, and
Health Plan's right to exclude inappropriate line items to adjust payment and reimburse Provider at
the revised allowable level. Provider also acknowledges Health Plan's right to conduct utilization
reviews to determine medical necessity and to conduct post -payment billing audits. Provider shall
cooperate with Health Plan's audits of Claims and payments by providing access to requested Claims
information, all supporting medical records, Provider's charging policies, and other related data.
Health Plan shall use established industry claims adjudication and/or clinical practices, state and
federal guidelines, and/or Health Plan's policies and data to determine the appropriateness of the
billing, coding and payment.
i. Payments which are the Responsibility of a Capitated Provider. Provider agrees that if Provider is
or becomes a party to a subcontract or other agreement with another provider contracted with Health
Plan who receives capitation from Health Plan and is responsible for paying for Covered Services
through subcontract arrangements ("Capitated Provider"), Provider shall look solely to the Capitated
Provider, and not Health Plan, for payment of Covered Services provided to Members that are
covered by Health Plan's agreements with such Capitated Providers.
j. Timely Submission of Encounter Data. Provider understands Health Plan may have certain
contractual reporting obligations that require timely submission of Encounter Data. If a Clean Claim
does not contain the necessary Encounter Data, Provider will submit Encounter Data to Health Plan.
This section will survive any termination.
2.9 Compliance with Applicable Law. Provider shall comply with all applicable state and federal laws
governing the delivery of Covered Services to Members including, but not limited to, Title XIX and Title
XXI of the SSA and Title 42 CFR, Title VI of the Civil Rights Act of 1964; Title IX of the Education
Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975;
the Rehabilitation Act of 1973; the Balanced Budget Act of 1997; the Americans with Disabilities Act,
and Federal Drug and Alcohol Confidentiality Laws in 42 CFR Part 2, 42 U.S.C. § 1396a(a)(43),
1396d(r), and 42 CFR 438.6(i):
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 11 of25
a. Provider acknowledges that this Agreement and all Covered Services rendered pursuant to this
Agreement are subject to applicable state licensing statutes and regulations. Accordingly, Provider
shall abide by those provisions set forth in Attachment 1.
b. Provider acknowledges that all Covered Services rendered in conjunction with the state Medicaid
program are subject to the additional provisions set forth in Attachment 2, the effect of which
provisions is limited solely to activities and Covered Services related to the state Medicaid program.
c. For Covered Services rendered to Members enrolled in a Molina Marketplace Product, Medicaid
statutes and regulations referenced in this Agreement are inapplicable, and Provider shall comply
with all statutory and regulatory requirements of the Washington Health Benefit Exchange Act,
including the 2012 regular session laws, chapter 87 Affordable Care Act Implementation and
regulations adopted pursuant to RCW 43.71.
2.10 Provider Non -solicitation Obligations. Provider shall not unilaterally assign or transfer patients served
under this Agreement to another medical group, IPA, or provider without the prior written approval of
Health Plan. Nor shall Provider solicit or encourage Members to select another health plan for the primary
purpose of securing financial gain for Provider. Nothing in this provision is intended to limit Provider's
ability to fully inform Members of all available health care treatment options or modalities.
2.11 Fraud and Abuse Reporting. Provider shall report to Health Plan's compliance officer all cases of
suspected fraud and/or abuse, as defined in Title 42, of the Code of Federal Regulations, Section 455.2,
where there is reason to believe that an incident of fraud and/or abuse has occurred, by subcontractors,
Members, providers, or employees within ten (10) business days of the date when Provider first becomes
aware of, or is on notice of, such activity. Provider shall establish policies and procedures for identifying,
investigating, and taking appropriate corrective action against fraud and/or abuse in the provision of
health care services under the Medicaid program or by state or federal agencies. Upon the request of
Health Plan and/or the State, Provider shall consult with the appropriate State agency prior to and during
the course of any such investigations.
2.12 Advance Directive. Provider shall document all patient records with respect to the existence of an
Advance Directive in compliance with the Patient Self -Determination Act (Section 4751 of the Omnibus
Reconciliation Act of 1990), as amended, and other appropriate laws.
2.13 Reassignment of Members. Health Plan reserves the right to reassign Members from Provider to another
provider or to limit or deny the assignment or selection of new Members to Provider during any
termination notice period or if Health Plan determines that assignment to Provider poses a threat to the
Members' health and safety. If Provider requests reassignment of a Member, Health Plan, in its sole
discretion, will make the determination regarding reassignment based upon good cause shown by the
Provider. When the Health Plan reassigns Member(s), Provider shall forward copies of the Member's
medical records to the new provider within ten (10) business days of receipt of the Plan's or the
Member's request to transfer the records.
2.14 Reciprocity Agreements. Provider will cooperate with Affiliates and agrees to ensure reciprocity of
health care services to Affiliate's enrollees. For Affiliate enrollees, Provider will be compensated for
Clean Claims that are determined to be payable in accordance with Laws and Government Program
Requirements. If there is not a law or Government Program Requirement governing reimbursement,
Provider will be compensated at the rates set forth in this Agreement. Provider will follow the hold
harmless provisions of this Agreement for Affiliate's enrollees.
ARTICLE THREE - HEALTH PLAN'S OBLIGATIONS
3.1 Compensation. Health Plan shall pay Provider in accordance with the terms and conditions of this
Agreement and the compensation schedule set forth in Exhibit 1 and its applicable sub -exhibits.
3.2 Member Eligibility Determination. Health Plan shall maintain data on Member eligibility and
enrollment. Health Plan shall promptly verify Member eligibility at the request of Provider.
3.3 Prior Authorization Review. Health Plan shall timely respond to requests for prior authorization and/or
determination of Covered Services.
MJIWPROV22.3 MHWPSA/Revised Jan 2024 Page 12 or25
3.4 Medical Necessity Determination. Health Plan's determination with regard to Medically Necessary
services and scope of Covered Services, including determinations of level of care and length of stay
benefits available under the Member's health program shall govern. The primary concern with respect to
all medical determination shall be the interest of the Member.
3.5 Member Services. Health Plan will provide services to Members including, but not limited to, assisting
Members in selecting a primary care physician, processing Member complaints and grievances, informing
Members of the Health Plan's policies and procedures, providing Members with membership cards,
providing Members with information about Health Plan, and providing Members with access to Health
Plan's Provider Directory, updated from time to time, identifying the professional status, specialty, office
address, and telephone number of Health Plan contracted providers.
3.6 Provider Services. Health Plan will maintain a Provider Manual describing Health Plan's policies and
procedures, Covered Services, limitations and exclusions, and coordination of benefits information.
Health Plan will maintain a Provider Services Department available to educate Provider regarding Health
Plan's policies and procedures.
3.7 Medical Director. Health Plan will employ a physician as medical director who shall be responsible for
the management of the scientific, technical, and medical aspects of Health Plan.
ARTICLE FOUR - TERM AND TERMINATION
4.1 Term. This Agreement shall commence on the Effective Date indicated on page one of this Agreement
and will continue in effect for one (1) year and will renew for successive one (1) year terms unless
terminated by either Party in accordance with this Agreement or in accordance with applicable state
licensing statutes and regulations set forth in Attachment 1 and Attachment 2.
4.2 Termination without Cause. This Agreement may be terminated without cause by either party on at
least one hundred twenty (120) days written notice to the other party.
4.3 Termination with Cause. In the event of a breach of any material provision of this Agreement, the party
claiming the breach will give the other party written notice of termination setting forth the facts
underlying its claim(s) that the other party has breached the Agreement. The party receiving the notice of
termination shall have thirty (30) days from the date of receipt of such notice to remedy or cure the
claimed breach to the satisfaction of the other party. During this thirty (30) day period, the parties agree to
meet as reasonably necessary and to confer in good faith in an attempt to resolve the claimed breach. If
the party receiving the notice of termination has not remedied or cured the breach within such thirty (30)
day period, the party who provided the notice of termination shall have the right to immediately terminate
this Agreement.
4.4 Immediate Termination. Notwithstanding any other provision of this Agreement, Health Plan may
immediately terminate this Agreement and transfer Member(s) to another provider by giving notice to
Provider in the event of any of the following:
a. Provider's license or certificate to render health care services is limited, suspended or revoked, or
disciplinary proceedings are commenced against Provider by the state licensing authority.
b. Provider fails to maintain insurance required by this Agreement.
c. Provider loses credentialed status.
d. Provider becomes insolvent or files a petition to declare bankruptcy or for reorganization under the
bankruptcy laws of the United States, or a trustee in bankruptcy or receiver for Provider is appointed
by appropriate authority.
e. if Provider is capitated and Health Plan determines Provider to be financially incapable of bearing
capitation or other applicable risk -sharing compensation methodology.
f. Health Plan determines that Provider's facility and/or equipment is insufficient to render Covered
Services to Members.
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 13 of25
g. Provider is excluded from participation in Medicare and state health care programs pursuant to
Section 1128 of the Social Security Act or otherwise is terminated as a provider by any state or
federal health care program.
h. Provider engages in fraud or deception, or knowingly permits fraud or deception by another in
connection with Provider's obligations under this Agreement.
i. Health Plan determines that health care services are not being properly provided, or arranged for, and
that such failure poses a threat to Members' health and safety.
4.5 Termination Notification to Members. Upon receipt of termination by either Health Plan or Provider,
Health Plan will inform affected Members of such termination notice in accordance with the process set
forth in the Provider Manual. Health Plan will make a good faith effort to ensure that such notice is
provided at least thirty (30) days prior to the effective date of the termination or immediately for a
termination for cause that results in less than thirty (30) days' notice to all Members. Members may then
be required to select another provider contracted with Health Plan prior to the effective date of
termination of this Agreement.
ARTICLE FIVE - GENERAL PROVISIONS
5.1 Indemnification. Each party shall indemnify and hold harmless the other party and its officers, directors,
shareholders, employees, agents, and representatives from any and all liabilities, losses, damages, claims,
and expenses of any kind, including costs and attorneys' fees, which result from the duties and
obligations of the indemnifying party and/or its officers, directors, shareholders, employees, agents, and
representatives under this Agreement.
5.2 Relationship of the Parties. Nothing contained in this Agreement is intended to create, nor shall it be
construed to create, any relationship between the parties other than that of independent parties contracting
with each other solely for the purpose of effectuating the provisions of this Agreement. This Agreement is
not intended to create a relationship of agency, representation, joint venture, or employment between the
parties. Nothing herein contained shall prevent any of the parties from entering into similar arrangements
with other parties. Each of the parties shall maintain separate and independent management and shall be
responsible for its own operations. Nothing contained in this Agreement is intended to create, nor shall be
construed to create, any right in any third party, including but not limited to Health Plan's Members. Nor
shall any third party have any right to enforce the terms of this Agreement.
5.3 Entire Agreement. This Agreement, together with Attachments, Exhibits, Amendments and incorporated
documents or materials, contains the entire agreement between Health Plan and Provider relating to the
rights granted and obligations imposed by this Agreement. Additionally, as to the Medicaid products
offered by Health Plan, the contract between HCA and the Health Plan shall be the guiding and
controlling document when interpreting the terms of this Agreement. Any prior agreements, promises,
negotiations, or representations, either oral or written, relating to the subject matter of this Agreement are
of no force or effect.
5A Severability. If any term, provision, covenant, or condition of this Agreement is held by a court of
competent jurisdiction to be invalid, void, or unenforceable, the remaining provisions shall remain in full
force and effect and shall in no way be affected, impaired, or invalidated as a result of such decision.
5.5 Notice.
a. Delivery. All notices required or permitted by this Agreement will be in writing and will be
delivered: (i) in person; (ii) by U.S. Postal Service ("USPS") registered, certified, or express mail
with postage prepaid; (iii) by overnight courier that guarantees next day delivery; (iv) by facsimile
transmission; or (v) by e-mail. Any notice sent with signature delivery confirmation or return receipt
requested, is deemed given on the date of delivery. If no delivery date is shown, notice is deemed
given two (2) business days after the postmark date. Notice delivered by USPS express mail, Federal
Express, or by overnight courier that guarantees next day delivery is deemed given two (2) business
days after delivery of the notice to USPS or the overnight courier. For delivery by facsimile
transmission, the notice is deemed delivered upon confirmation of receipt of the transmission. For
MHWPROV223 MHWPSA/Revised San 2024 Page 14 of25
delivery by e-mail, the notice is deemed given on the date sent. All notices are deemed given if
delivered as specified in this section.
b. Names & Addresses. The name, mailing address, e-mail address, and facsimile number set forth
under the Signature Page will be the particular party's information for delivery of notice. Each party
may change its information through written notice in compliance with this section without amending
this Agreement.
5.6 Amendments.
a. Regulatory Amendments. Health Plan may, without Provider's consent, immediately amend this
Agreement to maintain consistency and/or compliance with any state or federal law, policy, directive,
or government sponsored program requirement.
b. Non -Regulatory Amendments. Notwithstanding the Regulatory Amendments section, Health Plan
may otherwise amend this Agreement upon sixty (60) days prior written notice to Provider. If
Provider does not deliver to Health Plan a written notice of rejection of the amendment within that
sixty (60) day period, the amendment shall be deemed accepted by and shall be binding upon
Provider. In the event that the amendment is considered a "material amendment" as defined in RC W
48.39.005, Provider shall have the right to reject the amendment and such rejection will not affect the
existing terms of the Agreement.
5.7 Assignment. Provider may not assign, transfer, subcontract or delegate, in whole or in part, any rights,
duties, or obligations under this Agreement without the prior written consent of Health Plan. Subject to
the foregoing, this Agreement is binding upon, and inures to the benefit of the Health Plan and Provider
and their respective successors in interest and assigns. Neither the acquisition of Health Plan nor a change
of its legal name shall be deemed an assignment.
5.8 Dispute Resolution Process.
a. Submission of Non -Claims Payment Related Disputes
i. Provider shall submit any dispute (other than a dispute relating to Claims Payment, which are
subject to Section 2.8(g)) to Health Plan in writing within sixty (60) days of when the issue arises.
ii. Provider shall submit such disputes to the attention of Health Plan's Provider Services
Department.
b. Health Plan Response to Non -Claims Payment Related Disputes
i. Health Plan shall use best efforts to acknowledge by phone, e-mail or other writing, receipt of a
dispute (other than a dispute relating to Claims, which are subject to Section 2.8(g)) within seven
(7) business days.
ii. Health Plan's decision regarding disputes shall be communicated within sixty (60) days of Health
Plan's receipt of Provider's written correspondence requesting review. If additional time is
required, Health Plan shall communicate this information to Provider within sixty (60) days.
iii. Health Plan shall use its best efforts to investigate and resolve disputes within sixty (60) days of
Health Plan's receipt of Provider's written correspondence.
c. Nonbinding Mediation. If Health Plan fails to grant or reject Provider's request for review of a
dispute within thirty (30) days after it is received, the Provider may proceed as if the complaint has
been rejected. If Provider is dissatisfied with Health Plan's final resolution of a dispute, Provider may
submit the dispute to nonbinding mediation pursuant to chapter 7.07 RCW. Nonbinding mediation
shall not be utilized to adjudicate matters that primarily involve review of Provider's professional
competence or professional conduct and shall not be available as a mechanism for appeal of any
determinations made as to such matters.
5.9 Corrective Action, Fair Hearing Plan, and Reporting to the State of Washington Medical
Commission and the NPDB. Provider has a procedural right to appeal in the event that Health Plan's
peer review committee recommends filing a report to the Washington Medical Commission and the
MHWPROV22.3 MHWHA/Revised Jan 2024 Page 15 of25
NPDB. The appeal right, Fair Hearing process, and the requirement to report to the Washington Medical
Commission and NPDB are described in Health Plan's Fair Hearing Plan.
5.10 Arbitration. Health Plan and Provider agree, as a condition precedent to the commencement of any civil
action in any court of competent jurisdiction, to submit to arbitration all disputes arising from or related to
this Agreement and the rendition of services to Members pursuant to this Agreement which are not
otherwise resolved pursuant to the processes set forth at Sections 2.8(g) or 5.8; provided, however, that
arbitration shall not be utilized to adjudicate matters that primarily involve review of Provider's
professional competence or professional conduct, and shall not be available as a mechanism for appeal of
any determinations made as to such matters. Arbitration shall proceed according to the rules and
regulations of JAMS Optional Arbitration Appeal Procedure, then in effect, and shall be conducted in
King County, Washington. The arbitrator shall have no authority to award damages or provide a remedy
that would not be available to such prevailing party in a court of law. Nor shall the arbitrator have the
authority to award punitive damages. The parties recognize that the arbitrator's decision is not binding
and that either party may seek judicial remedies following the arbitration of a dispute. The panel of
arbitrators shall be selected as follows: one arbitrator shall be designated by Health Plan; one arbitrator
shall be designated by Provider; and the third arbitrator shall be selected by the arbitrators designated by
Provider and Health Plan. Health Plan and Provider shall divide and share equally the cost of arbitration.
Each party shall be responsible for its own attorneys' fees.
5.11 Attachments. Each of the Attachments and Exhibits (as selected) and identified below is hereby made a
part of this Agreement:
®Attachment 1 —Required Provisions (Health Care Service Plans)
®Attachment 2 — Required Provisions (Health Care Authority)
❑Attachment 3 — Medicare Program Requirements -Health Care Services
❑Attachment 4— Molina Marketplace - Laws and Government Program Requirements
❑Attachment 5 — Indian Health Care Providers Medicaid/CHIP Provisions
❑Attachment 6 — Delegated Services Addendum (Version 1)
❑Attachment 6 — Delegated Services Addendum (Version 2) (Facility/HDO)
❑Attachment 6-A — Information Security & Cybersecurity for Delegated Services
®Exhibit 1-A Compensation Schedule Medicaid (Version 1)
❑Exhibit 1-A Compensation Schedule Medicaid (Version 2)
[]Exhibit 1-A Compensation Schedule Medicaid (Version 3)
❑Exhibit 1-A Compensation Schedule Medicaid (Version 4)
❑Exhibit 1-B Compensation Schedule Medicare (Version 1)
❑Exhibit 1-B Compensation Schedule Medicare (Version 2)
❑Exhibit 1-C Compensation Schedule Molina Marketplace (Version 1)
❑Exhibit 1-C Compensation Schedule Molina Marketplace (Version 2)
❑Exhibit 1-C Compensation Schedule Molina Marketplace (Version 3)
❑Exhibit 1-C Compensation Schedule Molina Marketplace (Version 4)
❑Exhibit 1-C Compensation Schedule Molina Marketplace (Version 5)
❑Exhibit 1-C Compensation Schedule Molina Marketplace (Version 6)
5.12 Conflict with Health Plan Product. Nothing in this Agreement modifies any benefits, terms or
conditions contained in the Member's Health Plan Product. In the event of a conflict between this
Agreement and the benefits, terms, and conditions of the Health Plan Product, the benefits, terms or
conditions contained in the Member's Health Plan Product shall govern.
5.13 Execution in Counterparts and Duplicates. This Agreement may be executed in counterparts, each of
which will be deemed an original, but all of which together will constitute one and the same instrument.
The Parties agree facsimile signatures, pdf signatures, photocopied signatures, electronic signatures, or
signatures scanned and sent via email will have the same effect as original signatures.
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 16 of25
5.14 Force Majeure. Neither Party will be liable or deemed to be in default for any delay or failure to perform
ally duty under this Agreement resulting directly or indirectly, from acts of God, civil or military
authority, acts of a public enemy, war, accident, fire, explosion, earthquake, flood, strikes by either
Party's employees, or any other similar cause beyond the reasonable control of such Party if it is
determined that such Party: (i) used the efforts a reasonable person would during a force majeure event to
perform its duties under this Agreement; and (ii) the Party's inability to perform its duties during the force
majeure event is not due to its failure to take measures to protect itself against the force majeure event.
5.15 Expenses. Unless otherwise specifically stated in the Agreement, all costs and expenses incurred in
connection with this Agreement will be paid by the Party incurring the cost or expense.
5.16 Adjustments. If a governmental agency imposes a penalty, sanction, or other monetary adjustment or
withhold due to Provider's non-compliance with this Agreement, Health Plan will be able to collect the
amount imposed on or withheld from Health Plan. Health Plan may collect the amount: (i) by offsetting
from amounts due to Provider; or (ii) Health Plan may issue a recoupment letter and Provider will remit
funds pursuant to the terms of the recoupment letter. If required, such offset or recoupment will be done
in a manner that is compliant with Laws and Government Program requirements. This section will
survive any termination.
5.17 Confidentiality. Any information disclosed by either Party in fulfillment of its obligations under this
Agreement, including, but not limited to, health care information, compensation rates, and the terms of
the Agreement, will be kept confidential. Information provided to Provider, including, but not limited to,
Member lists, QI Program, credentialing criteria, compensation rates, and any other administrative
protocols or procedures of Health Plan, is the proprietary property of Health Plan and will be kept
confidential. Provider will not disclose or release such material to a third party without the written
consent of Health Plan. This section will survive any termination.
5.18 Headings and Construction. The headings in this Agreement are for reference purposes only and are not
considered a part of this Agreement in construing or interpreting its provisions. It is the Parties' desire
that if a provision of this Agreement is determined to be ambiguous, then the rule of construction that
such provision is construed against its drafter will not apply to the interpretation of the ambiguous
provision. The following rules of construction apply to this Agreement: (i) the word "day" means
calendar day unless otherwise specified; (ii) the term "business day" means Monday through Friday,
except federal holidays; (iii) all words used in this Agreement will be construed to be of such gender or
number as circumstances require; (iv) references to specific statutes, regulations, rules or forms, such as
CMS-1500, include subsequent amendments or successors to them; and (v) references to any government
department or agency include any successor departments or agencies.
MHWPROV22.3 MIIWPSA/Revised Jan 2024 Page 17 of25
ATTACHMENT
REQUIRED PROVISIONS
(HEALTH CARE SERVICE PLANS)
This attachment sets forth applicable State Laws or other provisions necessary to reflect compliance with State
Laws. This attachment will be automatically modified to conform to subsequent changes to Law. All provisions
of the Agreement not specifically modified by this attachment remain unchanged and will control. In the event of
a conflict between this attachment and any other provision in the Agreement, the provisions in this attachment
will control. Capitalized terms used in this attachment will have the same meaning ascribed to them in the
Agreement unless otherwise set forth in this attachment. Any purported modification or any provision in this
attachment that is inconsistent with Law will not be effective and will be interpreted in a manner that is consistent
with the applicable Law. For the avoidance of doubt, this attachment does not apply to the Medicare Product or
the Medicare -Medicaid Product to the extent such Products are preempted by Federal Law.
1. Provider hereby agrees that in no event, including, but not limited to nonpayment by Health Plan, Health
Plan's insolvency, or breach of this Agreement shall Provider bill, charge, collect a deposit from, seek
compensation, remuneration, or reimbursement from, or have any recourse against a Member or person
acting on their behalf, other than Health Plan, for services provided pursuant to this Agreement. This
provision shall not prohibit collection of deductibles, co -payments, coinsurance, and/or noncovered
services, which have not otherwise been paid by a primary or secondary carrier in accordance with
regulatory standards for coordination of benefits, from Members in accordance with the terms of the
Member's health program.
2. Provider agrees, in the event of Health Plan's insolvency, to continue to provide the services promised in
this Agreement to Members of Health Plan for the duration of the period for which premiums on behalf of
the Member were paid to Health Plan or until the Members discharge from inpatient facilities, whichever
time is greater.
3. Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be construed to
modify the rights and benefits contained in the Members health program.
4. Provider may not bill the Member for Covered Services (except for deductibles, co -payments, or
coinsurance) where Health Plan denies payments because Provider has failed to comply with the terms or
conditions of this Agreement.
5. Provider further agrees (i) that the provisions of (1), (2), (3), and (4) of this Attachment shall survive
termination of this Agreement regardless of the cause giving rise to termination and shall be construed to
be for the benefit of Members, and (ii) that this provision supersedes any oral or written contrary
agreement now existing or hereafter entered into between Provider and Members or persons acting on
their behalf.
6. If Provider contracts with other providers or facilities who agree to provide Covered Services to Members
of Health Plan with the expectation of receiving payment directly or indirectly from Health Plan, such
providers or facilities must agree to abide by the provisions of (1), (2), (3), (4), (5), (7), (11) and (12) of
this Attachment.
7. Willfully collecting or attempting to collect an amount from a Member knowing that collection to be in
violation of this Agreement constitutes a class C felony under RCW 48.80.030 (5) & (6).
8. Health Plan will provide Provider not less than sixty (60) days' notice of changes that affect Provider's
compensation and that affect health care service delivery unless changes to federal or state law or
regulations make such advance notice impossible, in which case notice shall be provided as soon as
possible. Subject to any termination and continuity of care provisions of the contract, Provider may
terminate the contract without penalty if the Provider does not agree with the changes. No change to this
Agreement may be made retroactive without the express consent of Provider.
9. Health Plan does not preclude or discourage Provider from informing Members of the care they require,
including various treatment options, and whether in their view such care is consistent with medical
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 18 of25
necessity, medical appropriateness, or otherwise covered by the patient's service agreement with Health
Plan. Health Plan will not prohibit, discourage, or penalize Provider if otherwise practicing in compliance
with the law from advocating on behalf of a Member with Health Plan. Members are free to contract at
any time to obtain any health care services outside their Health Plan on any terms or conditions the
Members choose. Nothing in this section shall be construed to authorize Provider to bind Health Plan to
pay for any service.
10. Health Plan does not preclude or discourage Member or those paying for their coverage from discussing
the comparative merits of different health carriers with Provider. This prohibition specifically includes
prohibiting or limiting Providers participating in those discussions even if critical of a Health Plan.
11. Provider will make health records available to appropriate state and federal authorities involved in
assessing the quality of care or investigating complaints, grievances, appeals or review of any adverse
benefit determinations of Members subject to applicable state and federal laws related to the
confidentiality of medical or health records. Provider is required to cooperate with audit reviews of
encounter data in relation to the administration of Health Plan risk adjustment and reinsurance programs.
12. Provider shall furnish Covered Services to Members without regard to the Members enrollment in Health
Plan as a private purchaser of the plan or as a participant in publicly financed programs of health care
services. This requirement does not apply to circumstances when Provider should not render services due
to limitations arising from lack of training, experience, skill, or licensing restrictions.
13. Provider may, in good faith, report to state or federal authorities any act or practice by Health Plan that
jeopardizes Member health or welfare or that may violate state or federal law.
14. Terms and Conditions of Payment
a. For Covered Services provided to Members, Health Plan shall pay Provider, and Provider shall pay
any of its subcontractors, as soon as practical but subject to the following minimum standards
including any applicable federal regulations (i.e. 42 CFR 422.52O(b)):
i. Ninety-five (95%) percent of the monthly volume of Clean Claims shall be paid within thirty (30)
days of receipt by Health Plan or Health Plan's agent;
ii. Ninety-five percent (95%) of the monthly volume of all Claims shall be paid or denied within
sixty (60) days of receipt by Health Plan or Health Plan's agent;
iii. Ninety-nine percent (99%) of the monthly volume of Clean Claims shall be paid within ninety
(90) calendar days of receipt, except as agreed to in writing by the parties on a Claim -by -Claim
basis.
b. A Claim is a bill for services, a line item of service or all services for one Member within a bill.
c. The date of receipt of a Claim is the date Health Plan or Health Plan's agent receives either written or
electronic notice of the Claim.
d. The date of payment is the date of the check or other form of payment.
e. Health Plan shall establish a reasonable method for confirming receipt of Claims and responding to
Provider inquiries about Claims.
f. For those State products/programs covered by the Washington Administrative Code (WAC), failure
of Health Plan to abide by the timely Claims payment standards delineated in WAC 284-170-431(2)
shall result in a requirement to pay interest on undenied and unpaid Clean Claims more than sixty-one
days old until Health Plan meets the standards under that subsection. Interest shall be assessed at the
rate of one percent per month and shall be calculated monthly as simple interest prorated for any
portion of a month. Health Plan shall add the interest payable to the amount of the unpaid claim
without the necessity of Provider submitting an additional claim.
g. When Health Plan issues payment in Provider's name and the Member's name, Health Plan shall
make Claim checks payable in the name of the Provider first and the Member second.
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 19 of25
h. These standards do not apply to Claims about which there is substantial evidence of fraud or
misrepresentation by Providers, facilities or Members, or instances where Health Plan has not been
granted reasonable access to information under Provider's control.
L Health Plan and Provider are not required to comply with these terms and conditions of payment if
the failure to comply is occasioned by any act of God, bankruptcy, act of a governmental authority
responding to an act of God or other emergency, or the result of a strike, lockout, or other labor
dispute.
15. Notwithstanding any other provision of this Agreement, Provider is not required to grant Health Plan
access to health information and other similar records unrelated to Members. This provision shall not
limit Health Plan's right to ask for and receive information relating to the ability of Provider or facility to
deliver health care services that meet the accepted standards of medical care prevalent in the community.
16. Notwithstanding any other provision of this Agreement, any access Provider must grant Health Plan to
medical records for audit purposes must be limited to only that necessary to perform the audit.
17. Provider maintains a reciprocal right to audit Health Plan's denials of Provider's Claims when Health
Plan audits Provider's Claims.
18. In the event Provider participates in Health Plan's Medicare Programs, the following provisions shall
apply:
a. Provider shall make all of its "Relevant Records" available for inspection, examination and copying
by all federal and state agencies with regulatory authority over the subject matter of this Agreement.
Provider shall permit such inspection at Provider's place of business and at all reasonable times.
"Relevant Records" shall mean all books and records of Provider related directly or indirectly to the
goods and services furnished under the terms of this Agreement. Provider shall maintain such
Relevant Records for the period of time required by applicable federal and state statutes, but in no
event less than ten (10) years. This provision shall survive termination of the Agreement. (42 CFR
422.504(e)(2), 422.504(e)(3), 422.504(e)(4), and 422.504(i)(2)(ii)).
b. Provider shall comply with the confidentiality and enrollee record accuracy requirements set forth in
42 CFR 422.118. (42 CPR 422.504(a)(13)).
c. Provider agrees that under no circumstance shall a subscriber or enrollee in Health Plan's Medicare
Programs be liable to the Provider for any sums owed by Health Plan to Provider. (42 CFR
422.504(g)(1)(i) and 42 CFR 422.504(i)(3)(i)).
d. If Provider is delegated any of the activities or functions of Health Plan as required in its contract
with CMS, Provider agrees to comply with all applicable contractual provisions in the same manner
as if Provider had executed such contract with CMS directly. The activities or functions delegated to
Provider are set forth in the Agreement. In the event CMS or Health Plan determines, in its sole
discretion, that Provider has not performed the delegated activities or functions satisfactorily, the
delegated activities shall be revoked upon not less than five (5) days prior written notice. The
performance of such delegated activities shall be monitored by Health Plan on an ongoing basis, and
Provider shall cooperate with all reasonable requests made by Health Plan in order to accomplish
such monitoring. If Provider is delegated credentialing activities, Provider's credentialing process will
be reviewed and approved by Health Plan, and such credentialing process will be audited by Health
Plan on an ongoing basis; further, Provider agrees that its credentialing process will comply with all
applicable NCQA standards. (42 CFR 422.504(i)(3)(iii) and 422.504(i)(4)).
e. Provider agrees that any services it performs will be consistent with and comply with Health Plan's
contractual obligations with CMS. (42 CFR 422.504(i)(1) and 422.504(i)(3)(iii)).
f. In the event of termination of this Agreement or Health Plan's insolvency, Provider agrees to comply
with the continuation of benefits provisions included in the Provider Manual. (42 CFR
422.504(g)(2)).
MHWPROV22.3 MHWHA/Revised Jan 2024 Page 20 of 25
19. Upon termination of this Agreement without cause, Provider will continue to render Covered Services to
Members until the earliest of the following: (1) the date Covered Services being rendered to Member by
Provider are completed or medically appropriate provisions have been made by Health Plan for another
provider to assume responsibility for providing such Covered Services; or (2) sixty (60) days following
notice to the Member of Provider's contract termination. The provision of such Covered Services and the
reimbursement to Provider for such Covered Services shall be subject to all applicable terms of this
Agreement on the same basis as Covered Services provided during the term of this Agreement.
20. Provider will satisfy and be in compliance with all of the requirements in WAC 284-170-421(5).
21. Provider will ensure that all of its subcontractors will satisfy and be in compliance with all of the
requirements in WAC 284-170-421(5).
22. Telemedicine Services.
i. Pursuant to RCW 48.43.735(8) and its implementing regulations, if Provider intends to bill a Member or
Health Plan for an audio -only telemedicine service, Provider must obtain Member consent for the billing
in advance of service being delivered.
ii. Beginning January 1, 2023, Provider must have an established relationship with the Member to be
eligible for reimbursement for audio -only telemedicine (RCW 48.43.735).
iii. "Established Relationship" means the provider providing audio -only telemedicine has access to
sufficient health records to ensure safe, effective, and appropriate care services and:
(A) The Member has had, within the past three years, at least one in -person appointment, or at least one
real-time interactive appointment using both audio and video technology, with the provider
providing audio -only telemedicine or with a provider employed at the same medical group, at the
same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter
48.44 or 48.46 RCW as the provider providing audio -only telemedicine; or
(B) The Member was referred to the provider providing audio -only telemedicine by another provider
who has had, within the past three years, at least one in -person appointment, or at least one real-
time interactive appointment using both audio and video technology, with the Member and has
provided relevant medical information to the provider providing audio -only telemedicine.
23. Drug Utilization Review. Health Plan maintains documented drug utilization management criteria to align
with RCW 48.43.420 and WAC 284-43-2020(2) and can be found on Health Plan's website,
https://www.molinamarketplace. com/marlcetplace/wa/en-us/Providers/Drug-List
MHWPROV22.3 MHW PSA/Revised Jan 2024 Page 21 of 25
ATTACHMENT
REQUIRED PROVISIONS
(Health Care Authority)
This attachment sets forth applicable Laws and Government Program Requirements, or other provisions necessary
to reflect compliance for the Medicaid Products. This attachment will be automatically modified to conform to
subsequent changes to Laws or Government Program Requirements. All provisions of the Agreement not
specifically modified by this attachment remain unchanged and will control. In the event of a conflict between
this attachment and any other provision in the Agreement, the provisions in this attachment will control for the
Medicaid Products. Capitalized terms used in this attachment will have the same meaning ascribed to them in the
Agreement unless otherwise set forth in this attachment. Any purported modification or any provision in this
attachment that is inconsistent with a Law or Government Program Requirement will not be effective and will be
interpreted in a manner that is consistent with the applicable Law and Government Program Requirement. This
attachment only applies to Medicaid Products.
1. Provider shall provide reasonable access to facilities and financial and medical records, computers or other
electronic systems where Medicaid -related activities or work is conducted at any time, for duly authorized
representatives of the CMS, HCA, Department of Social & Health Services ("DSHS") or the Department of
Health & Human Services ("DHHS") for audit purposes and immediate access for Medicaid fraud
investigators. The Provider must comply with behavioral health supplemental data reporting requirements,
including the requirements outlined in SERI and the Behavioral Health Data Guide (BHDG). The BHDG
describes the content of the supplemental data for each transaction, requirements for frequency of reporting,
required data fields, valid values for data fields, and timeliness reporting guidelines.
2. Provider shall completely and accurately report encounter data to Health Plan. Provider shall have the
capacity to submit all required data to enable Health Plan to meet the requirements in the Encounter Data
Transaction Guide published by HCA.
3. Provider shall comply with Health Plan's fraud and abuse policies and procedures. Provider shall permit the
State of Washington, including HCA, the Medicaid Fraud Control Division ("MFCD") and State auditor,
and federal agencies, including but not limited to: CMS, Government Accountability Office, Office of
Management and Budget, Office of the Inspector General, Comptroller General, and their designees to
access, inspect, evaluate, and audit any records, books, contracts, documents, computers or other electronic
systems of Provider, at any time, and shall permit inspection of the premises, physical facilities, equipment,
books, records, contracts, computers, or other electronic systems where Medicaid -related activities or work
is conducted, at any time.
4. As applicable, Provider shall adhere to the WISe (Wraparound with Intensive Services) Manual and
participate in all WISe-related quality activities.
5. Provider shall not assign this Agreement without HCA's written agreement.
6. Provider shall comply with any term or condition of Health Plan's contracts with HCA that is applicable to
the services to be performed by Provider.
7. Provider shall accept payment from the Health Plan as payment in full and shall not request payment from
HCA or any enrollee for Covered Services performed under this Agreement.
8. Provider agrees to hold harmless HCA and its employees, CMS and its employees, and all enrollees served
under the terms of this Agreement in the event of non-payment by Health Plan. Provider further agrees to
indemnify and hold harmless HCA and its employees against all injuries, deaths, losses, damages, claims,
suits, liabilities, judgments, costs and expenses which may in any manner accrue against HCA or its
employees through the intentional misconduct, negligence, or omission of Provider, its agents, officers,
employees or contractors.
9. Provider agrees to comply with the HCA appointment wait time standards. Provider agrees to Health Plan's
regular monitoring of timely access to Provider's services, and agrees to corrective action up to and
including termination for cause in the event that Provider fails to comply with the appointment wait time
standards.
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 22 of 25
10. Provider shall assure that all sterilizations and hysterectomies performed under this Agreement are in
compliance with 42 CFR 441 Subpart F, and that the Sterilization Consent Form (DSHS 13-364(x)) or its
equivalent is used.
11. Provider shall make reasonable accommodation for enrollees with disabilities, in accord with the Americans
with Disabilities Act, for all Covered Services and shall assure physical and communication barriers shall
not inhibit enrollees with disabilities from obtaining Covered Services.
12. Provider shall comply with all Program Integrity provisions, including, but not limited to the Washington
Medicaid Contract and the following regulations: Sections 1902(a)(68) and 1128J(d) of the Social Security
Act, 42 C.F.R. § 438.608 , 42 C.F.R. § 455, 42 C.F.R. § 1000 through 1008, and Chapter 182-502A WAC,
and Chapters 74.09 and 74.66 RCW and as documented in Health Plan Provider Manual and as set forth by
42 CFR 438.608 and the Health Plan's contracts with HCA.
13. Provider shall comply with Patient Identifying Information from an alcohol or drug abuse "program", as
defined in 42 C.F.R. §2.11, that is federally assisted in the manner described in 42 C.F.R. §2.12(b), then it
is fully bound by the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient
Records, 42 C.F.R. Part 2, with respect to such information and records, including but not limited to the
duty to resist injudicial proceedings any efforts to obtain access to such information or records, other than
as permitted by law.
14. Provider warrants and represents that it has not been convicted of crimes as specified in Section 1128 of the
Social Security Act (42 U.S.C. 1320a-7), excluded from participation in the Medicare or Medicaid program,
assessed a civil penalty under the provisions of Section 1128, entered into a contractual relationship with an
entity convicted of a crime specified in Section 1128, or taken any other action that would prohibit it from
participation in Medicaid and/or state health care programs.
15. Behavioral Health Services. If Provider provides behavioral health services, Provider must:
a. Hold all necessary licenses, certifications, and/or permits as required by law for the performance of the
activity to be performed under this Agreement.
b. Notify the Health Plan in the event of a change in status of any required license or certification.
c. Use the Global Appraisal of Individual Needs -Short Screener ("GAIN -SS") and assessment process
that includes use of the quadrant placement.
i. Failure to implement and maintain the Integrated Co -Occurring Disorder Screening and Assessment
process shall result in corrective action.
ii. If the results of the GAIN -SS are indicative of the presence of a co-occurring disorder, this
information must be considered in the development of the treatment plan including appropriate
referrals.
16. As applicable, Provider shall ensure that all written information provided to Members or potential Members
is: accurate, not misleading, comprehensible to its intended audience, designed to provide the greatest
degree of understanding, written at the sixth (6) grade reading level, provided in a font size no smaller than
12 point, and fulfills other requirements of the Contract as may be applicable to the materials. Molina must
have the written approval of HCA prior to use, as required by the Washington Medicaid Contract (42 CFR
438.10(d)(6)).
17. As applicable, for Members who have primary health insurance, benefits available under the Washington
Medicaid Contract shall be secondary to any other medical coverage, in accordance with applicable state
and federal law. Provider shall not refuse or reduce services provided under the Washington Medicaid
Contract solely due to the existence of similar benefits provided under any other health care contracts.
Health Plan shall pay preventive pediatric care, and services covered under EPSDT, including Applied
Behavior Analysis treatment services and medically intensive children's program services, and then seek
reimbursement from third parties (42 CFR 433.139(b)(3), 42 USC 1396(a)(25), RCW 41.05A.005).
18. As applicable, Provider shall not directly or indirectly conduct door-to-door telephonic, or other cold -call
marketing of enrollment (42 CFR 438.104(b)(1)(v)).
MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 23 of 25
19. Health Plan shall provide to Provider required information on the grievance and appeal system (42 C.F.R. §
438.414 and 42 C.F.R. § 438.10(g)(1)). This information shall include the toll -free numbers to file oral
Grievances and Appeals, the availability of assistance in filing a Grievance or Appeal, including informing
the Enrollee about Ombuds services and how to access these services, the Member's right to request
continuation of Medicaid benefits during an appeal or hearing and, if the Health Plan's Adverse Benefit
Determination is upheld, that the Member may be responsible to pay for the cost of the benefits received for
the first sixty (60) calendar days after the appeal or hearing request was received, the Member's right to file
Grievances and Appeals and their requirements and timeframes for filing, the Member's right to a hearing,
how to obtain a hearing, and representation rules at a hearing. The Provider may file a Grievance or request
an adjudicative proceeding on behalf of a Member. Health Plan and Provider shall retain as applicable,
Member Grievance and Appeal records pursuant to 42 CFR § 438.416, base data pursuant to 42 CFR §
438.5(c), Medicaid Loss Ration reports pursuant to 42 CFR § 438.8(k), and the data, information, and
documentation specified in 42 CFR § 438.605, 438.606, 438.608, and 438.610 for a period of no less than
ten (10) years.
20. Provider shall have and maintain insurance appropriate to the services to be performed and shall make
copies of Provider's Certificates of Insurance available to Health Plan if requested.
21. If Provider is at financial risk, as defined in the Washington Medicaid Contract, Health Plan will establish,
enforce and monitor solvency requirements, and Provider shall comply with such requirements.
22. As applicable, Members have the right to self -refer for certain services to participating or nonparticipating
local health departments and participating or nonparticipating family planning clinics paid through separate
arrangements with the state of Washington. The services to which Members may self -refer are: 1 - family
planning services and supplies, and sexually transmitted disease screening and treatment services provided
at participating or non -participating providers, including but not limited to family planning agencies, such
as Planned Parenthood, 2 — immunizations, sexually -transmitted disease screening and follow up, HIV
screening, tuberculosis screening and follow up, and family planning services through and if provided by a
local health department, 3 — immunizations, sexually transmitted disease screening, family planning and
behavioral health services through and if provided by a school -based health center, 4 - all services received
by American Indian or Alaska Native Members at an IHCP, and 5 — crisis response services, including
crisis intervention, crisis respite, investigation and detention services; and evaluation and treatment services.
Self -referrals can also be made for assessment and intake for behavioral health services.
23, Provider shall disclose the following to Health Plan upon contract execution, upon request during the re-
validation of enrollment process, and within thirty-five (35) business days after any change in ownership of
Provider: the name and address of any person (individual or corporation) with an ownership or control
interest in Provider; if Provider is a corporate entity, the disclosure must include primary business address,
every business location, and P.O. Box address; if Provider has corporate ownership, the tax identification
number of the corporate owner(s); if Provider is an individual, date of birth and Social Security Number; if
Provider has a 5 percent ownership interest in any of its subcontractors, the tax identification number of the
subcontractor(s); whether any person with an ownership or control interest in Provider is related by
marriage or blood as a spouse, parent, child, or sibling to any other person with an ownership or control
interest in Provider; if Provider has a 5 percent ownership interest in any of its subcontractors, whether any
person with an ownership or control interest in such subcontractor is related by marriage or blood as a
spouse, parent, child, or sibling to any other person with an ownership or control interest in Provider; and
whether any person with an ownership or control interest in Provider also has an ownership or control
interest in any Managed Care entity.
24. As applicable, Provider shall ensure interpreter services are provided free of charge for Enrollees and
Potential Enrollees with a primary language other than English or those who are Deaf, DeafBlind, or Hard
of Hearing. This includes oral interpretation, Sign Language (SL), and the use of Auxiliary Aids and
Services as defined in this Contract (42 C.F.R. 438.10(d)(4)). Interpreter services, provided by certified
interpreters, shall be provided for all interactions between such Enrollees or Potential Enrollees and Health
Plan, or Provider, or any of its providers, including but not limited to customer service, all interactions with
any provider for any covered service, Emergency Services and all steps necessary to file Grievances and
Appeals including requests for Independent Review of Health Plan decisions.
MHWPROV22.3 MHWHA/Revised Jan 2024 Page 24 of 25
25. This Agreement does not terminate Health Plan's legal responsibility to HCA for any work performed
under the Washington Medicaid Contract nor for oversight of any functions and/or responsibilities Health
Plan delegates to Provider.
26. The Health Plan and its subcontractors shall forthwith produce all records, documents, or other data
requested as part of such inspection, review, audit, investigation, monitoring, or evaluation If the requesting
agency asks for copies of records, documents, or other data, the Health Plan and its subcontractors shall
make copies of records and shall deliver them to the requestor, within thirty (30) calendar days of request,
or any shorter timeframe as authorized by law or court order. Copies of records and documents shall be
made at no cost to the requesting agency. (42 C.F.R. § 455.21(a)(2); 42 C.F.R. § 431.107(b)(2)). The right
for the parties named above to audit, access, and inspect under this Section exists for ten (10) years from the
final date of the contract period or from the date of completion of any audit, whichever is later, or any other
timeframe authorized by law. (42 C.F.R. § 438.3(h)).
27. As applicable, Health Plan and its subcontractors are required to comply with chapter 71.32 RCW (Mental
Health Advance Directives).
28. Provider shall agree to subrogate, to the state of Washington for all criminal, civil and administrative action
recoveries undertaken by any government entity, including, but not limited to, all claims the Contractor or
subcontractor has or may have against any entity or individual that directly or indirectly receives funds
under this Contract including, but not limited to, any Health Care Provider, manufacturer, wholesale or
retail supplier, sales representative, laboratory, or other provider in the design, manufacture, marketing,
pricing, or quality of drugs, pharmaceuticals, medical supplies, medical devices, Medical Equipment, or
other health care related products or services.
29. Provider agrees to Release to Health Plan any information that is necessary for Health Plan to perform any
of its obligations under the HCA Contract.
30. As applicable, Health Plan may not prohibit a Provider acting within their lawful scope of practice from
advising or advocating on behalf of a Member who is their patient for any information the Member needs to
decide among all relevant treatment options.
31. Provider shall investigate and disclose to Health Plan at contract execution or renewal, and upon request by
Health Plan, the identity of any person who has been convicted of a criminal offense related to that person's
involvement in any program under Medicare, Medicaid, or the title XX services program since the
inception of those programs and who is a person who has an ownership or control interest in Provider, an
agent or person who has been delegated the authority to obligate or act on behalf of Provider, or an agent,
managing employee, general manager, business manager, administrator, director, or other individual who
exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day
operation of Provider pursuant to 42 C.F.R. § 455.106(a) and § 455.101.
32. If Provider is also a home health agency, Provider shall be in compliance with the surety bond requirements
of Section 4312(b) of the Balanced Budget Act of 1997 and 42 C.F.R. § 441.16.
33. Provider agreement shall be in writing and be consistent with the provisions of 42 C.F.R. § 434.6, §
438.230 and § 438.214, as applicable and shall identify services to be performed by Provider. If Health Plan
allows Provider to further subcontract, all requirements under the HCA contract must be propagated to any
other lower tiered subcontracts.
34. Provider agrees to allow a process for monitoring the Provider's performance and a periodic schedule for
formally evaluating performance, consistent with industry standards or state managed care laws and
regulations. Provider agrees the Health Plan may conduct compliance reviews when the Health Plan has
identified deficiencies or areas requiring improvement and provide for corrective action. Provider shall
provide Health Plan with reports sufficient to show that Provider has complied with all data submission
requirements established by HCA for all services funded by HCA under this Agreement.
MHWPROV22.3 MHWHA/Revised Jan 2024 Page 25 of 25
EXHIBIT 1-A
Compensation Schedule -Standard - Medicaid (Version 1)
Health Plan agrees to compensate Provider for Clean Claims for Covered Services rendered to Members, in
accordance with Health Plan's programs participation, on a fee -for -services basis, at the lesser of; (i) Provider's
billed charges, or (ii) the amounts set forth below, less any applicable Member co -payments, deductibles, co-
insurance, or amounts paid or to be paid by other liable third parties, if any;
Covered Services shall be paid at one hundred percent (100%) of the prevailing local and geographically adjusted
State of Washington Medicaid Fee -For -Service Program fee schedule in effect on the date of service.
If there is no payment rate in the State of Washington Medicaid Fee -For -Service Program fee schedule as of the
date of service, payment shall be at one hundred percent (100%) of the prevailing Medicare Fee -For -Service
Program fee schedule, in effect on the date of service.
If there is no payment rate achieved in the above methodologies, reimbursement shall be paid at fifty percent
(50%) of billed charges.
MlJWPROV.CS22.3 Comp Schedule/Sept 2024 Page I of 1