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Home My WebLink About20240262.tiffRESOLUTION RE: APPROVE PROVIDER PARTICIPATION AGREEMENT FOR REGIONAL ACCOUNTABLE ENTITY (RAE) NORTHEAST HEALTH PARTNERS BEACON HEALTH OPTIONS AND AUTHORIZE CHAIR TO SIGN - CARELON BEHAVIORAL HEALTH, INC. WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with a Provider Participation Agreement for Regional Accountable Entity (RAE) Northeast Health Partners Beacon Health Options between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Carelon Behavioral Health, Inc., commencing upon full execution of signatures, with further terms and conditions being as stated in said agreement, and WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Provider Participation Agreement for Regional Accountable Entity (RAE) Northeast Health Partners Beacon Health Options between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Department of Human Services, and Carelon Behavioral Health, Inc., be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. c�. f-ISD 03/2912L1 2024-0262 HR0096 PROVIDER PARTICIPATION AGREEMENT FOR REGIONAL ACCOUNTABLE ENTITY (RAE) NORTHEAST HEALTH PARTNERS BEACON HEALTH OPTIONS - CARELON BEHAVIORAL HEALTH, INC. PAGE 2 The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 31st day of January, A.D., 2024. BOARD OF COUNTY COMMISSIONERS ATTEST: ~.,) , iez. 4 Weld County Clerk to the Board ByUatUJ01.yiaht0� Deputy Clerk to the Board Coun Date of signature: 1,f4 WELD COUNTY, C Kevi Perry L. BucI ( Pro-Tem Mike FAeeman Scott 2024-0262 HR0096 Crrh'oc+ t Dk4 11R I BOARD OF COUNTY COMMISSIONERS PASS -AROUND REVIEW PASS -AROUND TITLE: Carelon Behavioral Health, Inc. Provider Participation Agreement DEPARTMENT: Human Services DATE: January 24, 2024 PERSON REQUESTING: Jamie Ulrich, Director, Human Services Brief description of the problem/issue: The Department is requesting to enter into a Provider Participation Agreement with Carelon Behavioral Health, Inc., which would allow WCDHS to be a contracted, credentialed provider with the Regional Accountable Entity (RAE) Northeast Health Partners. This Agreement will enable the Department to bill Carelon Behavioral Health, Inc. for services rendered by WCDHS Wrap Facilitators under a licensed practitioner staff. Anticipated services that will be billed to this vendor for reimbursement will be for Comprehensive Community Support Services and Skills Training Development. This Agreement has been reviewed and approved by Legal (B. Howell). The term of this Agreement will commence on the Effective Date of the Agreement and will renew automatically for additional one (1) year terms unless otherwise terminated. What options exist for the Board? • Approval of the Provider Participation Agreement and associated attachments between WCDHS and Carelon Behavioral Health; Inc. • Deny approval of the Provider Participation Agreement and associated attachments between WCDHS and Carelon Behavioral Health, Inc. Consequences: WCDHS will not have an Agreement with Carelon Behavioral Health, Inc. Impacts: WCDHS will not be able to bill for WCDHS Wrap Facilitator services. Costs (Current Fiscal Year / Ongoing or Subsequent Fiscal Years): • There is no associated cost to this Agreement. The Department will be receiving payment for allowable billed services under this Agreement. Recommendation • Approval of the Provider Participation Agreement and associated attachments and authorize the Chair to sign. Perry L. Buck, Pro -Tern Mike Freeman Scott K. James Kevin D Ross, Chair Lori Saine Support Recommendation Schedule Place on BOCC Agenda Work Session Dig vt a entel fr Vi G( £moLL Other/Comments: Pass -Around Memorandum; January 24, 2024 — CMS ID TBD 2024-0262 t/51 k121)094 Karla Ford From: Sent: To: Subject: I approve Perry Buck Get Outlook for iOS Perry Buck Wednesday, January 24, 2024 2:00 PM Kevin Ross; Karla Ford; Mike Freeman; Lod Saine; Scott James Re: Please Reply - URGENT PA FOR ROUTING: Carelon Provider Participation Agreement (CMS TBD) From: Kevin Ross <kross@weld.gov> Sent: Wednesday, Jaruary 24, 2024 1:56:20 PM To: Karla Ford <kfordPweld.gov>; Mike Freeman <mfreeman@weld.gov>; Perry Buck <pbuck@weld.gov>; Lori Saine <Isaine@weld.gov>; S :ott James <sjames@weld.gov> Subject: Re: Please Reply - URGENT PA FOR ROUTING: Carelon Provider Participation Agreement (CMS TBD) I approve Kevin Ross From: Karla Ford <kfordi@weld.gov> Sent: Wednesday, Jan wary 24, 2024 1:55:33 PM To: Mike Freeman cm reeman@weld.gov>; Perry Buck <pbuck@weld.gov>; Lori Saine <Isaine@weld.gov>; Scott James <sjames@weld.gov>; :evin Ross <kross@weld.gov> Subject: Please Reply - URGENT PA FOR ROUTING: Carelon Provider Participation Agreement (CMS TBD) Please review this urgi nt pass around. I have it out on the counter for review, but thought if some of you are not coming back in today c r tomorrow, you could review electronically. Please advise if you approve recommendation. Thanks! Karla Ford 4 Office Manager, Board of veld County Commissioners 1150 O Street, P.O. Box 75;i, Greeley, Colorado 80632 :: 970.336-7204 :: kford@veldgov.com :: www.weldgov.com **Please note my workingtours are Monday -Thursday 7:00a.m.-5:00p.m.** 1 Confidentiality Notice: This elec ronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by re -urn e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any atta hments by anyone other than the named recipient is strictly prohibited. 1 Karla Ford From: Sent: To: Subject: yes Lori Saine Weld County Commissioner, District 3 1150 O Street PO Box 758 Greeley CO 80632 Phone: 970-400-4205 Fax: 970-336-7233 Email: Isaine@weldgov.com Website: www.co.weld.co.us In God We Trust Lori Saine Wednesday, January 24, 2024 5:10 PM Karla Ford RE: Please Reply - URGENT PA FOR ROUTING: Carelon Provider Participation Agreement (CMS TBD) Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. From: Karla Ford <kford@weld.gov> Sent: Wednesday, January 24, 2024 1:56 PM To: Mike Freeman <mfreeman@weld.gov>; Perry Buck <pbuck@weld.gov>; Lori Saine <Isaine@weld.gov>; Scott James <sjames@weld.gov>; Kevin Ross <kross@weld.gov> Subject: Please Reply - URGENT PA FOR ROUTING: Carelon Provider Participation Agreement (CMS TBD) Importance: High Please review this urgent pass around. I have it out on the counter for review, but thought if some of you are not coming back in today or tomorrow, you could review electronically. Please advise if you approve recommendation. Thanks! 1 88 carelon. 05/31/2023 NPI NUMBER: 1649991225 PROVIDER NUMBER: 1205527 WELD COUNTY DEPT. OF HUMAN SERVICES 315 N 11TH AVE GREELEY CO 80631-2014 RE: Invitation for Network Participation PLEASE READ CAREFULLY - TIME SENSITIVE DOCUMENTS ENCLOSED Dear Group Administrator: As the largest independently held managed behavioral health care company, we would like to invite providers in your group to join the Carelon Behavioral Health, Inc. (here and after "Carelon") network of participating providers. Enclosed are our Practitioner Data Form and Group Practitioner Agreement. Each provider in your group will need to complete and sign the Practitioner Data Form. In addition, the Group Practitioner Agreement and staff roster will need to be completed. Further, we strongly encourage you to include the name of group administrator or office manager as well as their contact information (e.g., phone number, email address) on each practitioner's application. This will allow for one central point of contact in the event that we require additional information or have questions during the credentialing process Return these documents within 30 calendar days from the date of this letter to: Carelon Behavioral Health, Inc. ATTN: Angela Manley P.O. Box 989 Latham, NY 12110 Fax: 866-612-7790 E-mail: Angela.Manley@beaconhealthoptions.com Carelon will review the provider applications to ensure that credentialing criteria have been satisfied. Upon completion of the credentialing process, we will execute the agreement and return one copy to you for your records. In the event that we learn of any adverse information about a provider reported by a third party through the Primary Source Verification process, a provider will have the right to review and coned any erroneous information in writing within ten (10) days of notification. A helpful tip sheet and checklist is also enclosed with this invitation. If you have any further questions, please call our National Provider Line at (800) 397-1630, between 8 a.m. and 8 p.m. ET, Monday through Friday. We sincerely hope you will join us in our mission to deliver innovative and quality driven behavioral health care! Sincerely, National Network Services Enclosures: 1. Group Checklist, 2. Group Practice Tip Sheet 3. Group Roster and Instructions, 4. Practitioner Data Form 5. Group Agreement DS32 New Group Cover Letter - Cost Code 301-0182 OO0 - 0.226,2- GROUP CHECKLIST Organizatio,al Name: Weld County Department of Human Services TIN/EIN Number 84-6000813 Group Contact Name: Rachel Wisdom -Vidal Group Contact Phone Number 970-400-6765 Group Contact Email: wisdomre@weld.gov Mailing Adcress for Executed Contract: hs-contractmanagement@co.weld.co.us (email preferred) PO Box A, Greeley, Colorado 80632 Attn: Welc County Department of Human Services Contract Management Group Proider ID # (found on upper right corner of cover application cover letter) 1205527 Please Check boxes next to documents included with this submission) One (1) original of Beacon Health Options: 0 Group Agreement ❑ Amendnent MOS Participation Statement for each participating group clinician If Other: Amendmerts, addendum (if appropriate) ❑ Commercial ° CHCS O MOS O EAP ❑ VOC Other: OutpatientProfessional Fee Reimbursement Schedule (if applicable) Commercial ❑ HMO ❑ CHCS ❑ MVP ❑ Emblem MOS EAP ❑ VOC ❑ Medicare ® Medicaid Other: X] Practitioner Group Data Form (Credentialing Applications) Number of Applications Included: 1 Q Group Roster Comments_ beacon health option. health option: Provider Name: Telehealth Attestation Weld County Department of Human Services Beacon Provider Number of Individual NPI 1649991225 Provider's Telehealth Platform: Microsoft Teams Changes individually for each secure meeting Provider's Telehealth Phone Number: I understand and agree that. as part of Beacon Health Options (Beacon) provider network(s). it is necessary to meet all requirements pertaining to the provision of Telehealth services and requirements of Beacon Health Options network participation. I acknowledge that it is also necessary to meet all state and federal requirements pertaining to the provision of Telehealth services to eligible Beacon members. I further understand and agree that I am responsible for knowing, understanding and meeting said requirements. I understand and agree that all capitalized terms not otherwise defined in this Attestation shall have the meanings ascribed to them in the Beacon Practitioner Participation Agreement (Agreement). Telehealth Specifications: Telehealth services (also known as "Telehealth") are services provided from a remote location using a combination of interactive video: audio, and externally acquired images through a networking environment between a member and a Beacon contracted and credentialed provider. 2 The services must be of sufficient audio and visual fidelity and clarity as to be functionally equivalent to a face- to-face contact. Telehealth services do not include telephone conversations or internet-based communication between providers or between providers and members. 3 Providers must utilize a HIPAA-compliant tool for the networking environment when providing Telehealth services. 4 Medical record requirements for Telehealth services are the same as those for face-to-face services: however, a notation must also be made in the medical record that indicates that the service was provided via Telehealth. Telehealth may apply to all outpatient codes listed within the Agreement including psychotherapy and evaluation and management (E&M) codes. Coverage is determined by the executed Provider Service Agreement. Reimbursement for these services is subject to the same restrictions as face-to-face contacts as described in the provider manual. Requirements: First visit between member and provider will be face-to-face/in person where required by state and/or federal laws and established patient care standards. 2. Telehealth services are live. interactive audio and visual transmissions of a physician -patient encounter from one site to another, using telecommunications technologies. 3 Providers must get parental consent for treatment of minors, as defined by state regulations,. and consequently a parent must participate in a portion of the initial session. The parent is not required to participate in additional sessions unless clinically appropriate. Cs";) beacon health options health options S 4 Prior to rendering services, Provider must verify that Client's benefit package includes telehealth services. All EAP services may be provided via telehealth if clinically appropriate and agreed to by both parties (provider and member). 5 When permitted by a provider's licensure, provider policies include procedures for the practitioner to provide members with timely and accurate prescriptions by mail, phone and/or fax. 6 When permittec by a provider's licensure, provider policies include procedures for prescriptions needed immediately an I the handling of Federal Schedule II controlled drugs. Member Rights: 1 The member m st provide informed consent to the provider rendering services via telehealth in order to participate in ar y telehealth services. The member has the right to refuse these services and must be made aware of the alt3rnatives such as faced -to -face services, including any delays in service. need to travel, or risks associates with not having services provided by telehealth. 2 The member m ist be informed and fully aware of the role of the physician, clinician, and other staff who are going to be res 'onsible for follow-up or ongoing care. 3 The member m ist be informed and aware of the location of the provider rendering services via telehealth and all questiors regarding the equipment, technology. etc. must be addressed. The member ha the right to be informed of all parties who will be present at each end of the telehealth transmission ar d has the right to exclude anyone from either site unless the member is a child in which case the guardian ha that right. Equipment: *Please refereice current American Telemedicine Association documents for more detailed technology specifics: "Practice Guidelines for Videoconferencing-Based Telemental Health" — October 2009 http://www.anraricantelemed.org/does/default-source/standards/practice-guidelines-for-videoconferencing- based- telen-antal-health.pdf?sfvrsn=6 -Practice Guilines for Video -Based Online Mental Health Services" - May 2013 http://www.arraricantelemed.org/does/default-source/standards/practice-guidelines-for-video-based-online- mental- heati-services.pdf?sfvrsn=6 All Telehealth t ansmissions must be performed on dedicated. secure telephone lines or must utilize an acceptable met -god of encryption adequate to protect the confidentiality and integrity of the information being transmitted via other methods, including the internet. 2 Transmissions must employ acceptable authentication and identification procedures by both sites. 3 All telehealth p -oviders must have a written procedure detailing the contingency plan when there is a transmission falure or other technical difficulties that render the service undeliverable. 4 The technology utilized to provide the service must conform to industry wide compressed audio -video communicatior standards for real-time,. two-way interactive audio -video transmission. 5 Internet -based services including internet-based phone -calls (e.g.. skype) or chat rooms are not considered telehealth. Beacon does not provide coverage of internet-based services because they do not offer adequate privacy and se .urity. The following are not considered telehealth services because they do not meet the definition of interactive telecommunication system: Phone -based services including phone counseling. email, texting, voicemail, or facsimile; G) beacon health options health options Remote medical monitoring devices; Virtual reality devices. 6 If it is determined that the member is to receive home -based telehealth services. Beacon is not responsible for providing the eligible member with the necessary technology and equipment. Emergencies: Acutely ill members should not be managed via telehealth. If the member's clinical status changes, the provider should make themselves (if possible) or another contracted clinician available to conduct a face-to-face assessment. This process should be reviewed with the member prior to the provision of telehealth. 2 All telehealth providers, must have a written process detailing availability of face-to-face assessments by a physician or other clinician in an emergency situation. These policies and processes may be requested for review by Beacon. Provider Responsibilities: All telehealth providers shall have established written quality of care protocols to ensure that the services meet the requirements of state and federal laws and established patient care standards. 2 The provider performing the telehealth services must abide by the laws, regulations and policies of the state in which he/she practices. 3 The provider must hold an independent license in the state in which he/she is performing the service. 4 All providers must be assessed and approved through Beacon's credentialing and re-credentialing process. 5 A review of telehealth services should be integrated into the provider's quality management process. 6 All providers much adhere to Beacon's prescription and medical record requirements as detailed within the telehealth program specifications. Certification I certify that all information provided by me is current, true, correct, accurate and complete to the best of my knowledge and belief, and is furnished in good faith. I acknowledge that I have read and understand the foregoing Attestation, and will abide by all the Telehealth requirements. I understand and agree that a facsimile or photocopy of this Attestation. shall be as effective as the original. Kevin D. Ross, Chair Board of Weld County Commissioners Name Signature JAN 3 1 2024 r, Date 88 careIon. CREDENTIALING — DISCLOSURE & OWNERSHIP FORM Complete one form per Tax ID (photocopy as needed) Directions In order to comply with Federal law (42 C: R 420.200 - 420.206 and 455.100- 455.106) health plans with Medicaid or Medicare business are required to obtain certain information regarding the ownership and control of entities with which the health pi n contracts for services for which payment is made under the Medicaid or Medicare program or any line of business that provides healthcare for federal employees. The Centers for Medicaid and Medica-e E rvices (CMS) requires Carelon Health Options, Inc. to obtain this information to demonstrate that we are not contracting with an entity that has been excluded from federal and state health programs, or win- entity that is owned or controlled by an individual who has been convicted of a cnminal offense, has had civil monetary penalties imposed against them or has been excluded from participation in Medicare or Medicaid. Please complete the following 2 pages b -ow and fax the completed forms to 866-612-7795. This form is required if you wish to participate or continue to participate in the plan. You are also reminded that any changes to this information in the future must be reported to Carelon Health Options, Inc. within 35 business days of the change and updated information will be requested upon recredentialing. Please provide information for Owners, persons with Corral interests, Agents and Managing employees of the Provider Entity. Attach a separate sheet/report if needed, Definitions Provider Entity Any individual or ent ty ►-igaged in the delivery of health care services in a State and is licensed or certified by the State to engage in that activity in that State if such licensure or certification is required by State law or regulation. Master List The list of owners the provirar will be disclosing on form. All owners on the master list, rust include their Home Address SSN. DOB, If any owners are a Non -Profit gency please indicate the following c Name of Entity o Owner DOB 8 Owner SSN leave Blank. o N/A in the % of C ynership column. o Check YES in the Non -Profit column. o Business address of Entity % of Ownership Owner: is a person or business entity w—ich owns 5% or more of the assets, stock or profits of the Provider Entity. This 5% may be Direct owners; ip or Indirect ownership i.e.. an individual might own 50% of a company that owns the actual Provider Entity meaning their indirect ownership is 50%. In addition to ownership of stom, (2) Owner is also a person who owns a legal obligation like a mortgage or loan that is secured by the assets of the Provider Entity. Control Interest is someone who directs4he Provider Entity and includes Directors, Trustees and Officers of Corporations and Partners in a Partnership. Managing Employee is someone who nrkes the day to day decisions for the Provider Entity. These individuals include office or billing managers for smaller providers, and for larger Provider Entities the heads of the major operating groups of the prov.ier like, Head of Accounting, or Director of same day services. In other words, the line of individuals typically listed below the corporate officers on an organizational chart. Debarred or Excluded means an indivival or entity that is not allowed to do business with the Federal government. including healthcare programs receiving Federal funding or reimbursement. Terminated means the Provider lost the ight to bill a State's Medicaid or CHIP programs for a cause related to fraud or abuse. Immediate Family is defined as a pe-so 's husband or wife, natural or adoptive parent. child or sibling, stepparent_ stepchild, stepbrother or stepsister; father-, mother-, daughter-. son-, brother- or sister-in-law. grandparent or grandchild, or spouse of .. grandparent or grandchild. Member of Household is. with respect to a person any individual with whom they are sharing a common abode as part of a single family unit, including domestic employees and other who live together as a family unit. A roomer or boarder is not considered a member of household. Agent is an individual who has the legal _bility to bind the Provider Entity, i.e., the Provider Entity may use an Agent to obtain contracts for it. Subcontractor is a person or company -gat this Provider Entity has contracted with to do some of the Provider Entities management functions. i.e., billing agent. or provide medical services i.e. a medical lab. Supplier means an individual, agency c organization from which the Provider Entity purchases goods and services used in carrying out its responsibilities under Medicaid (e.g.. a commercial laundry. a manufacturer of hospital beds or a pharr Acy. ) 1 iPage 88 carelon CREDENTIALING - DISCLOSURE & OWNERSHIP FORM Complete one form per Tax ID (photocopy as needed) I. Identifying Information Rachel Wisdom -Vidal 970-400-6765 Name of Person Completing Form Phone Number of Person Completing Form Weld County Department of Hun Provider's Name Provider Entity Information: County of Weld Weld County Department of Human a Name of Entity Entity DBA (If Different from Entity Name) 846000813 1649991225 Entity Tax ID Entity NPI Number 315 N 11th Ave. Bldg A Practice Address Line 1 Greeley Practice Address Line 2 City CO 80631 State ZIP II. OWNER OR CONTROL INFORMATION (If more than 4 owners. please submit make copies of this page) A Master List: Owners must have minimum of 5% ownership to be considered part of the Master List Totals of Master list must equal 100%, unless the agency is Non -Profit, • WNER NAME OWNER DOB OWNER SSN . % OF OWNERSHIP Non -Profit Yes 7 No T County of Weld dba Weld County Department of Human Serve NA OWNER'S ADDRESS LINE 1 315 N 11th Avenue. Bldg A OWNER'S ADDRESS UNE 2 CITY Greeley STATE ZIP CO 80631 • WNER NAME OWNER DOB OWNER SSN % OF OWNERSHIP Non -Profit ;Yes 7 No 7 • WNER'S ADDRESS LINE 1 OWNER'S ADDRESS LINE 2 CITY STATE ZIP •WNER NAME OWNER DOB OWNER SSN % OF OWNERSHIP Non -Profit Yes E No PA • WNER'S ADDRESS LINE 1 OWNER'S ADDRESS LINE 2 CITY STATE ZIP • WNER NAME OWNER DOB OWNER SSN % OF OWNERSHIP Non -Profit Yes ❑ No Z • WNER'S ADDRESS UNE 1 OWNER'S ADDRESS LINE 2 CITY STATE ZIP B. Specific Questions 1 Is any person on the Master List related to another person on the Master List as a spouse, parent, child or sibling? If attaching a report. please indicate corresponding columns below Yes No NAME OF FIRST RELATED PERSON NAME OF SECOND RELATED PERSON TYPE OF RELATIONSHIP 2 Does any person or entity in the Master List have an Ownership or Control interest in any other Provider Entity, 2 If attaching a report, please indicate corresponding columns below Yes No NAME OF OTHER PROVIDER ENTITY ADDRESS CITY STATE ZIP TAX 10 3 Have any of the individuals or entities on the Master list been convicted of a criminal offense related to that person's involvement in any program under Medicare. Medicaid, Tricare or the CHIP services program since the inception of those programs? Yes No ✓ NAME ON COURT RECORDS SSN/TIN MATTER OF OFFENSE CONVICTION DATE EXCLUSION PERIOD (IF APPLICABLE) 4 Have any of the individuals or entities on the Master List ever been Debarred or Excluded from participation in Federal Government contracts (Medicaid, Medicare, CHIP or Tncare)7 Yes No V. WHEN WERE YOU DEBARRED LENGTH OF DEBARMENT REASON FOR DEBARMENT 2IPage 88 carelon. CREDENTIALING - DISCLOSURE & OWNERSHIP FORM Complete one form per Tax ID (photocopy as needed) 5 Has any person or entity on the Master List ever been Terminated or had Civil Monetary Penalties from a State's Medicaid or CHIP programs for reasons having to do with Program Integrity (fraud or abuse)? Yes 'Nov PRACTICING STATE WHEN TERMINATED REASON FOR TERMINATION DATE OF TERMINATION 6 Did anyone on the Master List obtain their Direct or Indirect Ownership interest 1) as a result of a transfer of Direct or Indirect ownership from someone who was about to be Excluded or Terminated from participation in a Federal healthcare program, or was in fact Excluded or terminated from participation in a federal healthcare program and 2) where the original Owner is or was a member of the current Owner's Immediate Family or Member of the current owner's household, at the time of the transfer of ownership? If attaching a report, please indicate corresponding columns below Yes No ✓ NAME OF ORIGINAL OWNER SSN OR TAX ID OF ORIGINAL OWNER PLACE OF TRANSFER DATE OF TRANSFER 7 Do you have any Subcontractor in which this Provider Entity has a Direct or Indirect Ownership interest of at least a 5%2 (A Subcontractor is a person or company that this Provider Entity has contracted with to do some of the Provider Entities' management functions, i e billing agent, or provide medical services i e a medical lab) If attaching a report, please indicate corresponding columns below Yes No ✓ AME OF SUBCONTRACTOR ADDRESS CITY STATE ZIP TAX ID 8 For each Subcontractor(s) listed in question 7 above please provide the following information for the individuals with Direct or Indirect Ownership or Control Interest in the Subcontractor(s). See the Introduction section above for a definition of those terms Attach a separate sheet if necessary If attaching a report, please indicate corresponding columns below NAME ADDRESS an STATE ZIP TAX ID % OF OWNERSHIP TITLE 9. Is any persons from question 7, in the list above related to any person in the Master List'? If attaching a report. please indicate corresponding columns below NAME OF FIRST RELATED PERSON NAME OF SECOND RELATED PERSON TYPE OF RELATIONSHIP III. BUSINESS TRANSACTIONS IV. 1 Please list the Subcontractors with whom you have done business over the last 5 years where the contract is worth at least 5% of your Provider Entities' total operating expenses or S25,000 whichever is less Use a separate sheet if necessary Do not include the Subcontractors listed in II 7a in which you have an Direct or Indirect Ownership interest If attaching a report, please indicate corresponding columns below 2 Does the Provider Entity wholly own a Supplier? If attaching a report please indicate corresponding columns below Yes J No LI If yes, supply the following information about the Supplier: Answer the following questions by checking "Yes" or "No' If any of the questions are answered "Yes," list names and addresses of individuals or corporations and/or provide date and an explanation on a separate sheet of paper 1 Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting. auditing, or similar capacity who were employed by the institution's organization's or agency's fiscal intermediary or carrier within the previous 12 months'? (Title XVRN providers only) 2 Has there been a change in ownership or control within the last year'? 3 Do you anticipate any change of ownership or control within the year) 4. Do you anticipate filing for bankruptcy within the year? 5 Is this facility, agency institution or organization operated by a management company, or leased in whole or part by another organization? 6 Has there been a change in Administrator, Director of Nursing. or Medical Director within the last year? 7. Is this facility agency, institution or organization chain affiliated? (If yes, list name, address of Corporation. and EIN) 8 If the answer to Question 7 is No, was the facility. agency. institution or organization ever affiliated with a chain'? 9 (For Facilities Only) Have you increased your bed capacity by 10 percent or more or by 10 beds, whichever is greater, within the last 2 years? Signature Yes ❑ No VI Yes El No V. Yes ❑ No I. Yes ❑ No [ Yes El No 1 Yes ❑ No ZI Yes ❑ No 71 Yes ❑ No Yes El No 71 Carelon Health Options, Inc may refuse to enter into, renew, or terminate an agreement with a Provider if it is determined that a Provider did not fully, accurately, and truthfully make the disclosures required by this statement Additionally, false statements or representations of the required disclosures may be prosecuted under applicable federal or state laws 42 C F R § 455 106 The signature below MUST be the written signature of an individual who can legally bind this Provider Enti ---�� Kevin D. Ross, Chair Name of Entity Owner Signature IA . Board of Weld County Commissioners _ Title Date �O./n��3IPage `t- v weer ,� , i beacon MEDICAID/MEDICARE ID REQUEST FORM Dear Provider: In the attached packet you should have received correspondence from ValueOptions® regarding participation in the ValueOptions Colorado Medicaid Network. The purpose of this correspondence is to notify you that in order to participate in the ValueOptions Colorado Medicaid Network, you must let ValueOptions® know if you participate with Colorado Medicaid or Medicare, and provide your Medicaid and Medicare numbers to ValueOptions®. To ensure that ValueOptions® has a valid Medicaid or Medicare number for you (or your organization) on file, please complete and return this validation form. Upon receipt, ValueOptions® will update our records to reflect your Medicare/Medicaid numbers. Please fax the completed validation form to (866) 612-7795. Do you have a valid Medicaid number? YES NO Last Name*: Weld County Department of Human Services First Name*: County of Weld dba. Address*: 315 N 11th Ave. Bldg A, Greeley, CO 80631 Phone Number*: 970-400-6777. Are you a certified Medicaid Provider? YES Colorado Medicaid Number*: 9000214746 Are you a certified Medicare Provider'? NO UPIN Number: If you have any questions about the contents of this package please feel free to call us at (800) 397-1630 between 8 a.m. and 8 p.m. Eastern Time, Monday through Friday. A provider representative will be available to assist you with any questions. Once again, thank you for your time and we look forward to a continued working partnership with you! Sincerely, Director, Practitioner Credentialing beacon MEDICAID/MEDICARE ID REQUEST FORM Dear Provide: In the attached packet you should have received correspondence from ValueOptions® regarding participation n the ValueOptions Colorado Medicaid Network. The purpose of this correspondence is to notify you that in order to participate in the ValueOptions Colorado Medicaid Network, you must let ValueOptions® know if you participate with Colorado Medicaid or Medicare, and provide your Medicaid and Medicare numbers to ValueOptions®. To ensure that ValueOptions® has a valid Medicaid or Medicare number for you (or your organization) Dn file, please complete and return this validation form. Upon receipt, ValueOptionsS will update our records to reflect your Medicare/Medicaid numbers. Please fax the completed validation form to (866) 612-7795. Do you have a valid Medicaid number? YES NO Last Name*: Wisdom -Vidal First Name*: Rachel. Address*: 315 N 11. Ave. Bldg A, Greeley, CO 80631 Phone Number": 970-400-6765. Are you a certi=fied Medicaid Provider? YES Colorado Medcaid Number*: 9000215039 Are you a cert ied Medicare Provider? NO UPIN Number_ If you have and questions about the contents of this package please feel free to call us at (800) 397-1630 between 8 a.m. and 8 p.m. Eastem Time, Monday through Friday. A provider representative will be available to assist you with any questions. Once again, thank you for your time and we look forward to a continued working partnership with you! Sincerely, Director, Practiioner Credentialing beacon health c,p• one GROUP ROSTER TIP SHEET FOR GROUP ADMINISTRATORS New Groups and/or New Clinicians being added: Practitioner Data Form: Please complete one for each clinician in the group. Any provider that is being enrolled through your group, must complete their CAQH profile and provide Beacon Health Options access to view the data in addition to completing the Practitioner Data Fonn. Note: Any missing or inaccurate data, will not be considered for Network Participation. Demographic information (e.g., Address, Phone Number, Email Address) on each practitioner's application, should be the Group Administrator's information, NOT the provider's personal information. This will allow for one central point of contact for any additional information we may need during the credentialing process. Individual providers are not considered in network under the group agreement until all credentialing is completed. Do not begin to see patients until you receive notification from Beacon Health Options that you are in the network and the effective date of that status. Formal, written notification will be sent confirming provider participation. Include a full staff roster with your group agreement as well as the individual provider's applications. Return all documents to Beacon Health Options at the same time. This will ensure that all providers are appropriately linked to the group in our system. o Note: The authorized group signatory is the only signature required on the group agreement. This signatory agrees to the contractual terms for all members of the practice. The group will not be considered in the network until one (1) individual has completed credentialing. If applying for Participation with Military OneSource: o For all practitioners in the group wishing to participate with the Military OneSource network, each practitioner must sign the "Military OneSource Program Provider Statement of Understanding". The group practice signatory should sign the "Military OneSource Short Term Non -Medical Counseling Program Amendment." Once Approved, the Group Administrator will be responsible for: Please be sure to have any demographic changes as well as any questions or issues about contracts or claims funnel through you as the group administrator, or through one main contact at the group. A full updated staff roster will need to be submitted to Beacon Health Options annually. Notify Beacon Health Options of any changes to your group's staff roster, prior to 30 days of the change Visit our website at www.beaconhealthoptions.com to access important provider specific information (e.g, Provider Handbook, webinar presentations, forms, provider newsletters, etc.) as well as try the demonstration of ProviderConnect, our on-line provider web portal. ProviderConnect offers 24/7 access to member eligibility, benefits, claims and authorizations. If you have any questions, please contact the Beacon Health Options National Provider Line at (800) 397-1630, between 8a.m. and 8p.m. ET, Monday through Friday. beacon GROUP ROSTER Group Information: County of Weld, DBA Weld County Department of Human Services 846000813 1649991225 Group Practice Name 315 N 11th Ave Address Line 1 Point of Contact Information: Rachel Wisdom -Vidal Name Bldg A Tax ID NPI Number Address Line 2 970-400-6765 Phone # Greeley City Fax wisdomre@weld.gov CO 80631 State Zip Code Email Address BHO Provider ID Last Name - First Name NP1 Licensure Network/Products Medicare ID Medicaid ID CAQH # Add/Delete 9000215039 Wisdom -Vidal Rachel 1285822536 LCSW 9000215039 15891387 ADD beacon iealth ootlont tfvnuEo P11 ON S® FEDERAL SERVICES INC. a Seaton yesltn Options company Provider Business Size Self -Certification ValueOptions Federal Services. (a Beacon Health Options company), is a contractor to the U S. Government and is required to verify the business size of our Network providers as well as their socioeconomic status. This information will be used in aggregate to supply data to the Federal government as part of a government contracting process. These questions should be answered considering the Group TIN in which claims are filed if you are part of a Group. If you are an individual practitioner/sole proprietor. the questions should be answered based on the TIN in which you file your claims. In order to assist us in facilitating this process, we ask you complete the questions below for the TIN in which your claims are filed. If you file claims under multiple TINs, please fill out a form for each TIN. PRIMARY PRACTICE INFORMATION County of Weld. DBA Weld County Department of Human Services 846000813 Company Name 315 N 11th Ave Tax ID: Bldg A Practice Address Line 1 Practice Address Line 2 Greeley CO City State Rachel Wisdom -Vidal Contact Name 80631 Weld Zip wisdomre@weld.gov Email Address County 970-400-6765 Phone Number What is the North American Industrial Classification System Code (NAICS) for this business? This field has been populated with the options to select one of the two NAICS codes Offices of Mental Health Practitioners (except Physicians) or Offices of Physicians. Mental Health Specialists. If you do not feel this code is appropriate, see Appendix A or contact the Small Business Administration at http://www.sba.gov/size 621330 i For the following questions, please respond to ALL that apply. Definitions are provided in Appendix B Is this business considered a small business as defined by the Small Business Administration? Yes 11 No O Is this business considered a Women -Owned Small Business? Yes No SI Is this business considered a Small Disadvantaged Business? Yes No ✓ Is this business considered 8(a) certified? If yes, please include a copy of certification. Yes ❑ No SI Is this business considered a Veteran -Owned Small Business? Yes El No Fl Is this business considered a Service Disabled Veteran -Owned Small Business? Yes ❑ No12.] Is this business considered a HUBZone Small Business? Yes 'El No 0 Is this business considered a large business as defined by the Small Business Administration? Yes No NI Is this business considered a Historically Black College/Minority Institution? Yes El No ✓ If your business could be classified as a minority owned business, which of the following categories would it fall under? (optional) Black (African, Jamaican or West Indian descent, Native American or Alaskan Native (persons having origins in any of the onginal peoples of America) Hispanic (Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin) Asian or Pacific Islander (persons having origins in any of the original peoples of the Far East. Southeast Asia, the Indian subcontinent or the Pacific Islands) Caucasian I certify the socioecomic information provided- ove is true. CA- Komppny pres tative Sig ure evin D D. Koss, Lnal r , Board of Weld County Commissioners Name (Please Print) Beacon CAS ID (if known) JAN 3 1 202k Date Signed Please Return Completed Form To: Beacon Health Options PO Box 989 Latham, NY 12110 Fax: 866-612-7795 or E-mail: provider.information©beaconhealthoptions.com 02-400141--0026.2 11PagP Provider Business Size Self -Certification Revised 04/14/2022 Carelon Behavioral Health, Inc. Provider Participation Agreement ca relon.. Behavioral Health BHONationalAG 03.01.2023_V.05 CO Table of Contents Article I: Definitbns 5 Article II: Relationship 8 2.1 Engagement8 2.2 Independent Contractors 8 2.3 Provider/Patient Relationship 9 2.4 Referrals. 9 2.5 Qooperation. 9 Article III: Provicer Information 9 3.1 Authority. 9 3.2 LLcensure. 9 3.3 Liability Coverage. 10 3.4 Locations. 10 3.5 Practitioners 10 Article IV: Carelan Information 12 4.1 Authority. 12 4.2 Lbensure. 12 4.3 Insurance. 12 4.4 Relationship with Payors 12 Article V: Participation, Policies & Procedures 12 5.1 Network Participation. 12 5.2 Restrictions 13 5.3 Telephone Audits. 13 5.4 Credentialing & Re-credentialing 13 5.5 Caelon's Policies and Programs/ Provider Manual. 14 5.6 Case Management/Quality Initiatives/Data Sharing 15 5.7 Actions 15 5.8 Acxess to Record/Audits16 Article VI: Services 16 6.1 Eligibility Verification & Certification16 6.2 Services. 16 6.3 Nor Incentive. 17 6.4 Books and Records 17 6.5 Access to Health Information Records. 18 6.6 Non -Certified Services. 18 6.7 Veification of Eligibility. 18 6.8 Occpatient Treatment Reports & Payment for Outpatient Covered Services. 18 6.9 Appeal Process. 19 2 BHONationalAG 03.J1.2023_V 05_CO 6.10 Excluded Providers. 19 Article VII: Claims & Payment 19 7.1 Claims Submission. 19 7.2 Payment20 7.3 Recoupment/Offset/Adjustment for Overpayments. 20 7.4 Coordination of Benefits. 21 7.5 No Balance Billing 21 7.6 Multiple Agreements. 22 7.7 Claims Disputes. 22 Article VIII: Term & Termination 22 8.1 Term 22 8.2 Termination Without Cause. 22 8.3 Termination With Cause. 22 8.4 Suspension or Termination. 23 8.5 Practitioner/Provider/Facility/Location Exclusion from Participation23 8.6 Payor Termination 23 8.7 Termination Related to Amendments. 23 8.8 Application 23 8.9 Continuation of Service24 8.10 Transition 24 8.11 Audits & Investigations. 24 Article IX: Governing Law and Compliance 24 9.1 Governing Law24 9.2 Legal Compliance 24 9.3 Individual State Laws. 25 9.4 Other Plan Specific Provisions25 9.5 Excluded or Precluded Individuals/Entities. 25 9.6 Confidentiality of Member Records. 25 9.7 Regulatory Access. 26 9.8 Physician Incentive Plans. 26 9.9 Ownership Disclosure 26 9.10 Solicitation26 9.11 Reporting. 26 9.12 Discrimination Employment Practices 26 9.13 Compliance Program and Anti -Fraud Initiatives. 26 Article X: Dispute Resolution 27 10.1 Unresolved Disputes. 27 Article XI: Miscellaneous 29 11.1 Notice 29 11.2 Amendments29 3 BHONationalAC 03.01.2023_V.05 CO 11.3 Scope/Change in Status/Newly Acquired Persons/Entities. 29 11.4 Assignment 30 11.5 leurement/Affiliates/Subcontracting. 30 11.6 Third Party Beneficiary 30 11.7 Use of Name 30 11.8 Indemnification. 31 11.9 Confidentiality 31 11.10 Non -exclusivity. 32 11.11 Force Majeure. 32 11.12 Vtaiver32 11.13 Severability. 32 11.14 Entire Agreement/Construction32 11.15 Survival of Provisions. 33 11.16 H`sadings and Captions. 33 11.17 Counterparts. 33 EXHIBIT A: REIMBURSEMENT 35 Colorado IMO Professional Fee Schedule 36 Colorado Icon-HMO/Commercial Professional Fee Schedule 37 Colorado Medicaid Network Professional Fee Schedule (Health Colorado) 38 Colorado !Medicaid Network Professional Fee Schedule (Northeast Health Partners) 41 Exhibit A-2 44 EXHIBIT A-3: GHI 3MP Reimbursement 45 Exhibit B: State Specific Provisions 47 Exhibit C: Payor/Government Program/Plan Specific Provisions 50 EXHIBIT C-3: EmbemHealth Specific Provisions 53 EXHIBIT C-4: COLORADO MEDICAID & OTHER GOVERNMENT SPONSORED HEALTH BENEFIT PROGRAM PROVISIONS 55 EXHIBIT C-4.1.1: Patient Consent and Authorization Form for Disclosure of Substance Use Disorder Health Information to Medicaid 59 EXHIBIT C-4.1.2: Formulario de Consentimiento y Autorizacion del Paciente para Is Divulgacion de Informacion de Salud sobre el Trastorno de Uso de Sustancias a Medicaid 60 Exhibit C-5: Anthem Specific Provisions 61 4 BHONationalAG 03.01.2023_V.05 CO This Carelon Provider Participation Agreement ("Agreement") is made and entered into, by and between Weld County Department of Human Services, a Group Practice, for itself and on behalf of those Practitioners and/or facilities identified per the provisions hereof (severally and collectively, as the context may require, "Provider") and Carelon Behavioral Health, Inc. and Carelon Behavioral Health Strategies, LLC, on behalf of themselves and each of their respective Affiliates (individually and collectively, as applicable, referred to herein as "Carelon"), to be effective on the date set forth as the Effective Date on the Signature Page of this Agreement. WHEREAS, Carelon contracts with government entities, health insurers, employee benefit plans, insurance exchanges, and other organizations to provide behavioral health management services to certain individuals and Carelon desires to engage Provider to provide certain mental health or substance use disorder services to these individuals and Provider is ready, able and willing to provide such services. WHEREAS, Provider wishes to become a participating provider of mental health and/or substance use disorder services under the terms and conditions set forth in this Agreement. NOW, THEREFORE, in consideration of the mutual promises herein contained, and for other good and valuable consideration, receipt and sufficiency of which are hereby acknowledged, the parties hereby agree as follows: Article I: Definitions Capitalized terms used in this Agreement and/or in the introductory paragraphs above, all of which are hereby incorporated by reference, shall, unless otherwise defined in a Payor or Plan specific exhibit to this Agreement, have the following meanings: 1.1 "Affiliate" means any entity that is owned or controlled, either directly or through a parent or subsidiary entity, by FHC Health Systems, Inc., including but not limited to: Carelon Behavioral Health, Inc. Carelon Health Strategies LLC Carelon Behavioral Health of California, Inc. Carelon Behavioral Health IPA Strategies, LLC ValueOptions of New Jersey, Inc. Massachusetts Behavioral Health Partnership Carelon Health of Pennsylvania, Inc. ValueOptions Federal Services, Inc. ValueOptions of Texas, Inc. Carelon Behavioral Health IPA, Inc. 1.2 "Agency(ies)" means a federal, state or local agency, administration, board or other governing body with jurisdiction over the governance or administration of a Plan. 1.3 "Agreement" means this Provider Services Agreement, all exhibits, schedules and addenda attached hereto. 1.4 "Applicable Rules" shall mean, individually and collectively, any and all applicable federal, state and local laws, statutes, ordinances, codes, rules, regulations, standards, instructions, directives, Plan or Payor instructions, orders, guidance and other governmental requirements of any kind, as amended, including but not limited to, those relating to (as applicable) (i) affirmative action and equal employment opportunity, (ii) nondiscrimination based on race, color, creed, religion, sex, age, ethnic origin, sexual orientation, gender identity or expression, (iii) wages and hours, (iv) workers' compensation and unemployment insurance, (v) labor and employment conditions, occupational safety and health, (vi) the prevention or amelioration of fraud, waste and abuse, including the Federal anti -kickback statute and other laws governing the recipients of funds from Federal health care programs, (vii) the federal Currency and Foreign Transactions Act, (viii) the Foreign Corrupt Practices Act, (ix) the Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA"), and (x) the Americans with Disabilities Act ("ADA"). See 42 C.F.R. 422.504(h), 422.504(i)(3)(iii) and 504(i)(4)(v). "Applicable Rules" 5 BHONationalAG_03.01.2023_V 05 CO shall also include the Plans' and Carelon's policies and procedures and manuals (including but not limited to Provider Manuals) in existence as of the execution of this Agreement or as subsequently amended or established. 1.5 "Books and Records" means any pertinent contracts, books, documents, papers and records, including without limitation health information records pertaining to Provider's provision of Services to Members and fulfillment of its obligations under this Agreement, including without limitation those necessary to substantiate properly submitted daims for payment hereunder. 1.6 "Case Management" means the case management programs and processes implemented and directed by Carelon with respect to care of Members and/or the provision of Covered Services. 1.7 "Certificatiorit' or "Certifies" or "Certified" means the decision of Carelon or its designee, or of a Plan's designee, resulting from the Case Management or Utilization Review processes to determine whether proposed, ongoing or rendered treatment is Medically Necessary. "Certification" or "Certifies or "Certified" includes references to prior authorization and similar processes used by Plans and Carelon to determine if a proposed procedure, service or medication is Medically Necessary. 1.8 "Clean Claim' means a claim for Covered Services that Provider rendered that accurately contains all data elements Carelon, a Plan or a Payor requires as specified in the Provider Manual, Carelon's 837 Companion Guide, and/or such Plan's or Papr's provider manual and all data elements required by federal Medicare provider manuals, Plan transmittals and/or Applicable Rules, that Provider submits within the time frame(s) specified in this Agreement or as required by Applicable Rules. 1.9 "Confidential Information" means a party's non-public information, data, content, utilization management procedures, credentialing criteria, patient treatment records, finances, eamings, volume of business, methods, systems, practices, plans, technical and ion -technical data, and any other confidential, proprietary or non-public information. Confidential Information also includes:information that has been disclosed to Carelon by a Payor, Plan or other third -party and which Carelon is obligated to treat as confidential. Confidential Information includes the terms of this Agreement subject to the provisions set forth in Section 11.9 of this Agreement. 1.10 "Covered Services" means those Medically Necessary mental health, alcohol and/or substance use disorder services for which Members are covered pursuant to a Plan and for which a Member covered thereunder is entitled. 1.11 "Days" means calendar days unless otherwise specified. 1.12 "Downstream Entity" means any entity that enters into a written arrangement descending from and subordinate to the Agreement wit Provider, which is entered into for the purpose of providing delegated health care or administrative services to Plans. "Dmvnstream Entity" includes any physician, medical provider, hospital, facility or other provider of health care services or supplies that has entered into a separate written contract, directly or indirectly, with Provider to provide Covered Services to Members under this Agreement. 1.13 "Effective Dab" is the date specified by Carelon on the signature page of this Agreement. 1.14 "Emergency" Dr "Emergency Medical Condition" means, unless otherwise defined in a Member's Plan or by Applicable Rules, an occurrence or medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity (including severe pain) such that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in (i) placing the health of a Member or another person in serious jeopardy, (ii) serious impairment to bodily function, and/or (iii) serious dysfunction of any body organ or part, as further defined in § 1867(e)(I)(B) of the Social Security Act, 42 U.S.C. § 1395dd(e)(1)(B). 1.15 "HIPAA" mears the federal Health Insurance Portability and Accountability Act of 1996, including without limitation its privacy, securiy and administrative simplification provisions, and the rules and regulations promulgated thereunder, each as may be amended from time to time. 6 BHONationalAG 03. 1.2023_V. 05 CO 1.16 "Levels of Care" means the duration, frequency, location, intensity and/or magnitude of a treatment setting, treatment plan, or treatment modality, including, but not limited to: (a) acute care facilities; (b) less intensive inpatient or outpatient alternatives to acute care facilities such as residential treatment centers, Provider homes or structured outpatient programs; (c) outpatient visits; or (d) medication management. 1.17 "Line of Business" means a set of related Plans as determined by Carelon based on regulatory, accounting and/or statutory principles. Examples include but are not limited to Medicaid Plans, or Commercial Plans. 1.18 "Medical Necessity" or "Medically Necessary", shall be as defined by Applicable Rules, when required, or in the absence of such requirement, as defined by the Member's Plan, or in the absence of a definition supplied by either Applicable Rules or the Member' Plan, shall mean health care services that are intended to prevent, diagnose, correct, cure, alleviate or preclude deterioration of a diagnosable condition and that are consistent with nationally accepted standard dinical evidence generally recognized by mental health or substance use care professionals and publications, as determined by whether the service: (a) is the most appropriate level of service for the Member in question considering potential benefits and harms to the individual and where no equally effective and less costly treatment is available; (b) is known to be effective, based on scientific evidence, professional standards and coped opinion, in improving health outcomes; (c) is consistent with the diagnosis and treatment of the Member's behavioral health condition and is essential to improve the Member's health outcome through a positive effect on overall health; (d) is safe and consistent with the level of skilled services that are provided and is furnished in the least intensive type of clinical setting required by the Member's condition; (e) is not experimental or furnished primarily for the convenience or religious preference of the Member or his/her family, caregiver or Provider; and (f) is not a substitute for non -treatment services addressing environmental factors. No payment shall be made for any health care services that are not Medically Necessary. 1.19 "Member" means an individual who is enrolled in a Plan and eligible to receive Covered Services under such Plan as of the time health care services are rendered. 1.20 "Member Expense" or "Member Expenses" means those copayments, coinsurance, deductible and/or other cost -share amounts due from Members for Covered Services in effect at the time of delivery of services pursuant to their respective Plan. The Member Expense amount is specified on the Member's health coverage identification card or may be obtained by contacting the applicable Plan's member services department. 1.21 "NCQA" shall mean National Committee for Quality Assurance. 1.22 "Non -Covered Services" means, for purposes of this Agreement, those services, items, supplies or levels of care that (i) are not Medically Necessary; (ii) are not a kind of service covered by a Plan; (iii) are not a service a Member is entitled to receive under the Plan; (iv) are excluded from coverage under a Member's Plan; (v) the Member has exhausted as available benefits under their Plan; and/or, (vi) are or were not performed in accordance with the Member's Plan and the Provider Manual. This Agreement does not provide for compensation to Provider for Non -Covered Services. 1.23 "Payor" shall mean a Plan or some third party entity that has assumed financial risk for Covered Services on behalf of a Plan. Carelon is a Payor only if, and to the extent, it has entered into a risk -agreement with a Plan and, under such agreement, Carelon has agreed in writing to accept the financial responsibility for paying Provider for Covered Services as permitted under Applicable Rules. Otherwise, Plan or some third party alone are financially responsible for funding payment to Provider for Services in accordance with this Agreement. A Payor may directly perform its obligations under this Agreement or do so through a designee. 1.24 "Plan" shall mean a health benefit plan or program sponsored or maintained by an employer, a multiple employer trust, a union trust, an Agency, a governmental entity (including without limitation CMS and state Medicaid agencies), a health maintenance organization (HMO), a preferred provider organization (PPO), an indemnity carrier, an insurance exchange, or any other entity that arranges and provides a program of behavioral health services to individuals (i.e., Members) and which is identified by Carelon as being subject to this Agreement. The parties acknowledge that Plans may have delegated the performance of certain administrative responsibilities to Cordon (by way of example but not limitation, network development, credentialing, Utilization Review, Case Management, and claims payment), but agree that any such delegation does not transfer any liability for funding claim payments under this Agreement from Plan to Carelon. 7 BHONationalAC 03.01.2023_V.05 CO 1.25"Practitioner" means an appropriately trained and licensed or certified individual psychiatrist, psychologist, psychiatric social worker or other licensed mental health or substance use provider who is (a) employed by and/or contracted with Provider; (b)rvho is identified in a manner accepted by Carelon and who will be providing Covered Services to Members under this Agreement; (c) properly licensed, meet Carelon's credentialing/re-credentialing criteria and standards, and otherwise qualified to provide Covered Services being provided; (d) where such individual is: (i) an employee of Provider, uses the same federal tax identification number as Provider, or (ii) contracted with Provider, uses their individual federal tax identification number; and (e) for whom Provider will submit claims for Covered Services hereunder. The term "Practitioner' does not include residents, interns, fellows, externs or other trainees. If Provider is an individual practitioner (not a group or facility), then references to "Practitioner" shall also mean the Provider and such individual Provider shall abide by duties imposed by this Agreement on both Provider and Practitioner. 1.26 "Protected Health Information" or "PHI" means a Member's 'individually identifiable health information' as defined in 45 C.F.R. § 1613 103 and/or analogous state law, as well as 'patient identifying information' as defined in 42 C.F.R. Part 2, all as may be amended from time to time. 1.27 "Provider Manual" means Carelon's proprietary document(s), as amended, that sets out Payors and Carelon's policies and procedues related to its contracted providers. Carelon, in its sole discretion, may amend the Provider Manual from time to time. 'Provider Manual" shall also include "provider handbooks," a term used interchangeably by some Plans and Payors, as well as historically by Candor. The Provider Manual, available and accessible through the "provider" section of Carelon's website. 1.28 "Qualified Locations" shall mean locations suitably constructed, equipped, located, duly licensed and accredited for provision of Covered Services, that meet Carelon's credentialing/re-credentialing criteria and standards, and satisfy such conditions as may be further required in this Agreement. 1.29 "Rate Schedule" means the rates payable to Provider by a Payor, as payment in full, for Covered Services rendered to Members at le applicable Quaffed Location. Payment to Provider shall be as specified in Exhibit A and shall be subject to any limitatbns, exclusions and Member Expenses of the Member's Plan. Unless otherwise expressly provided for in a Rate Schelde, reimbursements for facilities, hospitals, institutions or programs made on a per diem, per case or other global payment are all inclusive of facility fees, technical fees, and professional fees of Practitioners and any other individual health care provider. The Fee and/or Rate Schedule(s) set out in Exhibit A will identify the Lines of Business for which they apply, as well as any Plan -specific applicability. 1.30 "Utilization Review" shall mean a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include, but are not limited to, ambulatory review, prospective review, second opinion, certification, concurrent review, case management: discharge planning or retrospective review. Such reviews shall be conducted in accordance with any Applicable Rues. Article II: Relationship 2.1 Engagement. Carelon hereby engages Provider to provide and Provider hereby agrees to provide, services to Members in accordance with this Agreement. The services shall be provided in a timely and efficient manner by Provider and its Practitioners in Qualified Locatons and in accordance with Applicable Rules. 2.2 Independent Contractors. Nothing contained in this Agreement is intended to create, nor shall be deemed or construed to create, any relationship between Carelon and Provider other than that of independent entities contracting with each other solely for the purpose of effecting the provisions of this Agreement. Except as specifically provided for in this Agreement, the parties agree that neither Carelor nor Provider will be liable for the activities of the other nor their representative agents or employees, including without limitation, any liabilities, losses, damages, injunctions, lawsuits, fines, penalties, claims or demands of any kind or nature by or on behalf of any person, party or government agency arising out of or related to this Agreement. 8 BHONationalAG 03 01.2023_V.05_CO Nothing contained in this Agreement shall grant the employees, agents or representatives of one party rights or claims against the other party for vacation pay, paid sick leave, retirement benefits, health care coverage, state mandated coverage, social security, workers compensation, disability, professional malpractice or unemployment insurance benefits or any other employee benefit of any kind. Notwithstanding the foregoing, any rights to indemnification that may be available to either party at law or in equity are not affected by execution of this Agreement. The provisions of this Section shall survive termination of this Agreement. 2.3 Provider/Patient Relationship. Nothing in this Agreement shall change or alter any clinical relationship that exists or may come to exist between Provider and any Member(s) or a Practitioner and any Member(s). Provider and Practitioner: (a) shall have the same duties, liabilities and responsibilities to Members as exist generally between Provider/Practitioner and patient; (b) shall always exercise their best independent medical judgment in the treatment of Members; and (c) are not agents of Carelon, and shall not hold themselves out as agents of Carelon. The parties acknowledge and agree that: (a) nothing contained in this Agreement is intended to interfere with or hinder communications between providers of care and Members regarding their respective health condition or mental health or substance use disorder or available treatment options; and (b) all patient care and related decisions are the sole responsibility of the treating practitioners/providers and their patients and that, regardless of any coverage or payment determination(s) made or to be made by Carelon or a Plan, neither Carelon nor a Plan dictates nor controls clinical decisions with respect to the medical and/or behavioral health care or treatment of Members. 2.4 Referrals. Provider understands that Carelon does not, by this Agreement or future patterns of practice, promise or guarantee any minimum volume or value of referrals of Members to Provider by Carelon or any Payor. 2.5 Cooperation. The parties agree to cooperate and take such further actions and execute such other documents or instruments as necessary or appropriate to implement this Agreement. Article III: Provider Information 3.1 Authority. Provider represents and warrants that it and, in particular, its signatory to this Agreement, has the legal authority to enter into and bind itself and any and all Practitioners to the terms of this Agreement. Whenever in this Agreement the term "Provider" is used to describe an obligation or duty, such duty or obligation shall also be the responsibility of each individual Practitioner, as the context may require. Without limiting the generality of the foregoing, Provider represents and warrants that with respect to each Practitioner, the Provider maintains a written agreement(s) and specifically, as a provision thereof, (a) the Practitioner has assigned to Provider the right to bill for and receive, hold, and disburse all fees and income generated by the Practitioner; (b) the Practitioner has authorized Provider to enter into this Agreement on his or her behalf and to be bound by the provisions thereof; and (c) the Practitioner has agreed not to bill or collect from any person or entity for the Services provided hereunder except through the Provider. The Provider further represents and warrants that (i) it agrees that it is the Provider's responsibility to assure compliance of all Practitioners with the terms and conditions of this Agreement; (ii) all Practitioners are appropriately licensed and/or certified under the laws of the states in which such Practitioner renders services and for which such Practitioner is credentialed; and (iii) bill and submissions for Services rendered to Member by Practitioners are prepared and submitted in accordance with Applicable Rules. 3.2 Licensure. Provider agrees that during the term of this Agreement and any required continuation period following the Agreement's termination, Provider and each Practitioner, as applicable, shall maintain (a) all licensure, certification and/or registration in good standing and without encumbrances under Applicable Rules; (b) all requisite certifications, accreditations, approvals and authorizations required under Applicable Rules to operate each of its Qualified Locations; (c) all requisite certifications, accreditations (by way of example, but not limitation, accreditation by The Joint Commission (JC), Commission on Accreditation of Rehabilitation Facilities (CARF), or the American Osteopathic Association (AOA), as applicable to type of facility), approvals and authorizations required under applicable laws and regulations to operate each of its facilities and/or locations; and, (d) to the extent such licensure and/or certification permits the prescribing of drugs, certification by the DEA. 9 BHONationalAG 03.01.2023_V.05 CO Evidence of such licensure, certifications, registrations, and accreditations shall be submitted to Carelon in a timely manner upon Carelon a reasonable request. Provider represents and warrants that any and all information it submits to Carelon as required by the Section is to the best of Provider's knowledge and belief true, accurate and complete. Provider, on behalf of itself and its Practitioners, shall promptly (and, in no instance, later than five business days) notify Carelon in wrdng of any: (i) action against state licenses, certifications and/or registrations; (ii) action taken regarding Medicaid program participation status, or by a review organization; (iii) change in insurance, licensure, certification, registration, or accreditation status; (iv) change in ownership or business address; (v) legal or government action initiated that could maerially affect the obligations or rendering of services under this Agreement; (vi) claim, suit, criminal or administrative proceeding action commenced against Provider or a Practitioner by or on behalf of or in regard to a Member or services provided to a Member, the quality of services provided by Provider or Practitioner, or Provider's or Practitioner's compliance wilt community standards and/or Applicable Rules; (vii) compromise, settlement or judgment of a malpractice claim against Provider or a Practitioner; (viii) initiation of bankruptcy or insolvency proceedings with regard to Provider whether voluntary or involuntary; or (ix) other occurrence known to Provider that could materially affect the rendering of services under this Agreement. No Claims shall be submitted or be payable for any services rendered by the Provider or Practitioner during any period when Provider or Practitioner, as applicable, lacked required qualifications. 3.3 Liability Coverage. Provider agree to procure and maintain on behalf of itself and its Practitioners such policies of comprehensive general liability insurance, as are reasonably necessary to insure Provider, its employees, Practitioners, and agents against any claim or claims for damages arising out of personal injuries or death occasioned directly or indirectly in connection with the provision of any service provided hereunder, the use of any property and facilities provided by it, or its employees or agents, and activities performed by Provider, or its employees, Practitioners, or agents, in connection with this Agreement. Additionally, Provider shall maintain for itself and for each Practitioner professional liability insurance coverage or, with Carelon's express approval, self-insurance or equivalent, with a limit for each of not less than the greater of (i) the amount required by Applicable Rules or (ii) one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) aggregate per dear. In the event Provider maintains professional liability insurance coverage on a "claims made" basis, Provider also agrees to maintain such policy in effect, or maintain appropriate "tail coverage" following any termination of this Agreement with no breaks in the continuity of coverage for at least until the expiration of the applicable statutes of limitations spedfied by Applicable Rules. Provider shall also: (a) supply upon reasonable request a copy of the face sheet reflecting any changes in insurance coverage prior to their effective date; (b) supply upon reasonable request a copy of the face sheet for each annual renewal of professional liability coverage; (c) ensure that Carelon receives such face sheet within ten (10) days of each annual renewal; and (d) ensure that Carelon is notified at least thirty (30) days prior to the expiration, terrrtnation or material change to such professional liability coverage. The provisions of this Section shall survive termination of this Agreement. 3.4 Locations. Provider must identify all facility and/or office locations in the manner prescribed by Carelon at the time of execution of this Agreement and provide written notice to Carelon of additions and deletions to this listing as far in advance as reasonably possible. All facility and/or office locations must meet Carelon credentialing/re-credentialing criteria and standards as a Qualified Locatbn prior to being permitted to render services to Members as a participating site for Carelon's network under this Agreement Provider shall provide written information required to Carelon under this Agreement. When care is rendered by Practitionersat a Qualified Location, payment for Covered Services rendered to Members at these sites will be according to the applicable Rate Schedule(s) in this Agreement for the particular Qualified Location. 3.5 Practitioners. (a) Provider shall require all its Practitioners rendering Covered Services to Members under this Agreement to comply with the terms and conditions of this Agreement. (b) Where Provider is a hospital, facility, clinic, or other institutional entity: (i) Practitioners admitting Members to and rendering care to Members at a Qualified Location will be members in good standing of Provider's medical staff and subject to all Provider medical staff rules and regulations 10 BHONationalAG 0_01.2023_[!05 CO including, without limitation, Provider's quality assurance review program. It is expressly understood by the parties hereto that Provider has the sole and exclusive responsibility for all medical staff membership determinations and that Carelon shall in no way participate in and/or control the medical staff membership decision -making process. (ii) Provider represents and warrants that as part of its standard privileging and credentialing bylaws, policies and procedures, Provider requires all Practitioners employed by and/or contracted with Provider to be appropriately licensed and/or certified under Applicable Rules. (iii) In order to constitute a Clean Claim for Covered Services, Provider shall include all data elements for itself and for each and every Practitioner that rendered services to a Member. In the event that the claim does not provide sufficient information to identify the applicable payment rate fora particular Covered Services, Carelon reserves the right in its discretion to process the claim based on the provided information and paying the claim based on the lowest fee for the same service listed on Exhibit A or other applicable fee schedule for the Covered Service at issue. (c) At the inception of and throughout the term of the Agreement, Provider shall provide Carelon, in the manner and to the extent reasonably required by Carelon, with (i) an accurate and complete list of all of its Practitioners, which list will include for each Practitioner information reasonably required by Carelon, including but not limited to the Practitioner's name, the office location(s) actually practiced at by the Practitioner, the Practitioner's address and hours of operation, e-mail address, name and phone number of office contact person, and the name and address of the Practitioner's billing office and the name and phone and facsimile numbers for such billing office, linguistic capability and medical specialty or program; (ii) an accurate listing of Provider locations; and (iii) accurate tax identification/NPI/government program numbers. For the avoidance of doubt, the above information regarding Practitioners must be personalized as to each individual Practitioner and not at an enterprise level. In the event that the listing or information of any Practitioner require additions or deletions or changes; a change in the tax identification number/NPI/government program number of any Provider or Practitioner; any changes in information or in the ability to deliver services as set forth in this Agreement; or, of the closing of or change in location of a Qualified Location or any office location and/or any office or clinic location where Provider or Practitioners render services to Members, Provider shall provide Carelon with updated information with as much advance written notice as is commercially reasonable, but in no event any later than thirty (30) days in advance of the change (unless such is not feasible, in which case, as soon as possible) or within ten (10) days after Provider becomes aware of an unplanned change. Failure on the part of the Provider to provide timely updates to required information and adhere to practices mandated by Provider Manual may, in Carelon's sole discretion, warrant temporary suspension of new referrals or from network participation, or be deemed a material breach of the Agreement giving grounds to terminate this Agreement. (d) Provider represents and warrants that Provider maintains written agreements directly with Practitioners. Provider further represents and warrants that (i) where Practitioners are employees of Provider, Provider will bill and submit claims for Covered Services rendered to Members identifying the rendering Practitioner but using the Provider's single tax identification; and, (ii) where Practitioners are contracted with Provider, Provider will bill and submit claims for Covered Services rendered to Members using Practitioner's individual tax identification number; provided, however, that in all instances, Practitioner will look to Provider for compensation for Covered Services rendered to Members under this Agreement and Provider shall pay Practitioners for professional services from the payments paid hereunder. (e) To the extent a Provider or Practitioner is not available or on vacation or is otherwise unable to provide twenty-four (24) hour on -call Services to member under its treatment, Provider will coordinate call coverage to ensure timely care to Members. Any "on -call" or "coverage" pay is the responsibility of Provider. Should a covering health care practitioner not be a participating network provider in Member's Plan, any non -emergency services rendered to Members by such non -participating covering health care practitioner must be Certified in advance of the provision of services by Carelon or its designee, or, where applicable, the Plan, in order to be considered for payment as a Covered Service. Provider shall provide Carelon with written notice of Provider's current on -call service. (f) In the event of any conflict between Provider's agreement with its Practitioners and the terms of this Agreement, this Agreement shall control with respect to Covered Services rendered to Members. Upon reasonable request and where 11 BHONationalAG 03.01.2023_V.05 CO necessarf to meet regulatory and/or government contract requirements and/or where necessary to confirm payment for services rendered to Members, Provider agrees to provide Carelon, and/or an authorized government agency, with access tccopies of Provider's written agreements with Practitioners. (g) Residents; interns, fellows, externs and other clinicians in training (collectively "Trainees") are not qualified to serve as Practitioners. Any services rendered to Members by a Trainee must be under the direct supervision and oversight of a Practitioner who is responsible to review the Trainee's delivery of care and preparation of medical records and who cosigns the Trainee's documentation in the manner required by Applicable Rules. Provider shall not submit claims for services p-ovided by a Trainee (even if the services were supervised by a Practitioner). A Trainee is not to be identified as a contracted provider of Carelon. (h) Provider warrants that any nurses or other health professionals employed by, staffed by, or providing services for Provider mall be duly licensed or certified under Applicable Rules. Article IV: Carelon Information 4.1 Authori . The signatory signing this Agreement has the legal authority to enter into and to bind Carelon Behavioral Health, Inc. and Carelon Behavioral Health Strategies, LLC and each of their respective Affiliates to the terms of this Agreement. 4.2 Licensure. Carelon represents that it maintains in good standing appropriate licensure or certification as required by Applicable Rules. Carelon will naify Provider, through public notice or otherwise, of: (a) final revocation of its license or authorization to do business under Applicable Rules; or (b) initiation of bankruptcy or insolvency proceedings with regard to Carelon whether voluntary or involuntary. 4.3 Insurance. Carelon shall procure and maintain such policies of comprehensive and general liability insurance coverage or self -insured coverage as am reasonably prudent to insure Carelon, its employees, officers and directors against any claim or claims for damages arisirg out of performance under this Agreement. 4.4 Relationship with Payors. Unless Carelor's contractual relationship with a Payor includes the transfer of financial risk for claims, the Payor, and not Carelon, is ultinately responsible for making sufficient amounts available for claims payments for Covered Services. Article V: Participation, Policies & Procedures 5.1 Network Participation. (a) General. Provider agrees to participate in provider networks of Carelon Lines of Business made available to Members covered under Plans offered or administered by Payors and as identified on the Member's health coverage identification card or obtained by contacting the applicable Payor's member services department. Lines of Business include without limitation commercial plans, State Medicaid or government programs, in accordance with the terms and conditions of this Agreement, and for which there is a Rate Schedule or fee schedule (Exhibit A) attached to this Agreement. Notwithstanding the foregoing or anything else to the contrary in this Agreement, Provider is not guaranteed inclusion in the Caron network for purposes of servicing Members of every Plan or Line of Business with which Carelon has contracted to arrange for the provision of mental health or substance use disorder services. Nothing in this section is intended to create a right for the Provider to reiect participation in a given Plan within a Line of Business in which the Provider has chosen to participate. (b) Network Leasing. To the extent permitted by Applicable Rules, Carelon may sell, lease, rent, assign or grant access to Provider health care services, discounted rates or the fees established in the Agreement to a health benefit plan or program sponsored or maintained by an employer, multiple employer trust, or union trust, a governmental entity (including without limitation CMS and state Medicaid agencies), an Agency, a health maintenance organization (HMO), 12 BHONationalAG 0..01.2023_[!05 CO a preferred provider organization (PPO), an indemnity carrier, an insurance company, an insurance exchange, a third - party administrator, a Payor, or any other entity that arranges and provides a program of behavioral health services to individuals (individually and collectively, "Entity"). Carelon will provide Provider with thirty (30) days' prior notice (or longer, if required by Applicable Rules) of any such leasing arrangement. Carelon reserves the right to develop policies and procedures for the implementation and operation of network leasing programs and will provide Provider with thirty (30) days' prior written notice of such policies and procedures. Provider agrees to comply with the Entity's policies and procedures, as applicable, and accept payment directly from Entity as applicable in accordance with the terms of this Agreement. Provider may, upon ninety (90) days' prior written notice to Carelon cease participation in the network of providers leased to such Entity. 5.2 Restrictions. Provider shall notify Carelon in writing promptly if it is no longer accepting new Members, is only available during limited hours or in certain settings, or, has any other restrictions on treating Members. 5.3 Telephone Audits. Regulatory agencies periodically conduct telephonic audits by contacting providers in Carelon's participating provider networks. Provider shall, and shall require Practitioners to, provide information and respond to questions from regulatory agencies and/or individuals or entities conducting surveys or inquiries on their behalf as to those provider networks and products/lines of business (e.g., commercial, commercial EPOs, commercial provider networks supporting self -funded ERISA Provider health plans, etc.) in which Provider and Practitioners participate under this Agreement. 5.4 Credentialing & Re-credentialing. Provider understands that participation in Carelon's provider networks and billing for Covered Services thereunder is subject to the successful and timely completion of Carelon's credentialing and re-credentialing procedures and conformance with Applicable Rules, NCQA standards and any other applicable standards. Provider acknowledges and agrees that, irrespective of the Effective Date set forth in this Agreement, a Practitioner may not begin treating Members under the terms of this Agreement and Provider shall not bill under this Agreement for Services provided by such Practitioner unless and until that Practitioner has been properly and fully credentialed in accordance with this Agreement and any applicable delegation agreement, and such credentialed status remains in good standing at the time services are provided. Provider represents and warrants that any and all information it submits to Carelon describing Provider's and Practitioners' credentials, programs and Services in the provider application and otherwise, both before and during the term of this Agreement, is, to the best of Provider's knowledge and belief, true, accurate and complete as of the date submitted and continues to be as such during the term of the Agreement unless updated as set forth herein. Provider agrees to: (a) comply with the requirements of Carelon's credentialing program including responding to any requests for information from Candor within the time period requested; (b) notify Carelon in writing immediately of any (i) change in information included in credentialing and/or re-credentialing applications submitted to Carelon or its designee with regard to Provider and any Practitioner, including, but not limited to, a change in address or telephone number, linguistic capability, specialty or program, or licensure or accreditation or any of the information set forth this Agreement; (ii) discontinuance of any Services provided; (iii) addition or departure of any Practitioner; and, (iv) to the extent applicable, a change in hospital privileges of Provider or any of its Practitioner; and, (c) submit required information timely and with the frequency requested using the process, certifications, attestations and designee specified by Carelon for this purpose. Such notification shall be submitted in writing, to Carelon as of the earlier of, ninety (90) days prior to a planned change or within ten (10) days after Provider becomes aware of an unplanned change (unless a shorter period is required by a different portion of the Agreement and then by such shorter period). Changes and updates to Provider and Practitioner information should be submitted, whenever possible, to Carelon via CAQH (or if such is not possible, via Carelon's provider portal or by contacting Carelon directly). Providers, on behalf of themselves and their Practitioners, must also attest to the accuracy of their information at least quarterly via CAQH. Without limiting the generality of any other provision, Provider acknowledges and agrees that information provided regarding individual Practitioners must be reported at the individual practitioner level and not at the group or facility level. In the event of any failure of Provider and any of its Practitioners to remain in continuous compliance with Carelon's credentialing and/or re-credentialing standards and/or to provide required updates to a Provider's or Practitioner's information, Provider acknowledges that, at Carelon's sole discretion, (i) Provider and/or Practitioner, as applicable, may 13 BHONationalAG 03.01.2023_V 05_CO be removed fom the provider directory listing; (ii) Provider's and/or Practitioner's participation in Carelon's provider networks may be terminated or suspended, and/or (iii) this Agreement may be terminated on the grounds of material breach. (i) Facilities. For purposes of this subsection, the term "Facility Practitioners" shall mean professional health care providers if Providers who are at facilities and: (1) who render professional health care services only at a Provider's Qualified Location; (2) who do not maintain a separate practice site or office; (3) who will in no event submit independently from the Provider a claim or bill for their respective professional health care services rendered to Members at a Provider's Qualified Location; and, (4) for whom Provider will, in all instances, submit claims for professional services to Members on their behalf under this Agreement. To the extent that (a) Provider represents and warrants that a Facility Practitioner has privileges at the Provider's facility under the Provider's medical -staff by-laws, policies and procedures, which include an initial privileges/credentialing process and a re-evaluation process for continued privileges/re-credentialing at least every three (3) years, and (b) upon Carelon's request, Provider agrees to provide documentation related to privileging and credentialing/re-credentialing of the Facility Practitioner, then Carelon agrees to accept the Provider's privileges/credentialing of a Facility Practitioner in lieu of submission to credentialing/recredentialing by Carelon. Provider shall provide to Carelon, to the extent and in the manner reasonably required by Carelon, a roster listing all Facility Practitioners, including all information regarding the Facility Practitioner as Carelon requests, at the time of signing of this Agreement and prompt updates when necessary to reflect additions and deletions of Facility Practitioners. Practitioners of Provider that do not meet the criteria of a Facility Practitioner will need to beindividually credentialed by Carelon in accordance with Carelon's credentialing/re-credentialing policies and procedures. (ii) IndividualsrGroups. All individual Providers and Practitioners of Group Providers must be individually credentialed and re-credentialed by Carelon in accordance with Carelon's credentialing/re-credentialing policies and procedures. For Group Providers, these requirements extend to, but are not limited to, any newly employed or contracted Practitioners being added following execution of this Agreement. (iii) Provider agrees that: (1) Payors may periodically conduct reasonable investigations of the licenses and background of Provider and Practitioners; and (2) subject to any legal or contractual restrictions, that Carelon may provide Payors with information reasonably requested by Payors regarding the credentialing and/or re-credentialing of Practitioners. (iv) Provider agrees to indemnify, to the extent permitted under Colorado Law, and hold harmless Carelon and its officers, employees agents, directors, and members of the credentialing committee, and all Payors and Plans, from any and all liability resulting from their respective good faith use of any information about Provider and/or Practitioners in the performance of credentialing and/or re-credentialing activities. 5.5 Carelon's Policies and Programs/ Provider Manual. Provider agrees to comply with, cooperate with, and upon request, and participate in, Carelon's policies and programs and such other acrrmistrative policies, programs and requirements identified or set out in the Provider Manual and as may be amended by Carelon from time to time, as well as in any Payor specific policies and procedures made available to participating providers and related to participation in such Payor's provider network(s) for their Members and any Covered Services rendeed to their respective Members. By way of example but not by way of limitation, policies and/or programs may include those related to credentialing, re-credentialing, utilization management, case management, Utilization Review, referral, quality assurance, quality improvement, and appeals and grievances. Compliance shall include responding to any requests for information from Carelon within the time period requested. The terms of the Provider Manual are in addition to the terms of thin Agreement and the Provider must abide by those terms. Except to the extent specifically provided for by Applicable Rules, in the event of any conflict between the terms of this Agreement and the terms of the Provider Manual, the provisions o this Agreement shall control. (a) Provider, in the course of participation in the Carelon provider network(s), supports the statement of Members' rights and responsibilities contained in the Provider Manual. (b) In the greater of thirty (30) days in advance or such longer period of time as required by Applicable Rules or accredtation requirements of private sector accreditation organizations, Carelon will give Provider notice of any material changes, additions, deletions and/or modifications to the Provider Manual, including, but not limited to, 14 BHONationalAG 0101.2023_V.05 CO Carelon's procedures, documents or requirements, including without limitation those associated with Utilization Review, Case Management, quality management and improvement, credentialing and preventive health services, that have a substantial impact on the rights or responsibilities of the Provider, through the Carelon's provider newsletter, formal notice or through Carelon's website. Notice to Provider is notice to all Practitioners hereunder. Provider shall be deemed to have accepted all revisions upon notice by Carelon except to the extent Applicable Rules impose alternative notice and acceptance requirements, in which case the alternative notice and acceptance requirements shall be followed. (c) E -Commerce. Provider agrees to comply with the E -commerce requirements set forth in the Provider Manual ("E - Commerce Requirements"). E -Commerce Requirements relate to use of electronic processes for all routine transactions in place of paper -based processes, including but not limited to: Submission of claims • Submission of authorization requests • Verification of eligibility inquiries • Submission of re-credentialing applications • Updating of provider information • Electronic fund transfer • Provider claims and authorization status checks If E -Commerce Requirements are not adhered to, Certifications or claims payments may be delayed or denied. In addition, Carelon reserves the right to re-evaluate the participation status of Provider or Practitioners who repeatedly fail(s) to comply with E -Commerce Requirements, and Carelon further reserves the right to either terminate and/or sanction the Provider or Practitioners. 5.6 Case Management/Quality Initiatives/Data Sharing. Provider agrees to participate in case management directed by Carelon of the Provider's Members for the provision of Covered Services, care coordination and/or discharge planning, including but not limited to assisting with Member outreach as appropriate. Provider agrees to comply with, participate in and cooperate with quality initiatives and to use best efforts to make reasonable modifications to Provider's methods of services delivery that are required of Carelon by quality assurance committees, accrediting bodies (e.g., NCQA, URAC), Payors, Agencies, government agencies, and/or quality improvement and performance management programs (including but not limited to clinical and service measure programs). Provider authorizes Carelon and Payor to use its data for any quality improvement activities and/or initiatives that Carelon or Payor partake in voluntarily or by reason of imposed requirements, provided that Carelon and Payor adhere to Applicable Rules. Without limiting the generality of the foregoing, the parties acknowledge and agree that each party's access to better clinical and administrative data is critical to further the goal of improving the quality of care and services, member experience and efficiency of health care quality, and therefore, and upon Carelon's request, Provider agrees to provide data and records (including but not limited to Member treatment records) to Carelon and Payor for treatment purposes, for payment purposes, for health care operations, and/or for purposes of health care fraud and abuse detection or compliance. Provider also agrees to cooperate with other Providers (including but not limited to outpatient providers cooperating with inpatient providers, and vice -versa) to ensure that the Member receives continuity of care (e.g., coordinated treatment, treatment hand-off, discharge planning, medication management). Provider also agrees to cooperate in the collection and evaluation of performance measurement data. Provider acknowledges and agrees that refusal to cooperate with Carelon's case management, quality improvement and/or Utilization Review activities may adversely affect continued network participation status or result in sanctions up to and including termination of network participation status. 5.7 Actions. Carelon may take certain actions as described in the Provider Manual with regard to Provider or Practitioner if it fails to carry out its obligations to comply with Carelon's policies, programs, the Provider Manual, the terms of this Agreement or with Applicable Rules. Any disputes concerning actions undertaken pursuant to this Section shall be resolved pursuant to the dispute resolution procedures of this Agreement, as may be further specified in the Provider Manual as to a specific Plan; provided, however, that implementation of any second or subsequent notification(s), suspension or termination shall not be delayed due to the filing of any grievance by Provider. 15 BHONationalAG 03.01.2023_V.05 CO 5.8 Access to Record/Audits. Upon reasonable written request, Provider agrees that Payors and Carelon, and their respective designee(s), shall have the right to aucit and other reasonable access, including without limitation the opportunity to examine, copy, excerpt and transcribe at rus charge during normal business hours, on at least forty-eight (48) hours' advance notice, or such shorter period of time as may be imposed on Payor or Carelon, or by a federal or state regulatory agency or accreditation organization, tie facilities, billing and financial books, records (including but not limited to Member's treatment records) and operations of P ovider, Practitioners, any individual or entity performing services for or on behalf of Provider, or any related organization orentity, as they apply to the obligations of Provider under this Agreement. Without limiting the generality or scope of the f€regoing, Providers shall cooperate with treatment record reviews and audits conducted by Payors and Carelon, by, amongst other actions, providing access to Member medical records related thereto. The purpose of the foregoing requaeements is to permit Payor and Carelon to assure compliance by Provider with financial, operational, quality assurance, Medical Necessity, concurrent review, appropriateness of care, claims payment rules, accuracy of claims coding and payment, and all other obligations of Practitioner under Applicable Rules, this Agreement and Provider's continuing ability to meet such obligations. Provider acknowledges that failure to submit records in accordance with this provision and/or the Prow der Manual(s) may result, amongst other consequences, in a denial of a claim for payment under review, whether on pm -payment or post -payment review, or a payment retraction on a paid claim, and Provider further acknowledges teat Provider is prohibited from balance billing the Member in any of the foregoing circumstances. Provider further acknowbdges and agrees that refusal to cooperate with the audit and access requirements set forth in this section may adversely affect the Provider's continued network participation status or result in sanctions up to and including termination of network participation status. Nothing in this paragraph shall be construed to limit or prevent Payor or Carelon from conducting, unannounced audits to investigate concerns related to potential fraud, waste or abuse or from conducting medical record review for quality, risk adjustment or risk management initiatives. Article VI: Services 6.1 Eligibility Verification & Certification. Carelon maintains processes or makes available access to processes for Provider to: (a) verify Member eligibility; (b) where required to do so, to obtain Certification for proposed services and/or transition between Levels of Care; or (c) where not required to obtan Certification to provide notice of all inpatient admissions, which notice must be done within twenty-four (24) hours of ary such inpatient admission. Provider agrees to use these processes and to verify Member eligibility and obtain Certificabon (where required) prior to the provision of non -emergency services. Provider: (i) understands that failure to obtain Certification where required for proposed non -emergency services may result in an administrative denial of any Claim submitted thereafter for lack of Certification; and (ii) in the event of an administrative denial of any Claim submitted thereafter for lack of Certification as identified above, Provider may not bill, charge or otherwise seek payment or reimbursement tom the Member or the Member's authorized representative. In the event that Provider is reimbursed for in -patient stays at inclusive case rates, Carelon will not reimburse Provider for any costs of a readmission to the same facility within 3Dcalendar days from a hospital discharge related to the original condition. (a) Once Carebn has Certified a proposed Covered Service as Medically Necessary, and unless the information initially provided by Provider during the Certification process was erroneous or incomplete or the initially proposed services differ materially from the services actually provided and documented in the Member's health information records or the plan of treatment, Carelon shall not thereafter (i) reverse the Medically Necessary determination for services previously Certified, or (ii) deny payment for those services based solely on Medical Necessity. (b) Where Provider is uncertain as to whether a service is covered, the Provider shall make reasonable efforts to contact Carelon ant obtain a coverage determination prior to advising a Member as to coverage and liability for payment and prior to providing the service. 6.2 Services. To receive payment hereunder, Provider agrees to provide to Members Covered Services and to prepare and maintain records related bereto (a) in accordance with generally accepted medical standards, all Applicable Rules and the provisions of this Agreement; (b) pursuant to the same standards as services rendered to Provider's other patients; (c) in a non- discriminatory renner and without regard for race, color, gender, sexual orientation, age, religion, national origin, marital status, place of residence, mental or physical disability, genetic information, health status, health plan membership or source 16 BHONationalAG 03 01.2023_V.05 CO of payment, including without limitation Medicaid, as well as in a manner that is accessible and appropriate for Members with one or more disabilities, including, but not limited to, developmental, hearing, learning, physical, psychological and visual impairments, or whether or not Member has executed an advance directive; (d) that are within the scope of Provider's and/or Practitioner's respective licensure; (e) that are within the scope of services for which Provider and/or Practitioner is credentialed and/or re-credentialed; (f) that are Medically Necessary; and (g) at Qualified Locations. Provider shall limit (if at all) acceptance of Members as patients under no more stringent terms than apply to all other potential new patients of the Provider and as otherwise permitted in the Provider Manual and Applicable Rules. Further, Provider shall provide Covered Services to Members with behavioral health needs consistent with Carelon's emphasis on promoting evidence - based practices, strength -based rehabilitation, and recovery -oriented care that integrates each Member's culture, disabilities, race, ethnic and class backgrounds. Subject to the foregoing, Provider shall provide Covered Services in the most cost effective, clinically appropriate setting and manner. In addition, in accordance with the Provider Manual(s) and all other policies, programs and procedures, Provider shall utilize participating network providers in Member's Plan, and when Medically Necessary or appropriate, refer and transfer Members to such participating network providers for all Covered Services, including but not limited to specialty, laboratory, ancillary and supplemental services. Services for Emergency Medical Conditions should be provided in clinically appropriate locations. In an Emergency, Provider shall contact Carelon within twenty-four (24) hours or the next business day after a Member presents for treatment. Pre -Certification is not required for services for Emergency Medical Conditions; however, where required by the Member's Plan and permitted under Applicable Rules, Provider agrees to obtain Certification for post -stabilization and other services following an Emergency. (i) Members shall have the option of calling the local pre -hospital emergency medical service system by dialing 911, or its local equivalent, when confronted with an Emergency Medical Condition. No Member shall in any way be discouraged from using the local pre -hospital emergency medical service system, the 911 telephone number or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such Emergency Medical Condition. Provider shall ensure that when it becomes aware that a Member is in need of Emergency Services, the Member is connected with Emergency Service Providers (ESPs) in the Member's geographic area as appropriate. (ii) Provider agrees, except in case of an Emergency, that Provider shall coordinate all referrals with Carelon. Documentation of referrals must be noted in the patient record. If Provider is required to refer a Member for services that are not within the scope of Provider's licensure, certification or expertise or that Provider is otherwise unable to provide, whether in an Emergency or otherwise, Provider shall use its best efforts to refer the Member to another provider that is participating in the applicable Plan network; provided, however, that Provider may, subject to the Member's clinical needs and Applicable Rules, make referral to another appropriate provider even if such provider is not participating in applicable Plan's network if the Member has indicated in writing that he or she understands that his or her Plan may not cover the out -of -network referrals and, as a result, the Member may be held financially responsible for non -emergency out -of -network services. (iii) Notice of adverse determinations or denial of Certification or determination that a service is not Medically Necessary will be in accordance with applicable Plan rules and Applicable Rules to which the applicable Plan is subject. 6.3 Not Incentive. Nothing contained in this Agreement shall be construed as limiting or restricting in any way Provider's discharge of professional duty to deliver services to Members that, in Provider's or Practitioner's professional independent judgment formed in light of clinical, rather than financial, considerations, are appropriate for the promotion of a Member's well-being. Furthermore, nothing contained in this Agreement shall be construed as an arrangement or an agreement between Carelon and Provider for any incentive plan or specific payment to Provider as an inducement to reduce, delay or limit specific services covered by Member's Plan. In addition, nothing herein shall be construed as authorizing or permitting Provider to abandon any Member. 6.4 Books and Records. Provider shall prepare, maintain and retain all medical, patient care, financial, claims related, administrative data, records and information related to services provided to Members in the manner required by generally accepted medical practice, 17 BHONationalAC 03.01.2023_V05_CO Applicable Rules and by the applicable terms of the Provider Manual and other Carelon or Plan directives. Records shall be retained for the longer of: (a) the time required by Applicable Rules, or, where applicable, the government sponsored program, or (bj ten (10) years from the date of service. In the event that a Member receiving Services is a minor at the time such Services are rendered, the Provider is required to retain all patient records for a period of ten (10) years from the termination dab of this Agreement, or for ten (10) years after the Member attains the age of majority under Applicable Rules, whichever is longer. If any litigation, claim, negotiations, audit or other action involving such records is commenced prior to the exliration of such retention period, all records shall be retained at least until completion of such action and resolution of all issues resulting therefrom. 6.5 Access to Heath Information Records. Upon reasonable notice and during Provider's regular business hours, Carelon, its authorized representatives, and duly authorized thin parties (such as government agencies, quality improvement organizations (QIOs and QI0-like entities), accreditation organizations, and Payors) shall have the right to inspect and/or be given copies of medical and claims related records and ober health information records directly related to services rendered to Members by Provider. Copies of requested heals' information records shall be provided and sent at no cost to Carelon and any Payor. Provider represents and warrants flat Member consent (or authorization) has been obtained in accordance with Applicable Rules to disclose all health information records (including but not limited to patient identifiable records related mental health and substance use disorders) shared with Carelon and the Plan or Payor, as applicable, for treatment, payment, and health care operations. Prcvider shall use best efforts to comply with requests by Candor to distribute to Members consent forms regarding access to patient records by the Member's Primary Care Clinician (PCC). This Section shall survive termination of this Agreement. 6.6 Non -Certified Services. Notwithstandinc anything to the contrary herein, Provider understands and agrees that in the event that Provider fails to request timely Certification from Carelon or Payor where required by the Member's Plan for services that are included in the Member's Flan, neither Payor nor its designee shall be obliged to pay for services rendered and the Member shall not be held liable fc r the cost of such services. Where Provider has requested Certification in a timely manner but Carelon or Payor has not Certified the services to be Medically Necessary, then Provider may pursue the following when permitted by Applicable Rules: (a) After Carelon notifies Provider (1) that a proposed treatment or services for a Member will not be Certified, or (2) that treatment or services fora Member which had previously been Certified will no longer continue to be Certified, or (3) that services already rendered will not be Certified, then Provider may initiate, subject to receipt of an assignment from the Member, an appeal on behalf of the Member in accordance with appeals policies and procedures set out in the Provider Manual and as provided for in the Member's Plan. (b) After Provider has exhausted all appeals provided for in the Provider Manual and Member's Plan with respect to the lack of Cerification, Provider may seek payment for services from Member if it (i) advises the Member that the service or services are not Certified and will not be covered or paid for by the Payor along with the reason as to why the services were not Certified; and (ii) obtains written acknowledgment from the Member that the Member is and will be financially esponsible for all costs of all services not Certified. 6.7 Verification of Eligibility. Provider shall le responsible for verifying a Member's eligibility for Covered Services as outlined in the Provider Manual prior to providing any services to that Member. Such verification shall be used to determine the initial and continuing qualification of ai individual to receive Covered Services hereunder as a Member. If, however, it is subsequently determined that a Member vas not eligible for coverage under a Plan as of the time the services were rendered (even if as a result of retro-active diseirollment or mistaken information), Payor has no obligation to pay for services for which Member was ineligible. If Prcvider discovers a discrepancy between Provider's records as to an individual's eligibility for Covered Services, Provider should notify Carelon's Member Services department to resolve the discrepancy regarding the Member's eligibility. 6.8 Outpatient Treatment Reports & Payment for Outpatient Covered Services. 18 BHONationalAG 0_01.2023_V05_CO Where Certification is required for outpatient services by a Member's Plan, or when requested by Carelon, Provider shall complete and sign the Carelon outpatient treatment report and supply other requested substantiating documentation related to continued treatment authorization requests and/or Claims submitted for outpatient Covered Services. Regardless of any provision to the contrary, failure to complete the outpatient treatment report where required by the Member's Plan and/or failure to respond to a request from Carelon for completion of an outpatient treatment report and/or other substantiating documentation may result in denial of Claims submitted for such outpatient services. 6.9 Appeal Process. Provider agrees to: (a) cooperate fully with Carelon's complaints, grievances and appeal processes (as stated in the Provider Manual) maintained to resolve Members' or Providers' concerns and any complaints by Members regarding Provider's or Practitioner's services, and (b) exhaust all Carelon and/or Payor complaint, grievance and/or appeal processes available prior to pursuit of any available legal or equitable remedies (including without limitation pursuit of any alternative dispute resolution pursuant to the provisions of this Agreement) and/or seeking payment from a Member for any services not Certified and/or for any Non -Covered Services. Regardless of any provision to the contrary, the parties understand and agree that the determination of Member eligibility, what is a Covered Service, and appeal rights for Members shall be pursuant to, and in accordance with, the applicable Member Plan. 6.10Exctuded Providers. Payor shall not reimburse for services that Provider or a Practitioner provides or prescribes while it, he or she is not credentialed or has been excluded from participation in government programs. Article VII: Claims & Payment 7.1 Claims Submission. Unless expressly stated otherwise in a Provider Manual with respect to a particular Plan or in an applicable State Specific exhibit attached hereto, Provider agrees to prepare and submit Clean Claims for Covered Services in the form and manner required by Carelon as specified in the Provider Manual such that they are received within the longer of: (a) ninety (90) days of the date of service; (b) sixty (60) days of the date of claim determination by the primary payor (in instances of other health benefits coverage); or (c) the minimum period required by Applicable Rules (individually and collectively as "Timely Submission Period"). Provider: (i) understands that failure to submit Claims within the Timely Submission Period will be denied for lack of timely filing; and (ii) in the event of such a denial of any Claim submitted thereafter for lack of timely filing as identified above, Provider may not bill, charge or otherwise seek payment or reimbursement from the Member or the Member's authorized representative. Provider, for itself and any permitted assignees, waives any and all claims for payment for Covered Services that are not submitted within the Timely Submission Period. Provider agrees to cooperate with Carelon in providing any information reasonably requested in connection with claims processing and in obtaining necessary information relating to coordination of benefits, subrogation, verification of coverage, and health status. (i) When submitting claims, Provider: (1) shall use the most current coding methodologies on all forms; (2) shall abide by all applicable coding rules and associated guidelines, including without limitation inclusive code sets; and (3) agrees that regardless of any provision or term in this Agreement, in the event a code is formally retired or replaced, Provider agrees to discontinue use of such code and begin use of the new or replacement code following the issue date by the appropriate coding entity or government agency. Should Provider submit claims using retired or replaced codes, Provider understands and agrees that Carelon, or Payors, may reject or deny such claims until completely and appropriately coded and re -submitted. (ii) Unless expressly stated otherwise, the Fee or Rate Schedules on Exhibit A are global rates, inclusive of all technical and professional services and all other service components, and constitute payment in full. Provider agrees that it will not knowingly, and shall contractually require its Practitioners not to, bill Carelon, Payor or Member separately for Practitioner's services when they are included as part of a comprehensive (global) payment in the Fee or Rate Schedule. If certain Practitioner services are excluded from amounts paid to the Provider directly, payments made directly to the Practitioner should be considered a comprehensive payment pursuant to Carelon professional fee schedule(s). 19 BHONationalAG 03.01.2023_V 05 CO (iii) All Claim submissions by Provider will be considered final, unless Provider requests reconsideration of the Claim or submits apcorrected Claim within period of time as required by Applicable Rules or the Provider Manual (or within sixty (60) daysif no period is specified therein) of receipt of a request to submit a corrected Claim, payment or denial from the Payor Any corrected claims submitted must be identified as a corrected Claim. 7.2 Payment. (a) Subject to the terms of this Agreement and of the Member's Plan and unless a longer or shorter period is mandated by Applicable Rules (in which case, such longer or shorter mandated period shall apply), payment for uncontested amounts fir Covered Services rendered to Members will be made to Provider: (i) by Payor within ninety (90) days of receipt of a Clean Claim submitted by Provider; or (ii) by Carelon, where Carelon is functioning as a Payor, within sixty (60) days of receipt of a Clean Claim submitted by Provider. Carelon or Payor shall notify Provider in writing of the reason(s) for nonpayment and/or what additional information or documentation is necessary to complete properly rejected Ci3iMS within the noted period following receipt of such claims. If the Provider is not notified or paid for Clean Claims within the period stated above, Provider will be paid, in addition to any reimbursement due for Services, any mandated interest on amounts payable from the first day following the expiration of the mandated period (i.e., as applicable the 91. or 61St day or the day following expiration of the period mandated by Applicable Rules) after Payor or Candor's receipt of the Clean Claim until payment. The rate of interest shall be the minimum mandated by Applicable Rules. The provisions of this paragraph relating to interest payments shall not apply to (1) a claim that Payor or Carelon is investigating because of a good faith belief of suspected fraud or other reason permitted by Applicable Rules or (2) if permitted by Applicable Rules, to a claim subject to an annual coding update but only for the ninety )90i days period immediately following issuance of annual coding updates. Unless required otherwise by Applicable Law, the date of receipt of a claim is the date Carelon or Payor receives the claim, as indicated by its date stamp on the claim; the date of payment is the date of the check or other form of payment. (b) Payment:i) for Covered Services shall be the lesser of the fee or rates specified in the applicable Fee or Rate Reimbursement Schedule (Exhibit A) or Provider's billed charges (unless Applicable Rules mandate a particular payment regardless of billed amount); (ii) for Covered Services is funded by Payors and not by Carelon, except where Carelon has specifically contracted with a client to function as a Payor for Covered Services; (iii) is based upon: (a) compliance with the terms of this Agreement; (b) the determination that the service is a Covered Service under the Member's °tan; and (c) Member's eligibility at the time of service. Reimbursement from the Payor plus any Member Expenses collected from the Member is payment in full for Covered Services rendered. Payor may from time to time authorize services not disclosed to Carelon prior to rendering and shall pay Provider for such services on the terms agreed upDn in advance or Carelon standard reimbursement for that line of business. Payment or coverage determinations by Carelon or Payors shall not be construed as a directive that medically appropriate treatment be withheld. b the extent that a Payor or Plan has a specific rate, the Payor or Plan specific rate shall govem over the general applicable rates. (c) Carelon is only obligated to authorize and/or direct payments under this Agreement if it has first received funding from the applicable Payor. Under no circumstances, including any Payor's insolvency or bankruptcy, shall Carelon be or be construed as, a Payor's guarantor. In the event that Payor fails to provide funding for Service payments to Provider, Provider's sole recourse for reimbursement for Services is against Payor. (d) Provider stall be responsible for the billing and collecting of Member Expense from Members relating to Covered Services rendered. As more fully set forth in Section 7.5 below, Provider agrees that under no circumstances shall Provider seek payment from Members or their authorized representatives for Covered Services other than for applicable Member Expenses as authorized by Member's Plan. Provider shall not seek payment from any State agency for any Covered Services. 7.3 Recoupment/Cffset/Adjustment for Overpayments. Carelon and Payor shall be entitled to offset and recoup an amount equal to any overpayments or improper payments made to Provider against any payments due and payable to Provider with respect to any Plan subject to the Agreement. Provider shall voluntarily refund all duplicate or erroneous claim payments regardless of the cause, including, but not limited to, MemPPer not being eligible for coverage as of the time services were provided, payments for claims where the 20 BHONationalAC 0_.01.2023_V.05 CO claim was miscoded, non -compliant with industry standards, or otherwise billed in error, whether or not the billing error was fraudulent, abusive or wasteful. Upon determination by Carelon or Payor that any recoupment, improper payment, or overpayment is due from Provider, Provider must refund the amount to Carelon or Payor, as applicable, within thirty (30) days of when Carelon or Payor notifies Provider (or, if a longer period of time is required by Applicable Rules, then within the minimum amount of days required by reason thereof); provided, however, that Carelon or Payor may recover any payments inadvertently made on duplicated claims submitted by Providers automatically through offset against future claims payments to Provider due under the same Plan or any other Plan subject to this Agreement. If such reimbursement is not received by Carelon or Payor within the thirty (30) days following the date of such notice (or, if a longer period of time is required by Applicable Rules, then within the minimum amount of days required by reason thereof), Carelon or Payor shall be entitled to offset such overpayment against any Claims payments due and payable to Provider under any Plan subject to this Agreement in accordance with Applicable Rules. In such event, Provider agrees that all future claim payments applied to satisfy Provider's repayment obligation shall be deemed to have been paid in full for all purposes. Should Provider disagree with any determination by Carelon or Payor that Provider has received an overpayment, Provider shall have the right to appeal such determination under the applicable Plan's procedures set forth in the Provider Manual, and such appeal shall not suspend the Payor or Carelon's right to recoup the overpayment amount during the appeal process, unless suspension of the right to recoup is otherwise required by Applicable Rules. Carelon reserves the right to employ a third party collection agency in the event of non-payment. 7.4 Coordination of Benefits. The coordination of benefit rules of the applicable Member's Plan will determine payment to Provider. In no event, shall a Payor be obligated to pay Provider any portion of a secondary payment whereby the sum of the primary payment, plus the secondary payment, plus any Member Expense, exceeds the compensation specified in the Exhibit A. Provider agrees to cooperate with Carelon and Payor in providing any information reasonably requested in connection with claims and in obtaining necessary information relating to coordination of benefits, subrogation, verification of coverage, and health status. Provider agrees to: (a) make reasonable efforts to determine if Members have insurance or other health care coverage other than through Payor and promptly report any duplicate coverage to Carelon; and (b) notify Carelon promptly in the event it provides services in connection with work -related injuries, motor vehicle accidents, or other occurrences that may involve third -party liability. Nothing contained herein, however, shall restrict or otherwise affect Provider's rights or obligations with respect to third -party payors other than Payor. 7.5 No Balance Billing. Provider agrees that in no event, including, but not limited to nonpayment by Carelon or Payor, insolvency of Carelon or Payor, or breach of this Agreement, shall Provider bill, charge, collect a deposit from, seek remuneration or reimbursement from, or have any recourse against, a Member, subscriber, enrollee, person to whom health care services have been provided, or person acting on behalf of the Member, for whom health care services were provided pursuant to this Agreement. This does not prohibit Provider from collecting Member Expenses or: (a) fees for Non -Covered Services delivered on a fee -for -service basis to persons referenced above (provided that Provider complies with all of the requirements described in this Agreement and Applicable Rules); (b) fees for services that are Non -Certified as outlined above; or (c) from recourse against Carelon or Payors. Provider: (i) agrees that this provision supersedes any oral or written agreement to the contrary previously entered into between Provider and Member or anyone acting on their behalf; and (ii) Provider shall abide by the terms of this provision in the event of non-payment by Carelon or Payor for any reason, including, but not limited to voluntary or involuntary bankruptcy proceedings involving Carelon or Payor. (1) Provider agrees that: (a) Provider shall not bill Members for services which have been denied for payment because they were not submitted to Carelon or Payor, as applicable, within the Timely Submission Period as required above. (2) Notwithstanding the above and prior to rendering any Non -Covered Services and if permitted by Applicable Rules and the applicable Plan, Provider: (A) shall advise the Member that the service or services are not covered; and (B) will obtain written acknowledgment from the Member that the service or services will not be covered or paid for by Carelon or the Payor and further that the Member is financially responsible for all costs of such Non -Covered Services. Moreover, if permitted by Applicable Rules and the applicable Plan, then to the extent a Plan differentiates Member Expense based on whether or not a provider is in -network, Provider may refer or transfer an impacted Member to a non -participating provider after obtaining a written acknowledgement (e.g., written waiver form) from the Member, prior to the provision of the service, indicating that: (1) the Member was advised that no coverage or only out -of -network 21 BHONationalAG 03.01.2023_V05_CO coverage, as applicable, would be available from the non -Government Plan; and (2) the Member agreed to be financialy -esponsible for additional costs related to such service. (3) At the direction of Carelon or in the event of non-payment by the Payor to Carelon for any reason, including the insolvency, or bankruptcy of any Payor, Provider may request payment for Services provided under the Agreement from a Papr for such Services. The parties further acknowledge and agree that in the event that Carelon's contract with a Plan is terminated for any reason or Carelon for any reason discontinues its business operations, the Plan shall be responsible for care coordination, authorization and reimbursement of Services provided to its Members. In such event, Provider shall recognize Plan to the same extent and in the same manner as it recognized Carelon under this Agreement for purposes of continuity of care to Members so long as the Payor is not EOHHS or CMS or there is some other applicable prohibition. (4) This Section and its subparts: (A) shall survive the termination of this Agreement regardless of the cause; (B) shall be construed b be for the benefit of Members; and (C) supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and a Member or any person acting on such Member's behalf. 7.6 Multiple Agreements. In the event Provider or any Practitioner is a party to more than one agreement with Carelon for the provision of Covered Services to Members, Provider or Practitioner, as applicable, will be paid by the Payor, or where applicable Carelon, for Covered Services under the agreement selected by Carelon. Provider agrees that it shall not request payment for Covered Services provided under this Agreement from any Plan in which it participates that is not a Payor. 7.7 Claims Disputes. In accordance with and subject to Carelon's policies and procedures and subject to the terms of the applicable Member Plan, Provider nay appeal administrative Claim denials based upon lack of timely submission or lack of Certification or authorization. Pi such Claims payments administrative appeals must be made in writing to Carelon within sixty (60) days of the date of payment. Article VIII: Term & Termination 8.1 Term. Unless a longer period is mandated by Applicable Rules, the term of this Agreement shall be for a period of one (1) year commencing orrthe Effective Date of this Agreement and will renew automatically for additional one (1) year terms unless and until: (a) either party notifies the other party ninety (90) days prior to the renewal date that the Agreement will not be renewed; or (b) -his Agreement is terminated by either party in accordance with the termination provisions specified in this Agreement. If Applicable Rules mandate a term longer than one year, then the term of this Agreement shall be the minimum mandated period, subject to automatic renewals for additional one (1) year terms as otherwise specified in this Section. 8.2 Termination WEhout Cause. Unless prohibited by Applicable Rules, this Agreement may be terminated by either party for any reason upon sixty (60) days' written notce to the other; provided however, that Carelon shall not terminate Provider on the grounds that Provider: (a) advocated on behalf of a Member or communicated with one or more of Provider's prospective, current or former Members concerning a Payor's compensation to Provider for Services, (b) filed a complaint against Carelon, (c) appealed a decision of Caelon, or (d) requested a review or challenged a termination decision of Carelon. Carelon and Provider agree that there will be no requirement or obligation to provide a reason for exercising its right to terminate the Agreement pursuant to this provision unless same is otherwise specifically required by Applicable Rules. 8.3 Termination Wch Cause. This Agreement may be terminated by either party for cause upon at least sixty (60) days' written notice to the other of a breach by such ether party of its obligations hereunder. Any such termination shall take effect on the date specified in the notice without further action required by the non -breaching party provided that the breaching party has failed to cure the breach within the first thirty (30) days following receipt of such written notice to the reasonable satisfaction of the non - breaching party. 22 BHONationalAG 03'-01.2023_V.05 CO 8.4 Suspension or Termination. Notwithstanding the foregoing, this Agreement and/or an individual Practitioner's participation under this Agreement, as applicable, may be terminated or suspended immediately by Carelon, at its sole discretion, with written notice to Provider upon the occurrence of: (a) suspension, revocation, condition, expiration or other restriction of license, credentials or certification; (b) criminal charges related to the rendering of health care services being filed against Provider or the Practitioner or any of Provider's executive officers; (c) the termination or lapse of the insurance requirements, or failure to maintain the amount of insurance required as specified in this Agreement above; (d) failure to remain in compliance with Carelon's licensure and credentialing/re-credentialing standards, including but not limited to failure to update or to certify as to accuracy of provider and Practitioner -level information; (e) debarment, suspension, exclusion, or preclusion from participation in any federal or state government sponsored health program, including without limitation Medicaid; (f) a determination of fraud, waste or abuse; (g) a threat to the health or well-being of person(s) receiving services; (h) if Carelon becomes aware of prior license/certification sanctions against, or unsatisfactory malpractice history of, Provider or an individual Practitioner; or (i) if a Facility or Group Provider, where applicable, has not credentialed Practitioners qualified to provide services under the Agreement. Carelon may suspend referrals to, and/or reassign, Members from Provider and/or a particular Practitioner pending investigation of the alleged occurrences of the events listed in this Section and/or when Carelon determines in its sole discretion that an investigation is in the best interests of its Members, and Carelon shall notify Provider or the Practitioner, as applicable, in writing of same. Further, Carelon may terminate this Agreement immediately upon written notice to Provider in the event that (i) there is a change in control in Provider and/or the new owner or ownership is not acceptable to Carelon; (ii) Provider engages in or acquiesces to any voluntary or involuntary act of bankruptcy, insolvency, receivership or reorganization or assignment for the benefit of creditors; or (iii) Carelon' agreement with any of the Plans or Payors for management of their respective programs terminates. 8.5 Practitioner/Provider/Facility/Location Exclusion from Participation. Provider agrees that if Carelon requests in writing and with explanation that a Practitioner no longer renders services to Members pursuant to this Agreement, Provider shall immediately comply with such request and agrees to remove such Practitioner from participation under this Agreement. Provider agrees that should Carelon determine that it no longer desires to have one of Provider's and/or a Provider Practitioner's office locations or facilities participate under this Agreement, Provider will immediately remove such location or facility from participation under this Agreement. Notwithstanding anything to the contrary in this Agreement, Provider is not guaranteed inclusion in the Carelon network for purposes of servicing Members of every Plan or Line of Business with which Carelon has contracted to arrange for the provision of mental health or substance use disorder services. 8.6 Pavor Termination. The parties agree that a Payor may terminate Provider's and/or a Practitioner's participation and/or a Provider or Practitioner's office location or facility from such Payor's provider network(s) or Line of Business and their status as a participating provider with Payor upon at least sixty (60) days' prior written notice to Carelon and Provider containing the reason for the proposed termination in the event of the following: (a) the occurrence of an event that renders Provider or Practitioner, respectively, unable to provide services as required under this Agreement; (b) Payor determines Provider or the Practitioner, respectively, does not satisfy criteria for participation as a Payor participating provider, including without limitation criteria related to quality of care, utilization management, billing practices or failure to cooperate with re- credentialing processes; or (c) Payor determines that Provider or a Practitioner, respectively, fails to comply with the terms of this Agreement as they apply to services to Payor's Members, and Provider and/or Practitioner fails to cure such non- compliance during the above -noted sixty (60) day notice period. 8.7 Termination Related to Amendments. Either Party may terminate the Agreement on thirty (30) days' advance written notice based on Provider's inability or refusal to comply with an amendment to this Agreement submitted to Provider by Carelon pursuant to the terms of this Agreement. 8.8 Application. Regardless of any provision to the contrary, Provider understands and agrees that termination of this Agreement for any reason shall simultaneously terminate Provider's and all Practitioners' participation, through Carelon, in the Plans of all Payors. Provider agrees that Carelon may notify each Payor of the termination of Provider from the Carelon provider network(s). 23 BHONationalAG 03.01.2023_V.05_CO 8.9 Continuation of Service. Unless Carelon advises to the contrary, Provider shall continue to provide Covered Services, at the rates and pursuant to the requirement specified in this Agreement, to Members in an inpatient status or receiving active treatment at the time of suspension or termination of this Agreement for as long as required by Applicable Rules and until discharge for inpatient Covered Services or until the course of treatment is completed or until Carelon makes reasonable and medically appropriate arrangements b have another participating provider render such services. In the case of Members receiving inpatient service, on -going treatments shall include Medically Necessary post -discharge ambulatory services. Payment for Covered Services hereunder shall be in accordance with the applicable Rate Schedule in Exhibit A. In the event a decree or order is entered adjudicating Carelon or the applicable Plan or Payor bankrupt or insolvent, Provider shall continue to provide Services to Plan Members after notification of such insolvency adjudication for a period of (a) thirty (30) Days for all outpatient Providers, and (b) up to six (6) months for all inpatient Providers. 8.10 Transition. Upon notice of non -renewal or termination of this Agreement for any reason, Provider agrees to reasonably cooperate with Carelon and Payors to notify the Members and to enable and support the transition and/or transfer of Members under the care of Provider to other participating providers. 8.11 Audits & Investigations. To the extent that a claim for Covered Services is at issue and even if the Agreement has otherwise terminated, Provider shall continue to cooperate with an audit or investigation of the Payor or Carelon and to provide access to documents and records reasonably requested in the course of such audit or investigation. The provisions of this Section shall survive termination of the Agreement. Article IX: Governing Law and Compliance 9.1 Governing Law. This Agreement shall be interpreted and construed in accordance with the laws of the jurisdiction where the services at issue are performed, without regard to its conflicts of law provisions and except to extent preempted by Applicable Rules. Notwithstanding the foregoing, in the event that interpretation is required of the Member's Plan, such interpretation shall be based on the law of the jurisdiction where the Member's Plan was issued or the law otherwise applicable thereto, unless such state laws are otherwise preempted by federal law. 9.2 Legal Compliance. The parties agree to comply with all Applicable Rules. The alleged failure by either party to comply with Applicable Rules shall not be construed as allowing either party a private right of action against the other in any legal or administrative proceeding in matters in which such right is not recognized by such law, rule or regulation. Without limiting the generality of the foregoing, each party specifically represents and warrants that activities to be performed under this Agreement are not considered illegal remunerations (including kickbacks, bribes or rebates) as defined in 42 USCA § 1320(a) -7b or any other Applicable Rules. In entering into this Agreement, neither party (a) gives or receives remuneration in return for or to induce the provision or acceptance of business (other than business covered by the agreement) -or which payment may be made in whole or in part by a Federal health care program on a fee -for -service or cost basis, and (b) shifts the financial burden of the Agreement to the extent that increased payments are claimed from a Federal health care program. Each party will comply with Applicable Rules designed to prevent fraud, waste, and abuse, including withou_ limitation applicable provisions of federal criminal law, the False Claims Act (31 U.S.C. § 3729 et seq.), the Anti -Kickback statute (42 U.S.C. § 1320a-7b(b)), the Anti -Influencing statute (42 U.S.C. § 1320a-7a(a)(5)), and the Stark statute (4-2 U.S.C. § 1395nn). 42 C.F.R. §§ 422.504(h((1(, 423.505(h((1). Provider represents and warrants that Provider does not give, provide, condone or receive any incentives or kickbacks, monetary or otherwise, in exchange for the referral of a Member, and if a Claim for payment is attributable to an instance in which Provider provided or received an incentive or kickback in exchange for the referral, such Claim shall not be payable and, if paid in error, shall be refunded to Payor. Provider shall provide prompt notice to Carelon of any conflicts of interest or any basis for potential violations by Provider with respect to Applicable Rules that govern referrals required for the provision of certain healthcare services, including, Federal and State anti -kickback and anti -self referral laws, rules and regulations. Provider agrees to disclose to 24 BHONationalAC 03.01.2023_V.05 CO Carelon any interest, affiliation, or control by Provider or Provider's immediate family member of any other provider of medical, health, or administrative services to which Provider refers patients upon request. In submitting claims or requests for payment from the State health care program for items and services furnished in accordance with this Agreement, Provider must not claim or request payment for amounts in excess of the fee schedule from the Payors or Members (see 42 C.F.R. § 1001.952 (t)(1)(ii)). 9.3 Individual State Laws. In addition to the terms and conditions of this Agreement, the provisions of Exhibit B (including any sub -parts thereto) shall apply to Covered Services rendered to Members subject to a particular state's laws as further set forth therein. In the event of any conflict between any provision of Exhibit B and any other provision in this Agreement, the provisions of Exhibit B shall govern if the services in question are governed by that state's laws. If the services in question are not governed by that state's law, then the terms and conditions of Exhibit B shall not govem. 9.4 Other Plan Specific Provisions. For any Services provided to a Member covered under a Plan that has program specific requirements, the requirements contained in Exhibit C shall apply to services provided to Members of that Plan. In the event of any conflict between any provision of Exhibit C and any other provision in this Agreement, the provisions of Exhibit C shall govern if the services are related to Members covered by the Plan with program specific requirements to the extent permitted by Applicable Rules. If the services in question are not related to a Member covered by the Plan with specific provisions, the terms and conditions of Exhibit C shall not apply. 9.5 Excluded or Precluded Individuals/Entities. Provider and Carelon respectively represent that neither is, nor knowingly employs or contracts with individuals or entities, excluded from, or ineligible for, or precluded from, participation in any federal or state government sponsored health care program (including without limitation Medicare and Medicaid). Provider shall on a monthly basis monitor Practitioners, its employees, contractors and any downstream entities, against the federal and state exclusion or preclusion lists and provide prompt notice to Carelon in the event of a person or entity being placed on a federal or state exclusion or preclusion listing or charged with a criminal offense involving government business, or otherwise barred from performing services paid for by government monies. Provider acknowledges and agrees that neither Carelon nor Payor shall make payment under this Agreement for services performed in whole or in part by Provider or Practitioner or any downstream entity convicted of a crime involving government business or while such person or entity is listed on an exclusion or preclusion list. Provider shall indemnify and hold Carelon and Plan harmless from and against any claims, actions, liabilities, costs, damages, and expenses, including reasonable attorneys' fees, arising from or relating to Provider's direct or indirect involvement as or with Persons that are on excluded or precluded lists or convicted of criminal action involving government contracts. The provisions of this section shall survive termination of this Agreement. Provider shall notify Carelon if it has a civil judgment entered against it or a Practitioner for fraudulent activities or if it knows or should know that any downstream entity has a civil judgment entered against it/him/her for fraudulent activities. 9.6 Confidentiality of Member Records. The parties agree to: (a) have and implement procedures designed to preserve the privacy and confidentiality of Member records; and (b) maintain, retain, use and/or disclose such Member records and any Protected Health Information in accordance with HIPAA, 42 C.F.R. Part 2 as related to alcohol and/or substance use disorder services and/or records, and all other Applicable Rules. Provider acknowledges that Carelon and Payor will use Member record information for purposes of treatment, payment and health care operations and therefor Provider represents and warrants that release of Member heath information records (including but not limited to records related to mental health and/or substance use disorder treatment) to Carelon and Payors have been made pursuant to member consents conforming to Applicable Rules governing the use and disclosure of that information by and to Carelon and Payors for purposes of treatment, payment and health care operations. Provider shall ensure that all records maintained electronically meet all Applicable Rules related to the storage, transmission and maintenance of such records. Provider acknowledges that in the event that Carelon discloses Member patient -level data (such as health care service utilization, medical expenses, and demographics) to Provider for the purpose of carrying out treatment, coordinating care among providers and managing the care of their own patient panel, Provider shall share with individual Practitioners patient -level data related only to Members under treatment by that Practitioner. 25 BHONationalAG 03.01.2023_[!05 CO Provider shall review all Members' personally identifiable information received from Carelon to ensure no misrouted Protected Heath Information is included. Misrouted Protected Health Information includes information about Member that Provider is na currently treating. Provider shall immediately destroy any misrouted Protected Health Information or safeguard the Protected Health Information for as long as it is retained. In no event shall Provider be permitted to misuse or re -disclose nisrouted Protected Health Information. If Provider cannot destroy or safeguard misrouted Protected Health Information, Provider must contact Carelon to report receipt of misrouted Protected Health Information. 9.7 Regulatory Access. Provider health information records, encounter data, and financial information shall be open for inspection, review and copy upon request curing reasonable times by state and federal regulators with jurisdiction over Payors, Carelon and/or the Provider, inducing the U.S. Department of Health and Human Services, the Comptroller General of the United States, State Insurance Departments, and/or other authorized state or federal regulatory agencies or entities, or their duly authorized representatives to the extent and for the period of time required by Applicable Rules. This provision shall survive termination of the Agreement, regardless of the cause. 9.8 Physician Incentive Plans. Any incentive pzans between Carelon and Provider and/or between Carelon and physicians, practitioners, providers and/or facilities emploged or owned by and/or contracted with Provider to render services to Members under the Agreement shall be in compliance with Applicable Rules, including without limitation 42 C.F.R. §§ 417.479 and 434.70. Upon request, Provider agree: to disclose to Carelon and Payors the terms and conditions of any "physician incentive plan" as defined by Applicable Rules. 9.9 Ownership Disclosure. Upon request, Provider agrees to provide Carelon, each Plan, the U.S. Department of Health and Human Services, the U.S. Government Accountability Office, the Office of the Inspector General and/or state agencies with oversight or regulatory authority with all information concerning: (1) the ownership of any subcontractor with which Provider has had business transactions totaling more than $25,000 during a 12 -month look back period from the date of the request; (2) any significant business transactions between the Provider and any wholly -owned supplier or between the Provider and any subcontractor curing a five (5) -year look back period from the date of the request; and (3) such additional information as may be reasonably required. Provider shall provide such information at the time of signing of this Agreement and no later than thirty (30) gays after any future request for the information. 9.10Solicitation. Nothing contained herein shall be construed as an arrangement or an agreement for solicitation of patients for Provider, nor shall Carelon be required to advertise or promote Provider's services. Provider authorizes Carelon and the Plan to publish the nacre, business address and area of practice of Provider and any Practitioner in their provider directory. 9.11 Reporting. Upon reasonabb request, Provider agrees to provide Carelon and Payors with timely access to records, reports, clinical information andbr encounter data in the format required to meet obligations under contracts with any government agency sponsoring or overseeing Plans covered under this Agreement. 9.12Discrimination Employment Practices. Each party agrees that, in conformity with Applicable Rules (including, as applicable, 41 C.F.R. §§60-1.4(a), 60-300.5(a), and 60-741.5(a), it shall not discriminate against qualified individuals for employment based on their race, color, religion, sex, or national Jrigin or based on their status as protected veterans or individuals with disabilities or such other basis as may be added ky law or regulation. Provider and any Provider contractors shall take affirmative action to employ and advance in empbyment individuals without regard to race, color, religion, sex, gender identity or expression, national origin, protected veteran status, or disability. 9.13Compliance Pregram and Anti -Fraud Initiatives. Provider shall art shall cause its Practitioners and downstream entities to: 26 BKONationalAC 0.₹ 01.2023_V.05 CO (a) Institute, operate, and maintain an effective compliance program to detect, correct and prevent non-compliance with Applicable Rules and the incidence of fraud, waste and abuse relating to the Plans. (b) Upon Carelon or Plan's request, provide supporting documentation and certify, as necessary, compliance with applicable training and education requirements and other requirements of this Section. (c) Upon Carelon or Plan's request, demonstrate that appropriate standards of conduct and compliance policies and procedures are distributed to Provider, Practitioners, downstream entities and to each of their employees. (d) Cooperate and comply with Carelon and Plan compliance program activities. (e) Promptly report to Carelon, as the Plan's designee, any identified instances of non-compliance with Applicable Rules or this Agreement, or any actual or suspected fraud, waste or abuse in connection with any Plan so that Carelon can evaluate and determine if corrective action is necessary. Provider shall take such corrective actions that Carelon reasonably directs. Provider shall develop and implement written policies and procedures for such self -reporting and shall, upon request, provide copies of such policies and procedures to Carelon and be subject to audit to evaluate compliance with such policies and procedures. (f) Promptly provide Carelon and Plan with documentation necessary to satisfy a regulatory audit of Carelon or Plan and take corrective action reasonably directed by Carelon or Plan to satisfy Provider's obligations under the Agreement in conformance with Plan requirements. (g) Notify Carelon within thirty (30) days (or such shorter period as is required by Applicable Rules) after identifying an overpayment Provider received. Provider shall take appropriate steps to remedy the overpayment within sixty (60) days of the date of identification. 9.15 Pass -Through Charges. Provider agrees not to pass through to any Plan, Carelon or Member any charges that Provider incurs as a result of providing supplies or making referrals to another provider or entity. Examples include, but are not limited to, pass -through charges associated with laboratory services. If a permitted subcontractor of the Provider is a Participating Provider in a Plan applicable to services rendered to a Member, then the provider agreement with the subcontractor shall prevail over this Agreement with respect to payment for services rendered to that Member by the subcontractor. Article X: Dispute Resolution 10.1 Unresolved Disputes. Carelon and Provider agree to attempt to resolve all disputes concerning the performance or interpretation of this Agreement promptly by negotiation between the parties. As a condition precedent to the submission of any unresolved disputes to binding arbitration and/or pursuit of any termination of the Agreement pursuant to the provisions of this Article X, Provider agrees to exhaust all of Carelon's administrative review and/or grievance and appeal procedures as specified in the Provider Manual. (a) Notwithstanding any provision to the contrary, in the case of a dispute concerning Carelon credentialing or re- credentialing of Provider, or a dispute arising out of Carelon's implementation of any requirements imposed upon Carelon or Provider by a Payor, the decision of the respective Carelon internal grievance system for such kind of disputes shall be final and binding on Provider. Provider shall not maintain any action against Carelon, or its shareholders, officers, directors, agents or committee members, to seek financial or other compensation for any damages arising out of the Carelon's ministerial implementation of a Payor's credentialing determination. (b) The parties agree that, with the exception of the disputes handled pursuant to Section 10.1(a), above and as may be further specified in Provider Manual as to a particular Plan, the exclusive remedy for unresolved disputes under this Agreement, including without limitation a dispute involving interpretation of any provision of this Agreement, questions regarding application and/or interpretation of Applicable Rules, the parties' respective obligations under this Agreement, or otherwise arising out of the parties' business relationship, shall be resolved by binding individual arbitration as provided for below. Individual arbitration shall be in lieu of any and all lawsuits or other civil legal 27 BHONationalAG 03.01.2023_V.05 CO proceedings relating to the parties' relationship, including, but not limited to, class or multi -party actions either in court or arbitraton; provided, however, that the submission of any dispute to arbitration shall not adversely affect any party's right to seek available preliminary injunctive relief from a court of competent jurisdiction. (c) Notwithstanding any other provision to the contrary, enforcement of this arbitration clause, including the waiver of class actions, shall be determined under the Federal Arbitration Act ("FAA"), including the FAA's preemptive effect on state law. The parties agree that the arbitration shall be conducted on a confidential basis. Subject to any disclosures that may be required or requested under Applicable Rules, the parties further agree that they shall maintain the confidential nature of the arbitration, including without limitation, the existence of the arbitration, information exchanged during the arbitration, and the award of the arbitrator(s). Nothing in this provision, however, shall preclude either party from disclosing any such details regarding the arbitration to its accountants, auditors, brokers, insurers, reinsurers or retrocessimaires. (d) Any arbitration proceedings shall be held in the jurisdiction of the Qualified Location where the services at issue were delivered by Provider unless the parties mutually agreed upon a different location. Except as specified herein, any arbitration proceedings shall be conducted in accordance with and subject to the American Health Lawyers Association Rules of Procedure for Arbitration ("AHLA Rules") then in effect, or under such other mutually agreed upon guidelines. Arbitrations shall be conducted before a single arbitrator. (e) Notwithstanding the AHLA Rules, and unless the parties mutually agree to different limitations, discovery in all arbitration proceedings shall be limited to: (1) two fact depositions for each party; (2) ten document requests; and, (3) five interrogatories. Each party shall provide an expert disclosure substantively similar to those required under the Federal Rules of Civil Procedure for all testifying experts and make its testifying expert(s) available for deposition. Each party shall also have the right to file for summary judgment in arbitration and a merits evidentiary hearing shall be schedubd at a time no earlier than 45 days after the arbitrator's summary judgment decision is issued. (f) The arbitrator(s): (1) may construe or interpret but shall not vary or ignore the terms of this Agreement; (2) shall be bound by Applicable Rules; and, (3) shall not be empowered to certify any class or conduct any class based arbitration or award punitive or consequential damages. The decision of the arbitrator(s) shall be final, conclusive and binding. Judgment upon the award rendered in any such arbitration may be entered in any court of competent jurisdiction, or application may be made to such court for judicial application and enforcement of the award, as Applicable Rules may require or 4low. (g) Each party -shall assume its own costs (including without limitation its own attorneys' fees and such other costs and expenses recurred related to the proceedings), but the compensation and expenses of the arbitrator and any administrative fees or costs of any arbitration proceeding(s) hereunder shall be borne equally by Candor and Provider. (h) The parties on behalf of themselves and those that they may now or hereafter represent, each agree to and do hereby waive any light to join or consolidate claims in arbitration by or against other individuals or entities or to pursue, on a class basis, any dispute; provided, however, if there is a dispute regarding the applicability or enforcement of the waiver provision irr this paragraph, that dispute shall be decided by a court of competent jurisdiction. If a court of competent jurisdiction determines that such waiver is unenforceable for any reason with respect to a particular dispute, then the parties agree that the arbitration provisions shall not apply to such dispute and that such dispute shall be decided instead in a court of competent jurisdiction. (i) Limitations on Injunctive Relief. The parties, on behalf of themselves and those that they may now or hereafter represent, each agree that any injunctive relief sought against the other party shall be limited to the conduct relevant to the parties to the arbitration and shall not be sought for the benefit of individuals or entities who are not parties to the arbitration. The arbitrator(s) are not authorized to issue injunctive relief for the benefit of an individual or entity who is not a party to the arbitration. The arbitrator shall be limited to issuing injunctive relief related to the specific issues in the arbitration. 28 BHONationalAG 0i.01.2023_V.05 CO Article XI: Miscellaneous 11.1 Notice. Any notice required to be given pursuant to the terms of this Agreement shall be in writing and shall be delivered, costs prepaid, by hand, facsimile, electronic mail, mail or by recognized overnight courier, to the receiving party at the address set forth on the signature page of this Agreement; provided, however, if a party designates an updated address for itself by Notice in accordance with this Section, then notice should be sent to the updated address. Notice shall be deemed to be effective: (a) when delivered or refused by hand, (b) upon transmittal when transmitted by facsimile transmission or by electronic mail, (c) on the date of delivery or refusal as shown on the return receipt if delivered by mail or overnight courier, or (d) if sent by regular mail, five (5) days from the date set forth on the correspondence. Notice to Provider is notice to Provider and all of its Practitioners. 11.2Amendments. Except as provided for below, any amendment to this Agreement must be made in writing and executed by both parties. Notwithstanding the above: (a) this Agreement shall be automatically amended to comply with Applicable Rules and accreditation requirements to which Carelon is or may be subject; and/or (b) Carelon may amend this Agreement by giving Provider prior written notice setting forth the terms of the proposed amendment. Notice to Provider is notice to Provider and all of its Practitioners. Provider shall then have thirty (30) days, unless a longer period is required under Applicable Rules in which case the longer period shall apply, from the receipt of Carelon's notice to reject the proposed amendment by written notice of rejection to Carelon. If Carelon does not receive such written notice of rejection within that thirty (30) day period, the proposed amendment shall be deemed accepted by and shall be binding upon Provider, effective as of the end of such thirty (30) day period. If Provider rejects a proposed amendment, either party may, in its discretion, elect to terminate this Agreement upon thirty (30) days' written notice to the other party. 11.3 Scope/Chanqe in Status/Newly Acquired Persons/Entities. a. Carelon and Provider agree that this Agreement applies to Covered Services rendered by Provider at Qualified Locations. Carelon may, in its discretion, limit this Agreement to Provider's locations, operations, business or corporate form, status or structure in existence on the Effective Date of this Agreement and prior to the occurrence of any of the events set forth in this Section 11.3(a). Unless otherwise required by Applicable Rules, Provider shall provide at least ninety (90) days' prior written notice of any of the following events: (i) Provider (a) sells, transfers or conveys his/her/its business or any substantial portion of his/her/its business assets to another entity through any manner including but not limited to a stock, real estate or asset transaction or other type of transfer; (b) is otherwise acquired or controlled by any other entity through any manner, including but not limited to purchase, merger, consolidation, alliance, joint venture, partnership, association, or expansion; or (ii) Provider transfers control of his/her/its management or operations to any third party, including Provider entering into a management contract with a physician practice management company or with another entity which does not manage Provider as of the Effective Date of this Agreement, or there is a subsequent change in control of Provider's current management company; or (iii) Provider acquires or controls any other medical practice, facility, service, beds or entity; or (iv) Provider changes his/her/its locations, business or operations, corporate form or status, tax identification number, or similar demographic information; or (v) Provider creates or otherwise operates a licensed health maintenance organization or commercial health plan (whether such creation or operation is direct or through a Provider affiliate). b. Notwithstanding the termination provisions of this Agreement, and without limiting any of Carelon's rights as set forth elsewhere in this Agreement, Carelon shall have the right to terminate this Agreement by giving at least sixty (60) days' written notice to Provider if (i) Carelon determines, that as a result of any of the transactions listed in subsection 11.3(a), Provider cannot satisfactorily perform the obligations hereunder, or cannot comply with one or more of the terms and conditions of this Agreement, including but not limited to the confidentiality provisions herein; or (ii) Carelon elects in 29 BHONationalAG_03.01.2023_V.O5 CO its reascn�le business discretion not to do business with Provider, the successor entity or new management company, as a result of one or more of the events as set forth in subsection 11.3(a). c. Provider shall provide Carelon with thirty (30) days' prior written notice of: (i) Addltion or removal of individual provider(s) who are employed or subcontracted with Provider, if appicable. Any new individual providers must meet applicable credentialing requirements or other standards of participation prior to being designated as a participating provider under this Agreement; or (ii) A clange in mailing address. d. If Provider is acquired by, acquires or merges with another entity, and such entity already has an agreement with Carelon, Carelon will determine in its sole discretion which Agreement will prevail. If, after the Effective Date of this Agreement Provider transfers an existing business of Provider represented by one tax identification number to a different tax identification number and such transfer results in Provider being reimbursed at a higher reimbursement rate, then Provider and Carelon will discuss such movement to an entity with the new tax identification number, and will make qppropriate adjustments to compensation of Provider so that the movement shall be revenue neutral in that the business transferred will be reimbursed at the lower reimbursement rate as applied prior to the transfer. 11.4 Assignment. This Agreement, being intended to secure the services of Provider hereunder and therein constitute personal services, may not be assigned, delegated or transferred by Provider without the prior written consent of Carelon, which Carelon may withhold in its sale discretion; provided, however, that claims for money due hereunder may be assigned to a bank, trust company or otter financial institution without such consent so long as notice of such assignment is furnished promptly to Carelon. Carelen's approval of an assignment or subcontract in any one instance shall not constitute approval of any other assignment or subcontracting. Carelon may assign any of its rights or obligations under this Agreement, in whole or in part, in its discretion. 11.5 Inurement/Affiliates/Subcontracting. This Agreement shall inure to and be for the benefit of the parties and each of their respective transferees, successors and permitted assig is. In addition, this Agreement shall inure to the benefit of all Affiliates and their respective transferees, sucessors and permitted assigns, thereby granting such Affiliates the right to utilize this Agreement for their own benefit. For the avoidance of doubt, Provider acknowledges and agrees that if an Affiliate exercises its rights to avail itself of the terms of this Agreement, Provider shall look solely to such Affiliate for all matters related to services rendered for that Affiliate and theAffiliate's Plans, Payors and Members. For the avoidance of doubt, Provider understands and agrees that Carelon Behavoral Health, Inc., Carelon Behavioral Health Strategies, LLC and any Affiliate are not jointly and severally liable for any claims under this Agreement. The joinder of an Affiliate under the designation "Carelon" shall not be construed as imposing out responsibility or cross -guarantee between or amongst Carelon entities. In the event that any party enters into a permitted subcontract to perform any of that party's obligations hereunder, the subcontracting party shall be responsible for assuring performance by its subcontractor and a breach or default by a subcontractor shall be considered a breach or default by the subcontracting party hereunder. If a permitted subcontractor of the Provider is a participating provider in a Plan applicable to services rendered to a Member, then the provider agreement with the subcontractor shall prevail over this.Agreement with respect to payment for services rendered to that Member by the subcontractor. 11.6 Third Party Beneficiary. This Agreement does not create any third party beneficiary rights in any person or entity other than Plans, Payors and government sponsors as the context may require. 11.7 Use of Name. During the term of this Agreement, Provider consents to the use, publication, disclosure, and display of its name and other identifying and thscriptive information in provider directories and marketing materials and for other commercially reasonable general business purposes, either directly or through a third party, including but not limited to demographic information, information rega-ding credentialing, affiliations, performance data, rates and information related to Provider for transparency initiatives. Use of the Provider name, logos, trademarks or service marks in public advertising shall require prior written consent of the Provider. Provider may not use Carelon's name, logos, trademarks and service marks in marketing material 30 BHONationalAG 03_01.2023_V.05 CO or otherwise without Carelon's prior written consent, except that Provider may, without Carelon's consent, list Carelon in its standard list of contracted managed care organizations that is routinely provided to patients. 11.8 Indemnification. (a) Carelon shall defend, hold harmless and indemnify Provider and its directors, officers, agents, contractors or employees from and against any and all claims, suits, liabilities, damages, judgments, costs and expenses, including reasonable attorneys' fees, that may be imposed upon, or suffered or incurred by, any of them as a result of claims by third parties or Carelon employees that arise out of, derive from or pertain to Cordon's breach of obligations to Provider under this Agreement. For purposes of clarity, Carelon is not required to indemnify Provider for any expenses or liabilities, including, without limitation, judgments, settlements, attorneys' fees, court costs or any associated charges incurred in connection with any claim or action brought against Provider based on Provider's professional decisions or actions. (b) Provider shall defend, hold harmless and indemnify, to the extent permitted under Colorado Law, Carelon, Plan and Payor and their respective directors, officers, members, agents, contractors or employees from and against any and all claims, suits, liabilities, damages, judgments, costs and expenses, including reasonable attorneys' fees, that may be imposed upon or suffered or incurred by any of them as a result of claims by third parties or Provider's owners or employees that arise out of, derive from or pertain to any professional negligence and/or actual or alleged acts or omissions by, or on the part of, the Provider or any of its directors, officers, agents or employees in providing the Services. For purposes of clarity, Provider is not required to indemnify or defend Carelon for any expenses or liabilities, including, without limitation, judgments, settlements, attorney's fees, court costs or any associated charges incurred in connection with any claim or action brought against Carelon based on Carelon's or the applicable Plan's management decisions, Utilization Review provisions or other policies, guidelines or actions. (c) A party claiming indemnity or defense under this Section shall give written notice to the other party promptly upon becoming aware of any claim that may be subject to such indemnity or defense. Moreover, the indemnifying party agrees not to enter into any settlement or compromise of any claim or action in a manner that admits fault or imposes any restrictions or obligations on an indemnified party without that indemnified party's prior written consent, which will not be unreasonably withheld, and cooperating fully with the indemnifying party in connection with such defense and settlement. (d) Regardless of whether there is a total and fundamental breach of this Agreement or whether any remedy provided in this Agreement fails of its essential purpose, in no event shall either of the parties hereto be liable for any amounts representing loss of revenues, loss of profits, loss of business, the multiple portion of any multiplied damage award, or incidental, indirect, consequential, special or punitive damages, whether arising in contract, tort (including negligence), or otherwise regardless of whether the parties have been advised of the possibility of such damages, arising in any way out of or relating to this Agreement. Further, in no event shall Plan be liable to Provider for any extracontractual damages relating to any claim or cause of action assigned to Provider by any person or entity. 11.9 Confidentiality. Each party or their respective employees or agents may, in the course of the relationship established by this Agreement, disclose in confidence to the other party certain Confidential Information. Each party acknowledges that the disclosing party shall at all times be and remain the owner of all Confidential Information disclosed by such party, and that the party to which Confidential Information is disclosed shall in a manner consistent with the manner in which it protects its own Confidential Information, preserve the confidentiality of any such Confidential Information which such party knows or reasonably should know that the other party deems to be Confidential Information. Neither party shall use for its own benefit or disclose to third parties any Confidential Information of the other party without such other party's written consent. (a) Provider agrees that at no time during or after the term of this Agreement, except as may be required to carry out or its duties and obligations hereunder, shall Provider, Practitioners, or officers, directors, agents, contractors or employees of Provider, without the prior written consent of Carelon, whether directly or indirectly, or for competitive or other purposes, disclose or cause to be disclosed to a third party, or make or cause any unauthorized use of: (i) any Carelon's policy manuals or other proprietary information of Carelon; or (ii) any term or condition of this Agreement, its exhibits, attachments or schedules. Nothing herein shall be construed as prohibiting or penalizing communication between Provider and/or Practitioners and Members regarding any and all available treatment options, related to the health care 31 BHONationalAG 03.01.2023_V.05_CO needs of such Member regardless of benefit coverage exclusions or limitations or any terms or conditions relating thereto. (b) Provider shall protect the confidentiality of any Payor specific confidential or proprietary information received by Provider. 11.10 Non -exclusivity. Carelon ancFrovider each expressly reserve the right to enter into similar agreements with other organizations in order to obtain services for Members or to provide services for other payors, plans, or any other organization. 11.11 Force Maieire. (a) Except tr payment of sums due, neither party shall be liable to the other nor deemed in default under this Agreement if and to:the extent that such party's performance of this Agreement is prevented by reason of force majeure. (b) Force majeure means an occurrence that is beyond the reasonable control of the party declaring force majeure, which sech party is unable to prevent by exercising reasonable diligence and which occurs without its fault or negligence, and includes events such as acts of God; acts of the public enemy; war; riots; declared states of emergency; strikes; terrorism; mobilization; civil disorders; fire; flood; lockouts; pandemic; and failure or refusals to act by government authority. Force majeure shall not include the inability of either party to acquire or maintain any required insurance, bond, licenses or permits. (c) Force majeure shall be deemed to commence when the party declaring force majeure notifies the other party of the existent of the force majeure and shall be deemed to continue as long as the results or effects of the force majeure prevent fie party from resuming performance in accordance with this Agreement. (d) Any delay or failure in performance by either party hereto shall not constitute default hereunder or give rise to any claim for damages or loss of anticipated profits if, and to the extent that, such delay or failure is caused by force majeure. 11.12 Waiver. Waiver, wheher express or implied, of any breach of any provision of this Agreement shall not be deemed to be a waiver of any other provision or a waiver of any subsequent or continuing breach of the same provision. In addition, waiver of one of the remedies available to either party in the event of a default or breach of this Agreement by the other party shall not at any time be deemed a waiver of a party's right to elect such remedy(ies) at any subsequent time if a condition of default continues or recurs. 11.13 Severability. In the event hat any portion of this Agreement is determined to be illegal, invalid, void or unenforceable by a court of competent jurisdiction, such illegality, invalidity, voidance, or unenforceability will not render illegal, invalid, void or unenforceabE any other part or provision of this Agreement and that portion that is invalid, illegal or unenforceable shall be modified b the least extent possible so as to carry out the Parties' intent in an equitable manner. In the event that the provision camot be renegotiated in good -faith to reflect as nearly as possible the original intent of the Parties, then this Agreement may be terminated by either Party upon written notice upon the other, and no further obligations shall be owed by the Parties to each other. 11.14 Entire Agreement/Construction. This Agreement, and all addenda, schedules and Exhibits thereto, all as may be amended from time to time, constitute the entire uncerstanding and agreement of the parties and supersedes any prior written or oral agreement pertaining to the subject matter hereof. This Agreement shall be construed without regard to any presumption or other rule requiring construction against the party causing this Agreement to be drafted. Whenever required by the context of this Agreement, the singular shall include the plural and the plural shall include the singular, and the masculine, feminine and neuter genders shall' each include the others, and the word "person" shall include corporations, partnerships, agencies, or other entities. 32 BHONationalAC 0'.01.2023_V.05_CO 11.15 Survival of Provisions. As of the effective date of termination of this Agreement, no party shall have any further rights or obligations hereunder except for rights and obligations accruing prior to such effective date of termination, or arising as a result of any breach of this Agreement. Notwithstanding the foregoing, any provision of this Agreement, by its terms or by its nature, creating obligations beyond the term of this Agreement shall survive the termination of this Agreement, regardless of the reason for such termination or whether it is expressly identified as surviving. Neither expiration nor termination by either party shall relieve the other party of liability for any costs, injuries, penalties, damages or other charges sustained by either party, by virtue of any breach or default by either party, and each party retains the right to pursue any and all available legal and equitable remedies. 11.16 Headings and Captions. The headings and captions of the articles and sections of this Agreement are inserted for convenience of reference only, and shall not constitute a part hereof or be construed against the drafter. 11.17 Counterparts. This Agreement may be executed in one or more counterparts, each of which shall be deemed an original, but all of which constitute one and the same Agreement. The Parties further agree that an electronic signature, electronically scanned signature or facsimile signature shall have the same legal significance (for this document and any counterparts only) as an original signature. ---Signatures Follow --- 33 BHONationalAC 03.01.2023_!! 05_CO DocuSign Envelope ID: 62EC88E9-462E-4956-9CF8-920085705A99 THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION THAT MAYBE ENFORCED BY THE PARTIES Intending to be legally bound, the parties have caused their authorized representatives to execute this Agreement effective as of the date set forth by Carelon below. Provider:Weld County Department of Human Services, on behalf of itself and each of its Practitioners by and, through the Board of Weld County ssi rs uocu,sa by: 7 fJ JAN 3 1 2024 ekiatA, Serin,if, Signature Date Si�alure Kevin D. Ross, BOCC Chair Print Name S Title 84-6000813 Federal Tax Identification Number Address for Notice: Ryan Sorrell Carelon Behavioral Health, Inc. and Carelon Behavioral Health Strategies, LLC, on behalf of themselves and each of their Affiliates 2/20/2024 Date Regional vice President Print Name S Title Address for Notice: Weld County Department of Human Services[name] Carelon Behavioral Health 315 North 11th Avenue [street address] P.O. Box 989 Greeley, Colorado 80631 [city/state/zip] Latham, NY 12110 - 6402 Attention: Rachel Wisdom -Vidal Attn: National Provider Network Operations 970-353-5212 [Fax] wisdomre@weld.pov [Email] Please do NOT write below this line. For Carelon office use ONLY. 3/15/24 EFFECTIVE DATE BHONationalA G03.01.2023_V.05 CO / 34 02P021- D924 1� EXHIBIT A: REIMBURSEMENT In the event the fee schedule reference below was updated by any applicable federal, state and local laws, Carelon will update the fee schedule with a prospective effective date. The effective date of updated rate will be within ninety (90) days from published date or the effective date given by applicable federal, state or local Agencies, whichever is later. Inpatient days commence at 12:00 midnight, however, no payment is due for the date of discharge. No payment in addition to the applicable inpatient rate for Covered Services will be made for: (a) any outpatient services rendered in the emergency room of Facility prior to an inpatient admission; or (b) any outpatient observation services rendered prior to an inpatient admission. 35 BHONaiionalAG 03.01.2023 V..05 CO Exhibit A-1: Carelon Behavioral Health, Inc. Reimbursement Schedule Contracted Practitioner Reimbursement Schedule (1): Exhibit A Colorado HMO Professional Fee Schedule Carelon shall reimburse Provider for Services rendered to Members of Plans designated in the lines of business below according to the fee schedules for such line of business. To be reimbursable, a service provided to a member must be a covered benefit undtr the member's benefit plan. All reimbursements are less member responsibility and represent the total allowable reimbursement, including member responsibility, for all pre -authorized services only. Member's responsibility represents the applbable co -payment, coinsurance, and/or deductible, and is determined by type of insurance and/or benefit plan. Please verify tie plan benefits and co -pay at the time you register treatment. Carelon shall reimburse at one hundred percent (100%) of the Medicare professional fee schedule based on the provider locality at the time service, including application of CMS methodologies for practitioner types. 36 BHONationalAG_B.01.2023_V v5 CO Exhibit A-1: Carelon Behavioral Health, Inc. Reimbursement Schedule Contracted Practitioner Reimbursement Schedule (1): Exhibit Colorado Non-HMO/Commercial Professional Fee Schedule Carelon shall reimburse Provider for Services rendered to Members of Plans designated in the lines of business below according to the fee schedules for such line of business. To be reimbursable, a service provided to a member must be a covered benefit under the member's benefit plan. All reimbursements are less member responsibility and represent the total allowable reimbursement, including member responsibility, for all pre -authorized services only. Member's responsibility represents the applicable co -payment, coinsurance, and/or deductible, and is determined by type of insurance and/or benefit plan. Please verify the plan benefits and co -pay at the time you register treatment. Carelon shall reimburse at one hundred percent (100%) of the Medicare professional fee schedule based on the provider locality at the time service, including application of CMS methodologies for practitioner types. 37 BHONationalAG_03.01.2023_V.05 CO Exhibit A-1: Carelon Behavioral Health, Inc. Reimbursement Schedule Contracted Practitioner Reimbursement Schedule (1): Exhibit A Colorado Medicaid Network Professional Fee Schedule (Health Colorado) Groups and Individual Providers - Mental Health and Substance Use Disorder NOTE: Fee Schedule reimbursement is based on licensure, not on academic credentials. CPT®! HCPCS® _ Codes Outpatient Service Description (For MH DX: ll$e with Modifier: HE or -one of the.other CO Community Behavioral Health Program Modifiers) (For Mc'Use-with Modifiers: HE HF) MD/D0,3) Licensed Psychologist• Doctoral Level Licensed Mast_er's Level and CAC IIII/Ill APNPst3! and PA(nra) Fee Code HHCOMDI HHCSUI HHCPHDI HHCSU2 HHCOMAI HHCSU3 HHCAPNI _ = HHCSU4 90791 Psychiatric diagnostic interview examination - (no medical service) with or without code for Interactive Compexity (as appropriate) N/A $130.52 $102.80 $139.76 90792 Psychiatric diagrtstic interview examination with medical services - with or without code for Interactive Compexity (as appropriate) $195.80 N/A N/A $133.10 90785 Interactive Comrexity (list separately in addition to the code for primary procedur0 N/A N/A N/A N/A 90832 Psychotherapy, 30 minutes with patient and/or family member $64.90 $52.80 $41.80 $45.10 90833 Psychotherapy, 3) minutes with patient and/or family member when performed with an evaluation and management service add-on code (billed with appropriate outpatient E&M code) $11.00 N/A N/A $9.00 90834 Psychotherapy, w minutes with patient and/or family member $111.10 $77.00 $65.84 $77.00 90836 Individual psychatnerapy with medical eval and management services (38 to 5; minutes) $17.00 N/A N/A $13.00 90837 Psychotherapy, 6D minutes with patient and/or family member $118.97 $118.97 $94.71 $94.71 90838 Psychotherapy, ® rm minutes with patient and/or family member when perfoed with an evaluation and management service add-on code (billed with appropriate outpatient E&M code) $28.00 N/A N/A $22.00 90839 Psychotherapy farcrisis 30-74 minutes $147.40 $82.50 $71.50 $85.80 90840 Psychotherapy fo-crisis each additional 30 minutes beyond 90839 $70.40 $44.00 $40.43 $46.20 90846 Family psychotherapy (without the patient present) $116.60 $92.40 $72.60 $80.30 90847 Family psychotherapy (conjoint psychotherapy w/patient present) $122.43 $97.02 $76.23 $84.32 90849 Multiple -family gimp therapy $106.00 $84.00 $66.00 $73.00 90853 Group Therapy (diet than of a multiple -family group) $53.90 $34.10 $31.90 $37.40 90875 Individual psychadhysiological therapy incorporating biofeedback training by any modality, approximately 30ininutes $64.90 $52.80 $41.80 $45.10 90876 Individual psychathysiological therapy incorporating biofeedback training by any modality, approximately 45inninutes $86.80 $85.80 $74.80 $78.10 96130 Psychological evaluation services by physician or other qualified healthcare professional. This including integrabn of data or interpretation of test results, first hour only. $84.60 $94.60 N/A $66.00 96131 Add on Code for 16130. Psychological evaluation services by physician or other qualified healthcare professorial. This including integration of data or interpretation of test results, each additional hour. $94.60 $94.60 N/A $66.00 96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, cinsal decision making, treatment planning and report, and interactive feedback to the patient, famil, members) or caregiver(s), when performed; first hour only. $94.60 $94.60 N/A $66.00 96133 Add on Code for 16132. Neuropsychological testing evaluation services by physician or other qualified health are professional, including integration of patient data, interpretation of standardized bestir+esults and clinical data, clinical decision making, treatment planning and report, and interactive fe dback to the patient, family member(s) or caregiver(s), when performed; each additional hour. $94.60 $94.60 N/A $66.00 96136 Psychological tesing, (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology. e.g., MMPI, Rorschach, WAIS) for the first 30 minutes of the psychologists or wysician's time, both face-to-face time administering tests to the patient and time interpreting tiese test results and preparing the report. For each additional 30 minutes, add 96137. $47.30 $47.30 N/A $33.00 96137 Add on Code for 16136. Psychological testing, (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology. e.g., MMPI, Rorschach, MIS)$47.30 for each additiond 30 minutes of the psychologist's or physician's time, both face-to-face time administering less to the patient and time interpreting these test results and preparing the report. $47.30 N/A $33.00 96138 Psychological tesing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personalityand psychopathology, erg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, for the first 30 minutes of technician time, face-to-face. For each additional 30 minutes, add 96139 $43.00 $43.00 N/A $30.00 38 BHONationalAG G3.01.2023_V..05_CO CPT®1 • HCPCS® Codes Outpatient Service Description (For MH DX: Use with Modifier: HE or one of the other CO Community Behavioral Health Program Modifiers)(For SUD Dx: Use with Modifiers:' HEMP). - MD/D09Psychologist Licensed • Doctoral Level Licensed Master's Level andCAC IIIIIIIl APNPwrend PA(2, i4i 96139 Add on code for 96138. Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, for each additional 30 minutes of technician time, face-to-face. $43.00 $43.00 N/A $30.00 96146 Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only $70.00 $70.00 N/A $70.00 99202 Office or other outpatient visit for the evaluation and management of a new patient, Typically, 20 minutes face-to-face with patient $62.00 N/A N/A $49.00 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. 30- 44 minutes of total time is spent on the date of the encounter. $89.00 N/A N/A $71.00 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. 45-59 minutes of total time is spent on the date of the encounter. $136.00 N/A N/A $109.00 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. 60- 74 minutes of total time is spent on the date of the encounter. $168.00 N/A N/A $136.00 99211 Office or other outpatient visit for the evaluation and management of an established patient, Typically, 5 minutes $17.00 N/A N/A $13.00 99212 Office or other outpatient visit for the evaluation and management of an established patient, Typically, 10 minutes $36.00 N/A N/A $29.00 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. 20-29 minutes of total time is spent on the date of the encounter. $69.30 N/A N/A $55.44 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. 30-39 minutes of total time is spent on the date of the encounter. $96.80 N/A N/A $77.00 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. 40-54 minutes of total time is spent on the date of the encounter. $118.00 N/A N/A $94.00 99221 Initial hospital care, per day, for the evaluation and management of a patient, low complexity, Typically, 30 minutes $96.00 N/A N/A $67.00 99222 Initial hospital care, per day, for the evaluation and management of a patient, moderate complexity, Typically, 50 minutes $160.00 NIA N/A $111.00 99223 Initial hospital care, per day, for the evaluation and management of a patient, high complexity, Typically, 70 minutes $179.00 N/A N/A $121.00 99231 Subsequent hospital care, per day, for the evaluation and management, 15 minutes $47.00 N/A N/A $32.00 99232 Subsequent hospital care, per day, for the evaluation and management, 25 minutes $80.00 N/A N/A $56.00 99233 Subsequent hospital care, per day, for the evaluation and management, 35 minutes $96.00 N/A N/A $81.00 99238 Hospital discharge day management, 30 minutes or less $78.00 N/A N/A $61.00 99239 Hospital discharge day management, more than 30 minutes $101.00 N/A N/A $81.00 99251 Inpatient consultation fora new or established patient; the presenting problem(s) are self -limited or minor. Minimum, 20 minutes $58.90 N/A N/A N/A 99252 Inpatient consultation fora new or established patient, the presenting problem(s) are of low severity. Minimum, 40 minutes $118.00 N/A N/A N/A 99253 Inpatient consultation fora new or established patient; the presenting problem(s) are of moderate severity. Minimum, 55 minutes $162.00 N/A N/A N/A 99254 Inpatient consultation fora new or established patient; the presenting problem(s) are of moderate to high severity. Minimum, 80 minutes $175.00 N/A N/A N/A 99306 Initial nursing facility care, per day, for the evaluation and management of a patient of high severity, Typically, 45 minutes $144.00 N/A N/A $125.00 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, of low complexity, Typically, 15 minutes $47.00 N/A N/A $28.00 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, of moderate complexity, Typically, 25 minutes $80.00 N/A N/A $61.00 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, of high complexity, Typically, 35 minutes $86.00 N/A N/A $77.00 99366 Medical team conference, face-to-face with patient and/or family; 30 minutes plus N/A $85.00 $81.28 $85.00 99367 Medical team conference, without face-to-face contact with patient and/or family; 30 minutes or more; participation by physician $86.12 $85.00 $81.28 $85.00 39 BKONationalAG_03.01.2023_ V.. 05_CO . CPT_ - HCPCS® Codes Outpatient Service Description For MH DX: Uee with Modifier: HE or'one of the other CO Community Behavioral Health ( ty irogram Mod fiers)(For SUD Dc: Use with Modifiers: HE HF) • MD/DOS Licensed - Psychologist y , ogist , Doctoral Level Licensed Master's Level andCAC 1/111111 - • APNts rand .PosI , 99368 Medical team conerence, without face-to-face contact with patient and/or family; 30 minutes or more; participation by nonphysician qualified health care professional N/A $70.68 $59.40 $73.43 H0001 Alcohol and/or drg assessment; Per Encounter $125.00 $125.00 $85.05 $81.00 H0002 Behavioral healtlescreening to determine eligibility for admission to program; Per Encounter $7.70 $7.70 $7.70 $7/0 H0004 Behavioral healtlrvounseling and therapy, per 15 minutes $23.50 $23.50 $19.43 $18.50 H0005 Alcohol and/or dreg services, group counseling bye clinician; Per Hour $26.00 $26.00 $26.00 $26.00 H0006 Alcohol and/or dng services, targeted case management; Per 15 minutes $27.55 $27.30 $27.30 $27.30 H0020 Alcohol and/or dry_ services, methadone administration and/or services (provisions of the drug by a licensed program); Per Encounter $10.00 N/A N/A N/A H0023 Behavioral healthoutreach service (planned approach to reach a population) $13.92 $13.92 $13.92 $13.92 H0025 Behavioral healthorevention education service (delivery of services to affect knowledge, attitude and/or behavior) $56.60 $35.81 $33.50 $39.27 H0031 Mental health assessment, by a non -physician N/A $124.30 $97.90 N/A H0032 Mental health ser•ice plan development by non-physican N/A $97.02 $76.23 $84.32 H0033 Drug Administration, Per Encounter $10.00 N/A N/A $10.00 H0036 Community psych atric supportive treatment, face-to-face, per 15 minutes $20.00 $20.00 $20.00 $20.00 /10037 Community psycf•atric supportive treatment, face-to-face, Per Diem $250.00 $250.00 $250.00 $250.00 H0038 rfir Self help/peer seances; per 15 minutes N/A N/A $11.00 N/A H2000 Comprehensive multidisciplinary evaluation $116.60 $92.40 $72.60 $80.30 H2011 Crisis intervention service, per 15 minutes $45.10 $40.24 $40.24 $40.24 H2014 Skills training andklevelopment, per 15 minutes $23.10 $23.10 $23.10 $23.10 H2015 Comprehensive ©mmunity support services, per 15 minutes $23.10 $23.10 $23.10 $23.10 H2016 Comprehensive ©mmunity support services, Per Diem $250.00 $250.00 $250.00 $250.00 H2017 Psychosocial rehabilitation services, per 15 minutes $22.00 $22.00 $22.00 $22.00 H2027 Psychoeducabonslservice, per 15 minutes $13.92 $13.92 $13.92 $13.92 H2033 Multi -systemic thrrapy for juvenile, per 15 minutes $12.65 $12.65 $12.65 $12.65 S9485 Crisis intervention mental health services, Per Diem $103.00 $103.00 $86.10 $82.00 S9445 Drug screening and monitoring counseling; Per Encounter $15.00 $15.00 $15.75 $15.00 T1017 Targeted Case Management, each 15 minutes $31.82 $12.71 $12.71 $12.71 CPT®/ HCPCS® Codes Description MD/DO Fee Code HHCSU1 and HHCSDI-. H0020 Alcohol and/or dr►g services, methadone administration and/or services (provisions of the drug by a licensed program); Per Encounter. Place of Services 53,11, 22, 50, 72, 49, 52, 57 $10.00 H0020 Alcohol and/or drsg services, methadone administration and/or services (provisions of the drug by a licensed program); Per Encounter. Place of Service is home (POS 12) $3.00 Modifierss Description HE Behavioral Heald- Services with a Covered OH Diagnosis: For submission of clean claims, HE in first modifier position for State Plan Services OR one of the Colorado Community Behaioral Health Program Modifiers. HE HF Substance Abuse Program/Services with a Covered SUD Diagnosis: For submission of clean claims, HE in first modifier position AND HF in second modifier position. The listing of a service or CPTCMHCPCSO code above does not guarantee that it will be covered under every account -specific plan. To be reimbursable, a service provided to a member must be a covered benefit uncle- the member's benefit plan. All reimbursements are less member responsibility and represent the total allowable reimbursement, including member responsibility, for all pre-authorhed services only. Member's responsibility represents the applicable co -payment, coinsurance, and/or deductible, and is determined by type of insurance and/or benefit plan. Please veriy the plan benefits and co -pay at the time you register treatment. All services must be performed in accordance with the current version of the Colorado Uniform Service Coding Manua. The USCM can be found at https://hcptcolorado.gov/accountable-care-collaborative-phase-ii-provider-and-stakeholder-resource-center and should be consulted on description of seraces, licensure/certification levels, place of service, and service duration in providing each service as listed above. m These rates are for the Healt! Colorado, Inc. network. The rates herein includes 2% workforce enhancements. I7APN/ PA licensed/authorizedo prescribe psychotropic medication must be credentialed and contracted by Carelon as an APN/PA to be reimbursed for the CPT®/HCPCS® codes, which include medication management. APNs/PAs are required to maintain compliance with State licensing laws and Federal regulations. Must practice within the scope of their licensure. rci Inpatient CPT® Codes are or y reimbursable when Carelon does not have an all-inclusive reimbursement rate with the facility where services are delivered. r4> Physician Assistants mus: hire a Delegation of Services Agreement with MD(s). The scope of practice should be defined in the Delegation of Services Agreement. Carelon will only reimburse for Mental Health ari Substance Abuse services which are defined in the Agreement and have been contracted by Carelon. .When Billing Medicaid, proviers must use, as a first position modifier, one of the CO Community Behavioral Health Program Modifiers listed in the latest USCM. .Licensed Master's Level and -LAC I/I I/Ill can bill for this service when all the following criteria is met: (1) Practitioner will be billing under a Group TIN, (2) the services are rendered by a Peer Specialist, and (3) Practitiner supervised the services rendered by a Peer Specialist. * Note: APN's and PA's providig services in outpatient clinics, which are credentialed and contracted by Carelon, are excluded from the above statement. 40 BHONationalAG G3.01.2023 V05 CO Exhibit Al:-Carelon Behavioral Health, Inc. Reimbursement Schedule Contracted Practitioner Reimbursement Schedule (1): Exhibit A Colorado Medicaid Network Professional Fee Schedule (Northeast Health Partners) Groups and Individual Providers — Mental Health and Substance Use Disorder NOTE: Fee Schedule reimbursement is based on licensure, not on academic credentials. CPT®1 HCPCS® Codes Outpatient Service Description _ (For MH DX: Use with Modifier:. HE or one of the other CO Community Behavioral Health Program Modifiers). (For SUD Dv: Use with Modifiers: HE HF) MDIDOr3� Licensed Psychologist Doctoral Level Licensed Master's Level and CAC IIIIIIII. APNrIr r;r' _ and PAM Fee Code NEHPMD/ NEHSUI NEHPHDI NEHSU2 NEHPMAI NEHSU3 NEHAPN/ NEHSU4 90791 Psychiatric diagnostic interview examination - (no medical service) with or without code for Interactive Complexity (as appropriate) N/A $130.52 $102.80 $139.76 90792 Psychiatric diagnostic interview examination with medical services - with or without code for Interactive Complexity (as appropriate) $195.80 N/A N/A $133.10 90785 Interactive Complexity (list separately in addition to the code for primary procedure) N/A N/A N/A N/A 90832 Psychotherapy, 30 minutes with patient and/or family member $64.90 $52.80 $41.80 $45.10 90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service add-on code (billed with appropriate outpatient E&M code) $11.00 N/A N/A $9.00 90834 Psychotherapy, 45 minutes with patient and/or family member $111.10 $77.00 $65.84 $77.00 90836 Individual psychotherapy with medical eval and management services (38 to 52 minutes) $17.00 N/A N/A $13.00 90837 Psychotherapy, 60 minutes with patient and/or family member $118.97 $118.97 $94.71 $94.71 90838 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service add-on code (billed with appropriate outpatient E&M code) $28.00 N/A N/A $22.00 90839 Psychotherapy for crisis 30-74 minutes $147.40 $82.50 $71.50 $85.80 90840 Psychotherapy for crisis each additional 30 minutes beyond 90839 $70.40 $44.00 $40.43 $46.20 90846 Family psychotherapy (without the patient present) $116.60 $92.40 $72.60 $80.30 90847 Family psychotherapy (conjoint psychotherapy w/patient present) $122.43 $97.02 $76.23 $84.32 90849 Multiple -family group therapy $106.00 $84.00 $66.00 $73.00 90853 Group Therapy (other than of a multiple -family group) $53.90 $34.10 $31.90 $37.40 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality, approximately 30 minutes $64.90 $52.80 $41.80 $45.10 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality, approximately 45 minutes $86.80 $85.80 $74.80 $78.10 96130 Psychological evaluation services by physician or other qualified healthcare professional. This including integration of data or interpretation of test results, first hour only. $84.60 $94.60 N/A $66.00 96131 Add on Code for 96130. Psychological evaluation services by physician or other qualified healthcare professional. This including integration of data or interpretation of test results, each additional hour. $94.60 $94.60 N/A $66.00 96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour only. $84.60 $94.60 NIA $66.00 96133 Add on Code for 96132. Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour. $94.60 $94.60 N/A $66.00 96136 Psychological testing, (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology. e.g., MMPI, Rorschach, WAIS) for the first 30 minutes of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. For each additional 30 minutes, add 96137. $47.30 $47.30 N/A $33.00 96137 Add on Code for 96136. Psychological testing, (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology. e.g., MMPI, Rorschach, WAIS) for each additional 30 minutes of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report. $47.30 $47.30 N/A $33.00 41 BHONationalAG 03.01.2023_[! 05_CO CM': HCPCSWodes Outpatient Service Description (For MHTIK: Use with Modifier: HE or one of the other CO Community Behavioral Health Program Modifiers)(For SUD IN: Use with Modifiers: HE HF) MDIDO/3r - Licensed Psychologist Doctoral Level Licensed Master's Level endCAC.11llllll APPP grand PA( . 96138 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, pesonality and psychopathology, eg, MMPI and WAIS), with qualified health care professions interpretation and report, administered by technician, for the first 30 minutes of technician nne, face-to-face. For each additional 30 minutes, add 96139 $43.00 $43.00 N/A $30.00 96139 Add on code for 96138. Psychological testing (includes psychodiagnostic assessment of emotionality,, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, for each additional 33 minutes of technician time, face-to-face. $43.00 $43.00 NIA $30.00 96146 Psychological or neuropsychological test administration, with single automated, standardized instrument Fla electronic platform, with automated result only $70.00 $70.00 N/A $70.00 99202 Office or otter outpatient services: requires expanded problem focused history, expanded problem foused examination, and straightforward medical decision making. Typical time spent is 15-29 mnutes. $62.00 N/A N/A $49.00 99203 Office or oiler outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. 30.,y4 minutes of total time is spent on the date of the encounter. $89.00 N/A N/A $71.00 99204 Office or otter outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision mdcing. 45-59 minutes of total time is spent on the date of the encounter. $136.00 N/A N/A $109.00 99205 Office or otter outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. 60W4 minutes of total time is spent on the date of the encounter. $168.00 N/A N/A $136.00 99211 Office or od er outpatient visit for the evaluation and management of an established patient, Typically, :. minutes $17.00 N/A N/A $13.00 99212 Office or otter outpatient visit for the evaluation and management of an established patient, Typically, 7 minutes $36.00 N/A N/A $29.00 99213 Office or otter outpatient visit for the evaluation and management of an established patent, which requires a medically appropriate history and/or examination and low level of medical decision malting. 20-29 minutes of total time is spent on the date of the encounter. $69.30 N/A N/A $55.44 99214 Office or otter outpatient visit for the evaluation and management of an established patient, which requims a medically appropriate history and/or examination and moderate level of medical decision making. 30-39 minutes of total time is spent on the date of the encounter. $96.80 N/A N/A $77.00 99215 Office or otter outpatient visit for the evaluation and management of an established patient, which requFes a medically appropriate history and/or examination and high level of medical decision miring. 40-54 minutes of total time is spent on the date of the encounter. $118.00 N/A N/A $94.00 99221 Initial hospwl care, per day, for the evaluation and management of a patient, low complexity, Typically, 3'J minutes $96.00 N/A N/A $67.00 99222 Initial hospied care, per day, for the evaluation and management of a patient, moderate complexity,Typically, 50 minutes $160.00 N/A N/A $111.00 99223 Initial hosp®I care, per day, for the evaluation and management of a patient, high complexity, Typically, 7! minutes $179.00 N/A N/A $121.00 99231 Subsequen hospital care, per day, for the evaluation and management of a patient, Typically, 15 minutes $47.00 N/A N/A $32.00 99232 Subsequen hospital care, per day, for the evaluation and management of a patient, Typically, 25 minutes $80.00 N/A N/A $56.00 99233 Subsequen hospital care, per day, for the evaluation and management of a patient, Typically, 35 minutes $96.00 N/A N/A $81.00 99238 Hospital disharge day management, 30 minutes or less $78.00 N/A N/A $61.00 99239 Hospital disharge day management, more than 30 minutes $101.00 N/A N/A $81.00 99251 Inpatient ccvsultation fora new or established patient; the presenting problem(s) are self -limited or minor. Minimum, 20 minutes $58.90 N/A N/A N/A 99252 Inpatient ccrsultation fora new or established patient, the presenting problem(s) are of low severity. kivimum, 40 minutes $118.00 N/A N/A N/A 99253 Inpatient cersultation fora new or established patient; the presenting problem(s) are of moderate sverity. Minimum, 55 minutes $162.00 N/A N/A N/A 99254 Inpatient ccisultation fora new or established patient; the presenting problem(s) are of moderate tc high severity. Minimum, 80 minutes $175.00 N/A N/A N/A 99306 Initial nursiN facility care, per day, for the evaluation and management of a patient of high severity, Typically, 45 minutes $144.00 N/A N/A $125.00 42 BHONattonalAG CB.01.2023 V..05 CO • CPT®! HCPCS®Codes Outpatient Service Description MH DX: Use with Modifier: HE or one of the other CO Community Behavioral Health Program Modifiers)(For SUD Dx: Use with Modifiers: HE HF) MDIDOm Licensed Psychologist Doctoral Level Licensed Master's Level andCAG 1/11/111 APN!2 t wand(For PA!?t*t - 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, of low complexity, Typically, 15 minutes $47.00 N/A N/A $28.00 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patent, of moderate complexity, Typically, 25 minutes $80.00 N/A N/A $61.00 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, of high complexity, Typically, 35 minutes $86.00 N/A N/A $77.00 99366 Medical team conference, face-to-face contact with patient and/or family; 30 minutes or more N/A $85.00 $81.28 $85.00 99367 Medical team conference, without face-to-face contact with patient and/or family; 30 minutes or more; participation by physician $86.12 $85.00 $81.28 $85.00 99368 Medical team conference, without face-to-face contact with patient and/or family; 30 minutes or more; participation by nonphysician qualified health care professional N/A $70.68 $59.40 $73.43 H0001 Alcohol and/or drug assessment; Per Encounter $125.00 $125.00 $85.05 $81.00 H0002 Behavioral health screening to determine eligibility for admission to treatment program; Per Encounter $7.70 $7.70 $7.70 $7.70 H0004 Behavioral health counseling and therapy, per 15 minutes $23.50 $23.50 $19.43 $18.50 H0005 Alcohol and/or drug services, group counseling by a clinician; Per Hour $26.00 $26.00 $26.00 $26.00 H0006 Alcohol and/or drug services, targeted case management; Per 15 minutes $27.55 $27.30 $27.30 $27.30 H0020 Alcohol and/or drug services, methadone administration and/or services (provisions of the drug by a licensed program); Per Encounter $10.00 N/A N/A N/A H0023 Behavioral health outreach service (planned approach to reach a population) $13.92 $13.92 $13.92 $13.92 H0025 Behavioral health prevention education service (delivery of services to affect knowledge, attitude and/or behavior) $56.60 $35.81 $33.50 $39.27 H0031 Mental health assessment, by a non -physician N/A $124.30 $97.90 N/A H0032 Mental health service plan development by non -physician N/A $97.02 $76.23 $84.32 H0033 Drug Administration, Per Encounter $10.00 N/A N/A $10.00 H0036 Community psychiatric supportive treatment, face-to-face, per 15 minutes $20.00 $20.00 $20.00 $20.00 H0037 Community psychiatric supportive treatment, face-to-face, Per Diem $250.00 $250.00 $250.00 $250.00 H0038. Self help/peer services; per 15 minutes N/A N/A $11.00 N/A H2000 Comprehensive multidisciplinary evaluation $116.60 $92.40 $72.60 $80.30 H2011 Crisis intervention service, per 15 minutes $45.10 $40.24 $40.24 $40.24 H2014 Skills training and development, per 15 minutes $23.10 $23.10 $23.10 $23.10 H2015 Comprehensive community support services, per 15 minutes $23.10 $23.10 $23.10 $23.10 H2016 Comprehensive community support services, Per Diem $250.00 $250.00 $250.00 $250.00 H2017 Psychosocial rehabilitation services, per 15 minutes $22.00 $22.00 $22.00 $22.00 H2027 Psychoeducational service, per 15 minutes $13.92 $13.92 $13.92 $13.92 H2033 Multi -systemic therapy for juvenile, per 15 minutes $12.65 $12.65 $12.65 $12.65 S9485 Crisis intervention mental health services, Per Diem $103.00 $103.00 $86.10 $82.00 S9445 Drug screening and monitoring counseling; Per Encounter $15.00 $15.00 $15.75 $15.00 T1017 Targeted Case Management, each 15 minutes $31.82 $12.71 $12.71 $12.71 Modifiers Description HE Behavioral Health Services with a Covered MH Diagnosis: For submission of clean claims, HE in first modifier position for State Plan Services OR one of the Colorado Community Behavioral Health Program Modifiers. Substance Abuse Program/Services with a Covered SUD Diagnosis: For submission of clean claims, HE in first modifier position AND HF in second modifier position. HE HF The listing of a service or CPT®/HCPCS® code above does not guarantee that it will be covered under every account -specific plan. To be reimbursable, a service provided to a member must be a covered benefit under the member's benefit plan. All reimbursements are less member responsibility and represent the total allowable reimbursement, including member responsibility, for all pre -authorized services only. Member's responsibility represents the applicable co -payment, coinsurance, and/or deductible, and is determined by type of insurance and/or benefit plan. Please verify the plan benefits and co -pay at the time you register treatment. All services must be performed in accordance with the current version of the Colorado Uniform Service Coding Manual. The USCM can be found at https://hcpf.colorado.gov/accountable-care-collaborative-phase-ii-provider-and-stakeholder-resource-center and should be consulted on description of services, licensure/certification levels, place of service, and service duration in providing each service as listed above. w-rhese rates are for the Northeast Health Panthers network. The rates herein includes 2% workforce enhancements. ITTAdvance Practice Nurses (APN) and Physician Assistants (PA) licensed/authorized to prescribe psychotropic medication must be credentialed and contracted by Carelon as an APN or PA to be reimbursed for the CPT®/HCPCS® codes, which include medication management. APNs and PAs are required to maintain compliance with State licensing laws and Federal regulations, and must practice within the scope of their licensure. t31 Inpatient CPT® Codes are only reimbursable when Carelon does not have an all-inclusive reimbursement rate with the facility where services are delivered. gat Physician Assistants must have a Delegation of Services Agreement with MD(s). The scope of practice should be defined in the Delegation of Services Agreement. Carelon will only reimburse for Mental Health and Substance Abuse services which are defined in the Agreement and have been contracted by Carelon. .When Billing Medicaid, providers must use, as a first position modifier, one of the CO Community Behavioral Health Program Modifiers listed in the latest USCM. tet Licensed Master's Level and CAC I/II/III can bill for this service when all the following criteria is met: (1) Practitioner will be billing under a Group TIN, (2) the services are rendered by a Peer Specialist, and (3) Practitioner supervised the services rendered by a Peer Specialist. * Note: APN's and PA's providing services in outpatient clinics, which are credentialed and contracted by Carelon, are excluded from the above statement. 43 BHONationalAG 53.01.2023_V.A5_CO Exhibit A-2 Intentionally left blank 44 BHONationalAG 8.01.2023_V..05_CO EXHIBIT A-3: GHI-BMP Reimbursement Carelon Behavioral Health, Inc. Contracted Practitioner Reimbursement Schedule (1): Exhibit A GHI-BMP Professional Fee Schedule Rates for the Treatment of Children or Adolescents by a Psychiatrist NOTE: Fee Schedule reimbursement is based on licensure, not on academic credentials CPT® Code/ HCPCS® Code Service Description MDIDO Licensed Psychologist Doctoral Level ,,,Licensed Master's Level , APNs with Prescriptive Authority. ' GHWBMPFee Code GHI Medicare Fee Code - MOH BMPMRI PGH, . BMPMR2 - SGH ' BMPMR3 RGH 90791 Psychiatric diagnostic interview examinaton - (no medical service) with or without code for Interactive Complexity (as appropriate) $144.00 $79.00 $70.00 $80.00 (2,0792 Psychiatric diagnostic interview examination with medical services - with or without code for Interactive Complexity(as appropriate) $144.00 N/A N/A $80.00 +90785 Interactive Complexity (list separately in addition to the code for primary procedure Reimbursement included in primary service 90832 Psychotherapy, 30 minutes with patient and/or family member $55.00 $32.00 $45.00 $45.00 +90833 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service add-on code (billed with appropriate outpatient E&M code) $14.00 N/A WA $11.00 90834 Psychotherapy, 45 minutes with patient and/or family member $104.00 $65.00 $55.00 $55.00 +90836 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service add-on code (billed with appropriate outpatient E&M code) $63.00 N/A N/A $37.00 90837 Psychotherapy, 60 minutes with patient and/or family member $104.00 $65.00 $55.00 $67.00 +90838 Psychotherapy, 60 minutes with patient and/or family memberwhen performed with an evaluation and management service add-on code (billed with appropriate outpatient E&M code) $92.00 N/A N/A $44.00 90839 Psychotherapy for crisis 30-74 minutes $104.00 $65.00 $55.00 $67.00 +90840 Psychotherapy for crisis each additional 30 minutes beyond 90839 $55.00 $32.00 $45.00 $45.00 90846 Family psychotherapy (without the patient present) $90.00 $65.00 $55.00 $55.00 90847 Family psychotherapy (conjoint psychotherapy w/patient present) $90.00 $65.00 $55.00 $55.00 90853 Group psychotherapy (other than ofamufiple-familygroup) $48.00 $40.00 $45.00 945.00 (3190870 Electroconvulsive therapy (includes necessary monitoring) $14400 WA N/A 980.00 96112 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory, and/ or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour N/A $89.00 N/A WA +96113 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory, and/ or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; each additional 30 minutes N/A $44.50 N/A WA 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgement, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour N/A $89.00 N/A WA +96121 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgement, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; each additional hour WA $89.00 WA N/A 96130 Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour N/A $106.76 WA N/A +96131 Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour WA $81.20 WA N/A 96132 europsychological testing evaluation services by physician or other qualified health rare professional, including integration f patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and port and interactive feedback to he patient, family member(s) or caregiver(s), when performed; first hour WA $120.02 WA N/A +96133 europsychological testing evaluation services by physician or other qualified health care professional, including integration f patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and port and interactive feedback to the patient, family member(s) or caregiver(s), when performed; each additional hour N/A $91.55 WA N/A 96136 sychological or neuropsychological test administration and scoring by physician or other qualified health care professional, 0 or more tests, any method, first 30 minutes WA $43.03 N/A WA +96137 sychological or neuropsychological test administration and scoring by physician or other qualified ealth care professional, two or more tests, any method, each additional 30 minutes WA $39.79 N/A N/A 96138 sychological or neuropsychological test administration and scoring by technician, two or more ests, any method; first 30 minutes N/A $34.94 WA WA +96139 sychological or neuropsychological test administration and scoring by technician, two or more ests, any method; each additional 30 minutes N/A $34.94 N/A WA 96146 sychological or neuropsychological test administration, with single automated instrument via lectronic platform, with automated result only WA $89.00 WA N/A 45 BHONationalAG_03.01.2023_ U 05 CO EXHIBIT A-3: GHI-BMP Reimbursement Carelon Behavioral Health, Inc. Contracted Practitioner Reimbursement Schedule (1): Exhibit A GHI-BMP Professional Fee Schedule Rates for the Treatment of Children or Adolescents by a Psychiatrist NOTE: Fee Schedule reimbursement is based on licensure, not on academic credentials CPT® Code/ HCPCS® Code Service Description MD/DO Licensed Psychologist Doctoral Level to Licensed Master's • Local APRs with Prescriptive Authority GHI43MP Fee Code GHI Medicare Fee Code MGH BMPMR1 PGH BMPMR2 SGH . BMPMR3 RGH 96156 Health behavior assesenent or re -assessment (e.g., health -focused clinical interview, behavioral observations, clinical decision making) N/A $64.98 N/A N/A 96158 Health behavior interve-ltion, individual, face-to-face; initial 30 minutes N/A $4434 N/A N/A 96159 Health behavior interve tion, individual, face-to-face; each additional 15 minutes (List separately in addition to code for p imary service) N/A $15.48 N/A N/A 96164 Health behavior interve-Ition, group (2 or more patients), face-to-face; initial 30 minutes N/A $6.57 N/A N/A 96165 Health behavior intervedion, group (2 or more patients), face-to-face; each additional 15 minutes (List separately in addiwn to code for primary service) N/A $3.05 N/A N/A 96167 Health behavior intervrtion, family (with the patient present), face-to-face; initial 30 minutes N/A $47.62 N/A N/A 96168 Health behavior intervetion, family (with the patient present), face-to-face; each additional 15 minutes (List separate, in addition to code for primary service) N/A $16.89 N/A N/A 96170 Health behavior intervedion, family (without the patient present), face-to-face; initial 30 minutes N/A $53.96 N/A N/A 96171 Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (List separate, in addition to code for primary service) N/A $19/1 N/A N/A 99211 Office or other outpatiat visit for the evaluation and management of an established patient, Typically, 5 minutes $18.00 N/A N/A $15.00 99212 Office or other outpatiat visit for the evaluation and management of an established patient, Typically, 10 minutes $39.00 N/A N/A $28.00 99213 Office or other outpatat visit for the evaluation and management of an established patient, Typically, 15 minutes $41.00 N/A N/A $34.00 99214 Office or other outpatient visit for the evaluation and management of an established patient, Typically, 25 minutes $47.00 N/A N/A $38.00 99215 Office or other outpatiat visit for the evaluation and management of an established patient, Typically, 40 minutes $75.00 N/A N/A $61.00 (4199221 Initial hospital care, peachy, for the evaluation and management of a patient, low complexity, Typically, 30 minutes $55.00 N/A N/A $47.00 (4199222 Initial hospital care, peachy, for the evaluation and management of a patient, moderate complexity, Typically, 50 minutes $104.00 N/A N/A $88.00 (4199223 Initial hospital care, pesday, for the evaluation and management of a patient, high complexity, Typically, 70 minutes $104.00 N/A N/A $55.00 (4199231 Subsequent hospital cae, per day, for the evaluation and management of a patient, Typically, 15 minutes $55.00 N/A N/A $47.00 (4199232 Subsequent hospital cse, per day, for the evaluation and management of a patient, Typically, 25 minutes $55.00 N/A N/A $47.00 (4)99233 Subsequent hospital owe, per day, for the evaluation and management of a patient, Typically, 35 minutes $55.00 N/A N/A $47.00 (3) 99238 Hospital discharge iasnanagement, 30 minutes or less $55.00 N/A N/A $47.00 The listing of a service or CPT®/F CPCS® code above does not guarantee that it will be covered under every account -specific plan. To be reimbursable, a service provided to a member must be a covered benefit under the member's benefit plan. All reimbursements are less member responsibility and represent the total allowable reimbursement, including member responsibility, br all pre -authorized services only. Member's responsibility represents the applicable co -payment, coinsurance, and/or deductible, and is determined by type of insurance and/or benefit plan. Please verify the plan benefits and co -pay at the time you register treatment. Effective: 01/01/2020 (t1 These rates only applicable to tie GH I BMP program. In addition, these rates shall also apply to the GH I Medicare Choice PPO product when applicable. (�1 Master's level practitioners wittnut prescriptive authority will be reimbursed at Licensed Master's Level. (31 Inpatient CPT® Codes are onl) reimbursable when Carelon does not have an all-inclusive reimbursement rate with the facility where services are delivered. (4) Inpatient CPT® Codes are on'} reimbursable when Carelon does not have an all-inclusive reimbursement rate with the facility where services are delivered. 46 BHONationalAG_G3.0 1.2023_ V. 05_CO Exhibit B: State Specific Provisions Provider acknowledges and agrees that the provisions set out in the attached Exhibit B and any subparts thereto, each of which are incorporated herein by reference and made a pad of the Agreement, apply solely with respect to Members of the identified Plans subject to the laws of a particular State. 47 BHONationalAG_03.01.2023_ v 05 CO EXHIBIT B-1: COLORADO STATE PROVISIONS For Services Governed by Colorado State Law: In addition to the obligations set forth in the Agreement, Carelon and Provider agree to comply, and Provider agrees to require its qualified behavioral health providers and other Practitioners to comply, with the following requirements with respect to Colorado law, as amended, and regulations promulgated thereunder, with respect to Members and/or provider contracts govemed by Colorado law. Capitalized terms used but not defined in this Exhibit shall have the meanings set forth in the Agreement. Tie following shall apply only to the extent applicable in light of the specific services. In the event of any conflict or inconsistency between the terms in this Exhibit and the terms in any other section of the Agreement, then this Exhibit shal control for Members and/or any provider contracts govemed by Colorado state law; provided, however, that if Carelon and Provide- are capable of complying with both the requirements of such other section and this Exhibit, nothing herein shall be construed as wai'ing the obligations of Carelon or Provider under such other section. If the Services are net governed by Colorado state law, then the terms and conditions of this Exhibit shall not be applicable. ARTICLE I: GENERAL OBLIGATIONS 1.1 Medical Decisions. Provider shall not be prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of Payor or Carelon. Payor or Carelon shall not be prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of Provider. C.R.S. § 10-16- 121(1)(a). 1.2 Assignment. Frovider shall not assign or delegate the rights or responsibilities under the Agreement without the prior written consentof Carelon. C.R.S. § 10-16-705(8). 1.3 Nondiscrimination. Provider shall not discriminate, with respect to the provision of medical necessary Covered Services, against Members that are participants in a publicly financed program. C.R.S. § 10-16-705(9). 1.4 Preauthorizations. The sole responsibility for obtaining any necessary preauthorization for services, treatments, or procedures res2s with Provider, not with the Member. C.R.S. § 10-16-705(14). 1.5 Notice of Material Change. To the extent required by law and applicable to Provider, Carelon shall provide Provider with at least ninety 90) days' written notice prior to the effective date of a material change to the Agreement. For the purposes of this section, -he term "material change" shall have the meaning set forth in C.R.S. § 25-37-102(9). Such notice shall be conspicuously entitled "Notice of Material Change to Contract." If Provider objects in writing to the material change within fifteen (15) days of such notice and there is no resolution of the objection, Carelon or Provider may terminate the Agreement upon written naice of termination to the other party, but no later than sixty (60) days prior to the effective date of the material change. If Provider does not object to the material change within fifteen (15) days as required by this section, the material change shall be effective as specified in the notice of material change to the Agreement. If the material change is the addition of a new category of coverage and Provider objects within fifteen (15) days as required by this section, the material change shall nct be effective as to Provider, and such objection shall not be a basis upon which Carelon may terminate the Agreement. Nawithstanding anything in this section to the contrary, the Agreement may be modified by operation of law as required by any Applicable Rules and Carelon may disclose such change to Provider by any reasonable means. C.R.S. §§ 25-37-10k, 1'5-37-105. 1.6 Termination. Carelon shall not terminate the Agreement because Provider expresses disagreement with a decision by Payor or Carelon, if applicable, to deny or limit benefits to a Member; or because Provider assists the Member to seek reconsideration of such decision; or because Provider discusses with a current, former, or prospective patient any aspect of the patient's medical condition, any proposed treatments or treatment alternatives, whether covered by the patient's plans or not, pdicy provisions of a plan, or Provider's personal recommendation regarding selection of a health plan based on Provider's personal knowledge of the health needs of such patients. Further, Carelon shall not terminate the Agreement because the p©vider, acting in good faith, communicates with a public official or other person concerning public policy issues related to health-care items or services, files a complaint, makes a report, or comments to an appropriate government body regarding Carelon's or Payor's actions, policies, or practices that provider believes negatively affect quality of or 48 BHONati onalAG_CB. 01.2023_ V.. 05_CO access to patient care, provides testimony, evidence, opinion, or other public activity in any forum concerning a violation or possible violation of Applicable Rules, reports what the provider believes to be a violation of law to the appropriate authority, or participates in any investigation into a violation or possible violation of any provisions of this section. C.R.S. § 10-16- 121(1)(b). 1.7 Member Hold Harmless. With respect to Members enrolled in a health maintenance organization (HMO) plan, in no event, including but not limited to nonpayment by Payor or Carelon, insolvency of Payor or Carelon, or breach of the Agreement, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a Member or persons (other than Payor) acting on behalf of the Member for Covered Services provided pursuant to the Agreement. This provision does not prohibit Provider from collecting applicable Member Expenses or fees for services not covered by the Member's plan delivered on a 'fee -for -service' basis to the Member. This provision shall survive the termination of the Agreement for Covered Services rendered prior to the termination of the Agreement, regardless of the cause giving rise to termination, and shall be construed to be for the benefit of Members. This provision is not intended to apply to services provided after the Agreement has been terminated. This provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and the Member or persons acting on the Member's behalf insofar as such contrary agreement relates to liability for payment of Covered Services provided under the terms of the Agreement. Any modification, addition or deletion to this provision shall become effective on a date no earlier than thirty (30) days after the Colorado Commissioner of Insurance has received written notification of the proposed changes. 3 CCR 702-4-7-1-12. 1.8 Continuity of Care. Subject to applicable network adequacy/continuity of care regulations under 3 CCR 702-4-2-56, in the event that the Agreement is terminated without cause by Carelon, Members who have not been properly notified of the termination pursuant to C.R.S. § 10-16-705(7) shall be allowed to continue receiving Covered Services from Provider for sixty (60) days after the date of termination. In the event that coverage under a health benefit plan is terminated for any reason other than nonpayment of premium, fraud, or abuse, Provider shall continue rendering Covered Services to a Member being treated at an in -patient facility (if applicable) until the Member is discharged. C.R.S. § 10-16-705(4). During any such continuation of care periods, Provider agrees to render Covered Services to Members in accordance with the rates of compensation, terms, and conditions under the Agreement. C.R.S. § 25-37-111(1). ARTICLE 2: CLAIMS AND PAYMENT 2.1 Claims Processing. To the extent required C.R.S. § 10-16-121(1)(c), Carelon shall comply with the applicable prompt payment requirements of C.R.S. § 10-16-106.5(3), (4), and (5) in the performance of claims processing functions under the Agreement. 2.2 No Financial Disincentives. Provider shall not be subjected to financial disincentives based on the number of referrals made to participating providers for Covered Services, so long as Provider adheres to the utilization review policies and procedures of Carelon and Payor. Furthermore, Carelon shall not take an adverse action against a Provider or provide financial incentives or subject the Provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient's satisfaction with pain treatment. C.R.S. § 10-16-121(1)(d) and (e). ARTICLE 3: TERMINATION 3.1 Termination without Cause. In addition to the right to terminate the Agreement based on a material change to the Agreement in accordance with C.R.S. § 25-37-104(2), if the term of the Agreement is fora duration of less than two (2) years, the Agreement may be terminated by Provider or Carelon without cause upon at least ninety (90) days' prior written notice to the other party. Notwithstanding the forgoing to the extent that the Agreement provides fora longer notification period with respect to termination of the Agreement without cause, such longer notification period will apply. If the term of the Agreement is for a duration of two (2) years or more, the Agreement may be terminated without cause in accordance with the terms set forth in the Agreement, unless applicable network adequacy/continuity of care regulations under 3 CCR 702-4-2-56(5) require a longer notice period for termination without cause. C.R.S. § 25-37-111(2). 3.2 Termination for Cause. Carelon or Provider may terminate the Agreement for cause for the reasons stated in the Agreement, including the Provider Manual. Such notice of termination for cause shall be provided by the terminating party to the other party in accordance with the required method, timeframe, and address for giving such notices as specified in the Agreement. C.R.S. § 25-37-103(1)(c). 49 BHONationalAG 03.01.2023_V.05_CO Exhibit C: Payor/Government Program/Plan Specific Provisions Provider acknowledges and agrees that the provisions set out in the attached Exhibit C (including any subparts thereto) and on, each of which are incorporated herein by reference and made a part of the Agreement, apply solely with respect to Members of the identified Plans. 50 BHONationalAG G3.01.2023_V..05 CO EXHIBIT C-1: BLUE CROSS BLUE SHIELD ASSOCIATION ("BCBSA") BLUE CARD PROGRAM 1. The Blue Card Program is a national BCBSA program that enables members of one independent Blue Cross and/or Blue Shield Plan ("Blue Plan") to obtain healthcare service benefits while traveling or living in another Blue Plan's service area. The program links participating healthcare providers and facilities with the independent Blue Plans across the country and in more than 200 countries and territories worldwide through a single electronic network for claims processing and reimbursement. The program allows providers and facilities to submit claims for members from other Blue Plans to their local Blue Plan. In the states and for Blue Plans identified as BCBSA Licensed Companies ("BCBSA Licensed Receiving Company(ies)"), Provider agrees to act as BCBSA Licensed Receiving Company network provider and provide covered services to any person who is covered under a BCBSA Blue Card or other BCBSA reciprocal program and comply with all applicable provisions. 2. When acting as an BCBSA Licensed Receiving Company network provider in order to serve members of Blue Plans, Provider agrees to: a. Provide Covered Services to any person who is covered under a BCBSA Blue Card or other BCBSA reciprocal program. b. Submit claims for payment in accordance with current BCBSA claims filing guidelines. Provider shall accept payment by the applicable Blue Plan at that Plan's Rate for the equivalent Network as payment in full, except Provider may bill, collect and accept compensation for cost shares. c. Comply with the applicable Blue Plan's utilization management policies. d. Comply with the provisions of the Blue Card Program Provider Manual. The manual can be found online at www.anthem.com. Select Providers, then select state, then Provider Manuals. 3. Provider understands and expressly acknowledges that the agreement under which Provider is obligated to participate in the Blue Card program constitutes a contract between Carelon and Anthem, Inc. and its affiliates ("Anthem") or, if applicable, such other Blue Plan that Carelon may have contracted with ("Other Blue Plan"); that Anthem or such Other Blue Plan, as applicable, is an independent corporation operating under a license from the BCBSA, an association of independent Blue Cross and/or Blue Shield Plans, permitting Anthem or such Other Blue Plan, as applicable, to use the Blue Cross and/or Blue Shield service marks in this state; and, that Anthem or such Other Blue Plan, as applicable,is not contracting as the agent of the BCBSA. Provider further acknowledges and agrees that it has not entered into this Agreement based upon representations by any person other than Anthem or such Other Blue Plan, as applicable, and that no person, entity or organization other than Anthem or such Other Blue Plan, as applicable, shall be held accountable or liable to Provider for any of Anthem or such Other Blue Plan, as applicable, obligations to Provider created under this Agreement. Provider has no license to use the Blue Cross and/or Blue Shield names, symbols, or derivative marks (the "Brands") and nothing in the Agreement shall be deemed to grant a license to Provider to use the Brands. Any references to the Brands made by Provider is subject to review and approval by Anthem or such Other Blue Plan, as applicable. 51 BHONati onalAG_03. 01.2023_ V.. 05_CO EXHIBIT C-2: FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM 1. Provider fu[her acknowledges and understands that Carelon contracts with Anthem or such Other Blue Plan, as applicable, which participate in the Federal Employees Health Benefits Program ("FEHBP"), the health insurance program for federal employees. Provider further understands and acknowledges that FEHBP is a federal government program and the requirements of the program are subject to change at the sole direction and discretion of the United States Office of Personnel Management. Provider agrees to abide by the rules, regulations and other requirements of FEHBP as they exist and as they may be amended or changed from time to time. 2. Notwithstarding any other applicable laws or regulations goveming the time frame for overpayment recoveries, for erroneous ar duplicate claim payments made under FEHBP, either party shall refund or adjust, as applicable, all such duplicate cm erroneous claim payments regardless of the cause. Such refund or adjustment may be made within six (6) years from lie end of the calendar year in which the erroneous or duplicate Claim was submitted, or such other time period as establisled by the United States Office of Personnel Management. Plan may offset future claim payments in lieu of a refund. This paragraph applies to FEHBP only. 3. Per the Agmement, Provider acknowledges and agrees that in no event, including but not limited to the insolvency of Payor or Carelon, breach of the Agreement and/or non-payment for services by Payor or Carelon, as applicable, may Provider bill or seek compensation from or assert any legal action against Members or persons acting on behalf of Members for payment of any financial liabilities (including payment of fees) that are the obligation of Carelon or Payor. Provider shall not seek or accept Menber cost sharing that exceeds the amount a Member would be required to pay under Member's health benefit plan and agrees to accept the Payor's payment as payment in full, unless otherwise authorized by Applicable Rules. Provider may seek payment from a Member only if the Provider has obtained a waiver that contains the following: 1) Written notice identifying the proposed services; 2) Written acknowledgement that the Member has been informed that services may be deemed not medically necessary or experimental/investigational by the Plan; 3) An estimate of the cost for services; and 4) Member must agree in writing to be financially responsible in advance of receiving the services, and must sign and date the waiver. If the waiver does not include the above requirements, the waiver shall be deemed invalid and the Provider shall be responsible for the cost of services denied, if denied for lack of medical necessity or considered experimental/investigational. 4. Provider further agrees that in the event of a conflict between this Agreement and/or the Provider Manual, and the rules/regulations/other requirements of FEHBP, the terms of the rules/regulations/other requirements of FEHBP shall control. 52 BHONationalAG IB.01.2023_V.05 CO EXHIBIT C-3: EmblemHealth Specific Provisions The following additional provisions apply solely with respect to services rendered to Members covered under those certain Plans offered and/or administered by Group Health Incorporated, HIP Insurance Company of New York, and their respective affiliates (severally and collectively "EH"), a client of Carelon and a Payor and for which those certain EH Plans Carelon provides administrative services. Whenever in this Exhibit the term "Provider" is used to describe an obligation or duty, such obligation or duty shall also be the responsibility of each individual Practitioner, as the context may require. In the event of any conflict between the terms of the Agreement and this Exhibit, the provisions of this Exhibit shall control with respect to services rendered to EH Members and participation in provider network(s) made available to EH Plans. 1. Provider acknowledges and agrees that provisions of the EH Payor Contract as applicable to Provider services rendered to EH Members, and compliance with EH policies, procedures and programs and applicable laws and regulations apply to Provider, unless clearly inapplicable, each as may be amended. 2. In addition to the terms and conditions of the Agreement and as such are made available to participating providers, Provider agrees to comply with: (a) the requirements of the EH Behavioral Management Program (BMP); and (b) all applicable EH claims processing policies and procedures. 3. Provider agrees: (a) to participate in provider networks made available to EH Plans for which Carelon administers certain behavioral health service benefits, including without limitation EH's 'Network Access Program'; (b) to accept the rates set out in the applicable EH specific Rate Schedule in Exhibit A-3 of the Agreement, less any applicable EH Member Expenses, as payment in full for all Covered Services rendered to EH Members, except to the extent such payment rate in Exhibit A-2 or Provider's billed charges (as applicable and whichever is less) are less than the applicable EH Member Expenses and in which case Provider shall collect only such lesser payment rate or billed charge amount from Member versus the entire EH Member Expense amount; (c) to comply with: (i) EH's fraud and abuse policy; (ii) EH's QI and UM programs, where such activities are not otherwise delegated to the Carelon; (iii) EH grievance and appeals process, where such activities are not otherwise delegated to Carelon; and (iv) peer review and other professional review activities conducted by EH; (d) to cooperate with coordination of benefits and/or subrogation activities by Carelon and/or EH, or their designee (including without limitation submitting claims to known primary payors before submitting same to Carelon, maintenance of records regarding receipt of payment from primary payors and making such records available upon request from EH; (e) cooperate with EH in audits required by any regulatory agency or accreditation organization to which EH is subject, and: (i) provide copies of records required such regulatory agency or accreditation organization within five (5) business days (or such lesser period of time required) of request, and (ii) comply with directives and recommendations of such regulatory agency or accreditation as a result of such audit(s); and (f) that while EH is not a party to the Agreement, in certain instances EH may participate in negotiation of EH Plan specific rates. 4. In the event Provider has in effect an arrangement or contract with both Carelon and EH, Provider understands and agrees that this Agreement shall control with respect to behavioral health services rendered to EH Members. 5. Regardless of any provision to the contrary, Provider agrees: (a) the references to EH herein shall not be construed as imposing joint responsibility or cross guarantee between or among Carelon and EH; and (b) to look to Carelon or its designee for payment of Covered Services rendered to EH Plan Members covered under EH Plans for which Carelon is acting as the Payor under the Agreement. 6. With respect to those EH Plans administered by Carelon, in whole or in part, Provider agrees to comply with: (a) applicable state and/or federal laws, rules and/or regulations, government sponsored health benefit program requirements (e.g., New York State Medicaid Managed Care, New York State Family Health Plus, Federal Employee Health Benefit Program, etc.), including without limitation appointment availability and office hours, referrals and documentation of same in the Member's medical records, access to EH Member records, maintenance and retention of EH Member records, claims submission, EH Member hold harmless, and continuation of care requirements; and (b) with Carelon credentialing and re-credentialing standards, policies and procedures. 7. Provider agrees: (a) to provide Carelon and EH with timely access to records, reports, clinical information and/or encounter data in the format required to meet obligations under contracts with any government agency sponsoring or overseeing EH 53 BHONationalAG_03.01.2023_V. 05_CO Plans covered Jnder the Agreement; and (b) that Carelon may provide access to EH to Carelon' provider file for Provider (if any), Provider's provider contract with Carelon as well as Provider's credentialing/re-credentialing information and file and that through inclusion of this Exhibit in the Agreement that Provider affirmatively authorizes Carelon to provide such files and information to EH without the need for additional or subsequent written authorization from Provider. 8. For those Merroers currently inpatient at Provider and based upon the clinical status of the Member at the time, Provider will verbally notify tie Member of approvals and adverse determinations of authorization regarding the then current inpatient stay or continued inpatient stay of which the Provider is made aware by Carelon. 9. Provider appeals of initial and any concurrent review adverse Medical Necessity determinations are limited to those made on behalf of a EH EMP Member or where available under applicable law, rule or regulation and then only for such time period identified in the Agreement or within the one hundred and eighty (180) day period following receipt of notice of the adverse determination, whichever is less. 10. Provider agrees that if Carelon or EH requests in writing and with explanation, that a particular practitioner or physician employed by of contracted with Provider no longer render services to EH Members pursuant to the Agreement, Provider shall immediately comply with such request and agrees to remove such practitioner or physician from participating under the Agreement. Provider agrees that should Carelon determine that it no longer desires to have one of facilities or locations identified in the Agreement, Provider agrees to immediately remove such facility or location from participation under the Agreement anclor participation in the EH network. 11. Regardless of any provision in the Agreement to the contrary, Provider agrees that: should EH no longer be a client of Carelon and thus no longer a Payor (as defined under the Agreement), Carelon unilaterally may: (a) amend the Agreement to be assigned in part to EH to include EH and Provider as the parties and assign the Agreement in part (with the Agreement remaining in ful force and effect as between Provider and Carelon) and inclusive of all of the terms, conditions and the EH specific Rate Sthedule (Exhibit A-2) to EH; and (b) provide EH with a copy Provider's Carelon provider file, including without limitation credentialing and re-credentialing files, and that through inclusion of this Exhibit in the Agreement that Provider affirmatively authorizes Carelon to provide such files and information to EH without the need for additional or subsequent written authorisation from Provider. Carelon will provide Provider with written notice of such occurrence, which notice shall include the efffctive date of any such occurrence and the assigned and amended contract. 54 BHONationalAG CB.01.2023_V.05_CO EXHIBIT C-4: COLORADO MEDICAID & OTHER GOVERNMENT SPONSORED HEALTH BENEFIT PROGRAM PROVISIONS This Colorado Medicaid & Other Government Sponsored Health Benefit Program Exhibit incorporates additional provisions into the Agreement applicable to the Colorado Medicaid Community Mental Health Services Program (the "Program") as administered by one of the entities contracted with Carelon to perform certain administrative services ("Payor(s)"). A. Definitions. (1) All capitalized terms not otherwise defined in this Exhibit shall have the meanings ascribed to them in the Agreement. In the event of any conflict between terms defined in this Agreement, the Exhibit and the Payors' Medicaid Contract, the Medicaid Contract shall control. (2) For purposes of this Exhibit, the following additional terms shall have the meaning set out below: (a) "Covered Services" means those services covered by the Program. (b) "Department' means the Colorado Department of Health Care Policy and Financing. (c) "MCD Member(s)" means those designated individuals eligible for and enrolled in the Colorado Medicaid Plan and as specified in the Department's Program rules and regulations. References in the Agreement to 'Subscribers', 'Eligible Beneficiaries', 'Enrollees' or 'Members' include MCD Members. (d) "Medicaid Contract means a Payor's contract(s) with the Department, to arrange for the provision of certain behavioral health care services to MCD Members in designated service areas under the Program. (a) "Substance Use Services" means those Covered Services related to the identity, diagnosis, prognosis, or treatment of alcohol or drug abuse. B. General Provisions. (1) This Exhibit applies only as to covered services rendered to MCD Members (as defined above). (2) Whenever in this Exhibit the term "Provider' is used to describe an obligation or duty, such obligation or duty shall also be the responsibility of each individual licensed health care practitioner, facility and provider employed or owned by or under contract with Provider, as the context may require. (3) Provider agrees to participate in the Program and render services to MCD Members in accordance with the terms of the Agreement and this Exhibit. (4) Provider agrees to comply with Program policies and procedures as described in the Provider Manual. For purposes of participation in the Program and services rendered MCD Members hereunder, the term "Provider Manual" in the Agreement means the Colorado Medicaid Provider Network Handbook. (5) Neither Carelon nor Payors will prohibit, or otherwise restrict, Provider, acting within the scope of his/her professional license and scope of practice, from advising or advocating on behalf of a MCD Member who is his or her patient; including providers that serve high risk population or specialized conditions that require costly treatment. (6) This Exhibit may be amended from time to time by Carelon pursuant to the Agreement. C. Accountability & Oversight. Regardless of any provision to the contrary, Payors, or their respective designees, oversee and monitor the provision of services to their respective MCD Members on an on -going basis and Payors remain accountable and responsible to the Department for compliance with the terms and conditions of their respective Medicaid Contracts, regardless of the provisions of the Agreement or any delegation of administrative activities or functions to Carelon. D. Provider Status. (1) Provider represents that Provider: (a) Maintains full participation status in the Program (This includes Provider, all Provider employed and contracted health care practitioners, health care providers, and health care facilities, and those other employees, contracted individuals and entities who will provide services to MCD Members under the Agreement, including without limitation, mental health and/or substance abuse, utilization review, medical social work and/or other administrative services.); (b) Does not have any employees, agents, management staff, or persons with ownership or control interests whom have been convicted of criminal offenses related to their involvement in Medicaid, or social service programs under Title XX of the Social Security Act; 55 BHONationalAG_03.01.2023_V.05 CO (c) Has nor been and does not employ or contract with any individuals or entities who have been disbarred, suspended or otherwise excluded from participation in any government sponsored health care program, including without limitation the Colorado Medicaid program; and (d) Shall notify Carelon immediately in the event that Provider is debarred, suspended or otherwise excluded from participation in any government sponsored health care program. (2) Prior to rendering services to MCD Members and subject to any credentialing or re-credentialing processes, Provider understand and agrees that Provider must submit to Carelon Provider's NPI number and, if applicable, Colorado Medicaid prvider number. E. Compliance. (1) Provider agrees to: (a) Comps with all applicable local, state and federal laws, rules and regulations governing the Program, Program operating procedures, and applicable requirements of the Medicaid Contract(s), including without limitation those: (i) Designed to prevent or ameliorate fraud, waste, and abuse; (ii) Regarding the privacy, security, confidentiality, accuracy and/or disclosure of records, protected health inbrmation and/or personally identifiable information, including without limitation, the federal Health Insurance Pcrtability and Accountability Act of 1996 and the rules and regulations promulgated thereunder (each as may be amended); (b) Maintan professional liability or malpractice insurance coverage in accordance with the Agreement; (c) Comp' and cooperate with training and education given as part of a Payor's compliance plan to detect, correct and prevent fraud, waste and abuse; and (d) Submit the Colorado Client Assessment Record (CCAR) and all reports and clinical information required by Carelm and/or Payors that may be required by Medicaid Contract(s). (2) Consent tod)isclose Substance Use Disorder Information: (a) For each Covered Person receiving Substance Use Services, Provider shall obtain from the Covered Person an executed consent, compliant with 42 C.F.R. § 2.31, authorizing Provider to disclose information related to the Coveeed Person and his or her receipt of Substance Use Services to Payor for claims payment purposes. Such consent shall additionally authorize the re -disclosure of such information by Payor to the Department of Health Care'olicy and Financing (the "Department"), as required by and for the purposes set forth in Payor's contract with he Department. Forms of the consent documents are attached hereto as Exhibits C-4.1.1 and C-4.1.2 (ESP` and incorporated herein by reference. (b) Provider shall retain and maintain each such consent for a period of at least six (6) years from the last effective date of such consent. (c) If a Covered Person refuses to sign such a consent, Provider shall document its efforts to obtain such a consent and mall notify Payor prior to billing Payor for the provision of Substance Use Services for such Covered Persons. (d) Behavioral health providers are required to maintain and share, as appropriate, a member treatment/health record in accordance with professional standards. Which includes data -sharing, access to medical records when requested, including with other providers/organizations involved in the Member's care. F. Services. (1) Provider agrees to: (a) Make available to MCD Members those Medically Necessary Covered Services provided by Provider within the scopenf his/her/its professional license, registration and/or certification twenty-four (24) hours a day, seven (7) days a week; (b) Provide Carelon with all requisite information regarding his/her/its twenty-four (24) hour coverage, including: (i) any exended hours of operation; (ii) any additional morning, afternoon, or evening hours of operation or weekend hours of operation, and notifying Carelon immediately when needing to arrange alternate coverage; (c) Meet fie standards for timeliness of service and appointment standards set out in the Medicaid Contracts; (d) Work cooperatively with MCD Members' medical health providers of care to facilitate the delivery of health services as appropriate; (e) Bill Medicare for dual Medicare and Medicaid eligible MCD Members prior to billing Carelon, a Payor to the Department for Covered Services rendered to such 'dual eligible' MCD Members, acknowledging that Medicaid is the pavor of last resort for 'dual eligible' MCD Members; (f) To render services to MCD Members taking into account the MCD Member's rights consistent with Carelon's and any P€yor specific policies and procedures; 56 BHONationalAG 03.01.2023 V.05_CO (g) Develop on an annual basis and in conjunction with the MCD Member and/or participate in the development of individualized service plans (treatment plans or client care plans) for MCD Members who are patients of Provider, and modified if there is a change in the MCD Member's level of functioning and care needs; (h) Comply with Carelon and Payor specific policies and procedures, including but not limited to, those for quality assurance (including independent quality review and improvement organization activities), utilization review, and resolution of MCD Member appeals and grievances; (i) Comply with Carelon and any Payor specific credentialing and re-credentialing processes and requirements; (j) Cooperate with Payors' cultural competency plans, including without limitation providing language assistance services at no cost to MCD Members with limited English proficiency; (k) Comply with and implement corrective action where necessary and/or as established or required by Carelon, a Payor or the Department. G. Claims & Payment. (1) Provider shall submit Clean Claims for Covered Services rendered to MCD Members within the time period provided for in the Agreement; however, Provider must submit all Clean Claims for Covered Services within ninety (90) calendar days from the date of service or such claims will be denied and no payments made. (2) Subject to the terms and provisions set forth in the Agreement and this Exhibit, Carelon or its designee shall pay, deny or settle Clean Claims for Covered Services rendered to MCD Members submitted electronically within thirty (30) days of receipt and within forty-five (45) days of receipt when submitted by other means. Payment rates for Covered Services rendered to MCD Members are set out in the Rate Schedule or Schedules attached hereto and incorporated herein by reference. Provider agrees that payments hereunder (including any applicable MCD Member Copayments) shall constitute payment in full for the Provider's provision of Medically Necessary Covered Services to MCD Members. Notwithstanding the foregoing, in the event that the amount payable to a Payor under their Medicaid Contract is decreased, Provider agrees that Carelon may amend the Program payment rates to decrease the amount payable in accordance with the terms of the Agreement. (3) Provider acknowledges and agrees that in no event, including without limitation the insolvency of a Payor or Carelon, breach of the Agreement by Carelon, and/or non-payment for Covered Services, shall Provider bill, charge or seek compensation, remuneration or reimbursement from, or assert any legal action against MCD Members for payment of any fees or amounts that are the legal obligation of Carelon and/or the Payor. (4) Provider agrees that any payments made by Carelon, a Payor, or their respective designees, to Provider under the Agreement are not an inducement to reduce or limit Medically Necessary services to MCD Members. (5) Any incentive plans between Carelon and Provider and/or between Carelon and physicians, practitioners, providers and/or facilities employed or owned by and/or contracted with Provider to render services to MCD Members under the Agreement shall be in compliance with applicable state and federal laws, rules and regulations, including without limitation 42 C.F.R. §438.6, and in accordance with the respective Payors' Medicaid Contracts. Upon request, Provider agrees to disclose to Carelon and Payors the terms and conditions of any 'physician incentive plan' as defined by the Department and/or any state or federal law or regulation. H. Records. (1) Provider agrees to maintain records, including separate financial, administrative and medical records, related to Covered Services rendered by Provider to MCD Members for time periods set out in the Agreement or such longer period of time as may be required in the Medicaid Contract and/or by law. (2) Subject to any legal restrictions, Provider agrees to provide the Department, the Department of Health and Human Services (DHHS), the Office of Inspector General (OIG), the General Accounting Office (GAO), the Comptroller General, the Center for Medicare and Medicaid Services and/or other applicable regulatory agencies, Payors' accrediting bodies, or their respective designees with timely access to any contracts, books, financial records, medical records, documents, papers and other records and information, including without limitation financial or otherwise, and their respective facilities, as they apply to Provider's obligations under the Agreement and/or as related to services rendered to MCD Members and/or as required by the Program necessary for: (a) Payors to meet obligations under their Medicaid Contracts; and/or (b) the Department to administer and evaluate the Program. Provider agrees to cooperate in investigations conducted by the above noted authorized regulatory agencies and any resulting legal actions. This provision shall survive the termination of this Exhibit and the Agreement. 57 BHONationalAG_03. 01.2023_V.. 05 CO I. Provider -Member Communication. (1) Nothing under this Agreement prohibits, or otherwise restricts, a health care professional acting within the lawful scope of practice, -from advising or advocating on behalf of an MCD Member who is his or her patient, for the following: (a) The MCD Member's health status, medical care, or treatment options, including any alternative treatment that may be selfadministered. (b) Any inbrmation the MCD Member needs in order to decide among all relevant treatment options. (c) The risks, benefits, and consequences of treatment or non -treatment. (d) The MCD Member's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. 58 BHONationalAG w.01.2023_V..05_CO EXHIBIT C-4.1.1: Patient Consent and Authorization Form for Disclosure of Substance Use Disorder Health Information to Medicaid Member (name and information of member whose health information is being disclosed): Name: ID# or DOB: Substance Abuse Provider: ("Provider") Background: The Regional Accountable Entities (RAEs) listed below contract with the State of Colorado to provide mental health and substance use services to Medicaid members. The RAEs in turn contract with Provider to provide mental health and substance use services to Medicaid members. Medicaid has assigned you to one of the RAEs for the management of your services. The RAEs process claims for services submitted by Provider. The RAEs are also required to submit information on all claims paid or processed to Colorado Medicaid for Medicaid administration purposes. • I hereby authorize Provider to disclose my health information, including information related to my treatment for alcohol and/or drug abuse, to one of the RAEs listed below to which I have been assigned for the purpose of Provider submitting claims for payment to the RAE or other reason (please explain reason): • I hereby further authorize the RAE listed below who has received and processed a claim for services delivered to me by Provider, to re -disclose such information to Colorado Department of Health Care Policy and Financing (Medicaid) for its Medicaid administration purposes as is required by the contract that the RAE has with Medicaid. RAEs Authorized to Receive and Re -Disclose Information: Health Colorado, Inc. Northeast Health Partners OPTIONAL Additional description of information to be disclosed • My treatment may not be conditioned if I do not sign this form. • I have received a copy of this signed document. • I understand that I may revoke this authorization at any time by giving written notice to Provider, except to the extent that the Provider or the RAE has already acted on it. • This authorization will expire on the date that I am no longer a Colorado Medicaid member or two years from the date of my signature, whichever is earlier. Signature of Member or Legal Representative Date Signed Print Name of Legal Representative (if applicable) Relationship to Client 59 BHONationalAG 03.01.2023 v.05_CO EXHIBIT C-4.1.2: Formulario de Consentimiento y Autorizacion del Paciente para la Divulgacion de Informacion de Salud sobre el Trastorno de Uso de Sustancias a Medicaid Miembro (nombre einformacion del miembro cuya informacion de salud sera dada a conocer): Nombre: ID o Fecha de Naciniento: Proveedor Especial'sta en Abuso de Substancias: ("Proveedor") Historial: Las orgarizaciones regionales (RAE) de la lista mas abajo tienen contratos con el Estado de Colorado pars ofrecer servicios de salud rrEntal y uso de sustancias a los miembros de Medicaid. Las organizaciones regionales (RAE) listadas abajo tienen contratos cot el Estado de Colorado pars ofrecer servicios de salud mental y uso de sustancias a los miembros de Medicaid. Medicaid a ha asignado a usted una de estas RAEs pars el manejo de sus servicios. La RAE procesa los reclamos de servicios que endia el Proveedor. Tambien se requiere que la RAE envie informacion sobre todos los reclamos pagados o procesados a Colorado Medicaid con propositos administrativos de Medicaid. • Yo autorizc por este medio al Proveedor a divulgar mi informacion de salud, incluyendo informacion relacionada con mi tratamiento por abuso de alcohol y/o drogas, a una de las RAEs de la lista de abajo a la cual he sido asignado con el proposito de que el Proveedor envie reclamos por pago a la RAE u otras razones (especifique la razon): • Ademas, tsmbien autorizo a la RAE de la lista de abajo que ha recibido y procesado un reclamo por servicios que el Proveedor me im ofrecido, a volver a divulgar esa informacion al Colorado Department of Health Care Policy and Financing (Medicaid) pare sus propositos de administracion de Medicaid segun se requiere por el contrato que la RAE tiene con Medicaid. RAE autorizada a recibir y redistribuir informacion: Health Colorado, Inc. Northeast Health Partners • OPCION: E'escripcion adicional pars informacion que divulgar • Mi tratamiento no puede estar condicionado si no firmo este formulario. • He recibidc una copia de este documento firmado. • Comprend• que puedo revocar esta autorizacion en cualquier momento dandole aviso por escrito a mi Proveedor, excepto hasta el punto en el que el Proveedor o la RAE ya hayan actuado sobre ella. • Esta autoreacion expirara en la fecha en la que yo ya no sea miembro de Colorado Medicaid o dos arms a partir de la fecha de mi Irma, segun cual sea ocurra primero. Firma del miembro t representante legal Fecha en la que se firmo Nombre del representante legal en letra de molde Relacion con el Cliente (si corresponde) 60 BHONationalAG 08.01.2023_!! 05_CO Exhibit C-5: Anthem Specific Provisions The following additional provisions attached hereto as Exhibit C-5 shall govern only as to (1) Anthem Plan(s) or Other Blue Plan(s) and (2) Members of Anthem Plans or Other Blue Plans. For the avoidance of doubt, unless this Agreement is being applied to Anthem Plan(s) or Other Blue Plan(s) or Members of Anthem Plan(s) or Other Blue Plan(s), the terms and conditions of this Exhibit shall not be applicable. In the event of any conflict or inconsistency between the terms Applicable Rules, a Member's Plan, the Agreement or this Exhibit C-5 such that Carelon and Provider are not able to comply with all requirements thereof, then the order of preference between conflicting provisions shall be given as follows: 1. Applicable Rules, 2. Member's Plan 3. this Exhibit C-5 but only as it applies to and Members of Anthem Plan(s) or Other Blue Plan(s), and 4. the Agreement. I. DEFINITIONS The definitions set forth below shall apply with respect to all of the terms outlined in this Exhibit C-5. Terms not otherwise defined in this Exhibit C-5 and defined elsewhere in the Agreement shall carry the meanings set forth in the Agreement. "Anthem Plan" means i) a health plan owned by Anthem, Inc. ("Anthem"); ii) an affiliate entity either owned, under common control, or controlled either directly or through a parent or subsidiary entity by Anthem; or iii) entities utilizing the Networks/Plan Programs pursuant to an agreement with Anthem or its affiliate, and employers providing health benefit plans pursuant to self-administered or self -insured programs. "Anthem Rate" means the lesser of one hundred percent (100%) of Eligible Charges for Covered Services, or the total reimbursement amount that Provider has agreed to accept as set forth in this Exhibit and the applicable Rate Schedule. The Anthem Rate includes applicable Cost Shares, and shall represent payment in full to Provider for Covered Services. "Capitation" means the amount paid to a provider or management services organization on a per member per month basis for either specific services or the total cost of care for Covered Services. "Case Rate" means the all-inclusive Anthem Rate for an entire admission or one outpatient encounter for Covered Services. "Claim" means either the uniform bill claim form or electronic claim form in the format prescribed by Plan submitted by a provider for payment by a Plan for Health Services rendered to a Member. "Coded Service Identifier(s)" means a listing of descriptive terms and identifying codes, updated from time to time by CMS or other industry source, for reporting Health Services on the CMS 1500 or CMS 1450/UB-04 claim form or its successor as applicable based on the services provided. The codes include but are not limited to, American Medical Association Current Procedural Terminology ("CPT® -4"), CMS Healthcare Common Procedure Coding System ("HCPCS"), International Classification of Diseases, 10th Revision ("ICD-10"), National Uniform Billing Committee ("Revenue Code") and National Drug Code ("NDC") or their successors. "Cost Share" means, with respect to Covered Services, an amount which a Member is required to pay under the terms of the applicable Plan. Such payment may be referred to as an allowance, coinsurance, copayment, deductible, penalty or other Member payment responsibility, and maybe a fixed amount or a percentage of applicable payment for Covered Services rendered to the Member. "Covered Services" means those Medically Necessary mental health, alcohol and/or substance abuse Health Services for which Members are covered pursuant to a Plan and for which a Member covered thereunder is entitled. 61 BHONationalAG 03.01.2023 V..05 CO "Diagnosis -Related Group" ("DRG") means Diagnosis Related Group or its successor as established by CMS or other grouper, including but not limited to, a state mandated grouper or other industry standard grouper. "DRG Rate" means the all-inclusive dollar amount which is multiplied by the appropriate DRG Weight to determine the Anthem Rate for Covered Services. "DRG Weight" means the weight applicable to the specific DRG methodology set forth in the applicable Rate Schedule, including but not limited to, CMS DRG weights as published in the Federal Register, state agency weights, or other industry standard weights. "Eligible Charges" means those Provider Charges that meet Anthem's conditions and requirements fora Health Service to be eligible for reimbursement. These conditions and requirements include but are not limited to: Member program eligibility, Provider program eligibility, benefit coverage, authorization requirements, provider manual specifications, Anthem administrative, clinical and reimbursement policies and methodologies, code editing logic, coordination of benefits, Regulatory Requirements, and this Agreement. Eligible Charges do not include Provider Charges for any items or services that Provider receives and/or provides free of charge. "Emergency Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy to the health of the individual (or unborn child); (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. "Emergency Services" means those services necessary to screen for, diagnose or stabilize an Emergency Condition. Anthem shall compensate Provider for Emergency Services, if at all, according to the Member's Plan. "Encounter Data" means Claim information and any additional information submitted by a provider under capitated or risk -sharing arrangements for Health Services rendered to Members. "Encounter Rate" means the Anthem Rate that is all-inclusive of professional, technical and facility charges including evaluation and management, pharmaceuticals, routine surgical and therapeutic procedures, and diagnostic testing (including laboratory and radiology) capable of being performed on site. "Fee Schedule(s)" means the complete listing of Anthem Rate(s) for specific services that is payment for each unit of service allowed based on applicable Coded Service Identifier(s) for Covered Services. "Global Case Rate" means the all-inclusive Anthem Rate which includes facility, professional and physician services for specific Coded Service Identifier(s) for Covered Services. "Health Service(s)" means those services, supplies or items that a health care provider is licensed, equipped and staffed to provide and which he/she/it customarily provides to or arranges for individuals. "Inpatient Services" means Covered Services provided by a facility to a Member who is admitted and treated as a registered inpatient, is assigned a licensed bed within the facility, remains assigned to such bed and for whom a room and board charge is made. "Network" means a group of providers that support, through a director indirect contractual relationship, some or all of the produc(s) and/or program(s) in which Members are enrolled. "Other Blua Plan" means an independent Blue Cross and/or Blue Shield Plan under the Blue Cross Blue Shield Association that is not an Anthem, Inc. affiliate, and whose members are able to obtain healthcare service benefits while traveling or living in another Blue Cross and/or Blue Shield Plan's service area. "Outpatient Services" means Covered Services provided by a facility to a Member who is admitted and treated as a registered outpatient within the facility. 62 BHONationalAG GS. 01.2023 v 05 CO "Patient Day" means each approved calendar day of care that a Member receives, to the extent such day of care is a Covered Service under the terms of the Member's Health Benefit Plan, but excluding the day of discharge. "Percentage Rate" means the Anthem Rate that is a percentage of Eligible Charges billed by a provider for Covered Services. "Per Diem Rate" means the Anthem Rate that is the all-inclusive fixed payment for Covered Services rendered on a single date of service. "Per Hour Rate" means the Anthem Rate that is payment based on an increment of time for Covered Services. "Per Relative Value Unit" ("RVU") means the Anthem Rate for each unit of service based on the CMS, State Agency or other (e.g., American Society of Anesthesiologists (ASA)) defined Relative Value Unit (RVU). "Per Service Rate" means the Anthem Rate that is payment for each service allowed based on applicable Coded Service Identifier(s) for Covered Services. "Per Unit Rate" means the Anthem Rate that is payment for each unit of service allowed based on applicable Coded Service Identifier(s) for Covered Services. "Per Visit Rate" means the Anthem Rate that is the all-inclusive fixed payment for one encounter for Covered Services. "Plan Program" means any program now or hereafter established, marketed, administered, sold, or sponsored by Anthem Plan, or Blue Cross Blue Shield Association ("BCBSA") (and includes the plans that access, or are issued, or entered into in connection with such program). Plan Program shall include but is not limited to, a health maintenance organization(s), a preferred provider organization(s), a point of service product(s) or program(s), an exclusive provider organization(s), an indemnity product(s) or program(s), and a quality program(s). The term Plan Program shall not include any program excluded by Anthem Plan or BCBSA. "Provider Charges" means the regular, uniform rate or price Provider determines and submits to Anthem as charges for Health Services provided to Members. Such Provider Charges shall be no greater than the rate or price Provider submits to any person or other health care benefit payor for the same Health Services provided, regardless of whether Provider agrees with such person or other payor to accept a different rate or price as payment in full for such services. "Regulatory Requirement" means any requirements, as amended from time to time, imposed by applicable federal, state or local laws, rules, regulations, guidelines, instructions, government contract, or otherwise imposed by a federal, state or local agency or other governing body with jurisdiction over the governance or administration of a Plan,or government regulator in connection with the procurement, development or operation of a Plan, or the performance required by either party under this Agreement. The omission from this Agreement of an express reference to a Regulatory Requirement applicable to either party in connection with their duties and responsibilities shall in no way limit such party's obligation to comply with such Regulatory Requirement. II. GENERAL PROVISIONS Billing Form and Claims Reporting Requirements. Provider shall submit all Claims on a CMS 1500 or CMS 1450/UB- 04 claim form or its successor form(s) as applicable based on the Health Services provided in accordance with applicable Provider Manual, policies or Regulatory Requirements. Provider shall report all Health Services in accordance with the Coded Service Identifier(s) reporting guidelines and instructions using HIPAA compliant billing codes. In addition, Plan shall not pay any Claim(s) nor accept any Encounter Data submitted using non -compliant codes. Plan audits that result in identification of Health Services that are not reported in accordance with the Coded Service Identifier(s) guidelines and instructions, will be subject to recovery through remittance adjustment or other recovery action as may be set forth in the applicable Provider Manual. 63 BHONat ionalAG_03.01.2023_V. 05_CO Claim Subnissions for Pharmaceuticals. Each Claim submitted for a pharmaceutical product must include standard Coded Service Identifier(s), a National Drug Code ("NDC") number of the covered medication, a description of the product, art dosage and units administered. Unless otherwise required under Regulatory Requirements, Plan shall not reimbuse for any pharmaceuticals that are not administered to the Member and/or deemed contaminated and/or considered waste. Coding Upcates. Coded Service Identifier(s) used to define specific rates are updated from time to time to reflect new, deleted or -eplacement codes. Anthem shall use commercially reasonable efforts to update all applicable Coded Service Identifiers within sixty (60) days of release by CMS or other applicable authority. When billing codes are updated, F$ovider is required to use appropriate replacement codes for Claims for Covered Services, regardless of whether this Agreement has been amended to reflect changes to standard billing codes. If Provider bills a revised code prior b the effective date of the revised code, the Claim will be rejected or denied and Provider shall resubmit Claim with correct code. In addition, Claims with codes which have been deleted will be rejected or denied. Coding Sofware. Updates to Anthem's claims processing filters, code editing software, pricers, and any edits related thereto, as a result of changes in Coded Service Identifier(s) reporting guidelines and instructions, shall take place automaticaly and do not require any notice, disclosure or amendment to Provider. Modifiers. fII appropriate modifiers must be submitted in accordance with Regulatory Requirements, industry standard billing guidelines and the applicable Provider Manual and policies. If appropriate modifiers are not submitted, Claims may be rejected or denied. New/Exparded Service or New/Expanded Technology. As of the Effective Date of this Agreement, any New/Expanded Service or PJew/Expanded Technology (defined below) is not reimbursable under this Agreement. Notwithstanding the foregoing, mrovider may submit the following documentation to Carelon at least sixty (60) days prior to the implementation of any New/Expanded Service or New/Expanded Technology for consideration as a reimbursable service: (9a description of the New/Expanded Service or New/Expanded Technology; (2) Provider's proposed charge for the NevlExpanded Service or New/Expanded Technology; (3) such other reasonable data and information required by Anthem to evaluate the New/Expanded Service or New/Expanded Technology. In addition, approval may be required from the applicable Agency prior to a determination being made by Anthem that New/Expanded Service or New/Expanded Technology can be considered a reimbursable service. If the New/Expanded Service or New/Expanded Technology is determined to be reimbursable under this Agreement, Carelon will notify Provider, and then Provicer and Carelon agree to negotiate in good faith, a new Anthem Rate for the New/Expanded Service or New/Expanded Technology within sixty (60) days of Carelon's notice to Provider. If the parties are unable to reach an agreement= a new Anthem Rate for the New/Expanded Service or New/Expanded Technology before the end of the sixty (60) cay period, then such New/Expanded Service or New/Expanded Technology shall not be reimbursed by Plan, and the Payment in Full and Hold Harmless provision of this Agreement shall apply. a. "New/Expanded Service" shall be defined as a Health Service: (a) that Provider was not providing to Members as of the Effective Date of this Agreement and; (b) for which there is not a specific Anthem Rate as set forth inthe applicable Rate Schedule. b. "New/Expanded Technology" shall be defined as a technological advancement in the delivery of a Covered Service which results in a material increase to the cost of such service. New/Expanded Technology shall not include a new device, or implant that merely represents a new model or an improved model of a device or implant used in connection with a service provided by Provider as of the Effective Date of this Agreement. Non -Priced Codes for Covered Services. Carelon reserves the right to establish a rate for codes that are not priced in the applicable Rate Schedule, including but not limited to, Not Otherwise Classified Codes ("NOC"), Not Otherwise Specified NOS"), Miscellaneous, Individual Consideration Codes ("IC"), and By Report ("BR") (collectively "Non - Priced Codes"). Plan shall only reimburse Non -Priced Codes for Covered Services in the following situations: (i) the Non -Priced Code does not have a published dollar amount on the then current applicable Plan, State or CMS Fee Schedule, [ri) the Non -Priced Code has a zero dollar amount listed, or (iii) the Non -Priced Code requires manual pricing. In such situations, such Non -Priced Code shall be reimbursed at a rate established by Carelon for such Covered 64 BHONationalAG_0w. 01.2023_V.05_CO Service. Notwithstanding the foregoing, Non -Priced Codes that are not Covered Services under the Member's Plan shall not be priced or reimbursed by Plan. Provider may be required to submit medical records, invoices, or other documentation for Claims payment consideration. Reimbursement for Anthem Rate Based on Eligible Charges. Notwithstanding any reimbursement amount set forth in the applicable Rate Schedule, Provider shall only be allowed to receive such reimbursement if such reimbursement is for an Eligible Charge. In addition, if Provider reimbursement is under one or more of the following methodologies: Capitation, Case Rate, DRG Rate, Encounter Rate, Global Case Rate, Per Diem Rate, Per Relative Value Unit (RVU), and Per Visit Rate, then individual services billed shall not be reimbursed separately, unless otherwise specified in the applicable Rate Schedule. Reimbursement for Subcontractors. Plan shall not be liable for any reimbursement in addition to the applicable Anthem Rate as a result of Provider's use of a subcontractor. Provider shall be solely responsible to pay subcontractors for any Health Services, and shall via written contract, contractually prohibit such subcontractors from billing, collecting or attempting to collect from Anthem, Plan or Members. Notwithstanding the foregoing, if Anthem or Carelon has a direct contract with the subcontractor, the direct contract shall prevail over this Agreement and the subcontractor shall bill Anthem or Carelon, as applicable, under the direct contract for any subcontracted services, unless otherwise agreed to by the parties. Tax Assessment and Penalties. The Anthem Rate includes all sales and use taxes and other taxes on Provider revenue, gross earnings, profits, income and other taxes, charges or assessments of any nature whatsoever (together with any related interest or penalties) now or hereafter imposed against or collectible by Provider with respect to Covered Services, unless otherwise required by Agency pursuant to Regulatory Requirements. Neither Provider nor Plan shall add any amount to or deduct any amount from the Anthem Rate, whether on account of taxes, assessments, tax penalties or tax exemptions. Updates to Rate Schedule(s) Based on External Sources. Unless otherwise required by Regulatory Requirements, and notwithstanding any proprietary fee schedule(s)/rate(s)/methodologies, Anthem Plan or its designee for Claims processing shall use commercially reasonable efforts to update the applicable Rate Schedule(s) based on External Sources, which include but are not limited to, i) CMS Medicare fee schedule(s)/rate(s)/methodologies; ii) Medicaid or State Agency fee schedule(s)/rate(s)/methodologies; iii) vendor fee schedule(s)/rate(s)/methodologies; or iv) or any other entity's published fee schedule(s)/rate(s)/methodologies ("External Sources") no later than sixty (60) days after receipt by the Anthem Plan or its designee of the final fee schedule(s)/rate(s)/methodologies change from such External Sources, or on the effective date of such final fee schedule(s)/rate(s)/methodologies change, whichever is later. The effective date of such final fee schedule(s)/rate(s)/methodologies change shall be the effective date of the change as published by External Sources. Claims processed prior to the implementation of the new Rate Schedule(s) shall not be reprocessed, however, if reprocessing is required by Regulatory Requirements, and such reprocessing could result in a potential under and/or over payment to a Provider, then Plan may reconcile the Claim adjustments to determine the remaining amount Provider owes Plan, or that Plan owes to Provider. Any resultant overpayment recoveries (i.e., Provider owes Anthem Plan) shall occur automatically without advance notification to Provider. Unless otherwise required by Regulatory Requirements, Anthem Plan shall not be responsible for interest payments that may be the result of a late notification by External Sources of fee schedule(s)/rate(s)/methodologies change. III. PROVIDER TYPE Participating Provider(s) shall be limited to performing those Covered Services for which Participating Provider(s) is credentialed and licensed to perform. "Acute Care General Hospital" means an institution providing medical, nursing and surgical treatment for sick or injured Members, usually for a short term illness or condition. "Behavioral Health Facility" means a facility that provides psychiatric and/or substance abuse services usually for multiple levels of care with appropriate state licensure and quality accreditation certification. Behavioral health levels of care may include all of the following or a combination thereof — inpatient acute mental health, inpatient acute 65 BHONat i o nalA G_ 03.01.2 023 _ V. 05_CO detoxification, inpatient acute substance abuse rehabilitation, substance abuse residential treatment, psychiatric residential teatment, partial hospital programs (sometimes called day treatment), and intensive outpatient programs. "Behavioral Health Practitioner" means a licensed or certified mental health and/or substance abuse practitioner, or a group of licensed or supervised practitioners with varying specialties, who work either in an independent private practice, a group setting in one or more locations, or at an appropriately licensed clinic/facility or agency providing behavioral health and/or substance abuse Health Services. Provider wi use his or her best efforts to require any non -participating network health care provider to whom a Member is referred b abide by the terms of this Agreement. Provider must provide for the availability of emergency services twenty-four(24) hours, seven (7) days a week and to arrange for coverage by another provider when absent from his or her pramice and, if such covering health care provider is not a participating provider, to use Provider's best efforts to cause sat covering health care provider to abide by the terms of this Agreement. Unless Carelon and Anthem Plan explicitly agree otherwise, Provider acknowledges he or she is a participating provider at ALL locations and under ALL tax identification numbers. Furthermore, Provider agrees to notify Carelon in writing of each separate tax identification number under which Provider received compensation. IV. PROVIDES NETWORKS With respect to Anthem Plans, Provider shall be designated as being part of the Networks noted in this Section IV as of the laterof: 1) the Effective Date of this Agreement or; 2) as determined by Carelon and the Anthem Plan in their sole discretion, the date Provider has met applicable credentialing requirements, standards of participation and accreditation requirements: Commercid Lines of Business: Plans in wlich Members have access to a network of providers and receive an enhanced level of benefits when they obtain Cowered Services from Participating Providers regardless of product licensure status or funding source. Provider participates in Networks which support such Plans including but not limited to the following: HMO (ncludes group HMO and POS products such as: HMOC, HMO, Pathway HMO, Pathway Essentials, Blue Priorit) HMO. The following are effective as of January 1, 2023: Pathway HMO Standard, Pathway Essentials HMO Standard, and Mountain Enhanced Standard) • Indemnity/Traditional/Standard (includes indemnity/traditional/standard products such as: Indemnity) • Other . includes other products such as: Workers' Compensation) • PPO ancludes PPO, EPO and CDHP products such as: PPO, Pathway PPO/EPO, Pathway Essentials, Blue Prioritt PPO. The following are effective as of January 1, 2023: Pathway PPO Standard, Pathway EPO Standard, Pathway Essentials PPO Standard, and Pathway Essentials EPO Standard) WellCboice V. SPECIFIC REIMBURSEMENT TERMS COMMERCIAL BUSINESS i) For Covered Services provided by or on behalf of Provider to a Member who is enrolled in a product and/or pogram that is supported by a Network designated in this Exhibit, Provider agrees to accept as the applicable compensation hereunder, the lesser of Eligible Charges or the compensation as set forth in the applicable Rate Schedule. Allowances for Iniectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents. To the extent the applicable Rate Schedule is based, in whole or in part, on Medicare rates, pricing, fee schedules or payment methodologies published or established by CMS for Injectable/Infusible/Oral Drugs, Vaccines and Radiopharmaceutical Agents, the 66 BHONationalAG_C8. 01.2023_V. 05_CO allowance shall be automatically updated for injectable/infusible/oral drugs, vaccines and radiopharmaceutical agents on a quarterly basis in accordance with the quarterly updates made by CMS to its drug pricing file or any other external or internal source as set forth in the applicable Rate Schedule. Retroactive adjustments made by CMS to its drug pricing file shall be inapplicable to fee allowances and payment responsibility. Out -of -Network Compensation. Except for Government Programs, if Provider renders services to a Member who accesses a Network in which Provider does not participate, Provider will receive compensation as follows: Anthem Plan shall compensate Provider for Emergency Services rendered to a Member based on the applicable Indemnity/Traditional/Standard Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Members Plan requires authorization by Anthem Plan or a Provider for out -of - network Covered Services in order for the Member to have the highest level of benefits, and such authorization has been given, then Anthem Plan shall compensate Provider for such authorized Covered Services based on the applicable Participating Provider ("Indemnity/Traditional/Standard") Anthem Rate. Provider agrees to accept the Indemnity/Traditional/Standard Anthem Rate as payment in full and shall only bill for the applicable Cost Share. Except for Emergency Services, if the Member's Plan does not have out -of -network benefits unless authorized by Anthem Plan or Provider, then Anthem Plan shall have no liability for Health Services rendered without such authorization. In that event, Provider shall bill the Member for Health Services rendered. Except for Emergency Services, if the Member's Plan has out -of -network benefits without authorization being required by Anthem Plan or Provider, and no authorization has been given, then Anthem Plan will compensate Provider for Covered Services based on the Anthem Rate established for the Network and/or product that supports the Members Plan. For example, if the Member's access is supported by PPO Network, compensation is based on the applicable Anthem Rate for the PPO Network. Provider shall only bill for the applicable Cost Share as well as any amount designated as the Member's responsibility on the Provider payment voucher (or other written notice of explanation of payment). In no event shall payment from Anthem Plan and the Member exceed Provider's Charge for such Covered Services. EXCHANGES Provider agrees to participate in Anthem's exchange network(s) set forth in this Exhibit, which may support both products or programs offered by Anthem through state -based, regional or federal health insurance exchanges ("Exchanges") established by the Patient Protection and Affordable Care Act and products or programs offered by Anthem outside of Exchanges and agrees to accept the applicable Rate Schedule for the Exchanges. Provider acknowledges and understands that products or programs offered through or outside of the Exchanges may differ, and that such products or programs are subject to Regulatory Requirements. Provider agrees to abide by all Regulatory Requirements of the Exchanges as they exist and as they may be amended or changed from time to time. Should the name of the exchange network(s) set forth on the Provider Networks Attachment change, the Provider shall be notified. VI. DISPUTE RESOLUTION AND ARBITRATION Dispute Resolution. All disputes arising out of or related to Health Services provided to Anthem Members shall be resolved using the dispute resolution and arbitration procedures as set forth below. Provider shall exhaust any other applicable provider appeal/provider dispute resolution procedures under this Agreement and any applicable exhaustion requirements imposed by Regulatory Requirements as a condition precedent to Provider's right to pursue the dispute resolution and arbitration procedures as set forth below. 1. In order to invoke the dispute resolution procedures in this Agreement, a party first shall send to the other party a written demand letter that contains a detailed description of the dispute and all relevant underlying facts, a detailed description of the amount(s) in dispute and how they have been calculated and any other information that the Anthem provider manual(s) may require Provider to submit with respect to such dispute. If the total amount in dispute as set forth in the demand letter is less than two hundred thousand dollars ($200,000), exclusive of interest, costs, and 67 BHONat ionalAG_03. 01.2023_V. 05_CO attorneys' fees, then within twenty (20) days following the date on which the receiving party receives the demand letter, epresentatives of each party's choosing shall meet to discuss the dispute in person or telephonically in an effort to resolve the dispute. If the total amount in dispute as set forth in the demand letter is two hundred thousand dollars$200,000) or more, exclusive of interest, costs, and attomeys' fees, then within ninety (90) days following the date otthe demand letter, the parties shall engage in non -binding mediation in an effort to resolve the dispute unless both parties agree in writing to waive the mediation requirement. The parties shall mutually agree upon a mediator, and faing to do so, Judicial Arbitration and Mediation Services ("JAMS") shall be authorized to appoint a mediator. 2. Arbitraion. Any dispute within the scope of Section VI.1 hereof that remains unresolved at the conclusion of the applicaible process outlined in Section VI.1 shall be resolved by binding arbitration in the manner as set forth below. Except to the extent as set forth below, the arbitration shall be conducted pursuant to the JAMS Comprehensive Arbitraion Rules and Procedures, provided, however, that the parties may agree in writing to further modify the JAMS Compehensive Arbitration Rules and Procedures. The parties agree to be bound by the findings of the arbitrator(s) with respect to such dispute, subject to the right of the parties to appeal such findings as set forth herein. No arbitration demand shall be filed until after the parties have completed the dispute resolution efforts described in Section VI.1 hereof_ If the dispute resolution efforts described in Section VI.1 cannot be completed within the deadlines specified for sum efforts despite the parties' good faith efforts to meet such deadlines, such deadlines may be extended as necessary upon mutual agreement of the parties. Enforcement of this arbitration clause, including the waiver of class action .% shall be determined under the Federal Arbitration Act ("FAA"), including the FAA's preemptive effect on state law. TIC parties agree that the arbitration shall be conducted on a confidential basis pursuant to Rule 26 of the JAMS Compehensive Arbitration Rules and Procedures. Subject to any disclosures that may be required or requested under Regulatory Requirements, the parties further agree that they shall maintain the confidential nature of the arbitraton, including without limitation, the existence of the arbitration, information exchanged during the arbitration, and the award of the arbitrator(s). Nothing in this provision, however, shall preclude either party from disclosing any such details regarding the arbitration to its accountants, auditors, brokers, insurers, reinsurers or retrocessionaires. 2.1 Location of Arbitration. The arbitration hearing shall be held in the city and state in which the principal place of business of the Anthem, Inc. entity to which the Member at issue belongs. Notwithstanding the foregoing, both parties can agree in writing to hold the arbitration hearing in some other location. 2.2 Selection and Replacement of Arbitrator(s). If the total amount in dispute is less than four million dollars ($4,000,000), exclusive of interest, costs, and attorneys' fees, the dispute shall be decided by a single arbitrator selected, and replaced when required, in the manner described in the JAMS Comprehensive Arbitration Rules and Procedures. If the total amount in dispute is four million dollars ($4,000,000) or more, exclusive of interest, costs, and attorneys' fees, the dispute shall be decided by an arbitration panel consisting of three (3) arbitrators, unless the parties agree in writing that the dispute shall be decided by a single arbitrator. 2.3 Appeal. If the total amount of the arbitration award is five million dollars ($5,000,000) or more, inclusive of interest, costs, and attorneys' fees, or if the arbitrator(s) issues an injunction against a party, the parties shall have the right to appeal the decision of the arbitrator(s) pursuant to the JAMS Optional Arbitration Appeal Procedure. A decision that has been appealed shall not be enforceable while the appeal is pending. In reviewing a decision of the arbitrator(s), the appeal panel shall apply the same standard of review that a United States Court of Appeals would apply in reviewing a similar decision issued by a United States District Court in the jurisdiction in which the arbitration hearing was held. 2.4 Waiver of Certain Claims. The parties, on behalf of themselves and those that they may now or hereafter represent, each agree to and do hereby waive any right to join or consolidate claims in arbitration by or against other individuals or entities or to pursue, on a class basis, any dispute; provided however, if there is a dispute regarding the applicability or enforcement of the waiver provision in this sub -Section VI.2.4, that dispute shall be decided by a court of competent jurisdiction. If a court of competent jurisdiction determines that such waiver is unenforceable for any reason with respect to a particular dispute, then the parties agree that Section VI.2 shall not apply to such dispute and that such dispute shall be decided instead in a court of competent jurisdiction. 68 BHONationalAG_tTd.01.2023_ V.. 05_CO 2.5 Limitations on Injunctive Relief. The parties, on behalf of themselves and those that they may now or hereafter represent, each agree that any injunctive relief sought against the other party shall be limited to the conduct relevant to the parties to the arbitration and shall not be sought for the benefit of individuals or entities who are not parties to the arbitration. The arbitrator(s) are not authorized to issue injunctive relief for the benefit of an individual or entity who is not a party to the arbitration. The arbitrator shall be limited to issuing injunctive relief related to the specific issues in the arbitration. 3. Attorney's Fees and Costs. The shared fees and costs of the non -binding mediation and arbitration (e.g., fee of the mediator, fee of the independent arbitrator) will be shared equally between the parties. Each party shall be responsible for the payment of its own specific fees and costs (e.g., the party's own attorney's fees, the fees of the party selected arbitrator, etc.) and any costs associated with conducting the non -binding mediation or arbitration that the party chooses to incur (e.g., expert witness fees, depositions, etc.). Notwithstanding this provision, the arbitrator may issue an order in accordance with Federal Rule of Civil Procedure Rule 11. 4. Period of Limitations. Unless otherwise provided for in this Agreement or a Participation Attachment(s), neither party shall commence any action at law or equity, including but not limited to, an arbitration demand, against the other to recover on any legal or equitable claim arising out of this Agreement ("Action") more than two (2) years after the events which gave rise to such Action; provided, however, this two (2) year limitation shall not apply to Actions by Anthem or Carelon against Provider related to fraud, waste or abuse which shall be subject to the period of limitations set forth in applicable Regulatory Requirements. In the situation where Provider believes that a Claim has been underpaid, the Action arises on the date when the Claim was first denied or the Claim was first paid in an amount less than expected by Provider. In the situation where Anthem or Carelon believes that a Claim has been overpaid, the Action arises when Provider first contests in writing Anthem or Carelon's notice to it that the overpayment was made. The deadline for initiating an Action shall not be tolled by the appeal process, provider dispute resolution process or any other administrative process. To the extent an Action is timely commenced, it will be administered in accordance with this Article VI hereof. 69 BHONationalAG_03.01.2023 V.05 CO Contract Form Entity Information Entity Name* Entity ID* CARELON BEHAVIORAL HEALTH @00047288 New Entity? Contract Name* Contract ID CARELON BEHAVIORAL HEALTH PROVIDER 7791 PARTICIPATION AGREEMENT Contract Status CTB REVIEW Contract Lead * COBBXXLK Contract Lead Email cobbxxlk@co.weld.co.us Parent Contract ID Requires Board Approval YES Department Project # Contract Description * NEW PROVIDER PARTICIPATION AGREEMENT AND ASSOCIATED ATTACHMENTS TO BILL FOR SERVICES RENDERED BY WCDHS WRAP FACILITATORS UNDER A LICENSED PRACTITIONER STAFF. TERM: EFFECTIVE DATE OF AGREEMENT AND WILL RENEW AUTOMATICALLY FOR ADDITIONAL ONE (1) YEAR Contract Description 2 PA ROUTING THROUGH EXPEDITED APPROVAL PROCESS. ETA TO CTB 1/25/24. REQUEST FOR BOCC AGENDA 1/31/24. Contract Type * AGREEMENT Amount* $0.00 Renewable * YES Automatic Renewal Grant IGA Department Requested BOCC Agenda Due Date HUMAN SERVICES Date* 01/27/2024 01/31/2024 Department Email CM- HumanServices@weldgov. com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY@WEL DGOV.COM Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Termination Notice Period Contact Information Review Date* 11/29/2024 Renewal Date" 01/31/2025 Committed Delivery Date Expiration Date Contact Info Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2 Purchasing Purchasing Approver Purchasing Approved Date Approval Process Department Head Finance Approver Legal Counsel JAMIE ULRICH CHERYL PATTELLI BYRON HOWELL DH Approved Date Finance Approved Date Legal Counsel Approved Date 01/29/2024 01/29/2024 01/29/2024 Final Approval BOCC Approved Tyler Ref # AG 013124 BOCC Signed Date Originator COBBXXLK BOCC Agenda Date 01/31/2024 Houstan Aragon From: Sent: To: Subject: Follow Up Flag: Flag Status: noreply@weldgov.com Wednesday, December 11, 2024 10:20 AM CM-ClerktoBoard; Sara Adams; Lesley Cobb; CM-HumanServices-DeptHead Fast Tracked Contract ID (8950) Follow up Flagged Contract # 8950 has been Fast Tracked to CM -Contract Maintenance. You will be notified in the future based on the Contract information below: Entity Name: CARELON BEHAVIORAL HEALTH Contract Name: CARELON BEHAVIORAL HEALTH PROVIDER PARTICIPATION AGREEMENT Contract Amount: $0.00 Contract ID: 8950 Contract Lead: SADAMS No\-vae\-U-?9a)Department: HUMAN SERVICES Review Date: 11/28/2025 L� q� Renewable Contract: YES CnC�- -1vQdtge��i^- Renew Date: 1/31/2026 Expiration Date: Tyler Ref #: Thank -you Z0N - OZoZ tl iabOq(P Houstan Aragon From: Sent: To: Cc: Subject: Attachments: Follow Up Flag: Flag Status: Good morning CTB, FAST TRACK ITEM: Sara Adams Wednesday, December 11, 2024 10:15 AM CTB HS -Contract Management FAST TRACK - Carelon Behavioral Health Provider Participation Agreement (CMS #8950) Weld-Carelon Behavioral Health Provider Participation Agreement (e).pdf Follow up Flagged Attached please find the Carelon Behavioral Health Provider Participation Agreement (Tyler ID# 2024- 0262). The agreement has no expiration date. Julie Witkowski and Rachel Wisdom have confirmed there are no changes to the agreement. This is reviewed on a yearly basis. This will be a Fast Track item in CMS for tracking purposes only (CMS# 8950). Thank you, Sara Sara Adams Contract Administrative Coordinator Weld County Dept. of Human Services 315 N. 11th Avenue, Building A PO Box A Greeley, CO 80632 (970) 400-6603 sadams@weld.gov Confidentiality Notice: This electronic transmission and any attached documents or other writings are intended only for the person or entity to which it is addressed and may contain information that is privileged, confidential or otherwise protected from disclosure. If you have received this communication in error, please immediately notify sender by return e-mail and destroy the communication. Any disclosure, copying, distribution or the taking of any action concerning the contents of this communication or any attachments by anyone other than the named recipient is strictly prohibited. Hello