HomeMy WebLinkAboutFully Executed ContractAmendment to the Medical Group Participation Agreement
This amendment (this 'oAmendment") is to the Medical Group Participation Agreement, effective as
of 0610112026 (the 'oAgreement"), between UnitedHealthcare Insurance Company,
UnitedHealthcare of Washington, Inc., and UnitedHealthcare of Oregon, Inc. ("United")
contracting on behalf of each entity individually (collectively, oounited") and Kittitas County ("Medical
Group").
This Amendment is effective on0610l12026 (the "Amendment Effective Date").
The parties agree to modify the Agreement as follows:
1. The capitalized terms used in this Amendment, but not otherwise defined, will have the meanings
ascribed to them in the Agreement.
2. Appendix 4 to the Agreement is deleted in its entirety and replaced with the Appendix 4 attached
hereto.
3. Medical Group represents that it has provided United with a Medical Group Professional Roster
that includes all of the following data elements for each Professional: Any previous Professional
Roster aftached to the Agreement is deleted in its entirety'
- Name of Professional (first name, middle initial, last name)
- Degree (MD, DO, NP, PA, other)
- Gender (M/F)
- ProviderSpecialty(ies)(primary,secondary, additionalspecialties)
- Operates as and willing to be listed/assigned as a Primary Care Professional "PCP" (YA\l)
- State License Number
- Medicaid ID Number
- NPI Number
- Foreign Language(s)
- AdmittingHosPital(s)
If any data element is not applicable to a specific Medical Group Professional, Medical Group will
indicate "not applicable" in the appropriate field. Acceptable formats include in writing,
electronically in Excel, ANSI, or text (comma delineated) formats.
4. The attached "Behavioral Health Services and Payment Addendum" is hereby added to the
Agreement as Attachment l.
All other provisions of the Agreement shall remain in full force and effect. In the event of a conflict
between the terms of the Agreement and this Amendment, the Amendment will control.
UnitedHealthcare
C o nf de ntial and P ro pri e tary
Gen. Amd.SMGA. B H. WA.06. 2 5
Signature:
Print Narne:
UnitedHealthcare Insurance Company, as
signed by its authorized representative
J*r=*nr*_"Signature:
ScottWilliams
Title: VP, Network Management
pn1s, Jul 8,2026
UnitedHealthcare of Washington, Inc., as
sigrred by its authorized representative
Signature:
Scott Williams
Print Name: CI,AY ,1,,-VFR S
Title: stfEetFF
Date: a - 3A-t"t
TIN att - t'oo l3 Lt1
Kittitas County, as signed by its authorized
representative
Kittitas County, as signed by its authorized
representative
PrintName: CLIY t1y'r€Rs
Title:SHERIFF
Date: 6.t4'24
TIN:l - I.DD,,t
Signature:
Print Name:
Title: VP, Network Management
Date: Jul 8,2026
UnitedHealthcare of Oregon, Inc., as signed
by its authorized representative
Kittitas County, as signed by its authorized
representative
Signature:
Print Name:Scott \Mlliams
Signature d-u 4rts<to1-/
Print Narne: CLA7 ."ryEp5
Title: VP, Network Management Title:SAER,FF
pnls; Jul 8,2026 Date: 6. W'A/
Qt-l'Dol3L/1TIN
UnitedLlealthcare2Ge n.,4 url.SlllG,4. B ll. rI'4.06. 2 5
Confidential and Propiettuy
Appendix 4
Medical Group Service Locations
Medical Group attests that this Appendix identifies all services and locations covered under this Agreement.
IMPORTANT NOTE: Medical Group acknowledges its obligation pursuant to the agreement to promptly
report any change in Medical Group's name or Taxpayer tdentification Number. Failure to do so may result
in denial of claims or incorrect payment.
BILLTNC ADDRESS
Identiff only if a common name and address appears on all Medical Group service location bills
utilize the Medical S Identification Num under the
Practice Name: Kittitas County
Street Address: 307 W UMPTANUM RD
City: ELLENSBURG State:WA Zip: 98926
Taxpayer Identification Number(s) (TIN) 916001349
National Provider ID 1063226272
UnitedHealthcare
Confidential and Proprie tary
3
Nrl
MEDICAL GROUP LOCATION - List BOTH the Service Location and the Billing Address for the
Service Location
Service Location Billing Address for the Service Location (if
different from above)
Medical Group Name Medical Group Name
Kittitas County Kittitas County
Street Address Street Address
205 W 5TH AVE STE 1 205 W 5TH AVE STE 1
City Citv
ELLENSBURG ELLENSBURG
State and Zin Code State and Zip Code
wA 98926 wA 98926
Phone Number Phone Number
(s06) 962-7s27 (s0$ 962-7s27
TIN (Ifdifferent from tbove)
National Provider ID (NPD
ADDITIONAL MEDICAL GROUP LOCATIONS - List BOTH the Service Location and the Billing
Address for the Service Location
Service Location Billing Address for the Service Location (if
different from above)
Medical Group Name Medical Group Name
Street Address Street Address
Citv Citv
State and Zip Code State and Zip Code
G e n.Amd. S MG A. B H. WA.0 6. 2 5
Phone Number Phone Number
Tlll Uf different from above)
National Provider ID NPI)
Medical Group Name Medical Group Name
Street Address Street Address
Cifv ciw
State and Zip Code State and Zip Code
Phone Number Phone Number
TIN Uf different from abovel
National Provider ID (NPI)
Medical Group Name Medical Group Name
Street Address Street Address
City Citv
State and Zip Code State and Zip Code
Phone Number Phone Number
TIN (Ifdifferent from above)
National Provider ID NPI)
4 UnitedHealthcare
Confdential and Proprietary
Ge n.Amd. S MGA. B H. WA. 0 6.2 5
BILLING ADDRESS FOR MWSUD SERVICES ONLY
Identify only if a common name and address appears on all Medical Group service location bills
Identification Num under thethat utilize the Medical ts
S
Practice Name: Kittitas County
Street Address: 307 W UMPTANUM RD
City: ELLENSBURG State:WA Zip: 98926
Taxpayer ldentification Number(s) (TIN) 9 16001349
National Provider 226272
MADICAL GROI.'P LOCATION FOR MIUSUD SXRVICSS ONLY. List BOTH thc SETViCC
Location and the Billine Address for the Service Location
Billing Address for the Service Location (if
different from above)
Service Location
Medical Group NameMedical Group Name
Kittitas CountyKittitas County
Street AddressStreet Address
307 W UMPTANUM RD307 W UMPTANUM RD
ciwCitv
ELLENSBURGELLENSBURG
State and Zip CodeState and Zip Code
wA 98926w1^98926
Phone NumberPhone Number
(s06)' 962-7s27(50o 962-7s27
TIN Uf different from above)
National Provider ID (NPI)
ADDITIONAL MEDICAL GROUP LOCATIONS FOR MH/SUD SERVICES ONLY - LiSt BOTH
the Service Location and the Billing Address for the Service Location
Billing Address for the Service Location (if
different from above)
Service Location
Medical Group NameMedical Group Name
Street AddressStreet Address
CitvCity
State and Zip CodeState and Zip Code
Phone NumberPhone Number
TIN (Ifdifferent from above\
National Provider ID (NPI)
Medical Group NameMedical Groun Name
Street AddressStreet Address
5 UnitedHealthcare
Confide ntial and Proprietary
Ge n, Amd. S MGA. B H. WA. 0 6. 2 5
Citv Citv
State and Zip Code State and Zip Code
Phone Number Phone Number
TIN Uf different from abovel
National Provider ID NPI)
Medical Group Name Medical Group Name
Street Address Street Address
Citv Citv
State and Zip Code State and Zip Code
Phone Number Phone Number
TIN Qf different from above)
National Provider ID NPI)
6 UnitedHealthcareG e n. Amd. S MG A. B H. I,YA. 0 6. 2 5
Confdential and Proprietary
BEHAVIORAL HEALTH SERVICES AND PAYMENT ADDENDUM
WA.SHINGTON MEDICAID AND CHIP BENEFIT PLANS
This Behavioral Health Services and Payment Addendum (this "Addendum") sets forth the terms and
conditions under which Medical Group will participate in one or more behavioral health networks to provide
Covered MFVSUD Services (as defined below) to Customers enrolled in Washington Medicaid and CHIP
Benefit Plans. This Addendum applies to the Washington Medicaid network.
In the event of a conflict between the terms and conditions in this Addendum and the terms of the Agreement,
including all other addenda, appendices and attachments, the terms in this Addendum will control Medical
Group's provision of Covered MFVSUD Services, except that the terms of any regulatory requirements
appendix will control over any conflicting terms of this Addendum, as applicable. This Addendum does not
apply to Covered Services other than Covered MH/SUD Services.
ARTICLE 1
Definitions
Unless otherwise defined in this Article 1, capitalized terms used in this Addendum have the meanings
assigned to them in the Agreement. For purposes of this Addendum, the following definitions will apply:
CMHC: A Community Mental Health Center.
CMHC Provider: An employee of a CMHC who provides MH/SUD Services, but is not a CMHC
Supervising Provider.
CMHC Supervising Provider: A psychiatrist, psychologist, social worker, family or other therapist duly-
licensed and qualified in the state in which MH/SUD Services are provided to Customers who practices as
an employee of CMHC and has been approved as a CMHC Supervising Provider in writing by United.
Covered MH/SUD Services: MH/SUD Services that are (i) Covered Services under a Benefit Plan (ii)
provided at a Service Location listed in Appendix 4 of the Agreement as providing MH/SUD Services, and
(iii) which are set forth in one or more Behavioral Health Service Payment Appendices attached to this
Addendum.
Emergency Care for Mental Health Condition: Covered MH/SUD Services provided for an individual,
that, if not provided, would likely result in the need for crisis intervention or hospital evaluation due to
concerns of potential danger to self, others, or grave disability according to chapter 7l.05 RCW.
Facility-based Provider: A health care professional, who is employed by or under contract or supervision
to render MFVSUD Services to Customers. Facility-based Providers include, but are not limited to,
emergency room physicians, pathologists, radiologists, anesthesiologists, certified registered nurse
anesthetists ("CRNAs"), and intensivists.
Facility Participating Provider: A health care professional, facility, or other organization that has a
written Facility Participating Provider Agreement in effect with United, directly or through another entity,
to provide MH/SUD Services to Customers.
Group: Group-based Provider, and Group Participating Provider.
UnitedHealthcare
Confdential and Proprietary
7Ge n.Amd. SMGA. B H. IryA. 06.2 5
Group-based Provider: A health care professional, psychiatrist, psychologist, therapist or other behavioral
health professional who is employed by or under contract or supervision by Group to render MH/SUD
Services to Customers.
Group Participating Provider: An entity, organization, group, partnership or affiliation however
categorized, consisting of health care professionals, facilities, psychiatrists, psychologists, therapists or
other behavioral health professionals that is duly-licensed or certified to provided MH/SUD Services within
the state such MH/SUD Services are provided, and who has a written Group Participating Provider
Agreement in effect with United, directly or through another entity, to provide MFVSUD Services to
Customers.
Mental Health and Substance Use Disorder Services ("MH/SUD Services"): Health care services,
treatment or supplies that are used to treat a mental health or substance abuse illness, condition or disease,
MH/SUD Payment Policies: For purposes of this Addendum, MH/SUD Payment Policies are Payment
Policies or other guidelines adopted by United for calculating payment of claims for Covered MFVSUD
Services provided by Medical Group (including claims from Medical Group under this Addendum). The
MFVSUD Payment Policies operate in conjunction with the specific reimbursement rates and terms set forth
in the applicable Behavioral Health Services Payment Appendix to this Agreement. Like other Payment
Policies, the MH/SUD Payment Policies may change from time to time as discussed in -the Payment of
Claims provision of the Agreement.
MH/SUD Protocols: For purposes of this Addendum only, MH/SUD Protocols are Protocols limited to
those programs and administrative procedures adopted by United or a Payer to be followed Medical Group
in providing Covered MH/SUD Services and doing business with United and Payers under this Addendum.
These MH/SUD Protocols may include, among other things, credentialing and recredentialing processes,
utilization management and care management processes, quality improvement, peer review, Customer
grievance or concurrent review. The MH/SUD Protocols may change from time to time as described in the
Agreement and this Addendum.
MH/SUD Provider Manual: Those provisions of an administrative guide that apply to Covered MH/SUD
Services will be made available to Medical Group online, WWW.UHCProvider.com, or upon request. Any
changes to the manual will be made consistent with the terms of the Agreement.
ARTICLE 2
MH/SUD Services
2.1 Provision of MH/SUD Services. Medical Group hereby acknowledges and agrees to cooperate
and comply with all of the terms and conditions of this Addendum and the Agreement as a
participating provider for the provision of Covered MFVSUD Services to Customers as designated
by United or Payer. At the request of a Payer, Medical Group may not be authorized to provide
Covered MH/SUD Services for some or all of Payer's Customers. Medical Group will otherwise
accept Customers as new patients on the same basis as Group is accepting non-Customers as new
patients without regard to race, religion, gender, color, national origin, age or physical or mental
health status, or on any other basis deemed unlawful under federal, state or local law. At all times,
Medical Group will require any employed or subcontracted MH/SUD providers to comply with the
terms and conditions of this Addendum, all MH/SUD Protocols and MFVSUD Payment Policies,
as may be set forth in the MH/SUD Provider Manual and the requirements of all applicable laws
and regulations.
UnitedHealthcare
Confdential and Proprietary
8Ge n.Amd.S MGA. B H. Il/4. 0 6. 2 5
2.2
2.3
Cooperation with MH/SUD Provider Manual, MH/SUD Protocols, MH/SUD Payment
Policies. Medical Group will be bound by, accept, strictly comply with, and cooperate with
applicable MH/SUD Protocols and applicable MH/SUD Payment Policies, as may be set forth in
the MH/SUD Provider Manual. The MH/SUD Protocols and MH/SUD Payment Policies will be
made available to Medical Group online or upon request. Some or all MH/SUD Protocols and
MH/SUHD Payment Policies also may be disseminated in the MFVSUD Provider Manual or in
other communications. Currently, the MH/SUD Protocols and MH/SUD Payment Policies may be
found at www.UHCProvider.com. United will notiff Medical Group of Medical Group's failure to
comply with the applicable MH/SUD Protocols or applicable MH/SUD Payment Policies may
result in loss of or reduction of payment or reimbursement to Medical Group or the imposition of
other corrective action by United To the extent that the provisions of the MH/SUD Provider Manual
differ from this Addendum or the Agreement, the terms and conditions of the Agreement and this
Addendum govern. For purposes of Covered MH/SUD Services, the MFVSUD Protocols and the
MH/SUD Payment Policies control and supersede all other Protocols, Payment Policies or
administrative manuals or guides, with the exception of Additional Manuals, if applicable as
described in the Agreement.
Continuity of Care; Referral to Other Health Professionals. Medical Group will furnish
Covered MFVSUD Services, providing continuity of care and ready referral of Customers to other
participating providers as may be appropriate and consistent with the standards of care in the
community. As appropriate, Medical Group will coordinate and exchange Customer data with
Customer's primary care provider ("PCP"), to properly accomplish person-centered, integrated
care. If a Customer requires additional services or evaluation, including Emergency Care for Mental
Health Condition, Medical Group agrees to refer Customer to Customer's PCP or another
participating provider in accordance with the terms and conditions of Customer's Benefit Plan.
Medical Group will refer Customers requiring Emergency Care for Mental Health Condition to the
"9- I-I " emergency response system.
2,4 Payment of Services. All payments obligated by Payer will be paid to Medical Group in accordance
with the terms of the applicable Behavioral Health Services Payment Appendix to this Addendum and in
accordance with applicable MH/SUD Payment Policies. Medical Group agrees to continue to provide
MFVSUD Services to Customers who have exhausted his/trer covered benefits under the Benefit Plan and
agrees not to collect or charge more than the contracted rate for those MFVSUD Services. Medical Group may
bill the Customer directly for those MFVSUD Services for which there is no longer any coverage under the
Benefit Plan, provided the Medical Group obtained the Customer's prior written consent.
Each party agrees to defend, indemni$, and hold the other parly harmless for any claims, damages, actions, or
judgments arising from any employee or contractor related to the provision of MFVSUD Services to Customers.
ARTICLE 3
MH/SUD Submission of Claims.
Medical Group will submit claims for Covered MH/SUD Services to United in a manner and format
prescribed by United. [Medical Group agrees that claims received by United after the relevant time period(s)
set forth in the Agreement may be rejected for payment, at United's and/or Payer's sole discretion.
UnitedHealthcare
C o nf de nt ia I a nd P ro pri e t a ry
9C e n.Amd.SMGA. B H. \ryA.06.2 5
5.2
ARTICLE 4
Alcohol and Drug Abuse Patient Records
Medical Group acknowledges that in receiving storing, processing or otherwise dealing with information from
United or Payer about Customers, it is fully bound by the provisions of the federal regulations goveming
Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR PartZ, as amended (the "Confidentiality
Regulations"); an Medical Group agrees that it will resist in judicial proceedings any effort to obtain access to
information pertaining to patients otherwise than as expressly provided for in the Confidentiality Regulations.
ARTICLE 5
Miscellaneous
5.1 Survival. Upon termination of the Agreement or this Addendum, the provisions herein, which
contemplate performance or observance subsequent to termination, will survive and remain of full
force and effect between the parties.
Entire Agreement. On the Effective Date, this Agreement and this Addendum will supersede and
replace any existing provider agreements between the parties related to the provision of Covered
MHiSUD Services for Benefit Plans to which this Addendum applies as described in the preamble,
including any agreements between Medical Group and United or a United Affiliate including
United Behavioral Health. This Agreement, together with any and all attachments, addenda,
appendices, as may be amended or modified from time to time, whether contemporaneous or
subsequently made, are hereby incorporated herein by reference, and constitutes the entire
agreement between the parties in regard to its subject matter.
UnitedHealthcare
C onfi denti al and P ropri e tary
Gen.Amd.S MGA. B H. WA. 06. 2 5 10
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l::l*."::T"T#.:l:;::::ldoxjelm;mdd*hhnndrcmpr4iv;.oun,.rrnsand/o,c@.ddh,sfwnqere*dms ld'esr"
IER rnil,3 rq cmoffi: debild Dx: dm d delion d coryl.lrq coKelhs {do..m'd orhd 6€ilv pldhs l rI es/oP
I'obr.mbdmrinficdturbliktuil I
J kyComFnrns:6mp'ehe.tR Hr,Comprh.Bk urmj Md 0erkn HiSh 6mpLr r"*123.93
b,conprch.nrh&.mj Md e.hn Hr3h66pFr r*'"
lrmflsenqo.etVkil,
r hycohpienB omprch.n\b k;comp'.heniF tr.mi Md e,nn Hlsh 6mphr
Hrjcomprchenrtu &:m; Md &.Ln HEhGhpbx r""
k;ConpGhenrir &:nj Md ftdsn HEh6nPFr t**-
lad€qenryo.etviil,
I kycomFienB:6np'Pfi.nrk H\jConpteh.nsiE &rni Md edsn H!hGmpk,
rbn&Min,3€n.nt
lou/P
157,39
8291
loidalcil€,
EEtuilrn & Mmarm€it
lo'dol(r€,
Eerudbn & Mm4en€nr.rdd r roM'n
Fe -r c.'., 4;hrbn & Man,senpnt. addl 30 Min
lo13/oP
I
hiti nu6hB 6dhry d'€, ddnldkome hlbry;
I
rnilhr nu6hs hi,rq (,'€, dehild/.omp h\'oryi d€raidtomp d.mi ddbn m.hn3 ilnrd{osildnow codpknq
l0r0/P
r-*45,69
|hldalilEh3hdqcre,debild^omPhtslory'dehild/(onp.xan;d*ibnmrlin3rk.islbNild/ow.omplex.q
lhiDl
nuBins 6i.lq i r€, dehid/(omp hktotr deuild/omp drmj d(kbn milns'rdrdrbtuild/ow.omPr.r'q
lr'
4s/oP
t detrird/(omp hiltory; dehildtomp errm: dFirsn m*'ns*.i$trotu,'dlN (odpkilq
f^t
97,7t
r-*
I
hidr nunins h6lrv ra,e ddilrd/omp hLrory d.hird/mmp er.n: dd6.n m.r inB {,aid{oN.d/o* (omprsi\
UNITED HEALTHGRE
WASHINGION MEOICAID AND WASHINMON BENEFIT PLANS FOR THE UNINSURED BEHAUORAI- HEALTH PROFESSIONAL REIMSURSEMENTSCHEDUI.E
l.lual n!6lng hciliq.ilq ps d4 onp h&lory @mp exam; .nd rdk'l d*Eion nikiru ol mde..c .onpbxiq
l.id.l .!6ins h.ility.:rq pq d., @np hLto$ enp er:mi and mdk.l deLion ntkin8 of ndcEl. conPtsriq
lcfioP
ss5 lhldal .luing 6.ilit.rr., p.r d:, conp hktory @mp e$n; and mda.l d*blon m.kinB ot nd€nle compkxiq
lntd.l nruinr 6.i1to ctrq pa daL comp htstoryj @np .ra6; and ddk.l d-kion mtlina of md€db comphxiq
l.iual n!6lng h.iliq c.rq per d4 conp hblory .omp ex.mi .nd 6dkal ddLlon n.tl.g of md€GE conphxiq
lx.serP
1t,91
l.id.l n!6lng hciliq.:r., p.r d4 .onp hGlory; conp d.mi and Bdad d*don m.ri4 or md€nb conpbr'q
lnirial nuEh* hciliv.rs ps d., .oEp hnrory; comp .xrd) and ndkal d<kion mrtins of ndeEtc .omphriv r-"
hiuat nu6ine hcilO..re, per dir .omp htslory comp di6j and mdkd d*klon nali4 of mdaGb comphriV
loro/oP
724,92
nital n!6ing 6.ilq.'re, p€r dr%.omp htslory; .o6p qr6i ad ndbal d**n mari4 ot mdent€ conphrq
nlUal nuElns h.lld..r€, pcr d.y,.onp hLrory .onp d.mj :d mdtal dFtrn mall.3 ot mdeEb .omFkxiry
nldal nucing 6.il&.,r€, p€r dr%.omp htslory; .omp errnj id ndt.t dftkbn maki.3 ot htd conplerB
lo13/'
nital nuGing 6.il& .are, p€r d.f, tump htslory; .omp drnj rd ndbal dedion makins or h'O conpterrq r-*137,15
nital nuEins 6.illty ..r€, !€. dry, conD hGtory .onp d.hj .nd mdtal ddkn naling of hi$ compt.xiq
nital n!Eing h.ility ra.€, F.. d!r.onp hbbry .onp q.mj ..d hdkal d*nion ftaking ol hiS .ompl.xiq
nili:l nuGi.3 6cilq ctr€, pet d.t .omp hktory .onp dthj i.d ndhl dedion makins ot hrO .omprerq r*"*103.51
nidil nuEins h.iljty c..q pe. dry, .onp hktory (omp qami rnd ndkrl dftkion making ot hi$ .ompl.xiV
nir:l nuEi.g h.iliry ca.q par dat .omp hbtot$ .omp qam; r.d mdhrl dk&lon making of hid compl.xiq r"
nit.l nuEing h.ild ca.e per day, .omp hLiory; comp damj .nd mdkJ d-6ion m:klng of hi$ .ompleiq lc&P
nl&l nuRing h.iliq carq per d.t .omp hktory 6mp €nn; .nd ndki d4kion makina or hiS .onpl.xiV
nltil nuEinr ft.i|to cars p.. d.t romp hktoryj .onp €ram; .nd ndki deciion nakina of hld .onpl.xiry
il@i;$hs iaciliry@€, Fr drr 2 or: p.obkn due hitory; poblen 6.us er.m; sr:i$tu d€tun n.kins
lGf/P
s,39
iubelent nuuina fa.iliq a€, Fr d.r 2 of: p.obk6 tuue hktory; pmbleh bcus ex.m; .ts.ioM de4'on n.kn3
r-*
iub!{r.nt nuding h.llity .aE, Fr d" 2 ot: probbn hut hitory; poblem 6cus ex.n; rtai$tud de.Lio. mtkh8
f*"
,ubsquent nu6inBfaciliq.aE,tsrd.f, zofr ptobbm hGhhtory;pbbl€m fo.u5 errm;srai*&dd€c&io. m.lin!
1",^"
iu&qu.nt nuulng iaciliq car., Fr d.r 2 ot: probtsm &ue hitory; pobl€n 6.us ex.mi rt idtud decnbn o.lin8
1,,*,,
.uBquenr nuFinBfdcilry.r'.,tsrd., tor: probbm &urhbrory;p'oblem b(ue drn;sbriFtudde(Bion m.hn3
lu"n,",
,ubquent nuulnBla(iiq.rc,F' d.r 2ol: probkn kLihtrory;0'oblFn btus dadi stiidtuddelir.n maxi.g
l',",',
iublqu.nt nu6lnB h.ility c.r., Fr da, 2 ol: pbbhh tuut h&tory; pobl.m tocur dafrj 3hi$tud dedion mari.8
l-,*
.uB$u.nl nunlnsfrcilq.ate,Ftdatr 2ol:p'obhm toushlrory;Dtoblem b.BArmj !bJghtud dedion n,rin8
1.,
,*,,,
;uhqqlnmiq6:iliryqre, ts' dc 2 ot pDblemlddhroryprcblf, lNu*4 *r$d d6'{o. dbry t"*-'
;ubaufll lMiq fNiliry cue F &n 2 o[ dF! pr.blm fNB n\: svdd probld fND sn los d.cnion tu3 r*"
iuhqdl Mis f..Jiry cile, F &t 2 ot sxpdd poblm leu n\: qvdd problm INB mc low hiion m$g
lcf/oP
5634
;u&{Kr nufu Gcnity wq Fr S} 2 oF evdd pmbld rau h\; c$d troblfl IdE e4 low dNsDn Nrs r-"
rreqhl ffiiq bliliq cee, F 6! 2 ot e\pad prcblm rM h\i .gdd Pr.blm leE era los ddLion ftbs r*'"
nb@iq titly uq F &r 2 o[ e\pdd probld fNB L\i epJd p'oblfl leE {vr lotr JNbion tus
l"'gqtP
4t,52 42,S2
iop
.uk<u.nl nurinsfrritqdc,F.drt 2 ol:d.b,hd hnbtrd€tiddrmj ndc.aremedn.rdeGlon m.rjn3
iu&qu.nt no6i.C f..i$q oG, Fr da, 2 of: debihd hktry d.Eild .rid; mdeEle m€dical de.tion naling
@l nu6i.g f:.i{q dc, Fr da, 2 ofr del.ihd hkloryi &laild exrni md€Ele m€dical d..6ion nali.8
lG,0/P
61,55
,uBquenr nunlryfac'h\(ile,tsrd.9 2 of:d.L.hdhktqi del.ild
iu&qlenl .u6lq fi.iiry cie, tsr drt 2 ol: del.ihd hktq; d.hnd drm; md€El. m€di.al d..nron n:li.g
@nl nuEinsla.i$rycft,F.dar 2ol:d.blkdhktry; dabild.bn; mdeElem€diBld*ilon n.li.8 lr ee/oP 51.55
,ubqucnr nurlnshusryor.,Frdrv, zof:d.b'hdhtrtory detrild
iuB<uent nor3ins lr.ifiV ot , F. d.r 2 of, d.blkd hhtory dehild dam; ndedb m€diol ddbn makl.8
@ent nuGins fi.iliv crE, Fr drs 2 ol: d.l.ikd htrorv dettild €r.n; mdebE nedi@l ddbn m.ting
l2r
es/P
iuEqtr.nt nu6l.g h.irq or., F, ditr 2 of, deblkd hktory dehild exan; dd.dte medi€l decition nrkinS
iu&qtr.nt huGlns h.inv or., Fr irr 2 of, .onp hbbry .omp .x.o; nedical d..&ion m.kina of hish .omphxiq r**
'it{u.nt nuEins la.iliv or., Fr d., 2 oi: comP hLtorv .odp .ramj mcdidl d..Lion nakrns or hish .ompbxi!
lot3/oP
iu&qu.ntnur3lngl.rililyerc, Frdrn 2ot: conphklory.omp
iu&auenrnurrinrh.ilivorc, Frdir 2of: conp*lory.onpaah; h€dlol ddBlon ntrinsorhBh.onphiq
iubquentn.Bi.3f..iliryerc,tsld.r2of:conphklory.onp€Fmjm€didld..Blonnrti4olhi3s@npbxiq
u*smns tilnycare, Fr drr 2 ot: cdp hLlotyj @npsmi m€diol d.dnon m.kiryofhisfi dmphriq
lx4s/oP
,ubqucnl nursinsh.iiq..rc, Frd.r tol:.onp r-
iubqucnt n!6i.9 t ritq.rc, tsr d., 2 of: comp r""
iukquc.t n!.sin3 ,.citq dq Fr d., 2 ot: comp
lr!es/P
iuk4u.nt nluing L(itq..n, Fr d.r 2 ol: comp hBbry; omp drn; nedrdl dc.*b. mari.8 or hish conpEdv
UNITED HEALIHCARE
WSHINGTON MEDICAID AND WASHINGTON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAL HEAI.TH PROF65IONAL REIMBURSEMENTSCHEDULE
D*hirg€ 0.t kn:g.m.nqs Mne<61,51
4315
lfluuinshorryorxhile€
ory hnr3.m.nt; s Min d <
lN"uhcft.nqDr*h-s.
Dry trni&n.nr;s Mi. o <
lNuRhBr;oiryokhns€
Dry h
lNu6hBhalvokhils€
Dry hniFmenr; D Min o<
lNuuins
r;.ilrykh4c 0.y enrs.n.nr; il Min c <
lNu6hsrenryoi*hirs€
0.y enrsilenr:, 30M'n
lNuEincr.(ihyorkhilB.
Dry kniFn..t,> r0Min
lfluchs
harryDrkhns€ ory enrsn.nr; ) 30M'n
lfl
uBhs hoiryorkh'se0.y e
lft
uuin8h(irryoi*h4e Dry hnr*mcn!>30Min
lflurhs
holqD*h.'se D.y hn'Fm€nc > l0Mh
lh-kn.ry/.il
b.""kil, *"enLnr,p'oblem ldushktory;Fobhn lo ur.t'ni nc'dlloNard dEiDn nrhng
ltumkibryla'
homevl'l ncwpathnr, pEbrch.ru\hnbry;e,obFd r(u,.'h;d'ri$trofr.'d dRuonmahns
lemrilhrylsthomEvrir
eHm; ilnisf oil.d de*bn m'kin8
le-(hrylE{
bme viil, ** prrLnt, probl€n t*us hbbryj o'obhm ldus.rrn; iltid6fr rd dRmn drkins
lhmknary/€n
homevlil, n€weilknr,add prchr.m b(urhnbryj npdd p'obkm du'e1.m;rdde.xonmilrns
Bl25
lemknrry/€il
bmeEit, re*pilbnt,ddd prcbled b(us hLtoryi c$ddp'obhm tuu'ei.m;ro4dedbnnrkins
ltumknrryl6lh.."*ir**pilkniGrddp'oblem
b.ushlroryie4ddprobkmtuu!.r,djl*d€d.m:rinE
lemkniryhthomevkil,
re*pilbnt,€ldd problen b.6hitrqj stddorobkm tuueeDm;lowd..iionnrkins 103.4
lft
nshryr6t home vBil, mw eilpn. deDild
l&mkiliryl6r
hod. n,ii iew p*kd, drDild
lfr
hkniryl€n hone ytsii new pil!d, d.D'H
ltunkilirryl€n
hone vhil, new pilhnr' deEild
I
e-kn,ryl*t b."
"tsil,
** eilbnt, mmp hLtory, ronp er:nj dr.ibn naru or node,.ts .onpbiry
le-ftry16t
b.e "kil, ** pd.nr, tudp hLtory (ohP csm; dclmn d.hns orm.de,,r. iomple,q
lDd.iliq
dbm 6iL fts pridaryhiory.coryuv4d*$on nfusor nddro{4b$rl
lhiciliqd
bR rtiLd enidaryhkos
l&mkil;,ryl*'
h..".'i ies eil.nr.(onphkrory iompe..m:dedionharinqotfihh.odpreritt
lemknrry/r{hodevkrt,ne*eil.nr..anphiltoryompex.n:d.dbnmrh4orh'{h(onpE{ry
I
emkil :ryn$' hon. yts". new p.r€dt. (omp hnro'Yi ronp ei,dj de6bn m*r.3 or hish conpr.^iq
ltumkiltry/rd
homeurt. nes ert.nt.(omphnrory iodpe^.m:de.eionmatin. othiqh(ompleritv
lhhknrry/r{
honen,ii 6rp.denr.2of: p'abkm tuu'habry;pbb'Pn b.u!.rrnj\M ndtrdRFon mrrn3
lbnkihrylsthon.vnn,6tFbenr,
tol: ptobhm tGU3hLbryip'oblen ro(uism;rftd ndk.l dek'onmrrins
It.tltV*t
n..""rr, *rp.denr, tor: prob&m tcurhBtory;ptoblen b(uisn;1&d md(.1 dR&nn,rins
lbmkil['yl'e*hodevki',
Ar FE.nr. ror: p,obhm teuih.toryjp'obrem b.u'csnirM mdrd dehbnnirns
lkmkn.ry/Btbdevkil,
A' Fd.nr, )ot: ddd hktory:c,pdd rr
l&minrry/r{hone\kiidleabenl,2or:.rddhLroryi.rDddet.mibwdfr
Lionmitinc
ltudkn.ryhrh...riil,
*' e.benr, tor ddd hBtory;citdd erin: b*dftkion mitinr
ltumkinry/rcilhon.vilil.
nrtsdeni rof: ddd hkrory;.rodd er 36,45
lb-rn"rylsthdevkl,6lFdPnl
tor: d.cil.d hktory: deuild errmj mdde&n mrti.3
lm.tuV*,
n..."u, *tp"denl, zot:debilcd hnrotrd.rrild.rrn: hd dPrtun mrrins
ltumkilirryla'
hone ek[. 6r Fdeni, 2 ot: dcbir.d hkrory; d.trird
lemknn/re*hod.vkil,6rFd.n(
rol:deuilcdhLtory;der'ilddrmjmdderkbnm.rinB
l&-rilnryl*'
h.d.6{. 6iFuenr, 2ol:mnphnrory: onpGrin;md tohishdx;ion d.tins
l&mkihrylArhod.vL{.6rFfrenr,2or:.onphn'orv.onpsan;mdtohishddaionnsns
195.33 r95.31
lftdknrnfsthodc,k{,stFd.nL)ol:(omphLlory(omperrm;ddbhlEhd(tsionn,ring
ltumknnlsrho-.,iil,*tFd.nr,
)otj(omphtslo'yi@mpArf,;ndrohishd*tsio.m,t'ns
lHomeutil{e*Pr}xrycompn.nE
P,obFdu\*jP'obrdusE
lHode
u,tdewPt lxryconFnenE: P,ob r*ue hj Prcb rru\ a.m; stdtud kd Neion
lHomeseitNeq
Pt lxryconp.cnB.tttsnd ProbFdGHribprnd Probto(ue &ahj Md Ddn b*compld
lHomeMn
N." Pr lxq..nF.cnts.trFnd Prcbrsushjap.nd Ptobto(ur &amj Md D*n bwcomPlcr
lHodeu,it{ea
Pt }xryconFn?nB:btsnd t,obrcdi ki&pdnd P'obro(us kmj Md DKn bwbmprd
lHome
Msil New Pr rtq(orFi.na:bFnd pdb leut Hx:9prnd PDbro,ur bimi H Ddn bwconpl.r
lH"-.un
N.w Pi I (qc.-F.FnB:bFnd Pbb Iqur hi&prnd Prcb to(us 6rni Md 0<n bwconpl€r
HEAI.THCARE
WASHINGTON MEDICAID AND WASHINtrON EENEFIT PTANS FORTHE UNINSURED BEHAVIORAL HEAI,TH PROFESSIONAL RTIMBURSEMENTSCHEDUIE
lllmev!il\tsh3xcycoqord
&r'ildH\*bilcdf,unrrdudB'onrMrb4rNry r-*
lHohc
v!il NewF t eycryon*: Mild lt$ hiled Ebd\HDdnion lld comldito
lHme
v!il sgw R r Ney coryod tu,Jd H(, &bilcJ I $4 \d Deiion \ld coryldly
l)r
esloe
llrm.
v!il sew R J ky.@on*: cory'tuik E\. r@Ehi€li\fl rld htid rbd(-@le$ly r*-
lllone
vLil Netr R3 Keycoryond: cmFehne Hr corychEicE(m.\H hiion\bdcoql.{ry r"'"
lHomvnil
Nesft t kycqondr: ( mp,ffis! rr\:( @Ehtr.rw \rd h'nonrrod(!4k{ry r-"
lHof,c
vli NewF J eycoryond: GmpMir lL\:.wreki.Fw\rdhinonNbd(bqletry r""
ll
h-. vbil Ndv R r R.y coqond compr&bn. HY. c@dhir Elm\H kidon \bd.oql.{ly
lil.e$/P
lHof,.
Vlil lewF J kycoryond comprtuneltt: (-wrekEn.L(lfu\ld Le\srollod(bqr.urv l'-*
llhne
vLil r_cw R I Keyc@onil:.onp'&En. H\. c@(hi!Erm\H knion\bJcoqk{ry r*-
lHonsvnil\twft
I xeyhond: (-omp'*Enc Ey. cbmEhtrcr\mrH h'im Jor, !4rcsry r**
lllom.\
lir:_e{ ft 3 kvcoryond: comriehlie II\. GryftbBncEt4\ld hnior \bdcbryldly t^-"
llh-c
v!il se"A r kyc.a.n*..ory'&cie H\:.omEhi.E\m\rd h!'d vodcoqk{ly
ln
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ll
hrc vnil r_s\ ft 3 Ruy c@orM ComF€kn. H\corydftnt Etm\d Nrion HsI.omPlc{ry r"^"
151.97
lHon.Met
N.w h r xryconpnenE: cnpreh.neiv. hj6mp'pheniv. urnjMd kR'on ts'8h@mphrry r-"
lHon.van
N.w fr I Xq(omFh.nL:GmFchentyc Hrjbmptehenriv. &rm;Md knion HEhchpFiry
BA5
lHom.Mrt
New Pt I Xq(ompn.nb: (omr.hensiv€ kj6mpr.heniivc e?n;Md k.hlon HahGhpl.iry
lH.n.M.il
N"* Pr I kqCompnents:6m!,ehcn$r tujbmp'ehensive krmjMd kilon HdhGmPld'q
l,'4s/oP
lHoneM,t
New Pr 3 xrycompn.na: Gmp,€hc.eiv€ bjGmp,.h.nrto. &rmjMd &.tsro. Hdh@mprcriry
lHomeM.il
New P' r xrycompients: Gmpreh.Biv. ki6mp'chenn. &rmjMd &d'on HBhchphiry
lH...v"rNew
Pt 3 Xq(o-F.enb: bnp'€hcns'G kj6mprcheneive krmiMd Dd'on H€hGnplciity
lztsetP
lHoneM'tNew
Pt I xrycomFn.nb:Gmpiehcnive hi6mprch.n{c hrn;Md ed!on HBh@hpk{q
lHon.M1il
r{ Pr rr (e/comFnenc: P'ob rtru! lnrfllkj peb f(u. t/.m: ttdtod Md eiiion
Itomevet[.i
n r' r.rr.-F^ents: Prob lcbe lnlrlki Prob rtrusrrrmj srdM Md &(aion u,t
lHo..M,il
h! Pr )' (rycomNients: Prob rftb! lnrNlk; Prob rcutt,.m: trntod Md e.kion
lGil/P
lHomeu,it&r
Pt 2' xeycomFr.nts: P'ob 146 r.rorBj r,ob Fd
lHom.u!'
ti Pt r+ Ke/ComFF.nL: Prob rdur ln!frlH{j Pob kus t/.m: stdM Md edbn t""*
lHomesrttil
Pt F Xry(omFn.nb: P'ob rdus l.rolHrj Pbb rGueu:mi lrdtu Md &dio.
|
tr esloP
lHom.s!il
t{ P' h xeyconFn
lHomeu\il
r{ Pt r+ KerconFienG: Prob ra ur lnrNlH\j Pdb kus t\.m:5ldtod Md eiiion
TG
lHomeMilk'
n r' kycohFnents: Prob ldue lnlNlhi Pmb rtru\ rtrmjstdtod Md &(tsion
lHonesrttil
Pt h Kry(omFn.nb: P'ob rdus lniillH\j t,ob kur tuni srdtud Md &asion
|
tr esloe
ItsomevEittn
Pt 2' xrycomFnents:Frpind Pbb kurrnl h;&p'nd P'obrdushrm;M€d h( bkGmp
lHomeuil
t* Pt2. xeycomNne.tsr,pand P'ob reur hr Hr;&p.nd P,obr(u'&.m;Mrd D.c b*6mp s7.42
llbmev!illrrh,
xqGqondEsdPobFeBIdrlrFpsdEobFocBcero\ldhb{fory
lcx4
lHom.vsilFilR2
Keycoqon*EsdPohFdGIdEdv$dkobFocqEvn\HDdbw{bq r-*
Focu Ese\ld h ks cory
lHomu
vtuilEilA l Key.oryond Esd rdb tsNGrd Erts$$d Fob rbLB Lv4r'd &t but!4 r'**
lHonevn
&t Pt I kvcomFnrnb+rpind Prob r*us hl Hr;&Fnd p'obrduskrm;Md &c b* 6mp
lHoneWtE3ttt
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I6
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k' Pr r. kybdtsn€nE: &biled lnd hi e'aJd rirmj Md &(ion trd Gnpr.riry r'93,51
lHon.vFr
BtPtF f,sc".F"rnB: huil?d lnd H< &t.ld tr.ftj Md k.tsion hdGnp'e^ity
1020/0P
93.51
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Md &rBlon kdOnlleriq 93.51
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UNlTED
WNHINfiON MEDICAID AND WASHINGTON BENEFIT PI.ANS FORTHE UNINSURED BEHAVIORAI. HEAI.TH PROFESSIONAL REIMBUNSEMENTSCHEDUI-E
129.t3
839
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UNtrED HEAI-THCARE
WASHINGTON MEDICAID ANO WASHIN6TON BENEFIT PUNS fORTHE UNINSURED BEHAVIORALHEAI.TH PROFESSIONAI. REIMBURSEMENTSCHEOUI.E
FId
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HEALTHCARE
WASHIN6T0N MEDICAID ANO WASHINffON BENEFIT PLANS FOR THE UNINSURED BEHAVIORAI. HEALTH PROFESSIONAI. REIMBURSEMENTSCHEDUTE
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UNTED HEAI.THCARE
WASHINGION MEDICAID AND WASHINGTON SENEFIT PI.ANS FORTHE UNINSURED BEHAVIORAI. HEAITH PROFESSIONAL REIMBURSEMENT SCHEDU[E
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