HomeMy WebLinkAbout2021-350-EMS-E-WellCare Health Plans of NC Inc-Medicaid managed careRevised 07/20
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: WellCare Health Plans of NC Inc.Party/Vendor Contact Person:Heather Lowe Contact Phone:
(336) 930-3877 Party/Vendor Address: 3128 Highwoods Blvd City Raleigh State: NC Zip: 27604 Department:
Emergency Services Amount:At this point we are not able to predict the revenue but expect total revenue to be
$770,000 Purpose: Medicaid Managed Care Budget Code(s): 10757503-438500 Vendor # N/A (N/A if new vendor)
Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment
Effective Date July 1, 2021 Approved by Board Yes No Agenda Date: June 15, 2021
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on
this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
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6/30/2021
6/30/2021
7/1/2021
7/1/2021
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PARTICIPATING PROVIDER AGREEMENT
This Participating Provider Agreement (together with all Attachments and amendments, this “Agreement”)
is made and entered by and between Orange County, a local political subdivision of the State of North Carolina
(“Provider”) and WellCare Health Plans, Inc. (“WellCare”). This Agreement is effective as of the date designated
by WellCare on the signature page of this Agreement (“Effective Date”). For purposes of this Agreement, each of
Provider and WellCare may be referred to herein as a “Party” and collectively as the “Parties.”
WHEREAS, Provider desires to provide certain health care services to individuals in products offered by or
available from or through a Company or Payor (as hereafter defined), and Provider desires to participate in such
products as a Participating Provider (as defined herein), all as hereinafter set forth; and
WHEREAS, WellCare desires for Provider to provide such health care services to individuals in such
products, and WellCare desires to have Provider participate in certain of such products as a Participating Provider,
all as hereinafter set forth.
NOW, THEREFORE, in consideration of the recitals and mutual promises herein stated, the Parties hereby
agree to the provisions set forth below.
ARTICLE I - DEFINITIONS
When appearing with initial capital letters in this Agreement (including an Attachment), the following quoted
and underlined terms (and the plural thereof, when appropriate) have the meanings set forth below.
1.1. “Affiliate” means a person or entity directly or indirectly controlling, controlled by, or under
common control with such entity.
1.2. “Attachment” means any document, including an addendum, schedule or exhibit, attached to this
Agreement as of the Effective Date or that becomes attached pursuant to Section 2.2 or Section 8.8, all of which are
incorporated herein by reference and may be amended from time to time as provided in this Agreement.
1.3. “Clean Claim” has, as to each particular Product, the meaning set forth in the applicable Product
Attachment or, if no such definition exists, the Provider Manual.
1.4. “Company” means, as appropriate in the context, WellCare and/or one or more of its Affiliates listed
on Schedule D of this Agreement, except those specifically excluded by WellCare.
1.5. “Compensation Schedule” means at any given time the then effective schedule(s) of maximum rates
applicable to a particular Product under which Provider and Contracted Providers will be compensated for the
provision of Covered Services to Covered Persons. Such Compensation Schedule(s) will be set forth or described in
one or more Attachments to this Agreement, and may be included within a Product Attachment.
1.6. “Contracted Provider” means a physician, hospital, health care professional or any other provider of
items or services that is employed by or has a contractual relationship with Provider. The term “Contracted Provider”
includes Provider for those Covered Services provided by Provider.
1.7. “Coverage Agreement” means any agreement, program or certificate entered into, issued or agreed
to by Company or Payor, under which Company or Payor furnishes administrative services or other services in
support of a health care program for an individual or group of individuals, and which may include access to one or
more of Company’s provider networks or vendor arrangements, except those excluded by WellCare.
1.8. “Covered Person” means any individual entitled to receive Covered Services pursuant to the terms
of a Coverage Agreement.
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1.9. “Covered Services” means those services and items for which benefits are available and payable
under the applicable Coverage Agreement and which are determined, if applicable, to be Medically Necessary.
1.10. “Medically Necessary” or “Medical Necessity” shall have the meaning defined in the applicable
Coverage Agreement or applicable Regulatory Requirements.
1.11. “Participating Provider” means, with respect to a particular Product, any physician, hospital,
ancillary, or other health care provider that has contracted, directly or indirectly, with WellCare to provide Covered
Services to Covered Persons, that has been approved for participation by Company, and that is designated by
Company as a “participating provider” in such Product.
1.12. “Payor” means the entity (including Company where applicable) that bears direct financial
responsibility for paying from its own funds, without reimbursement from another entity, the cost of Covered Services
rendered to Covered Persons under a Coverage Agreement and, if such entity is not Company, such entity contracts,
directly or indirectly, with Company for the provision of certain administrative or other services with respect to such
Coverage Agreement.
1.13. “Payor Contract” means the contract with a Payor, pursuant to which Company furnishes
administrative services or other services in support of the Coverage Agreements entered into, issued or agreed to by
a Payor, which services may include access to one or more of Company’s provider networks or vendor arrangements,
except those excluded by WellCare. The term “Payor Contract” includes Company’s or other Payor’s contract with
a governmental authority (also referred to herein as a “Governmental Contract”) under which Company or Payor
arranges for the provision of Covered Services to Covered Persons.
1.14. “Product” means any program or health benefit arrangement designated as a “product” by WellCare
(e.g., WellCare Product, Payor-specific Product, etc.) that is now or hereafter offered by or available from or through
Company (and includes the Coverage Agreements that access, or are issued or entered into in connection with such
product, except those excluded by WellCare).
1.15. “Product Attachment” means an Attachment setting forth requirements, terms and conditions specific
or applicable to one or more Products, including certain provisions that must be included in a provider agreement
under the Regulatory Requirements, which may be alternatives to, or in addition to, the requirements, terms and
conditions set forth in this Agreement or the Provider Manual.
1.16. “Provider Manual” means the provider manual and any billing manuals, adopted by Company or
Payor which include, without limitation, requirements relating to utilization management, quality management,
grievances and appeals, and Product-specific, Payor-specific and State-specific requirements, as may be amended
from time to time by Company or Payor.
1.17. “Regulatory Requirements” means all applicable federal and state statutes, regulations, regulatory
guidance, judicial or administrative rulings, requirements of Governmental Contracts and standards and requirements
of any accrediting or certifying organization, including, but not limited to, the requirements set forth in a Product
Attachment.
1.18. “State” is defined as the state identified in the applicable Attachment.
ARTICLE II - PRODUCTS AND SERVICES
2.1. Contracted Providers. Provider shall, and shall cause each Contracted Provider, to comply with and
abide by the agreements, representations, warranties, acknowledgements, certifications, terms and conditions of this
Agreement (including the provisions of Schedule A that are applicable to Provider, a Contracted Provider, or their
services, and any other Attachments), and the Provider Manual, and fulfill all of the duties, responsibilities and
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obligations imposed on Provider and Contracted Providers under this Agreement (including each Attachment), and
the Provider Manual, in each case, to the same extent as if the Contracted Providers were parties hereto. Provider
shall be responsible for any breach of this Agreement by any Contracted Provider.
2.2. Participation in Products. Subject to the other provisions of this Agreement, each Contracted
Provider may be identified as a Participating Provider in each Product identified in a Product Attachment designated
on Schedule B of this Agreement or added to this Agreement in accordance with Section 2.2 hereof.
2.2.1. Provider shall, at all times during the term of this Agreement, require each of its Contracted
Providers to, subject to Company’s approval, participate as Participating Providers in each Product identified in a
Product Attachment that is designated on Schedule B to this Agreement or added to this Agreement in accordance
with Section 2.2 hereof.
2.2.2. A Contracted Provider may only identify itself as a Contracted Provider for those Products
in which the Contracted Provider actually participates as provided in this Agreement. Provider acknowledges that
Company or Payor may have, develop or contract to develop various Products or provider networks that have a variety
of provider panels, program components and other requirements. No Company or Payor warrants or guarantees that
any Contracted Provider: (i) will participate in all or a minimum number of provider panels, (ii) will be utilized by a
minimum number of Covered Persons, or (iii) will indefinitely remain a Participating Provider or member of the
provider panel for a particular network or Product.
2.2.3. Provider shall provide WellCare with the information listed on Schedule C entitled
“Information for Contracted Providers” for itself and the Contracted Providers as of the Effective Date. Provider
shall provide WellCare, from time to time or on a periodic basis as requested by WellCare, with a complete and
accurate list of Information for Contracted Providers and such other information as mutually agreed upon by the
Parties, and shall provide WellCare with a list of modifications to such list at least 30 days prior to the effective date
of such changes, when possible. Provider shall provide such lists in a manner and format mutually acceptable to the
Parties.
2.2.4. Provider may add new providers to this Agreement as Contracted Providers. The effective
date of any Contracted Provider added under this Agreement shall be the later of the Agreement Effective Date or
date by which the Contracted Provider’s enrollment as a Medicaid enrolled provider is effective within NC Tracks.
In such case, Provider shall provide written notice to WellCare of the prospective addition(s), and shall use best
efforts to provide such notice at least 60 days in advance of such addition. Provider shall maintain written agreements
with each of its Contracted Providers (other than Provider) that require the Contracted Providers to comply with the
terms and conditions of this Agreement and that address and comply with the Regulatory Requirements.
2.2.5. If Company desires to add one or more Contracted Providers to an additional Product,
Company or Payor, as applicable, will provide advance written notice (electronic or paper) thereof to Provider, along
with the applicable Product Attachment and the new Compensation Schedule, if any. The applicable Contracted
Providers will not be designated as Participating Providers in such additional Product if Provider opts out of such
additional Product by giving Company or Payor, as applicable, written notice of its decision to opt-out within 30 days
of Company’s or Payor’s, as applicable, giving of written notice. If Provider timely provides such opt -out notice, the
applicable Contracted Providers will not be considered Participating Providers in such Product. If Provider does not
timely provide such opt-out notice, then each applicable Contracted Provider shall be a Participating Provider in such
additional Product on the terms and conditions set forth in this Agreement and the applicable Product Attachment.
2.3. Covered Services. Each Contracted Provider shall provide Covered Services described or referenced
in the applicable Product Attachment(s) to Covered Persons in those Products in which the Contracted Provider is a
Participating Provider, in accordance with this Agreement. Each Contracted Provider shall provide Covered Services
to Covered Persons with the same degree of care and skill as customarily provided to patients who are not Covered
Persons, within the scope of the Contracted Provider’s license and in accordance wit h generally accepted standards
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of the Contracted Provider’s practice and business and in accordance with the provisions of this Agreement, the
Provider Manual, and Regulatory Requirements.
2.4. Provider Manual; Policies and Procedures. Provider and Contracted Providers shall at all times
cooperate and comply with the requirements, policies, programs and procedures (“Policies”) of Company and Payor,
which may be described in the Provider Manual and include, but are not limited to, the following: credentialing
criteria and requirements; notification requirements; medical management programs; claims and billing, quality
assessment and improvement, utilization review and management, disease management, case management, on -site
reviews, referral and prior authorization, and grievance and appeal procedures; coordination of benefits and third
party liability policies; carve-out and third party vendor programs; and data reporting requirements. The failure to
comply with such Policies could result in a denial or reduction of payment to the Provider or Contracted Provider or
a denial or reduction of the Covered Person’s benefits. Such Policies do not in any way affect or remove the obligation
of Contracted Providers to render care. WellCare shall make the Provider Manual available to Provider and
Contracted Providers via one or more designated websites or alternative means as promptly as possible following
WellCare’s receipt of any and all necessary regulatory review and approval thereof (whether by the North Carolina
Department of Health and Human Services, the North Carolina Division of Health Benefits or otherwise); provided,
however, that in no event shall WellCare be required to make the Provider Manual available earlier than one hundred
and twenty (120) days prior to North Carolina’s effective date of the Medicaid managed care program. Upon
Provider’s reasonable request, WellCare shall provide Provider with a written copy of the Provider Manual. In the
event of a material change to the Provider Manual, WellCare will provide Provider with at least sixty (60) days’
advance written notice of such change. Such notice may be given by WellCare through a periodic provider newsletter,
an update to the on-line Provider Manual, or any other written method (electronic or paper).
2.5. Credentialing Criteria. Provider and each Contracted Provider shall complete Company’s and/or
Payor’s credentialing and/or recredentialing process as required by Company’s and/or Payor’s credentialing Policies,
and shall at all times during the term of this Agreement meet all of Company’s and/or Payor’s credentialing criteria.
Provider and each Contracted Provider represents, warrants and agrees: (a) that it is currently, and for the duration
of this Agreement shall remain: (i) in compliance with all applicable Regulatory Requirements, including licensing
laws; (ii) if applicable, accredited by The Joint Commission or the American Osteopathic Association; and (iii) a
Medicare participating provider under the federal Medicare program or eligible to enroll as a Medicare participating
provider under the federal Medicare program and a Medicaid participating provider under applicable federal and
State laws; and (b) that all Contracted Providers and all employees and contractors thereof will perform t heir duties
in accordance with all Regulatory Requirements, as well as applicable national, State and local standards of
professional ethics and practice. No Contracted Provider shall provide Covered Services to Covered Persons or
identify itself as a Participating Provider unless and until the Contracted Provider has been notified, in writing, by
Company that such Contracted Provider has successfully completed Company’s credentialing process .
2.6. Eligibility Determinations. Provider or Contracted Provider shall timely verify whether an individual
seeking Covered Services is a Covered Person. Company or Payor, as applicable, will make available to Provider
and Contracted Providers a method, whereby Provider and Contracted Providers can obtain, in a timely manner,
general information about eligibility and coverage. Company or Payor, as applicable, does not guarantee that persons
identified as Covered Persons are eligible for benefits or that all services or supplies are Covered Services. If
Company, Payor or its delegate determines that an individual was not a Covered Person at the time services were
rendered, such services shall not be eligible for payment under this Agreement. In addition, Company will use
reasonable efforts to include or contractually require Payors to clearly display Company’s name, logo or mailing
address (or other identifier(s) designated from time to time by Company) on each membership card.
2.7. Referral and Preauthorization Procedures. Provider and Contracted Providers shall comply with
referral and preauthorization procedures adopted by Company and or Payor, as applicable, prior to referring a
Covered Person to any individual, institutional or ancillary health care provider. Except as required by applicable
law, failure of Provider and Contracted Providers to follow such procedures may result in denial of payment for
unauthorized treatment. Unless otherwise expressly authorized in writing by Company or Payor, Provider and
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Contracted Providers shall refer Covered Persons only to Participating Providers to provide the Covered Service for
which the Covered Person is referred.
2.8. Treatment Decisions. No Company or Payor shall be liable for, or exercise control over, the manner
or method by which a Contracted Provider provides items or services under this Agreement. Provider and Contracted
Providers understand that determinations of Company or Payor that certain items or services are not Covered Services
or have not been provided or billed in accordance with the requirements of this Agr eement or the Provider Manual
are administrative decisions only. Such decisions do not absolve the Contracted Provider of its responsibility to
exercise independent judgment in treatment decisions relating to Covered Persons. Nothing in this Agreement (i ) is
intended to interfere with Contracted Provider’s relationship with Covered Persons, or (ii) prohibits or restricts a
Contracted Provider from disclosing to any Covered Person any information that the Contracted Provider deems
appropriate regarding health care quality, medical treatment decisions or alternatives.
2.9. Carve-Out Vendors. Provider acknowledges that Company may, during the term of this Agreement,
carve-out certain Covered Services from its general provider contracts, including this Agreeme nt, for one or more
Products as Company deems necessary or appropriate. Provider and Contracted Providers shall cooperate with and,
when medically appropriate, utilize all third party vendors designated by Company for those Covered Services
identified by Company from time to time for a particular Product.
2.10. Disparagement Prohibition. Provider, each Contracted Provider and the officers of Company (each
a “Non-Disparagement Party”) shall not disparage any other Non-Disparagement Party during the term of this
Agreement or in connection with any expiration, termination or non-renewal of this Agreement. Neither Provider
nor Contracted Provider shall interfere with Company’s direct or indirect contractual relationships including, but not
limited to, those with Covered Persons or other Participating Providers. Nothing in this Agreement should be
construed as limiting the ability of WellCare, Company, Provider or a Contracted Provider to inform Covered Persons
that this Agreement has been terminated or otherwise expired or, with respect to Provider, to promote Provider to the
general public or to post information regarding other WellCares consistent with Provider’s usual procedures, provided
that no such promotion or advertisement is specifically directed at one or more Covered Persons. In addition, nothing
in this provision should be construed as limiting any Non -Disparagement Party’s ability to use and disclose
information and data obtained from or about another Non-Disparagement Party, including this Agreement, to the
extent determined reasonably necessary or appropriate by such Non -Disparagement Party in connection with its
efforts to comply with Regulatory Requirements and to communicate with regulatory authorities.
2.11. Nondiscrimination. Provider and each Contracted Provider will provide Covered Services to
Covered Persons without discrimination on account of race, sex, sexual orientation, age, color, religion, national
origin, place of residence, health status, type of Payor, source of payment (e.g., Medicaid generally or a State-specific
health care program), physical or mental disability or veteran status, and will ensure that its facilities are accessible
as required by Title III of the Americans With Disabilities Act of 1991. Provider and Contracted Providers recognize
that, as a governmental contractor, Company or Payor may be subject to various federal laws, executive orders and
regulations regarding equal opportunity and affirmative action, which also may be applicable to subcontractors, and
Provider and each Contracted Provider agree to comply with such requirements as described in any applicable
Attachment.
2.12. Notice of Certain Events. Provider shall give written notice to WellCare and Payor of: (i) any event
of which notice must be given to a licensing or accreditation agency or board; (ii) any change in the status of
Provider’s or a Contracted Provider’s license; (iii) termination, suspension, exclusion or voluntary withdrawal of
Provider or a Contracted Provider from any state or federal health care program, including but not limited to
Medicaid; or (iv) any final adverse determinations in connection with a lawsuit or claim filed or asserted against
Provider or a Contracted Provider alleging professional malpractice involving a Covered Person. In any instance
described in subsection (i)-(iii) above, Provider must notify WellCare and Payor in writing within 10 days, and in
any instance described in subsection (iv) above, Provider must notify WellCare and Payor in writing within 30 days,
from the date it first obtains knowledge of any such final adverse determination.
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2.13. Use of Name. Provider and each Contracted Provider hereby authorizes each Company and/or Payor
to use their respective names, telephone numbers, addresses, specialties, certifi cations, hospital affiliations (if any),
and other descriptive characteristics of their facilities, practices and services for the purpose of identifying the
Contracted Providers as “Participating Providers” in the applicable Products. Provider and Contracted Providers may
only use the name of the applicable Company or Payor for purposes of identifying the Products in which they
participate, and may not use the registered trademark or service mark of Company or Payor without prior written
consent.
2.14. Compliance with Regulatory Requirements. Provider, each Contracted Provider and Company agree
to carry out their respective obligations under this Agreement and the Provider Manual in accordance with all
applicable Regulatory Requirements, including, but not limited to, the requirements of the Health Insurance
Portability and Accountability Act, as amended, and any regulations promulgated thereunder. If, due to Provider’s
or Contracted Provider’s noncompliance with applicable Regulatory Requirements or this Agreement, sanctions or
penalties are imposed on Company, Company may, in its sole discretion, offset such amounts against any amounts
due Provider or Contracted Providers from any Company or require Provider or the Contracted Provider to reimburse
Company for such amounts.
2.15. Program Integrity Required Disclosures. Provider agrees to furnish to WellCare complete and
accurate information necessary to permit Company to comply with the collection of disclosures requirements
specified in 42 C.F.R. Part 455 Subpart B or any other applicable State or federal requirements, within such time
period as is necessary to permit Company to comply with such requirements. Such requirements include but are not
limited to: (i) 42 C.F.R. §455.105, relating to (a) the ownership of any subcontractor with whom Provider has had
business transactions totaling more than $25,000 during the 12-month period ending on the date of the request and
(b) any significant business transaction between Provider and any wholly owned supplier or subcontractor during the
five (5) year period ending on the date of the request; (ii) 42 C.F.R. §455.104, relating to individuals or entities with
an ownership or controlling interest in Provider; and (iii) 42 C.F.R. §455.106, relating to individuals with an
ownership or controlling interest in Provider, or who are managing employees of Provider, who have been convicted
of a crime.
ARTICLE III - CLAIMS SUBMISSION, PROCESSING, AND COMPENSATION
3.1. Claims or Encounter Data Submission. As provided in the Provider Manual and/or Policies,
Contracted Providers shall submit to Payor or its delegate claims for payment for Covered Services rendered to
Covered Persons. Contracted Provider shall submit encounter data to Payor or its delegate in a timely fashion, which
must contain patient data and identifying information, diagnosis and service codes, and provider identifiers, if and as
required in the Provider Manual. Payor or its delegate reserves the right to deny payment to the Contracted Provider
if the Contracted Provider fails to submit claims for payment or encounter data in accordance with the Provider
Manual and/or Policies.
3.2. Compensation. The compensation for Covered Services provided to a Covered Person
(“Compensation Amount”) will be the appropriate amount under the applicable Compensation Schedule in effect on
the date of service for the Product in which the Covered Person participates. Subject to the terms of this Agreement
and the Provider Manual, Provider and Contracted Providers shall accept the Compensation Amount as payment in
full for the provision of Covered Services. Subject to the terms of this Agreement, Payor shall pay or arrange for
payment of each Clean Claim received from a Contracted Provider for Covered Services provided to a Covered
Person in accordance with the applicable Compensation Amount less any applicable copayments, cost -sharing or
other amounts that are the Covered Person’s financial responsibility under the applicable Coverage Agreement.
Unless Company provides prior written approval to Provider, Provider shall make arrangements for and only accept
Compensation Amounts by way of electronic funds transfer via the automated clearing house network (EFT -ACH).
3.3. Financial Incentives. The Parties acknowledge and agree that nothing in this Agreement shall be
construed to create any financial incentive for Provider or a Contracted Provider to withhold Covered Services.
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3.4. Hold Harmless. Provider and each Contracted Provider agree that in no event, including but not
limited to non-payment by a Payor, a Payor’s insolvency, or breach of this Agreement, shall Provider or a Contracted
Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any
recourse against a Covered Person or person acting on the Covered Person’s behalf, other than Payor, for Covered
Services provided under this Agreement. This provision shall not prohibit collection of any applicable copayments,
cost-sharing or other amounts that are the Covered Person’s financial responsibility under the applicable Coverage
Agreement. This provision survives termination or expiration of this Agreement for any reason, will be construed
for the benefit of Covered Persons, and supersedes any oral or written agreement entered into between Pro vider or a
Contracted Provider and a Covered Person.
3.5. Recovery Rights. Payor or its delegate shall have the right to immediately offset or recoup any and
all amounts owed by Provider or a Contracted Provider to Payor or Company against amounts owed by the Payor or
Company to the Provider or Contracted Provider following not less than thirty (30) days’ advance written notice to
Provider. Such notice will be accompanied by adequate specific information to identify the specific claim and the
specific reason for the offset or recoupment. All offsets or recoupments will be made within the two (2) years after
the date of the original claim payment unless Payor has a reasonable belief of fraud or other intentional misconduct
by Provider, Contracted Provider or their respective agents or the claim involves the receipt of payment for the same
service from a government payor. Provider and Contracted Providers agree that all recoupment and any offset rights
under this Agreement will constitute rights of recoupment authorized under State or federal law and that such rights
will not be subject to any requirement of prior or other approval from any court or other government authority that
may now have or hereafter have jurisdiction over Provider or a Contracted Provider . If the recoupment is standard
in scope, then Payor or its delegate may immediately offset any and all overpayments or payments made in error
without prior notice to Provider. “Standard” means those overpayments or payments made in error that are discovered
by Payor or its delegate on an individual account review basis. If the recoupment is non-standard in scope, then
Payor or its delegate will provide written or electronic notice to Provider before using an offset as a means to recover
an overpayment, and will not implement the offset if, within thirty (30) days after the date of the notice, Provider
refunds the overpayment or initiates an appeal. The written or electronic notice from the Payor or its delegate shall
explain the reason and calculation of the overpayment or payment made in error. “Non-standard” means those
overpayments or payments made in error that are discovered by Payor or its delegate during an audit that is being
conducted to correct a systemic error. Appeals shall be made pursuant to procedures set forth in the Policies and/or
Provider Manual.
ARTICLE IV - RECORDS AND INSPECTIONS
4.1. Records. Each Contracted Provider shall maintain medical, financial and administrative records
related to items or services provided to Covered Persons, includi ng but not limited to a complete and accurate
permanent medical record for each such Covered Person, in such form and detail as are required by applicable
Regulatory Requirements and consistent with generally accepted medical standards.
4.2. Access. Provider and each Contracted Provider shall provide access to their respective books and
records to each of the following, including any delegate or duly authorized agent thereof, subject to applicable
Regulatory Requirements: (i) Company and Payor, during regular business hours and upon prior notice; (ii)
appropriate State and federal authorities, to the extent such access is necessary to comply with Regulatory
Requirements; and (iii) accreditation organizations, to the extent such access is necessary for WellCare to maintain
or apply for certain accreditations, as applicable. Provider and each Contracted Provider shall provide copies of such
records at no expense to any of the foregoing that may make such request. Each Contracted Provider also shall obtain
any authorization or consent that may be required from a Covered Person in order to release medical records and
information to Company or Payor or any of their delegates. Company and Payor agree to limit the number of copies
of records requested of Provider and each Contracted Provider to the minimum necessary to satisfy the applicable
obligation. Provider and each Contracted Provider shall cooperate in and allow on-site inspections of its, his or her
facilities and records by any Company, Payor, their delegates, any authorized government officials, and accreditation
organizations. Provider and each Contracted Provider shall compile information necessary for the expeditious
completion of such on-site inspection in a timely manner.
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4.3. Record Transfer. Subject to applicable Regulatory Requirements, each Contracted Provider shall
cooperate in the timely transfer of Covered Persons’ medical records to any other health care provider, at no charge
and when required.
ARTICLE V - INSURANCE AND INDEMNIFICATION
5.1. Insurance. During the term of this Agreement and for any applicable continuation period as set forth
in Section 7.3 of this Agreement, Provider and each Contracted Provider shall maintain policies professional liability
insurance to insure Provider and such Contracted Provider, respectively; their respective employees; and any other
person providing services hereunder on behalf of Provider or such Contracted Provider, as applicable, against any
claim(s) of personal injuries or death alleged to have been caused or caused by their performance under this
Agreement. Such insurance shall include, but not be limited to, any “tail” or prior acts coverage necessary to avoid
any gap in coverage. Insurance shall be through a licensed carrier acceptable to WellCare, and in a minimum amount
of $1,000,000 per occurrence, and $3,000,000 annual aggregate unless a lesser amount is accepted by WellCare or
where State law mandates otherwise. Provider and each Contracted Provider will provide WellCare with at least 15
days prior written notice of cancellation, non-renewal, lapse, or adverse material modification of such coverage.
Upon WellCare’s request, Provider and each Contracted Provider will furnish WellCare with evidence of such
insurance.
5.2. Indemnification by Provider and Contracted Provider. Provider to the extent provided by North
Carolina law and each Contracted Provider shall indemnify and hold harmless (and at WellCare‘s request defend)
Company, Payor and each of their respective officers, directors, agents, and employees from and against any and all
claims for any loss, damages, liability, costs, or expenses (including reasonable attorney’s fees) judgments or
obligations (collectively, “Losses”) arising from or relating to any negligence, wrongful act or omission, or breach of
this Agreement by Provider, a Contracted Provider, or any of their respective officers, directors, agents or employees .
5.3. Indemnification by WellCare. WellCare agrees to indemnify and hold harmless (and at Provider’s
request (as applicable) defend) Provider, Contracted Providers, and each of their respective officers, directors, agents
and employees from and against any and all Losses arising from or relating to any negligence, wrongful act or
omission or breach of this Agreement by Company or its directors, officers, agents or employees.
ARTICLE VI - DISPUTE RESOLUTION
6.1. Informal Dispute Resolution. Any dispute between Provider and/or a Contracted Provider, as
applicable (the “Provider Party”), and WellCare and/or Company, as applicable (including any Company acting as
Payor) (the “Administrator Party”), with respect to or involving the performance under, termination of, or
interpretation of this Agreement, or any other claim or cause of action hereunder, whether sounding in tort, contract
or under statute (a “Dispute”) shall first be addressed by exhausting the applicable procedures in the Provider Manual
pertaining to claims payment, credentialing, utilization management, or other programs. If, at the conc lusion of these
applicable procedures, the Dispute is not resolved to satisfaction of the Provider Party and the Administrator Party,
or if there are no applicable procedures in the Provider Manual, then the Provider Party and the Administrator Party
shall engage in a period of good faith negotiations between their designated representatives who have authority to
settle the Dispute, which negotiations may be initiated by either the Provider Party or the Administrator Party upon
written request to the other, provided such request takes place within 1 year of the date on which the requesting party
first had, or reasonably should have had, knowledge of the event(s) giving rise to the Dispute. If the Dispute has not
been resolved within 60 days of such request, either the Provider Party or the Administrator Party may, as its sole
and exclusive forum for the litigation of the Dispute or any part thereof, initiate arbitration pursuant to Section 6.2
below by providing written notice to the other party.
6.2. Arbitration. If either the Provider Party or the Administrator Party wishes to pursue the Dispute as
provided in Section 6.1, such party shall submit it to binding arbitration conducted in accordance with the Commercial
Arbitration Rules of the American Arbitration Association (“AAA”). In no event may any arbitration be initiated
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more than 1 year following, as applicable, the end of the 60 day negotiation period set forth in Section 6.1, or the date
of notice of termination. Arbitration proceedings shall be conducted by an arbitrator chosen from the National
Healthcare Panel at a mutually agreed upon location within the State. The arbitrator shall not award any punitive or
exemplary damages of any kind, shall not vary or ignore the provisions of this Agreement, an d shall be bound by
controlling law. The Parties and the Contracted Providers, on behalf of themselves and those that they may now or
hereafter represent, agree to and do hereby waive any right to pursue, on a class basis, any Dispute. Each of the
Provider Party and the Administrator Party shall bear its own costs and attorneys’ fees related to the arbitration except
that the AAA’s Administrative Fees, all Arbitrator Compensation and travel and other expenses, and all costs of any
proof produced at the direct request of the arbitrator shall be borne equally by the applicable parties, and the arbitrator
shall not have the authority to order otherwise. The existence of a Dispute or arbitration proceeding shall not in and
of itself constitute cause for termination of this Agreement. Except as hereafter provided, during an arbitration
proceeding, each of the Provider Party and the Administrator Party shall continue to perform its obligations under
this Agreement pending the decision of the arbitrator. Nothing herein shall bar either the Provider Party or the
Administrator Party from seeking emergency injunctive relief to preclude any actual or perceived breach of this
Agreement, although such party shall be obligated to file and pursue arbitration at the earliest reasonable opportunity.
Judgment on the award rendered may be entered in any court having jurisdiction thereof. Nothing contained in this
Article VI shall limit a Party’s right to terminate this Agreement with or without cause in accordance with Sec tion
7.2.
ARTICLE VII - TERM AND TERMINATION
7.1. Term. This Agreement is effective as of the Effective Date, and will, subject to Section 7.1.2 of this
Agreement, remain in effect for an initial term (“Initial Term”) of three (3) year(s), after which it will automatically
renew for successive terms of one (1) year each (each a “Renewal Term”), unless this Agreement is sooner terminated
as provided in this Agreement or either Party gives the other Party written notice of non-renewal of this Agreement
not less than one hundred eighty (180) days prior to the end of the then-current term. In addition, either Party may
elect to not renew a Contracted Provider’s participation as a Participating Provider in a particular Product for the next
Renewal Term, by giving Provider written notice of such non-renewal not less than one hundred eighty (180) days
prior to the, as applicable, last day of the Initial Term or applicable Renewal Term; in such event, Provider shall
immediately notify the affected Contracted Provider of such non-renewal. Termination of any Contracted Provider’s
participation in a particular Product will not have the effect of terminating either this Agreement or the Contracted
Provider’s participation in any other Product in which the Contract Provider participates under this Agreement.
7.2. Termination. This Agreement, or the participation of Provider or a Contracted Provider as a
Participating Provider in one or more Products, may be terminated or suspended as set forth below.
7.2.1. Upon Notice. This Agreement may be terminated by either Party giving the other Party at
least 120 days prior written notice of such termination. The participation of any Contracted Provider as a Participating
Provider in a Product may be terminated by either Party giving the other Party at least 120 days prior written notice
of such termination; in such event, Provider shall immediately notify the affected Contracted Provider of such
termination.
7.2.2. With Cause. This Agreement, or the participation of any Contracted Provider as a
Participating Provider in one or more Products under this Agreement, may be terminated by either Party giving at
least 90 days prior written notice of termination to the other Party if such other Party (or the applicable Contracted
Provider) is in breach of any material term or condition of this Agreement and such other Party (or the Contracted
Provider) fails to cure the breach within the 60 day period immediately following the giving of written notice of such
breach. Any notice given pursuant to this Section 7.2.2 must describe the specific breach. In the case of a termination
of a Contracted Provider, Provider shall immediately notify the affected Contracted Provider of such termination.
7.2.3. Suspension of Participation. Unless expressly prohibited by applicable Regulatory
Requirements, WellCare has the right to immediately suspend or terminate the participation of a Contracted Provider
in any or all Products by giving written notice thereof to Provider when WellCare determines tha t (i) based upon
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available information, the continued participation of the Contracted Provider appears to constitute an immediate threat
or risk to the health, safety or welfare of Covered Persons, or (ii) the Contracted Provider’s fraud, malfeasance or
non-compliance with Regulatory Requirements is reasonably suspected. Provider shall immediately notify the
affected Contracted Provider of such suspension. During such suspension, the Contracted Provider shall, as directed
by WellCare, discontinue the provision of all or a particular Covered Service to Covered Persons. During the term
of any suspension, the Contracted Provider shall notify Covered Persons that his or her status as a Participating
Provider has been suspended. Such suspension will continue until the Contracted Provider’s participation is
reinstated or terminated.
7.2.4. Insolvency. This Agreement may be terminated immediately by a Party giving written notice
thereof to the other Party if the other Party is insolvent or has bankruptcy proceedings initiated against it.
7.2.5. Credentialing. The status of a Contracted Provider as a Participating Provider in one or more
Products may be terminated immediately by WellCare giving written notice thereof to Provider if the Contracted
Provider fails to adhere to Company’s or Payor’s credentialing criteria, including, but not limited to, if the Contracted
Provider (i) loses, relinquishes, or has materially affected its license to provide Covered Services in the State, (ii)
fails to comply with the insurance requirements set forth in this Agreement; or (iii) is convicted of a criminal offense
related to involvement in any state or federal health care program or has been terminated, suspended, barred,
voluntarily withdrawn as part of a settlement agreement, or otherwise excluded from any state or federal health care
program. Provider shall immediately notify the affected Contracted Provider of such termination.
7.3. Effect of Termination. After the effective date of termination of this Agreement or a Contracted
Provider’s participation in a Product, this Agreement shall remain in effect for purposes of those obligations and
rights arising prior to the effective date of termination. Upon such a termination, each affected Contracted Provider
(including Provider, if applicable) shall (i) continue to provide Covered Services to Covered Persons in the applicable
Product(s) during the longer of the 90 day period following the date of such termination or such other period as may
be required under any Regulatory Requirements, and, if requested by Company, each affected Contracted Provider
(including Provider, if applicable) shall continue to provide, as a Participating Provider, Covered Services to Covered
Persons until such Covered Persons are assigned or transferred to another Participating Provider in the applicable
Product(s), and (ii) continue to comply with and abide by all of the applicable terms and conditions of this Agreement,
including, but not limited to, Section 3.4 (Hold Harmless) hereof, in connection with the provision of such Covered
Services during such continuation period. During such continuation period, each affected Contracted Provider
(including Provider, if applicable) will be compensated in accordance with this Agreement and shall accept such
compensation as payment in full.
7.4. Survival of Obligations. All provisions hereof that by their nature are to be performed or complied
with following the expiration or termination of this Agreement, including without limitation Sections 2.8, 2.10, 3.2,
3.4, 3.5, 4.2, 5.1, 5.2, 5.3, 5.4, 6.1, 6.2, 7.3, 7.4 and Article VIII, survive the expiration or termination of this
Agreement.
ARTICLE VIII - MISCELLANEOUS
8.1. Relationship of Parties. The relationship between or among WellCare, Company, Provider, and any
Contracted Provider hereunder is that of independent contractors. None of the provisions of this Agreement will be
construed as creating any agency, partnership, joint venture, employee-employer, or other relationship. References
herein to the rights and obligations of any “Company” under this Agreement are references to the rights and
obligations of each Company individually and not collectively. A Company is only responsible for performing its
respective obligations hereunder with respect to a particular Product, Coverage Agreement, Payor Contract, Covered
Service or Covered Person. A breach or default by an individual Company shall not constitute a breach or default by
any other Company, including but not limited to WellCare. Each Company (each an “Unaffiliated Party” and
collectively, the “Unaffiliated Parties”) acknowledge that references herein to their respective rights and obligations
under this Agreement are references to the rights and obligations of each such Unaffiliated Party individually and not
of the Unaffiliated Parties collectively. Notwithstanding anything that may be construed herein to the contrary, all
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such rights and obligations are individual and specific to each Unaffiliated Party and the reference to one Unaffiliated
Party herein in no way imposes any cross-guarantees or joint responsibility or liability on the other Unaffiliated Party.
A breach or default hereunder by an Unaffiliated Party shall not constitute a breach or default by the other Unaffiliated
Party.
8.2. Conflicts Between Certain Documents. If there is any conflict between this Agreement and the
Provider Manual, this Agreement will control. In the event of any conflict between this Agreement and any Product
Attachment, the Product Attachment will control as to such Product.
8.3. Assignment. This Agreement is intended to secure the services of and be personal to Provider and
may not be assigned, sublet, delegated, subcontracted or transferred by Provider without the WellCare’s prior written
consent; provided, however, WellCare shall, in addition to the rights provided under Section 8.2, have the right,
exercisable in its sole discretion, to assign or transfer all or any portion of its rights or to delegate all or any portion
of its interests under this Agreement or any Attachment to an Affiliate, successor of WellCare, or purchaser of the
assets or stock of WellCare, or the line of business or business unit primarily responsible for carrying out WellCare’s
obligations under this Agreement. Any attempted assignment or delegation in violation of this Section 8.3 shall be
void.
8.4. Headings. The headings of the sections of this Agreement are inserted merely for the purpose of
convenience and do not limit, define, or extend the specific terms of the section so designated.
8.5. Governing Law. The interpretation of this Agreement and the rights and obligations of WellCare,
Company, Provider and any Contracted Providers hereunder will be governed by and construed in accordance with
applicable federal and State laws.
8.6. Third Party Beneficiary. This Agreement is entered into by the Parties for their benefit, as well as,
in the case of WellCare, the benefit of Company, and in the case of Provider, the benefit of each Contracted Provider.
Except as specifically provided in Section 3.4, Section 5.2, Section 5.3 and/or Section 5.4 hereof, no Covered Person
or any other third party, other than Company, will be considered a third party beneficiary of this Agreement .
8.7. Amendment. Except as otherwise provided in this Agreement, this Agreement may be amended only
by written agreement of duly authorized representatives of the Parties.
8.7.1. WellCare may amend this Agreement by giving the Parties written notice of the amendment
to the extent such amendment is deemed necessary or appropriate by WellCare to comply with any Regulatory
Requirements. Any such amendment will be deemed accepted by the Parties upon the giving of such notice.
8.7.2. WellCare may amend this Agreement by giving Provider written notice (electronic or paper)
of the proposed amendment. When such an amendment proposes to modify Provider’s reimbursement or addresses
Covered Services routinely rendered by Provider to Covered Persons, the amendment will be evaluated by WellCare’s
Medical Affairs and Financial Matters Committees prior to WellCare giving written notice to Provider. Unless
Provider notifies WellCare in writing of its objection to such amendment during the 30 day period following the
giving of such notice by WellCare, Provider shall be deemed to have accepted the amen dment. If Provider objects
to any proposed amendment to this Agreement, WellCare may exclude one or more of the Contracted Providers from
being Participating Providers in the Product (or any component program of, or Coverage Agreement in connection
with, such Product) to which such amendment relates.
8.8. Entire Agreement. This Agreement, together with any attached or incorporated amendments,
schedules, exhibits, attachments and appendices, constitute the entire understanding and agreement of the parties with
respect to the subject matter hereof and supersedes all prior oral and written and all contemporaneous oral
negotiations, commitments and understandings between them. All prior or concurrent agreements, promises,
negotiations or representations either oral or written, between WellCare and Provider relating to the subject matter of
this Agreement, which are not expressly set forth in this Agreement, are of no force or effect.
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8.9. Severability. The invalidity or unenforceability of any terms or provisions hereof will in no way
affect the validity or enforceability of any other terms or provisions.
8.10. Waiver. Any term or condition of this Agreement may be waived at any time by the Party that is
entitled to the benefit thereof, but no such waiver shall be effective, unless set forth in a written instrument duly
executed by or on behalf of the Party waiving such term or condition; provided, however, that no Party shall be
permitted to make any such waiver by or on behalf of any other Party. The waiver by any Party of the violation of
any provision or obligation of this Agreement will not constitute the waiver of any subsequent violation of the same
or other provision or obligation.
8.11. Notices. Except as otherwise provided in this Agreement, any notice required or permitted to be
given hereunder is deemed to have been given when such written notice has been personally delivered or deposited
in the United States mail, postage paid, or delivered by a service that provides written receipt of delivery, addressed
as follows:
8.12. Force Majeure. No Party shall be liable or deemed to be in default for any delay or failure to perform
any act under this Agreement resulting, directly or indirec tly, from acts of God, civil or military authority, acts of
public enemy, war, accidents, fires, explosions, earthquake, flood, strikes or other work stoppages by the employees
of such Party, or any other similar cause beyond the reasonable control of such Party.
8.13. Proprietary Information. Each Party is prohibited from, and shall prohibit its Affiliates and
Contracted Providers from, disclosing to a third party the substance of this Agreement, or any information of a
confidential nature acquired from the other Party (or Affiliate or Contracted Provider thereof) during the course of
this Agreement, except to agents of such Party as necessary for such Party’s performance under this Agreement, or
as required by a Payor Contract or applicable Regulatory Requir ements. Provider acknowledges and agrees that all
information relating to Company’s programs, policies, protocols and procedures is proprietary information, and
except for such disclosures as are required by Regulatory Requirements, Provider shall not dis close such information
to any person or entity without WellCare’s express written consent.
8.14. Authority. The individuals whose signatures are set forth below represent and warrant that they are
duly empowered to execute this Agreement. Provider represents and warrants that it has all legal authority to contract
on behalf of and to bind all Contracted Providers to the terms of this Agreement. Provider and each Contracted
Provider acknowledges that references herein to the rights and obligations of any “Company” or a “Payor” under this
Agreement are references to the rights and obligations of each Company and each Payor individually and not of the
Companies or Payors collectively. Notwithstanding anything herein to the contrary, all such rights an d obligations
are individual and specific to each such Company and each such Payor and the reference to Company or Payor herein
in no way imposes any cross-guarantees or joint responsibility or liability by, between or among such individual
To WellCare at: To Provider at:
Attn: President Attn: ______________
WellCare Health Plans, Inc. Provider: _____________________
3128 Highwoods Blvd Address: _____________________
Raleigh, NC 27604
_____________________________
or to such other address as such Party may designate in writing. Notwithstanding the previous paragraph,
WellCare may provide notices to Provider by electronic mail, through its provider newsletter or on its provider
website.
DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210
Kirby Saunders
510 Meadowlands Dr
Hillsborough, NC
27278
Orange County NC
Page 13 of 48
Companies or Payors. A breach or default by an individual Company or Payor shall not constitute a breach or default
by any other Company or Payor, including but not limited to WellCare.
8.15. Counterparts. This Agreement may be executed in counterparts, each of which shall be deemed an
original, but all of which together shall be deemed to be one and the same agreement. A signed copy of this Agreement
delivered by facsimile, e-mail or other means of electronic transmission shall be deemed to have the same legal effect
as delivery of an original signed copy of this Agreement. Upon Provider’s reasonable written request, WellCare shall
provide Provider with a fully executed copy of this Agreement.
* * * * *
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THIS AGREEMENT CONTAINS A BINDING ARBITRATION PROVISION
THAT MAY BE ENFORCED BY THE PARTIES.
IN WITNESS WHEREOF, the Parties hereto have executed this Agreement, including all Product Attachments
noted on Schedule B, effective as of the date set forth beneath their respective signatures.
WELLCARE: PROVIDER:
WellCare Health Plans, Inc.
(Legibly Print Name of Provider)
Authorized Signature:
Authorized Signature:
Print Name: Troy Hildreth Print Name:
Title: State President Title:
Signature Date: Signature Date:
ICM #: Tax Identification Number:
State Medicaid Number:
To be completed by WellCare only: National Provider Identifier:
Effective Date:
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56-6000327
1629178629
3406929
6/30/2021
157444
Orange County NC
Bonnie Hammersley
County Manager
7/1/2021
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PARTICIPATING PROVIDER AGREEMENT
SCHEDULE A
CONTRACTED PROVIDER-SPECIFIC PROVISIONS
Provider and Contracted Providers shall comply with the applicable provisions of this Schedule A.
1 Hospitals. If Provider or a Contracted Provider is a hospital (“Hospital”), the following provisions
apply.
1.1 24 Hour Coverage. Each Hospital shall be available to provide Covered Services to Covered
Persons twenty-four (24) hours per day, seven (7) days per week.
1.2 Emergency Care. Each Hospital shall provide Emergency Care (as hereafter defined) in
accordance with Regulatory Requirements. The Contracted Provider shall notify Company’s medical management
department of any emergency room admissions by electronic file sent within 24 hours or by the next business day of
such admission. “Emergency Care” (or derivative thereof) has, as to each particular Product, the meaning set forth
in the applicable Coverage Agreement or Product Attachment. If there is no definition in such documen ts,
“Emergency Care” means inpatient and/or outpatient Covered Services furnished by a qualified provider that are
needed to evaluate or stabilize an Emergency Medical Condition. “Emergency Medical Condition” means a medical
condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson,
who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate
medical attention to result in the following: (i) placing the health of the individual (or, with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy; (ii) serious impairment to bodily functions;
or (iii) serious dysfunction of any bodily organ or part.
1.3 Staff Privileges. Each Hospital shall assist in granting staff privileges or other appropriate
access to Company’s Participating Providers who are qualified medical or osteopathic physicians, provided they meet
the reasonable standards of practice and credentialing standar ds established by the Hospital’s medical staff and
bylaws, rules, and regulations.
1.4 Discharge Planning. Each Hospital agrees to cooperate with Company’s system for the
coordinated discharge planning of Covered Persons, including the planning of any necessary continuing care.
1.5 Credentialing Criteria. Each Hospital shall (a) currently, and for the duration of this
Agreement, remain accredited by the Joint Commission or American Osteopathic Association, as applicable; and (b)
ensure that all employees of Hospital perform their duties in accordance with all applicable local, State and federal
licensing requirements and standards of professional ethics and practice.
1.6 National Committee for Quality Assurance (“NCQA”) Accreditation of WellCare’s
Standards. Each Hospital agrees to: i) cooperate with Quality Management and Improvement (“QI”) activities; ii)
maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement; and iii) allow
the Company to use Hospital’s performance data.
2 Practitioners. If Provider or Contracted Provider is a physician or other health care practitioner
(including physician extenders) (“Practitioner”), the following provisions apply.
2.1 Contracted Professional Qualifications. At all times during the term of this Agreement,
Practitioner shall, as applicable, maintain medical staff membership and admitting privileges with at least one hospital
that is a Participating Provider (“Participating Hospital”) with respect to each Product in which the Practitio ner
participates. Upon Company’s request, Practitioner shall furnish evidence of the foregoing to Company. If
Practitioner does not have such admitting privileges, Provider or the Practitioner shall provide Company with a
written statement from another Participating Provider who has such admitting privileges, in good standing, certifying
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that such individual agrees to assume responsibility for providing inpatient Covered Services to Covered Persons
who are patients of the applicable Practitioner.
2.2 Acceptance of New Patients. To the extent that Practitioner is accepting new patients, such
Practitioner must also accept new patients who are Covered Persons with respect to the Products in which such
Practitioner participates. Practitioner shall notify Company in writing 45 days prior to such Practitioner’s decision
to no longer accept Covered Persons with respect to a particular Product. In no event will an established patient of
any Practitioner be considered a new patient.
2.3 Preferred Drug List/Drug Formulary. If applicable to the Covered Person’s coverage,
Practitioners shall use commercially reasonable efforts, when medically appropriate under the circumstances, to
comply with formulary or preferred drug list when prescribing medications for Covered Persons.
2.4 National Committee for Quality Assurance (“NCQA”) Accreditation of WellCare’s
Standards. Each Practitioner agrees to: i) cooperate with Quality Management and Improvement (“QI”) activities;
ii) maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement; and iii)
allow the Company to use Practitioner’s performance data.
3 Ancillary Providers. If Provider or Contracted Provider is an ancillary provider (including but not
limited to a home health agency, durable medical equipment provider, sleep center, pharmacy, ambulatory surgery
center, nursing facility, laboratory or urgent care center)(“Ancillary Provider”), the following provisions apply.
3.1 Acceptance of New Patients. To the extent that Ancillary Provider is accepting new patients,
such Ancillary Provider must also accept new patients who are Covered Persons with respect to the Products in which
such Ancillary Provider participates. Ancillary Provider shall notify Company in writing 45 days prior to such
Ancillary Provider’s decision to no longer accept Covered Persons with respect to a particular Product. In no event
will an established patient of any Ancillary Provider be considered a new patient.
3.2 National Committee for Quality Assurance (“NCQA”) Accreditation of WellCare’s
Standards. Each ancillary provider agrees to: i) cooperate with Quality Management and Improvement (“QI”)
activities; ii) maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement;
and iii) allow the Company to use ancillary provider’s performance data.
4 FQHC. If Provider or a Contracted Provider is a federally qualified health center (“FQHC”), the
following provisions apply.
4.1 FQHC Insurance. To the extent FQHC’s employees are deemed to be federal employees
qualified for protection under the Federal Tort Claims Act (“FTCA”) and WellCare has been provided with
documentation of such status issued by the U.S. Department of Health and Human Services (such status to be referred
to as “FTCA Coverage”), Section 5.1 of this Agreement will not apply to those Contracted Providers with FTCA
Coverage. FQHC shall provide evidence of such FTCA Coverage to WellCare at any time upon request. FQHC
shall promptly notify WellCare if, any time during the term of this Agreement, any Contracted Provider is no longer
eligible for, or if FQHC becomes aware of any fact or circumstance that would jeopardize, FTCA Coverage. Section
5.1 of this Agreement will apply to a Contracted Provider immediately upon such Contracted Provider’s loss of FTCA
Coverage for any reason.
5 Facility Providers. If Provider or a Contracted Provider is a facility (including but not limited to
Clinic, FQHC, LTAC, Nursing Home, Rehab, Rural Health Clinic, Skilled Nursing) (“Facility Provider”) the
following provision applies.
5.1 National Committee for Quality Assurance (“NCQA”) Accreditation of
WellCare’s Standards. Each facility agrees to: i) cooperate with Quality Management and Improvement (“QI”)
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activities; ii) maintain the confidentiality of a Covered Persons information and records pursuant to the Agreement;
and iii) allow the Company to use facility’s performance data.
6 Long Term Services and Supports (“LTSS”) and Home and Community-Based Services (“HCBS”)
Providers. If Provider or a Contracted Provider is a provider of LTSS and/or HCBS services, the following provisions
apply.
6.1 Definition. LTSS generally includes assistance with daily self-care activities (e.g., walking,
toileting, bathing, and dressing) and activities that support an independent lifestyle (e.g., food preparation,
transportation, and managing medications). The broad category of LTSS also includes care and service coordination
for people who live in their own home, a residential setting, a nursing facility, or other institutional setting. Home
and community-based services (“HCBS”) are a subset of LTSS that functions outside of institutional care to maximize
independence in the community. Long-term care (“LTC”) is another subset of LTSS which provides benefits as
specified through the SMMC LTC Program.
6.2 HCBS Waiver Authorization. Provider shall not provide HCBS Covered Services to
Covered Person without the required HCBS waiver authorization.
6.3 Conditions for Reimbursement. No payment shall be made to the Provider unless the
Provider has strictly conformed to the policies and procedures of the HCBS Waiver Program, including but not
limited to not providing HCBS Covered Services without prior authorization of WellCare. For the purposes of this
Exhibit, “HCBS Waiver Program” shall mean any special Medicaid program operated under a waiver approved by
the Centers for Medicare and Medicaid Services which allows the provision of a special package of approved services
to Covered Person.
6.4 Acknowledgement. WellCare acknowledges that Provider is a provider of LTSS and is not
necessarily a provider of medical or health care services. Nothing in this Agreement is intended to require Provider
to provide medical or health care services that Provider does not routinely provide, but woul d not prohibit providers
from offering these services, as appropriate.
6.5 Notification Requirements. Provider or the applicable Contracted Provider shall provide the
following notifications to WellCare, via written notice or via telephone contact at a numbe r to be provided by
WellCare, within the following time frames:
6.5.1 Provider or the applicable Contracted Provider shall notify WellCare of a Covered
Person’s visit to urgent care or the emergency department of any hospital, or of a Covered Person’s hospitali zation,
within twenty-four (24) hours of becoming aware of such visit or hospitalization.
6.5.2 Provider or the applicable Contracted Provider shall notify WellCare of any change
to the designated/assigned services being provided under a Covered Person’s plan of care and/or service plan, within
24 hours of becoming aware of such change.
6.5.3 Provider or the applicable Contracted Provider shall notify WellCare if a Covered
Person misses an appointment with Provider, within 24 hours of becoming aware of such missed appointment.
6.5.4 Provider or the applicable Contracted Provider shall notify WellCare of any change
in a Covered Person’s medical or behavioral health condition, within 24 hours of becoming aware of such change.
(Examples of changes in condition are set forth in the Provider Manual.)
6.5.5 Provider or the applicable Contracted Provider shall notify WellCare of any safety
issue identified by Provider or Contracted Provider or its agent or subcontractor, within 24 hours of the identification
of such safety issue. (Examples of safety issues are set forth in the Provider Manual.)
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6.5.6 Provider or the applicable Contracted Provider shall notify WellCare of any change
in Provider’s or Contracted Provider’s key personnel, within 24 hours of such change.
6.6 Minimum Data Set. If Contracted Provider is a nursing facility, Provider or such Contracted
Provider shall submit to WellCare or its designee the Minimum Data Set as defined by CMS and required under
federal law and WellCare policy as it relates to all Covered Persons who are residents in Contracted Provider’s
facility. Such submission shall be via electronic mail, facsimile transmission, or other manner and format reasonably
requested by WellCare.
6.7 Quality Improvement Plan. Each Contracted Provider shall participate in WellCare’s LTSS
quality improvement plan. Each Contracted Provider shall permit WellCare to access such Contracted Providers’
assessment and quality data upon reasonable advance notice, which may be given by electronic mail.
6.8 Electronic Visit Verification. If Contracted Provider provides in-home services, Contracted
Provider shall comply with 21st Century Cures Act and WellCare’s electronic visit verification system requirements
where applicable and accessible.
6.9 Criminal Background Checks. Provider shall conduct a criminal background check on each
Contracted Provider prior to the commencement of services under this Agreement and as requested by WellCare
thereafter. Provider shall provide the results of such background checks to WellCare and member, if se lf-directed,
upon request. WellCare within a reasonable time period following the completion thereof. Contracted Provider
agrees to immediately notify WellCare of any criminal convictions of any Contracted Provider. Provider shall pay
any costs associated with such criminal background checks.
7 Person-Centered Planning, Care/Service Plan, and Services. Provider and Contracted Providers shall
comply with all State and federal regulatory requirements related to person-centered planning, care/service plans, and
services including, but not limited to:
7.1 Covered Persons shall lead the person-centered planning process and can elect to include,
and/or consult with, any of their LTSS providers in the care/service plan development process.
7.2 The care/service plan must be finalized and agreed to, with the informed consent of the
individual in writing, and signed by all individuals and providers responsible for its implementation through the
mechanism required by State and federal requirements. Non-medical service providers (such as meals or assistive
technology) can signify their agreement through this contract or written agreement in lieu of directly in the plan, if
permitted by the Covered Person.
7.3 LTSS providers shall be aware of, respect, and adhere to a Covered Person’s preferences for
the delivery of services and supports.
7.4 LTSS providers shall ensure services and supports are culturally appropriate, provided in
plain language (where applicable), and accessible to Covered Persons and the person(s) supporting them who have
disabilities and/or are limited English proficient.
7.5 WellCare agrees to complete the care/service plan in a timely manner (within at least 120
days of enrollment or annually, or less if State requirements differ) and provide a copy to LTSS provider(s)
responsible for implementation.
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PARTICIPATING PROVIDER AGREEMENT
SCHEDULE B
PRODUCT PARTICIPATION
Provider will be designated as a “Participating Provider” in the Product Attachments listed below as of the date of
successful completion of credentialing in accordance with this Agreement.
List of Product Attachments:
Attachment A: Medicaid
Attachment B: [Reserved]
Attachment C: [Reserved]
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PARTICIPATING PROVIDER AGREEMENT
SCHEDULE C
INFORMATION FOR CONTRACTED PROVIDERS
Provider shall provide WellCare with the information set forth below with respect to: (i) Provider; (ii) each Contracted
Provider; and (iii) if applicable, each Contracted Provider’s locations and/or professionals. To the extent Provider
provides the name of any Contracted Provider to WellCare hereunder, such entity and/or individual will be considered
a Contracted Provider under this Agreement regardless of whether the complete list of information set forth below
relating to such Contracted Provider is provided by Provider.
1. Name
2. Address
3. E-mail address
4. Telephone and facsimile numbers
5. Professional license numbers
6. Medicare/Medicaid ID numbers
7. Federal tax ID numbers
8. Completed W-9 form
9. National Provider Identifier (NPI) numbers
10. Provider Taxonomy Codes
11. Area of medical specialty
12. Age restrictions (if any)
13. Area hospitals with admitting privileges (where applicable)
14. Whether Providers are employed or subcontracted with Contracted Provider using the designation “E” for
employed or “C” for subcontracted.
15. For a subcontracted Provider, whether its Providers are employed or contracted with the subcontracted Provider
using the designation “E” for employed or “C” for contracted.
16. Office contact person
17. Office hours
18. Billing office
19. Billing office address
20. Billing office telephone and facsimile numbers
21. Billing office e-mail address
22. Billing office contact person
23. Ownership Disclosure Form, as required to comply with Laws, Program Requirements, and Government
Contract
NOTE: For a complete listing of the information and additional documentation required, please refer to the
enrollment application
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PARTICIPATING PROVIDER AGREEMENT
SCHEDULE D
COMPANY AFFILIATES
As of the Effective Date, the Affiliates of WellCare included as the “Company” are listed below.
Affiliates State
Celtic Insurance Company Multiple States
Health Net Community Solutions, Inc. Multiple States
Health Net Life Insurance Company Multiple States
WellCare Health Plans, Inc. Multiple States
WellCare of Alabama, Inc. Alabama
Bridgeway Health Solutions of Arizona, Inc.
Care1st Health Plan of Arizona Inc.
Health Net of Arizona, Inc., d/b/a Arizona Complete Health
One Care by Care1st Health Plan of Arizona Inc.
WellCare Health Insurance of the Southwest, Inc.
WellCare Health Plans of Arizona, Inc.
Arizona
Arkansas Health & Wellness Health Plan, Inc.
Arkansas Total Care, Inc.
NovaSys Health, Inc.
WellCare Health Insurance Company of America
Arkansas
Harmony Health Plan, Inc. Arkansas, Illinois, Mississippi,
South Carolina, Tennessee
California Health and Wellness Plan
Health Net of California, Inc.
WellCare of California, Inc., f/k/a Easy Choice Health Plan, Inc.
California
WellCare Health Insurance of Connecticut, Inc. Connecticut
WellCare of Connecticut, Inc. Connecticut, North Carolina
Sunshine Health Plan Community Solutions, Inc.
Sunshine State Health Plan, Inc.
WellCare Health Insurance of Arizona, Inc.WellCare of Florida, Inc.
Florida
Ambetter of Peach State, Inc.
Peach State Health Plan, Inc.
WellCare of Georgia, Inc.
Georgia
WellCare Health Insurance of Arizona, Inc., d/b/a ‘Ohana Health Plan, Inc.
WellCare Health Insurance of Hawaii, Inc. Hawaii
IlliniCare Health Plan, Inc.
Meridian Health Plan of Illinois, Inc.
WellCare of Illinois, Inc.
Illinois
Meridian Health Plan of Michigan, Inc. Illinois, Indiana, Michigan, Ohio
Coordinated Care Corporation, d/b/a Managed Health Services - IN Indiana
Iowa Total Care, Inc. Iowa
Sunflower State Health Plan, Inc. Kansas
WellCare Health Insurance Company of Kentucky, Inc., d/b/a WellCare of
Kentucky, Inc. Kentucky
Louisiana Healthcare Connections, Inc.
WellCare Health Insurance Company of Louisiana, Inc. Louisiana
WellCare of Maine, Inc. Maine
CeltiCare Health Plan of Massachusetts, Inc.
WellCare Health Plans of Massachusetts, Inc. Massachusetts
Meridian Health Plan of Michigan, Inc.
Michigan Complete Health, Inc. Michigan
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Affiliates State
Ambetter of Magnolia, Inc.
Magnolia Health Plan, Inc.
WellCare of Mississippi, Inc.
Mississippi
Home State Health Plan, Inc. Missouri
Nebraska Total Care, Inc. Nebraska
SilverSummit Healthplan, Inc. Nevada
Granite State Health Plan, Inc.
WellCare Health Insurance Company of New Hampshire, Inc.
WellCare of New Hampshire, Inc.
New Hampshire
WellCare Health Insurance Company of New Jersey, Inc.
WellCare Health Plans of New Jersey, Inc. New Jersey
Western Sky Community Care, Inc. New Mexico
New York Quality Healthcare Corporation, d/b/a Fidelis Care
WellCare Health Insurance of New York, Inc.
WellCare of New York, Inc.
New York
American Progressive Life and Health Insurance Company of New York New York, Maine
WellCare Health Insurance of North Carolina, Inc.
WellCare of North Carolina, Inc. North Carolina
Buckeye Community Health Plan, Inc.
Buckeye Health Plan Community Solutions, Inc. Ohio
WellCare Health Insurance Company of Oklahoma, Inc.
WellCare of Oklahoma, Inc. Oklahoma
Health Net Health Plan of Oregon, Inc.
Trillium Community Health Plan, Inc. Oregon
Pennsylvania Health & Wellness, Inc. Pennsylvania
WellCare Health Plans of Rhode Island, Inc. Rhode Island
Absolute Total Care, Inc.
WellCare of South Carolina, Inc. South Carolina
WellCare Health Insurance of Tennessee, Inc. Tennessee
SelectCare Health Plans, Inc.
SelectCare of Texas, Inc.
Superior HealthPlan Community Solutions, Inc.
Superior Healthplan, Inc.
WellCare National Health Insurance Company
WellCare of Texas, Inc.
Texas
WellCare Health Plans of Vermont, Inc. Vermont
WellCare of Virginia, Inc. Virginia
Coordinated Care of Washington, Inc.
WellCare Health Insurance Company of Washington, Inc.
WellCare of Washington, Inc.
Washington
Managed Health Services Insurance Corporation Wisconsin
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Attachment A: Medicaid
MEDICAID PRODUCT ATTACHMENT
This PRODUCT ATTACHMENT (“Attachment”) is made and entered between WellCare Health Plans, Inc.,
a North Carolina corporation (“WellCare”) and _Orange County, a local political subdivision of the State of North
Carolina_______________________________ (“Provider”).
WHEREAS, WellCare and Provider entered into that certain Participating Provider Agreement, as the same
may have been amended and supplemented from time to time (the “Agreement”), pursuant to which Provider and its
Contracted Providers participate in certain Products offered by or available from or through a Company;
WHEREAS, pursuant to the provisions of the Agreement, this Attachment is part of the Agreement and, as
such, the Contracted Providers identified herein will be designated and participate as “Participating Providers” in
the Product described in this Attachment; and
WHEREAS, the Agreement is modified or supplemented as hereafter provided.
NOW THEREFORE, in consideration of the recitals, the mutual promises herein stated, the parties hereby
agree to the provisions set forth below.
1. Defined Terms. For purposes of the Medicaid Product (as herein defined), the following terms have
the meanings set forth below. All capitalized terms not specifically defined in this Attachment will have the meanings
given to such terms in the Agreement, or, if not defined there, in the State Contract (as herein defined). All technical
managed care terms used in this Attachment are defined in the Agreement or this Attachment, and are consistent with
definitions included in Covered Person materials issued in conjunction with the Medicaid managed care program.
1.1. “Amendment” means any change to the terms of a contract, including terms incorporated by
reference that modifies fee schedules. A change required by federal or state law, rule, regulation, administrative
hearing, or court order is not an amendment.
1.2. “Clean Claim” means a claim for services submitted to WellCare by a Medicaid managed
care medical or pharmacy services provider that can be processed without obtaining additional information from the
submitter in order to adjudicate the claim.
1.3. “Emergency Medical Condition” means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that a prudent layperson, with an average knowledge of health
and medicine, could reasonably expect that the absence of immediate medical attention to result in the following:
placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. “Emergency
Medical Condition” also means a medical condition in which the symptoms appear quickly and are sever e enough
that a person with average knowledge of health and medicine would expect that, in the absence of immediate medical
attention, the health or life of the person experiencing the symptoms is in jeopardy or they are at risk of serious
damage to a bodily function, organ, or part.
1.4. “Emergency Services” means inpatient and outpatient services furnished by a qualified
provider needed to evaluate or stabilize an Emergency Medical Condition.
1.5. “Health Care Provider” means an individual who is licensed, certified, or otherwise
authorized under Chapter 90 or Chapter 90B of the General Statutes of North Carolina or under the laws of another
state to provide health care services in the ordinary course of business or practice of a profession or in an approved
education or training program and a facility that is licensed under Chapter 131E or Chapter 122C of the General
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Statutes of North Carolina or is owned or operated by the State of North Carolina in which health care services are
provided to patients.
1.6. “Medicaid Product” refers to those programs and health benefit arrangements offered by
WellCare or other Company pursuant to a State Contract. The Medicaid Product does not apply to any Coverage
Agreements that are specifically covered by another Product Attachment to the Agreement.
1.7. “Medically Necessary Service” or “Medically Necessary” means those Covered Services
that are within general accepted standards of medical care in the State community, as verified by independents
Medicaid Consultants, and not experimental in nature.
1.8. “Objective Quality Standards” means the objective standards for quality determinations
identified by WellCare that assess a provider’s ability to deliver care; include specific defined thresholds for adverse
quality determinations; meet standards established by the National Committee on Quality Assurance (NCQA); and
are not discriminatory.
1.9. “Primary Care Provider” or “PCP” means the participating physician, physician extender
(e.g. physician assistant, nurse practitioner, certified nurse midwife) or group practice/center selected by or assigned
to the Covered Person to provide and coordinate the Covered Person’s health care needs and to initiate and monitor
referrals for specialized services when required. Includes family practitioners, pediatricians, obstetricians, and
internal medicine physicians.
1.10. “State” means North Carolina.
1.11. “State Contract” means a contract between WellCare or other Company and one or more
state Medicaid agency(ies), or any successors thereto, to provide specified services and goods to covered beneficiaries
under state Medicaid-funded program(s) and to meet certain performance standards while doing so.
2. Medicaid Product.
2.1. Medicaid and/or CHIP Product. This Product Attachment constitutes the “Medicaid Product
Attachment” and is incorporated into the Agreement between Provider and WellCare. It supplements the Agreement
by setting forth specific terms and conditions that apply to the Medicaid Product with respect to which a Participating
Provider has agreed to participate, and with which a Participating Provider must comply in order to maintain such
participation. This Attachment applies only to the provision of health care services, supplies or accommodations
(including Covered Services) to Covered Persons enrolled in the Medicaid Product.
2.2. Participation. Except as otherwise provided in this Product Attachment or the Agreement,
Provider and all Contracted Providers under the Agreement will participate as Participating Providers in the Medicaid
Product and will provide to Covered Persons enrolled in the Medicaid Product, upon the same terms and conditions
contained in the Agreement, as supplemented or modified by this Product Attachment, those Covered Services that
are provided by Contracted Providers pursuant to the Agreement. In providing such services, Provider shall, and
shall cause Contracted Providers to, comply with and abide by the provisions of this Product Attachment and the
Agreement (including the Provider Manual).
2.3. Attachment. This Attachment constitutes the Product Attachment and Compensation
Schedule for the Medicaid Product.
2.4. Construction. This Product Attachment supplements and forms a part of the Agreement.
Except as otherwise provided herein or in the terms of the Agreement, the terms and conditions of the Agreement
will remain unchanged and in full force and effect as a result of this Product Attachment. In the event of a conflict
between the provisions of the Agreement and the provisions of this Product Attachment, this Product Attachment
will govern with respect to health care services, supplies or accommodations (including Covered Services) rendered
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to Covered Persons enrolled in or covered by a Medicaid Product. To the extent Provider or any Contracted Provider
is unclear about its, his or her respective duties and obligations, Provider or the applicable Contracted Provider shall
request clarification from WellCare. To the extent any provision of this Agreement (including any exhibit,
attachment, or other document referenced herein) is inconsistent with or contrary to any provision of the State
Contract, the relevant provision of the State Contract shall have priority and control over the matter.
3. Term. This Product Attachment will become effective as of the Effective Date, and will be
coterminous with the Agreement unless a Party terminates the participation of the Contracted Provider in this Product
in accordance with the applicable provisions of the Agreement or this Product Attachment.
4. Governmental Program Requirements. Schedule A to this Product Attachment, which is
incorporated herein by this reference, sets forth the provisions that are required by the applicable State Contract to be
included in the Agreement with respect to the Medicaid Product. Any additional requirements that may apply to the
Coverage Agreements or Covered Persons enrolled in or covered by this Product may be set forth in the Provider
Manual or another Attachment and are incorporated herein by this reference.
5. Other Terms and Conditions. Except as modified or supplemented by this Product Attachment, the
compensation hereunder for the provision of Covered Services by Contracted Providers to Covered Persons enrolled
in or covered by the Medicaid Product is subject to all of the other provisions in the Agreement (including the Provider
Manual) that affect or relate to compensation for Covered Services provided to Covered Persons.
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Attachment A: Medicaid
SCHEDULE A
GOVERNMENTAL PROGRAM REQUIREMENTS
This Schedule sets forth the special provisions that are specific to the North Carolina Medicaid Product under
the State Contract.
1. Compliance.
1.1 Compliance with State and Federal Laws. Participating Provider understands and agrees that it, he
or she is subject to all state and federal laws, rules, regulations, waivers, policies and guidelines, and court-ordered
consent decrees, settlement agreements, or other court orders that apply to the Agreement and State Contract, and all
persons or entities receiving state and federal funds. Participating Provider understands and agrees that any violation
by a provider of a state or federal law relating to the delivery of services pursuant to this Agreement, or any violation
of the State Contract could result in liability for money damages, and/or civil or crimina l penalties and sanctions
under state and/or federal law. (Section VII, Section G(3)(a)).
1.2 Department Authority Related to the Medicaid Program. Participating Provider agrees and
understands that in the State of North Carolina, the Department of Health and Human Services (“NC DHHS”) is the
single state Medicaid agency designated under 42 C.F.R. § 431.10 to administer or supervise the administration of
the state plan for medical assistance. The Division of Health Benefits is designated with administration, provision,
and payment for medical assistance under the Federal Medicaid (Title XIX) and the State Children’s Health Insurance
(Title XXI) (CHIP) programs. The Division of Social Services (DSS) is designated with the administration and
determination of eligibility for the two programs. (Section VII, G(3)(e)).
1.3 Credentialing. Each Participating Provider shall be enrolled as a Medicaid provider as required by
45 C.F.R. § 455.410 and maintain enrollment for the term of the Agreement. Participating Provider shall maintain
licensure, accreditation, and credentials sufficient to meet WellCare’s network participation requirements, as outlined
in WellCare’s Provider Manual and its Credentialing and Re-credentialing Policy. Participating Provider shall notify
WellCare of changes in the status of any information relating to Participating Provider’s professional credentials.
Participating Provider shall complete reenrollment or re-credentialing before renewal of the Agreement as set forth
below:
(a) during the provider credentialing transition period, no less frequently than every five (5)
years; and
(b) during the provider credentialing under full implementation, no less frequently than every
three (3) years, except as otherwise permitted by the NC DHHS. (Section VII, G(1)(f))
1.4 Liability Insurance. Participating Provider shall maintain professional liability insurance coverage
in an amount acceptable to WellCare. Participating Provider shall notify WellCare of subsequent changes in the
status of Participating Provider’s professional liability insurance on a timely basis. (Section VII, G(1)(g)).
1.5 Utilization Management. Participating Provider shall comply with WellCare’s utilization
management programs, quality management programs, and provider sanction programs, except to the extent that any
of these programs conflict with Participating Provider’s professional or ethical responsibility or interfere with
Participating Provider’s ability to provide information or assistance to patients. WellCare utilizes only NC Medicaid’s
Clinical Coverage Policies for utilization management/clinical guidelines and other NC DHHS-approved utilization
management/clinical guidelines. (Section VII, G(1)(o)).
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1.6 Dispute Resolution. Participating Provider shall utilize the applicable dispute resolution procedures
outlined in the Agreement to resolve disputes between WellCare and Participating Provider. (Section VII, G(1)(q)).
1.7 Reporting Requirements. Participating Provider shall promptly provide WellCare with the data and
information that WellCare requests in order to meet its reporting requirements under the State Contract. (Section VII,
J. Table 1).
1.8 Hours of Operation. Participating Provider will offer hours of operation to Covered Persons that are
not less than the hours of operation offered to commercial members or comparable to Medicaid fee -for-service, if
Participating Provider serves only Medicaid or NC Health Choice members. (Section V, D(1)(d)(iii)).
2. Entire Agreement. The Agreement identifies the documents that constitute the entire contract between the
parties. (Section VII, G(1)(a)).
3. Hold Harmless. Participating Provider agrees to hold the Covered Person harmless for charges for any
Covered Service. Participating Provider agrees not to bill a Covered Person for Medically Necessary Services
covered by WellCare so long as the Covered Person is eligible for coverage. (Section VII, G(3)(b)). Participating
Provider will not hold Covered Person’s responsible for any of the following: (a) WellCare’s debts in the event of its
insolvency; (b) Covered Services provided to the Covered Person for which: (i) NC DHHS does not pay WellCare,
or (ii) NC DHHS, or WellCare, does not pay the Participating Provider; (c) payments for Covered Services furnished
under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount that the
Covered Person would owe if WellCare covered the services directly. 42 C.F.R. § 438.106. (Section V, C(1)(i)(iii)
and Section V, C(2)(r)(iii)).
4. Liability. Participating Provider understands and agrees that NC DHHS does not assume liability for the
actions of, or judgments rendered against, WellCare, Payors, its employees, agents or subcontractors. Further,
Participating Provider understands and agrees that there is no right of subrogation, contribution, or indemnification
against NC DHHS for any duty owed to Participating Provider by WellCare or Payor or any judgment rendered
against WellCare or Payor. (Section VII, G(3)(c)).
5. Non-Discrimination.
5.1 Equitable Treatment of Covered Persons. Participating Provider agrees to render provider services
to Covered Persons with the same degree of care and skills as customarily provided to Participating Provider’s
patients who are not Covered Persons, according to generally accepted standards of medical practice. Participating
Provider and WellCare agree that Covered Persons and non-Covered Persons should be treated equitably.
Participating Provider agrees not to discriminate against Covered Persons on the basis of race, color, national origin,
age, sex, gender, or disability. (Section VII, G(3)(d)).
5.2 Interpreting and Translation Services. Participating Provider shall provide qualified sign language
interpreters if closed captioning is not the appropriate auxiliary aid for the Covered Person. Participating Provider
shall ensure that Participating Provider’s staff are trained to appropriately communicate with patients with various
types of hearing loss. Participating Provider shall report to WellCare, in a format and frequency determined by
WellCare, whether hearing loss accommodations are needed and provided and the type of accommodation provided.
(Section VII, G(1)(t)).
6. Term; Termination.
6.1 Term. This Attachment is coterminous with the Agreement, unless otherwise agreement by the
parties, but in no event will the term of this Attachment exceed the term of the State Contract (including, for avoidance
of doubt, any renewals of the State Contract) (Section VII, G(1)(c)).
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6.2 Termination. The Agreement sets forth the basis for termination of the Agreement by either party
and the related notice requirements. Notwithstanding anything in the Agreement or this Attachment to the contrary,
WellCare may immediately terminate the Agreement or this Attachment and a Participating Provider’s participation
thereunder upon: (1) a confirmed finding of fraud, waste or abuse by the NC DHHS or the North Carolina Department
of Justice Medicaid Investigations Division, or (2) failure of the Part icipating Provider to maintain enrollment as a
Medicaid provider. (Sections VII, G(1)(d) and G(1)(f)(i)).
6.3 Insolvency. If the Agreement or this Attachment terminates as a result of WellCare’s or Payor’s
insolvency, Participating Provider will cooperate in the transition of administrative duties and records and ensure the
continuation of care when inpatient care is on-going in accordance with the requirements of the Agreement, this
Attachment and the State Contract. If WellCare or Payor provides for or arranges for the delivery of health care
services on a prepaid basis, Participating Provider will continue inpatient care until the patient is ready for discharge.
(Section VII, G(1)(e)).
7. Covered Person Services.
7.1 Covered Person Billing. Participating Provider shall not bill any Medicaid Managed Care Covered
Person for Covered Services, except for specified coinsurance, copayments, and applicable deductibles. Participating
Provider is responsible for collecting applicable deductibles, copayments, coinsurance and fees for non-Covered
Services. This provision does not prohibit a Participating Provider and Covered Person from agreeing to continue
non-Covered Services at the Covered Person’s own expense, as long as the Participating Provider has notified the
Covered Person in advance that a Payor may not cover or continue to cover specific services and the Covered Person
to receive the services (Section VII, G(1)(h)).
7.2 Provider Accessibility. Participating Provider shall provide call coverage or other back-up to provide
service in accordance with WellCare’s standards for provider accessibility addressed set forth herein, in the Provider
Manual and/or in the State Contract. (Section VII, G(1)(i)). Participating Provider agrees to meet the NC DHHS
standards for timely access to care and services, taking into account the urgency of need for services. (Section V,
D(1)(d)(ii)). Participating Provider shall provide physical access, reasonable accommod ations, including parking,
exam and waiting rooms, and accessible equipment for Medicaid Covered Persons with physical or mental
disabilities. (Section V, (1)(d)(vi)).
7.3 Eligibility Verification. WellCare or Payor shall provide a mechanism that allows Participating
Provider to verify Covered Person eligibility, based on current information held by WellCare or Payor, as applicable,
before rendering Covered Services. (Section VII, G(1)(j)).
7.4 Covered Person Appeals and Grievances. Participating Provider shall cooperate with Covered
Person in regard to Covered Person appeals and grievance procedures. (Section VII, G(1)(l)). Participating Provider
has the right to file a grievance or appeal. WellCare’s internal appeal processes must be completed before seeking
other legal or administrative remedies under state or federal law. (Section V, D(2)(c)(xi)).
7.5 Appointment Wait Times. Participating Provider shall cooperate with WellCare to ensure that
appointment wait times for Covered Persons do not exceed the requirements set forth below, to the extent applicable.
(Section VII, F. Table 3).
(a) If Participating Provider is a PCP providing preventative care services, appointment wait
time shall not exceed thirty (30) calendar days for adults (21 years of age and older) and children ages six (6) months
to twenty (20) years of age, and fourteen (14) calendar days for children less than six (6) months of age.
(b) If Participating Provider is a PCP providing urgent care services, appointment wait time shall
not exceed twenty-four (24) hours.
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(c) If Participating Provider is a PCP providing services for routine/check-up without symptoms,
appointment wait time shall not exceed thirty (30) calendar days.
(d) If Participating Provider is a PCP providing after-hours access for emergent and urgent care,
care shall be administered immediately upon presentation at a service delivery site.
(e) If Participating Provider provides prenatal care, appointment wait time for initial
appointments within the first or second trimester shall not exceed fourteen (14) calendar days and appointment wait
time for initial appointments within the third trimester or for a high-risk pregnancy shall not exceed five (5) calendar
days.
(f) If Participating Provider provides specialty care, appointment wait time shall not exceed
twenty-four (24) hours for urgent care services or thirty (30) calendar days for routine/check-up without symptoms
services. For after-hours access for emergent and urgent care, care shall be administered immediately upon
immediately upon presentation at a service delivery site.
(g) If Participating Provider provides behavioral health care, appointment wait time shall not
exceed thirty (30) minutes for Mobile Crisis Management Services; twenty-four (24) hours for Urgent Care Services
for Mental Health or Urgent Care Services for SUDs; and fourteen (14) calendar days for Routine Services for Mental
Health or Routine Services for SUDs. For Emergency Services for Mental Health or SUDs, care should administered
immediately upon presentation at a service delivery site.
(h) To the extent Participating Provider performs Emergency Services, Participating Provider
shall make Emergency Services available twenty-four (24) hours a day, three hundred sixty-five (365) days a year.
8. Records.
8.1 Medical Records. Participating Provider shall maintain confidentiality of Covered Person medical
records and personal information and other health records as required by law. Participating Provider shall maintain
adequate medical and other health records according to industry and WellCare standards. Participating Provider shall
make copies of such records available to WellCare, Payor and NC DHHS in conjunction with its regulation of
WellCare. Participating Provider shall make available and furnish the records immediately upon request in either
paper or electronic form, at no cost to the requesting party. (Section VII, G(1)(k)).
8.2 Access to Provider Records.
(a) Participating Provider agrees to provide at no cost to the following entities or their designees
with prompt, reasonable, and adequate access to WellCare or Payor and the Agreement and any records, books,
documents, and papers that relate to WellCare or Payor and the Agreement and/or Participating Provider’s
performance of its responsibilities under this Agreement for purposes of examination, audit, investigation, contract
administration, the making of copies, excerpts or transcripts, or any other purpose NC DHHS deems necessary for
contract enforcement or to perform its regulatory functions: (i) the United States Department of Health and Human
Services or its designee; (ii) the Comptroller General of the United States or its designee; (iii) NC DHHS, its Medicaid
managed care program personnel, or its designee; (iv) the Office of Inspector General; (v) North Carolina Department
of Justice Medicaid Investigations Division; (vi) any independent verification and validation contractor, audit firm,
or quality assurance contractor acting on behalf of NC DHHS; (vii) the North Carolina Office of State Auditor, or its
designee; (viii) a state or federal law enforcement agency; and (ix) any other state or federal entity identified by NC
DHHS, or any other entity engaged by NC DHHS.
(b) Participating Provider shall cooperate with all announced and unannounced site visits,
audits, investigations, post-payment reviews, or other program integrity activities conducted by the NC DHHS.
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(c) Nothing in this section shall be construed to limit the ability of the federal government, the
Centers for Medicare and Medicaid Services, the U.S. Department of Health and Human Services Office of Inspector
General, the U.S. Department of Justice, or any of the foregoing entities’ contractors or agents, to enforce federal
requirements for the submission of documentation in response to an audit or investigation. (Section VII, G(3)(f)).
9. Provider Ownership Disclosure. Participating Provider agrees to disclose the required information, at the
time of application, and/or upon request, in accordance with 42 C.F.R.§ 455 Subpart B, related to ownership and
control, business transactions, and criminal conviction for offenses against Medicare, Medicaid, CHIP and/or other
federal health care programs. See 42 C.F.R. § 455, Parts 101 through 106 for definitions, percentage calculations,
and requirements for disclosure of ownership, business transactions, and information on persons convicted of crimes
related to any federal health care programs. Participating Provider agrees to notify, in writing, WellCare and the NC
DHHS of any criminal conviction within twenty (20) days of the date of the conviction. (Section VII, G(3)(g)).
10. Provider Payment.
10.1 Methodology. The Agreement includes a provider payment provision that describes the
methodology to be used as a basis for payment. Such provision does not include a rate methodology that provides
for automatic increases in rates, consistent with N.C. Gen. Stat. 58-3-227(a)(5). (Section VII, G(1)(m)).
10.2 G.S. 58-3-225, Prompt Claim Payments under Health Benefit Plans. Unless otherwise provided by
the NC DHHS’s Advanced Medical Home Program Policy, Pregnancy Management Program Policy, Care
Management for High-Risk Pregnancy Policy, or Care Management for At-Risk Children Policy, Participating
Provider shall submit all claims to the Payor for processing and payments within one-hundred-eighty (180) calendar
days from the date of covered service or discharge (whichever is later). However, Participating Provider’s failure to
submit a claim within this time will not invalidate or reduce any claim if it was not reasonably possible for
Participating Provider to submit the claim within that time. In such case, the claim should be submitted as soon as
reasonably possible, and in no event, later than one (1) year from the time submittal of the claim is otherwise required.
(Section VII, G(3)(h)).
(a) For medical claims (including behavioral health), Payor shall comply with the requirements
set forth below.
(i) The Payor shall within eighteen (18) calendar days of receiving a Medical Claim
notify Participating Provider whether the claim is a Clean Claim, or pend the claim and request from Participating
Provider all additional information needed to process the claim.
(ii) The Payor shall pay or deny a medical Clean Claim at lesser of thirty (30) calendar
days of receipt of the claim or the first scheduled provider reimbursement cycle following adjudication.
(iii) A medical pended claim shall be paid or denied within thirty (30) calendar days of
receipt of the requested additional information.
(b) For pharmacy claims, Payor shall comply with the requirements set forth below.
(i) The Payor shall within fourteen (14) calendar days of receiving a pharmacy claim
pay or deny a pharmacy Clean Claim or notify Participating Provider that more information is needed to process the
claim.
(ii) A pharmacy pended claim shall be paid or denied within fourteen (14) calendar days
of receipt of the requested additional information.
(c) If the requested additional information on a medical or pharmacy pended claim is not
submitted within ninety (90) days of the notice requesting the required additional information, the Payor shall deny
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the claim per § 58-3-225 (d). The Payor shall reprocess medical and pharmacy claims in a timely and accurate manner
as described in this provision (including interest and penalties if applicable).
(d) If the Payor fails to pay a Clean Claim in full pursuant to this provision, the Payor shall pay
interest and penalty. Late Payments will bear interest at the annual rate of eighteen (18) percent beginning on the
date following the day on which the claim should have been paid or was underpaid.
(e) Failure to pay a Clean Claim within thirty (30) days of receipt will result in the Payor paying
Provider a penalty equal to one (1) percent of the total amount of the claim per day beginning on the date following
the day on which the claim should have been paid or was underpaid.
(f) The Payor shall pay the interest and penalty from subsections (e) and (f) as provided in that
subsection, and shall not require Provider to requests the interest or the penalty.
10.3 Government Funds. Participating Provider and WellCare acknowledge that funds used for provider
payments are government funds. (Section VII, G (1)(s)).
11. Data to Provider. WellCare will provide certain data and information to the Provider, and changes to such
information, which may include performance feedback report if compensation is related to efficiency criteria,
information on benefit exclusions, administrative and utilization management requirements; credential verification
programs; quality assessment programs; and provider sanction policies (Section VII, G(1)(n)).
12. Provider Directory. Participating Provider authorizes WellCare and/or Payor to include, and WellCare and/or
Payor shall include, the name of Participating Provider and/or Participating Provider’s group in the provider directory
distributed to Covered Persons. (Section VII, G (1)(p)).
13. Assignment. Participating Provider shall not assign, delegate, or transfer any of its duties and/or
responsibilities under the Agreement without prior written consent of WellCare. WellCare shall notify Provider in
writing of any duties or obligations that are to be delegated or transferred, before the delegation or transfer. (Section
VII, G (1)(r)).
14. Providers of Perinatal Care. To the extent that Participating Provider offers prenatal, perinatal, and
postpartum services or is an obstetrician, Participating Provider shall comply with NC DHHS’s Pregnancy
Management Program. The Pregnancy Management Program is a set of mandatory standards and clinical initiatives
aimed at improving the quality of pregnancy care, improving maternal and infant outcomes and reducing health care
costs among participating providers. Participating Provider shall: (a) complete the standardized risk-screening tool
at each initial visit; (b) allow WellCare or WellCare’s designated vendor access to medical records for auditing
purposes to measure performance on specific quality indicators; (c) commit to maintaining or lowering the rate of
elective deliveries prior to thirty-nine (39) weeks gestation; (d) commit to decreasing the cesarean section rate among
nulliparous women; (e) offer and provide 17 alpha-hydroxyprogesterone caproate (17p) for the prevention of preterm
birth to women with a history of spontaneous preterm birth who are currently pregnant with a singleton gestation; (f)
complete a high-risk screening on each pregnant Medicaid Managed Care Covered Person in the program and
integrate the plan of care with local pregnancy care management; (g) decrease the primary cesarean delivery rate if
the rate is over NC DHHS’s designated cesarean rate (NC DHHS will set the rate annually at or below 20%); and (h)
ensure comprehensive post-partum visits occur within fifty-six (56) days of delivery (Section VII, G(1)(u)) and M(3)).
14.1 High-Risk Pregnancies Information Requirement. Participating Provider shall send all screening
information and applicable medical record information for Covered Persons in the Care Management of High-Risk
Pregnancies to WellCare and the Local Health Departments or other applicable local care management entities that
are contracted for the provision of providing care management services for high risk pregnancy within one business
day of the provider completing the screening (Section VII, M(3.3.i.)).
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15. Advanced Medical Homes. To the extent Participating Provider is an Advanced Medical Home (AMH),
Participating Provider shall comply with NC DHHS’ Advanced Medical Home Program, including the requirements
set forth below. (Section VII, G(1)(v)).
15.1 Identified as PCP. Participating Provider shall accept Covered Persons and be listed as a PCP in
WellCare’s Covered Person-facing materials for the purpose of providing care to Covered Persons and managing
their health care needs.
15.2 Care Coordination Services. Participating Provider shall provide primary care and patient care
coordination services to each Covered Person, in accordance with WellCare policies. (Section VII, G(1)(v)(i))
15.3 Primary Care Coverage. Participating Provider shall provide or arrange for primary care coverage
for services, consultation or referral, and treatment for emergency medical conditions, twenty -four (24) hours per
day, seven (7) days per week. Automatic referral to the hospital emergency department for services does not satisfy
this requirement.
15.4 Minimum Office Hours. Participating Provider shall provide direct patient care a minimum of 30
office hours per week.
15.5 Preventive Services. Participating Provider shall provide preventive services, in accordance with
Section VII. Attachment M. Table 1: Required Preventive Services of the State Contract as set forth on Attachment
A: Medicaid, Appendix A to Schedule A, Governmental Program Requirements to the Agreement.
15.6 Unified Medical Record. Participating Provider shall maintain a unified patient medical record for
each Covered Person following the WellCare’s medical record documentation guidelines.
15.7 Referrals. Participating Provider shall promptly arrange referrals for Medically Necessary health
care services that are not provided directly and document referrals for specialty care in the medical record.
15.8 Medical Record Transfer. Participating Provider shall transfer the Covered Person medical record
to the receiving provider upon the change of PCP at the request of the new PCP or WellCare (if applicable) and as
authorized by the Covered Person within thirty (30) days of the date of the request, free of charge.
15.9 Appointments. Participating Provider shall authorize care for the Covered Person or provide care
for the Covered Person based on the standards of appointment availability as defined by the WellCare’s network
adequacy standards.
15.10 Second Opinion. Participating Provider shall refer for a second opinion as requested by the Covered
Person, based on NC DHHS guidelines and WellCare standards.
15.11 Utilization Management.
15.11.1. Participating Provider shall review and use Covered Person utilization and cost reports
provided by WellCare for the purpose of AMH level utilization mana gement and advise WellCare of errors,
omissions, or discrepancies if they are discovered.
15.11.2. Prepaid Health Plans utilizes only North Carolina Medicaid’s Clinical Coverage Policies for
utilization management/clinical guidelines and other Department-approved utilization management/clinical
guidelines.
15.12 Enrollment Report. Participating Provider shall review and use the monthly enrollment report
provided by WellCare for the purpose of participating in WellCare or practice-based population health or care
management activities. (Section VII, M(2))
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15.13 Advanced Medical Home Tier 3 Standard Terms and Conditions. If Provider or a Contracted
Provider is a Tier 3 Advanced Medical Home (“AMH”) Participating Provider, the Agreement must include
provisions that outline the AMH Tier 3 care management model and requirements consistent with the State Contract
as set forth below. (Section VII, M(2 - 4 (a-e))
(a) (The AMH has primary responsibility for care management, and when the Prepaid Health
Plan (“PHP”) and AMH offer the same or similar disease management programs, the PHP will defer to the AMH
program when the member’s AMH is contracted as an Tier 3 AMH (“AMH3” or “AMH Level 3”) except where the
AMH is not performing to the operational or quality levels contractually required; and
(b) The PHP’s disease management and care coordination program shall coordinate and work
with the member’s Advanced Medical Home’s care coordination when the member’s AMH is contracted as a Tier 3
AMH.
Unless otherwise specified, any required element may be performed either by the Tier 3 AMH practice itself
or by a clinically-integrated network (“CIN”) with which the practice has a contractual agreement that contains
equivalent contract requirements. The WellCare shall maintain a contractual relationship with the AMH (not the
CIN).
15.13.1. Tier 3 AMH practices must be able to risk stratify all empaneled patients.
(a) The Tier 3 AMH practice must ensure that assignment lists transmitted to the practice by the
WellCare are reconciled with the practice's panel list and up to date in the clinical system of record.
(b) The Tier 3 AMH practice must use a consistent method to assign and adjust risk status for
each assigned patient.
(c) The Tier 3 AMH practice must use a consistent method to combine risk scoring information
received from the WellCare with clinical information to score and stratify the patient panel.
(d) The Tier 3 AMH practice must, to the greatest extent possible, ensure that the method is
consistent with the Contract of identifying "priority populations" for care management.
(e) The Tier 3 AMH practice must ensure that the whole care team understands the basis of the
practice's risk scoring methodology (even if this involves only clinician judgment at the practice-level) and that the
methodology is applied consistently.
(f) The Tier 3 AMH practice must define the process and frequency of risk score review and
validation.
15.13.2. Tier 3 AMH practices must be able to define the process and frequency of risk score review and
validation.
(a) The Tier 3 AMH practice must use its risk stratification method to identify patients who may
benefit from care management.
(b) The Tier 3 AMH practice must perform a Comprehensive Assessment (as defined below) on
each patient identified as a priority for care management to determine care needs. The Comprehensive Assessment
can be performed as part of a clinician visit, or separately by a team led by a clinician with a minimum credential of
RN or LCSW. The Comprehensive Assessment must include at a minimum:
i) Patients immediate care needs and current services;
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ii) Other state or local services currently used;
iii) Physical health conditions, including dental;
iv) Current and past behavioral and mental health and substance use status and/or
disorders;
v) Physical, intellectual developmental disabilities;
vi) Medications — prescribed and taken;
vii) Priority domains of social determinants of health (housing, food, transportation; and
interpersonal safety);
viii) Available informal, caregiver, or social supports, including peer supports.
(c) The Tier 3 AMH practice must have North Carolina licensed, trained staff organized at the
practice level (or at the CIN level but assigned to specific practices) whose job responsibilities encompass care
management and who work closely with clinicians in a team-based approach to care for high-need patients.
(d) For each high-need patient, the Tier 3 AMH practice must assign a care manager who is
accountable for active, ongoing care management that goes beyond office-based clinical diagnosis and treatment and
who has the minimum credentials of RN or LCSW.
15.13.3. Tier 3 AMH practices must use a documented Care Plan for each high-need patient receiving care
management.
(a) The Tier 3 AMH practice must develop the Care Plan within thirty (30) days of
Comprehensive Assessment, or sooner if feasible, while ensuring that needed treatment is not delayed by the
development of the Care Plan.
(b) The Tier 3 AMH practice must develop the Care Plan so that it is individualized and person-
centered, using a collaborative approach including patient and family participation where possible.
(c) The Tier 3 AMH practice must incorporate findings from the WellCare Care Needs
Screening/risk scoring, practice-based risk stratification and Comprehensive Assessment with clinical knowledge of
the patient into the Care Plan.
(d) The Tier 3 AMH practice must include, at a minimum, the following elements in the Care
Plan:
i) Measurable patient (or patient and caregiver) goals;
ii) Medical needs including any behavioral health and dental needs;
iii) Interventions, including medication management and adherence;
iv) Intended outcomes; and
v) Social, educational, and other services needed by the patient.
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(e) The Tier 3 AMH practice must have a process to update each Care Plan as Member needs
change and/or to address gaps in care; including, at a minimum, review and revision upon re-assessment.
(f) The Tier 3 AMH practice must have a process to document and store each Care Plan in the
clinical system of record.
(g) The Tier 3 AMH practice must periodically evaluate the care management services provided
to high-risk, high-need patients by the practice to ensure that services are meeting the needs of empaneled patients,
and refine the care management services as necessary.
(h) The Tier 3 AMH practice must track empaneled patients' utilization in other venues covering
all or nearly all hospitals and related facilities in their catchment area, including local emergency departments (EDs)
and hospitals, through active access to an admissions, discharge, and transfer (ADT) data feed that correctly identifies
when empaneled patients are admitted, discharged, or transferred to/from an emergency department or hospital in
real time or near real time.
(i) The Tier 3 AMH practice or CIN must implement a systematic, clinically appropriate car e
management process for responding to certain high-risk ADT alerts (indicated below).
i) Real time (minutes/hours) response to outreach from EDs relating to patient care or
admission/discharge decisions, for example arranging rapid follow up after an ED visit to avoid an admission.
ii) Same-day or next-day outreach for designated high-risk subsets of the population to
inform clinical care, such as beneficiaries with special health care needs admitted to the hospital; and
iii) Within a several-day period to address outpatient needs or prevent future problems
for high risk patients who have been discharged from a hospital or ED (e.g., to assist with scheduling appropriate
follow-up visits or medication reconciliations post discharge)
15.13.4. Tier 3 AMHs must be able to provide short-term, transitional care management along with
medication reconciliation to all empaneled patients who have an emergency department (ED) visit or hospital
admission / discharge / transfer and who are at risk of readmissions and other poor outcomes.
(a) The Tier 3 AMH practice must have a methodology or system for identifying patients in
transition who are at risk of readmissions and other poor outcomes that considers all of the following:
i) Frequency, duration and acuity of inpatient, SNF and LTSS admissions or ED visits;
ii) Discharges from inpatient behavioral health services, facility-based crisis services,
non-hospital medical detoxification, medically supervised or alcohol drug abuse treatment center;
iii) NICU discharges; and
iv) Clinical complexity, severity of condition, medications, risk score.
(b) For each patient in transition identified as high risk for admission or other poor outcome with
transitional care needs, the Tier 3 AMH practice must assign a care manager who is accountable for transitional care
management that goes beyond office-based clinical diagnosis and treatment and who has the minimum credentials of
RN or LCSW.
(c) The Tier 3 AMH practice must include the following elements in transitional care
management:
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i) Ensuring that a care manager is assigned to manage the transition
ii) Facilitating clinical handoffs;
iii) Obtaining a copy of the discharge plan/summary;
iv) Conducting medication reconciliation;
v) Following-up by the assigned care manager rapidly following discharge;
vi) Ensuring that a follow-up outpatient, home visit or face to face encounter occurs;
and
vii) Developing a protocol for determining the appropriate timing and format of such
outreach.
15.13.5. Tier 3 AMH practices must use electronic data to promote care management.
(a) The Tier 3 AMH practice must receive claims data feeds (directly or via a CIN) and meet
state-designated security standards for their storage and use.
16. Care Management for High-Risk Pregnancy. To the extent Participating Provider is a Local Health
Department (“LHD”) offering care management for high-risk pregnancy, this Section applies. Care Management for
High-Risk Pregnancy refers to care management services provided to a subset of high -risk pregnant women by LHDs
(Section VII, M(4)).
16.1 General Contracting Requirement. Participating Provider shall accept referrals from WellCare for
Care Management for High-Risk Pregnancy Services. Participating Provider shall comply with the requirements NC
DHHS’ Care Management for High-Risk Pregnancy Policy.
16.2 Care Management for High-Risk Pregnancy: Outreach. Participating Provider shall refer potentially
Medicaid-eligible pregnant women for prenatal care and Medicaid eligibility determination, including promoting the
use of presumptive eligibility determination and other strategies to facilitate early access to Medicaid coverage during
pregnancy. Participating Provider shall contact patients identified as having a priority risk factor through claims data
(Emergency Department utilization, antepartum hospitalization, utilization of Labor & Delivery triage unit) for
referral to prenatal care and to engage in care management.
16.3 Care Management for High-Risk Pregnancy: Population Identification and Engagement.
Participating Provider shall review and enter all pregnancy risk screenings received from Pregnancy Ma nagement
Program providers covered by the pregnancy care managers into the designated care management documentation
system within five (5) calendar days of receipt of risk screening forms. Participating Provider shall utilize risk
screening data, patient self-report information and provider referrals to develop strategies to meet the needs of those
patients at highest risk for poor pregnancy outcome. Participating Provider shall accept pregnancy care management
referrals from non-Pregnancy Management Program prenatal care providers, community referral sources (such as
Department of Social Services or WIC programs), patient self-referral, and provide appropriate assessment and follow
up to those patients based on the level of need. Participating Provider shall review available WellCare data reports
identifying additional pregnancy risk status data, including regular, routine use of the Obstetric Admission, Discharge
and Transfer (OB ADT) report, to the extent the OB ADT report remains available to Participa ting Provider.
Participating Provider shall collaborate with out-of-county Pregnancy Management Program providers and Care
Management for High-Risk Pregnancy teams to facilitate cross-county partnerships to ensure coordination of care
and appropriate care management assessment and services for all patients in the target population.
16.4 Care Management for High-Risk Pregnancy: Assessment and Risk Stratification. Participating
Provider shall conduct a prompt, thorough assessment by review of claims history and medical record, patient
interview, case review with prenatal care provider and other methods, on all patients with one or more priority risk
factors on pregnancy risk screenings and all patients directly referred for care management for level of need for care
management support. Participating Provider shall utilize assessment findings, including those conducted by
WellCare to determine level of need for care management support. Participating Provider shall document assessment
findings in the care management documentation system. Participating Provider shall ensure that assessment
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documentation is current throughout the period of time the care manager is working with the patient and should be
continually updated as new information is obtained. Participating Provider shall assign case status based on level of
patient need.
16.5 Care Management for High-Risk Pregnancy: Interventions. Participating Provider shall provide care
management services in accordance with program guidelines, including condition-specific pathways, utilizing those
interventions that are most effective in engaging patients and meeting their needs. This includes face -to-face
encounters (practice visits, home visits, hospital visits, community encounters), telephone outreach, professional
encounters and /or other interventions needed to achieve care plan goals. Participating Provider shall provide care
management services based upon level of patient need as determined through ongoing assessment. Participating
Provider shall develop patient-centered care plans, including appropriate goals, interventions and tasks. Participating
Provider shall utilize NC Resource Platform and identify additional community resources once NC DHHS has
certified it as fully functional. Participating Provider shall refer identified population to childbirth education, oral
health, behavioral health or other needed services included in the Covered Person’s WellCare network. Participating
Provider shall document all care management activity in the care management documentation system.
16.6 Care Management for High-Risk Pregnancy: Integration with WellCare and Providers. Participating
Provider shall assign a specific care manager to cover each Pregnancy Management Program provider within the
county or serving residents of the county. Participating Provider shall ensure that an embedded or otherwise
designated care manager has an assigned schedule indicating their presence within the Pregnancy Management
Program. Participating Provider shall establish a cooperative working relationship and mutually -agreeable methods
of patient-specific and other ongoing communication with the Pregnancy Management Program providers.
Participating Provider shall establish and maintain effective communication strategies with Pregnancy Management
Program providers and other key contacts within the practice within the county or serving residents of the county.
Participating Provider shall assure the assigned care manager participates in relevant Pregnancy Management
Program meetings addressing care of patients in the target population. Participating Provider shall ensure awareness
of WellCare Covered Persons’ “in network” status with providers when organizing referrals. Participating Provider
shall ensure understanding of WellCare’s prior authorization processes relevant to referrals.
16.7 Care Management for High-Risk Pregnancy: Collaboration with WellCare. Participating Provider
shall work with WellCare to ensure program goals are met. Participating Provider shall review and monitor WellCare
reports created for the Pregnancy Management Program and Care Management for High Risk Pregnancy services to
identify individuals at greatest risk. Participating Provider shall communicate with WellCare regarding challenges
with cooperation and collaboration with Pregnancy Management Program and non-Pregnancy Management Program
prenatal care providers. Participating Provider shall participate in pregnan cy care management and other relevant
meetings hosted by WellCare.
16.8 Care Management for High-Risk Pregnancy: Training. Participating Provider shall ensure that
pregnancy care managers and their supervisors attend pregnancy care management training offered by WellCare
and/or NC DHHS, including webinars, new hire orientation or other programmatic training. Participating Provider
shall ensure that pregnancy care managers and their supervisors attend continuing education sessions coordinated by
WellCare and/or NC DHHS. Participating Provider shall ensure that pregnancy care managers and their supervisors
pursue ongoing continuing education opportunities to stay current in evidence-based care management of pregnancy
and postpartum women at risk for poor birth outcomes. Participating Provider shall ensure that pregnancy care
managers and their supervisors utilize Motivational Interviewing and Trauma Informed Care techniques on an
ongoing basis.
16.9 Care Management for High-Risk Pregnancy: Staffing.
(a) Participating Provider shall employ care managers meeting pregnancy care management
competencies defined as having at least one of the following qualifications: registered nurse; or social worker with a
bachelor’s degree in social work (BSW, BA in SW, or BS in SW) or master’s degree in social work (MSW, MA in
SW, or MS in SW) from a Council on Social Work Education accredited social work degree program. Care Managers
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for High- Risk Pregnancy hired prior to September 1, 2011 without a bachelor’s or master’s degree in s ocial work
may retain their existing position; however, this grandfathered status does not transfer to any other position.
Participating Provider shall ensure that Community Health workers for Care Manager for High -Risk Pregnancy
services work under the supervision and direction of a trained care manager. Participating Provider shall include
both registered nurses and social workers in order to best meet the needs of the Target Population with medical and
psychosocial risk factors on their team. If the Participating Provider only has a single Care Manager for High-Risk
Pregnancy, the Participating Provider shall ensure access to individual(s) to provide needed resources, consultation
and guidance from the non-represented professional discipline. Participating Provider shall engage care managers
who operate with a high level of professionalism and possess an appropriate mix of skills needed to work effectively
with a pregnant population at high risk for poor birth outcome. This skill mix should reflect th e capacity to address
the needs of patients with both medically and socially complex conditions. Participating Provider shall establish
staffing arrangements to ensure continuous service delivery through appropriate management of staff vacancies and
extended absences, including following WellCare /NC DHHS guidance about communication with WellCare about
any vacancies or extended staff absences and adhering to guidance about contingency planning to prevent
interruptions in service delivery. Vacancies lasting longer than sixty (60) days shall be subject to additional oversight
by WellCare.
(b) Participating Provider shall ensure that Pregnancy Care Managers must demonstrate: (i) a
high level of professionalism and possess appropriate skills needed to work effectively with a pregnant population at
high risk for poor birth outcomes; (ii) proficiency with the technologies required to perform care management
functions; (iii) motivational interviewing skills and knowledge of adult teaching and learning principles; (iv) ability
to effectively communicate with families and providers; and (v) critical thinking skills, clinical judgment and
problem-solving abilities.
(c) Participating Provider shall provide qualified supervision and support for pregnancy care
managers to ensure that all activities are designed to meet performance measures, with supervision to include: (i)
provision of program updates to care managers; (ii) daily availability for case consultation and caseload oversight;
(iii) regular meetings with direct service care management staff; (iv) utilization of reports to actively assess individual
care manager performance; and (v) compliance with all supervisory expectations delineated in the Care Management
for High-Risk Pregnancy Program Manual.
17. Care Management for At-Risk Children. To the extent Participating Provider is a LHD offering care
management for at-risk children, this Section applies. Care Management for At-Risk Children is care management
services provided by to a subset of the Medicaid population ages 0-5 identified as being “high-risk” (Section VII,
M(5)).
17.1 Care Management for At-Risk Children: General Requirements. Participating Provider shall accept
referrals from WellCare for children identified as requiring Care Management for At-Risk Children. Participating
Providers shall comply with the requirements of NC DHHS’ Care Management for At-Risk Children Policy.
17.2 Care Management for At-Risk Children: Outreach. Participating Provider shall educate patients,
Advanced Medical Homes, other practices and community organizations about the benefits of the Care Management
for At-Risk Children Program and target populations for referral; disseminate the Care Management for At-Risk
Children Referral Form either electronically and/or in a paper version to potential referral sources. Participating
Provider shall communicate regularly with the Advanced Medical Homes and other practice serving children, to
ensure that children served by that medical home are appropriately identified for Care Management for At -Risk
Children services. Participating Provider shall collaborate with out -of-county Advanced Medical Homes and other
practices to facilitate cross-county partnerships to optimize care for patients who receive services from outside their
resident county. Participating Provider shall identify or develop if necessary, a list of community resources available
to meet the specific needs of the population. Participating Pro vider shall utilize the NC Resource Platform, when
operational, and identify additional community resources and other supportive services once the platform has been
fully certified by NC DHHS.
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17.3 Care Management for At-Risk Children: Population Identification. Participating Provider shall use
any claims-based reports and other information provided by WellCare, as well as Care Management for At-Risk
Children Referral Forms received to identify priority populations. Participating Provider shall establish and maintain
contact with referral sources to assist in methods of identification and referral for the target population. Participating
Provider shall communicate with the medical home and other primary care clinician about the Care Management for
At-Risk Children target group and how to refer to the Care Management for At-Risk Children program.
17.4 Care Management for At-Risk Children: Family Engagement. Participating Provider shall involve
families (or legal guardian when appropriate) in the decision-making process through a patient-centered, collaborative
partnership approach to assist with improved self-care. Participating Provider shall foster self-management skill
building when working with families of children. Participating Provider shall prioritize face-to-face family
interactions (home visit, PCP office visit, hospital visit, community visit, etc.) over telephone interactions for children
in active case status, when possible.
17.5 Care Management for At-Risk Children: Assessment and Stratification of Care Management Service
Level. Participating Provider shall use the information gathered during the assessment process to determine whether
the child meets the Care Management for At-Risk Children target population description. Participating Provider shall
review and monitor WellCare reports created for Care Management for At-Risk Children, along with the information
obtained from the family, to assure the child is appropriately linked to preventive and primary care services and to
identify individuals at risk. Participating Provider shall use the information gained from the assessment to determine
the need for and the level of service to be provided.
17.6 Care Management for At-Risk Children: Plan of Care. Participating Provider shall provide
information and/or education to meet families’ needs and encourage self-management using materials that meet
literacy standards. Participating Provider shall ensure children/families are well -linked to the child’s Advanced
Medical Home or other practice; provide education about the importance of the medical home. Participating Provider
shall provide care management services in accordance with program guidelines, including condition -specific
pathways, utilizing those interventions that are most effective in engaging patients, meeting their needs and achieving
care plan goals. Participating Provider shall identify and coordinate care with community agencies/resources to meet
the specific needs of the child; use any locally-developed resource list (including NC Resource Platform) to ensure
families are well linked to resources to meet the identified need. Participating Provider shall provide care
management services based upon the patient’s level of need as determined through ongoing assessment.
17.7 Care Management for At-Risk Children: Integration with WellCare and Providers. Participating
Provider shall collaborate with Advanced Medical Home/PCP/care team to facilitate implementation of patient -
centered plans and goals targeted to meet individual child’s needs. Participating Provider shall ensure that changes
in the care management level of care, need for patient support and follow up and other relevant updates (especially
during periods of transition) are communicated to the Advanced Medical Home PCP and/or care team. Wh ere care
management is being provided by WellCare and/or Advanced Medical Home practice in addition to the Care
Management for At-Risk program, the WellCare/AMH practice must explicitly agree on the delineation of
responsibility and document that agreement in the child’s Plan of Care to avoid duplication of services Participating
Provider shall ensure that changes in the care management level of care, need for patient support and follow up and
other relevant updates (especially during periods of transition) are communicated to the Advanced Medical home
PCP and/or care team and to WellCare. Participating Provider shall ensure awareness of WellCare Covered Person’s
“in network” status with providers when organizing referrals. Participating Provider shall en sure understanding of
WellCare’s prior authorization processes relevant to referrals.
17.8 Care Management for At-Risk Children: Service Provision. Participating Provider shall document
all care management activities in the care management documentation syst em in a timely manner. Participating
Provider shall ensure that the services provided by Care Management for At -Risk Children meet a specific need of
the family and work collaboratively with the family and other service providers to ensure the services ar e provided
as a coordinated effort that does not duplicate services.
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17.9 Care Management for At-Risk Children: Training. Participating Provider shall participate in NC
DHHS/ WellCare-sponsored webinars, trainings and continuing education opportunities as provided. Participating
Provider shall pursue ongoing continuing education opportunities to stay current in evidence-based care management
of high risk children.
17.10 Care Management for At-Risk Children: Staffing.
(a) Participating Provider shall hire care managers meeting Care Management for At-Risk
Children care coordination competencies and with at least one of the following qualifications: registered nurse; or
social worker with a bachelor’s degree in social work (BSW, BA in SW, or BS in SW) or master’s degre e in social
work (MSW, MA in SW, or MS in SW) from a Council on Social Work Education accredited social work degree
program. Non-degreed social workers cannot be the lead care manager providing Care Management for At -Risk
Children even if they qualify as a Social Worker under the Office of State Personnel guidelines. Participating
Provider shall engage care managers who operate with a high level of professionalism and possess an appropriate
mix of skills needed to work effectively with high-risk children. This skill mix must reflect the capacity to address
the needs of patients with both medically and socially complex conditions. Participating Provider shall ensure that
the team of Care Management for At-Risk Children care managers shall include both registered nurses and social
workers to best meet the needs of the target population with medical and psychosocial risk factors. If the Participating
Provider has only has a single Care Management for At-Risk Children care manager, the Participating Provider shall
ensure access to individual(s) to provide needed resources, consultation and guidance from the non -represented
professional discipline. Participating Provider shall maintain services during the event of an extended vacancy. In
the event of an extended vacancy, Participating Provider shall complete and submit the vacancy contingency plan
that describes how an extended staffing vacancy will be covered and the plan for hiring if applicable. Participating
Provider shall establish staffing arrangements to ensure continuous service delivery through appropriate management
of staff vacancies and extended absences, including following NC DHHS guidance regarding vacancies or extended
staff absences and adhering to NC DHHS guidance about contingency planning t o prevent interruptions in service
delivery. Vacancies lasting longer than sixty (60) days will be subject to additional oversight. Participating Provider
shall ensure that supervisors who carry a caseload must also meet the Care Management for At -Risk Children care
management competencies and staffing qualifications. Participating Provider shall ensure that Community Health
Workers and other unlicensed staff work under the supervision and direction of a trained Care Management for At -
Risk Children Care Manager.
(b) Participating Provider shall ensure that Care Management for At -Risk Children Care
Managers must demonstrate: (i) proficiency with the technologies required to perform care management functions –
particularly as pertains to claims data review and care management documentation system; (ii) ability to effectively
communicate with families and providers; (iii) critical thinking skills, clinical judgment and problem -solving
abilities; and (iv) motivational interviewing skills, Trauma Informed Care, and knowledge of adult teaching and
learning principles.
(c) Participating Provider shall provide qualified supervision and support for Care Management
for At-Risk Children care managers to ensure that all activities are designed to meet performance measures , with
supervision to include: (i) provision of program updates to care managers; (ii) daily availability for case consultation
and caseload oversight; (iii) regular meetings with direct service care management staff; and (iv) utilization of
monthly and on-demand reports to actively assess individual care manager performance.
18. N.C. Gen. Stat. Ch. 58 Requirements.
18.1 N.C. Gen. Stat. § 58-3-200(c), Coverage Determinations. If WellCare or Payor determines that
services, supplies or other items are Covered Services, WellCare or Payor shall not subsequently retract its
determination after such services have been provided, or reduce payments for such services furnished in reliance on
such a determination, unless the determination was based on a material misrepresentation about the Covered Person’s
health condition that was knowingly made by the Covered Person or the provider of the service, supply or other item.
(Section VII, G (1)(x)(i)).
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18.2 N.C. Gen. Stat. § 58-3-227(h), Contract Negotiations. When offering a contract to a Health Care
Provider, WellCare or Payor shall make available to Health Care Provider its schedule of fees associated with the top
30 services or procedures most commonly billed by the class of Provider. Upon the request of the Health Care
Provider, WellCare or Payor shall also make available the full schedule of fees for services or procedures billed by
that class of provider(s). If Health Care Provider requests fees for more than 30 services and procedures, WellCare
or Payor may require the Health Care Provider to specify the additional requested services and procedures and may
limit the Health Care Provider’s access to the additional schedule of fees to those associated with services and
procedures performed by or reasonably expected to be performed by such Health Care Provider. (Section VII,
G(1)(x)(ii)).
18.3 N.C. Gen. Stat. § 58-50-275(a)-(b), Notice Contact. Provider and WellCare have set forth in the
Agreement a “notice contact” provision listing the name or title and address of the person to whom all
correspondence, including proposed Amendments and other notices, pertaining to the contractual relationship
between the Parties shall be sent. Notwithstanding anything in the Agreement to the contrary, means for sending all
notices provided under the Agreement is one or more of the following, calculated as (i) five business days following
the date the notice is placed, first-class postage prepaid, in the United States mail; (ii) on the day the notice is hand
delivered; (iii) for certified or registered mail, the date on the return receipt; or (iv) for commercial courier service,
the date of delivery. Nothing in this section prohibits the use of an electronic medium for a communication other
than an Amendment if agreed to by WellCare and Provider (Section VII, G(1)(x)(iv)).
18.4 N.C. Gen. Stat. § 58-50-280(a)-(d), Proposed Amendment. WellCare shall date, label
“Amendment,” sign, include an effective date, and send any proposed Amendment to this Agreement or this
Attachment to the notice contact of Provider. Provider will have sixty (60) days from the date of receipt to object to
the proposed Amendment in writing. If Provider fails to object in writing within such sixty (60) days, the Amendment
will be effective. If Provider timely objects to a proposed Amendment in writing, then WellCare may terminate the
Agreement or this Attachment upon sixty (60) days’ written notice to Provider. (Section VII, G(1)(x)(v)).
18.5 N.C. Gen. Stat. § 58-50-285 (a)-(b), Policies and Procedures. WellCare or Payor shall provide a
Health Care Provider with a copy of its policies and procedures prior to execution of a new or amended contract and
annually to all Participating Providers. Such policies and procedures may be provided in hard copy, CD or other
electronic format, and may also be provided by posting the policies and procedures on the WellCare or Payor website.
Such policies and procedures will not conflict with or override any term of a contract, including contract fee
schedules. In the event of a conflict between a policy or procedure and the language in a contract, the contract
language shall prevail. (Section VII, G(1)(x)(vi)).
18.6 N.C. Gen. Stat. § 58-51-37(d)-(e), Pharmacy Participation. To the extent Participating Provider is a
pharmacy or pharmacist, this Section applies. Participating Provider shall not waive, discount, rebate, or distort a
copayment or a Covered Person’s portion of a prescription drug coverage or reimbursement. If Participating Provider
provides a pharmacy service to a Covered Person that meets the terms and requirements of the Coverage Agreement,
Participating Provider shall provide its pharmacy services to all Covered Persons covered by that Coverage
Agreement on the same terms and requirements. A violation of the foregoing is a violation of the Pharmacy Practice
Act subjecting the pharmacist to disciplinary authority of the North Carolina Board of Pharmacy. At least sixty (60)
days before the effective date of a Payor providing reimbursement to North Carolina residents for prescription drugs,
which restricts pharmacy participation, WellCare or Payor shall notify, in writing, all pharmacies within the
geographical coverage area of the Coverage Agreement and offer to the pharmacies the opportunity to participate
under identical reimbursement terms for providing pharmacy services, including prescription drugs. WellCare shall,
through reasonable means, on a timely basis, and on regular intervals in order to effectuate the purposes of this
section, inform the Covered Persons of the Coverage Agreement of the names and locations of pharmacies that are
participating in the plan as providers of pharmacy services and prescription drugs. Additionally, participating
pharmacies shall be entitled to announce their participation to their customers through a means acceptable to the
pharmacy and WellCare. The pharmacy notification provisions of this section do not apply when an individual or
group is enrolled, but when WellCare enters a particular county of the State. (Section VII, G(1)(x)(vii)).
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19. Indian Health Care Providers. To the extent Participating Provider is an Indian Health Care Provider,
Participating Provider shall execute and comply with the Medicaid Managed Care Addendum for Indian Health Care
Providers. (Section VII, H).
20. Conflict of Interest. Participating Provider will comply with all applicable federal and state conflict of
interest laws, including Section 1902(a)(4)(C) of the Social Security Act, 42 C.F.R. § 438.58, and N.C. Gen. Stat. §§
108A-65 and 143B-139.6C. Participating Provider agrees that financial considerations will not influence decisions
to provide medically appropriate care. Participating Provider shall abide by his or her professional obligations to
patients and Covered Persons and will not take any actions that conflict with such obligations. (Section V, A.9.i)
21. Vaccines for Children Program. If Participating Provider is a Primary Care Provider who services Covered
Persons under age 19, Participating Provider is encouraged to participate in the Vaccines for Children Progr am. If
Participating Provider is a Primary Care Provider, Participating Provider will administer vaccines consistent with the
AAP/Bright Future periodicity schedule. (Section V, C(1)(c)(ix) and Section V, C(2)(v)(vii)).
22. PCPs. If Participating Provider is a Primary Care Provider, Participating Provider will: (a) perform, during
preventive service visits, and as necessary at any visit, oral health assessments, evaluations, prophylaxis and oral
hygiene counseling for children under twenty-one (21) years of age in accordance with the NC DHHS’s Oral Health
Periodicity Schedule; (b) refer infant Medicaid Covered Persons to a dentist or a dental professional working under
the supervision of a dentist at age one (1), per the requirements of the NC DHHS’s Oral Health Periodicity Schedule;
and (c) include all of the following components in each medical screening: (i) routine physical examinations as
recommended and updated by the American Academy of Pediatrics (AAP) “Guidelines for Health Supervision III”
and described in “Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents”, screening
for developmental delay at each visit through the 5th year and screening for Autistic Spectrum Disorders per AAP
guidelines, (ii) comprehensive, unclothed physical examination, (iii) all appropriate immunizations, in accordance
with the schedule for pediatric vaccines established by the Advisory Committee on Immunization Practices, (iv)
laboratory testing (including blood lead screening appropriate for age and risk factors); and (e) health education and
anticipatory guidance for both the child and caregiver. (Section V, C.2.i).
23. Behavioral Health Providers. If Participating Provider is a behavioral health provider, Participating Provider
will coordinate with Primary Care Providers and specialists conducting EPSDT screenings. (Section V, C.2.j).
24. 340B Covered Entities. If Participating Provider is a 340B covered entity, the Participating Provider will:
(a) submit National Council for Prescription Drug Programs (NCPDP) code “08” in Basis of Cost Determination
field 423-DN or in Compound Ingredient Basis of Cost Determi nation field 490-UE at the point of sale to identify
claims submitted for drugs purchased through the 340B program; (b) identify outpatient hospital and physician -
administered drug claims submitted for drugs purchased through the 340B program using a UD mo difier or other
claim modifiers defined by the NC DHHS (42 C.F.R. § 438.3(s)(3)); (c) comply with the point of sale identification
of drugs purchased through the 340B program (42 C.F.R. § 438.3(s)(3)); and (d) resubmit the claims with the
appropriate NCPDP 340B claims identification codes when 340B claims are retroactively identified (42 C.F.R. §
438.3(s)(3)). (Section V, C(3)(i)(v)).
25. Exclusion. Participating Provider represents and warrants that he, she or it is not excluded from participation
in federal health care programs under either section 1128 or 1128A of the Social Security Act. 42 C.F.R. § 438.610(b).
Participating Provider will immediately notify WellCare in writing upon any change regarding foregoing. (Section
V, D(2)(c)(iv)).
26. High Level Clinical Setting Discharge. Participating Provider will notify WellCare when a Covered Person
in a high level clinical setting is being discharged. For the purpose of this section, a High Level Clinical Setting
includes but is not limited to:
(a) Hospital/Inpatient acute care and long-term acute care
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(b) Nursing Facility
(c) Adult Care Home
(d) Inpatient behavioral health services
(e) Facility-based crisis services for children
(f) Facility-based crisis services for adults
(g) ADATC
(Section V, D(2)(c)(xiv)).
27. Claim Submission. Participating Provider will not submit claim or encounter data for services covered by
Medicaid managed care and WellCare directly to the NC DHHS. (Section V, D(2)(c)(xviii)).
28. Provider Preventable Conditions. Participating Provider will comply with 42 C.F.R. § 438.3(g), which, at a
minimun, means non-payment of provider-preventable conditions as well as appropriate reporting, as required by
WellCare. (Section V, D(2)(d)(ii)).
29. Program Integrity. Participating Provider: (a) will have compliance plans that meet the requirements of 42
C.F.R. § 438.608 and policies and procedures that meet the requirements of the Deficit Reduction Act of 2005; (b)
will have policies and procedures that recognize and accept Medicaid as “the payer of last resort”; and (c) is prohibited
from billing Covered Persons for Covered Services any amount greater than would be owed if the Participating
Provider provided the service directly as provided in 42 C.F.R. §§ 438.3(k) and 438.230(c)(1)-(2). (Section V,
D(2)(f); Section V, J(2)(b)(iii)(c)).
30. No Auto-Enrollment in Other Products. WellCare will not require individual practitioners, as a condition of
contracting with it, to agree to participate or accept other products offered by the WellCare nor will WellCare
automatically enroll the provider in any other product offered by it. This requirement does not apply to facility
providers. (Section V, D(2)(c) (viii))
31. Grievance and Appeals. WellCare shall handle appeals and grievances raised by Provider in connection with
the Medicaid Product promptly, consistently, fairly, and in compliance with state and federal law and Department
requirements, through an appeals and grievance system that is distin ct from that offered to Covered Persons. Such
appeals and grievance system, additional information about which is set forth in the Provider Manual, shall meet the
requirements set forth below:
(a) Grievances. WellCare will have a process in place to receive and resolve complaints or
disputes with Provider, in a timely manner, where remedial action is not requested. WellCare will accept and resolve
Provider’s grievances regarding WellCare that are referred from the Department. WellCare will make available to
Provider a method for submitting grievances through WellCare’s provider portal.
(b) Appeals. WellCare will offer Provider appeal rights as described in the State Contract and
Provider Manual. WellCare will provide written notice of Provider’s right to appeal along with any notice of a
decision giving rise to Provider’s right to appeal. WellCare will make available to Provider a method for submitting
appeals through WellCare’s provider portal. WellCare will accept a written request for an appeal from Provider
within thirty (30) calendar days of the date on which (i) Provider received written notice from WellCare of the
decision giving rise to the right to appeal; or (ii) WellCare should have taken a required action and failed to take such
actions. WellCare will acknowledge receipt of each appeal request within five (5) calendar days of receipt of the
request, and will extend such timeframe by thirty (30) calendar days if Provider’s request is for an appeal for good
cause shown, as determined by WellCare. WellCare will consider the voluminous nature of required
evidence/supporting documentation, and the appeal of an adverse quality decision, as good cause reasons to extend
such timeframe. Provider shall exhaust WellCare’s internal appeals process before seeking recourse under any other
process permitted by contract or law.
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(c) Resolution of Appeal. WellCare will establish a committee to review and make decisions
on Provider’s appeals, which committee will consist of at least three (3) qualified individuals who were not involved
in the original decision, action, or inaction giving rise to the right to appeal, as well as an external peer reviewer when
the issue on appeal involves whether the provider met the Objective Quality Standards. WellCare will provide written
notice of decision of the appeal (which notice shall include information regarding further appeal rights) within thirty
(30) calendar days of receiving a complete appeal request, or if an extension is granted to the provider to submit
additional evidence, the date on which all evidence is submitted to WellCare. Provider may be represented by an
attorney during the appeals process.
(d) Appeals of Suspension or Withhold of Provider Payment. In cases of the suspension or
withholding of Provider payments, WellCare will limit the issue on appeal to whether WellCare had good cause to
commence the withholding or suspension of payments to Provider; WellCare will not address whether Provider has
or has not committed fraud or abuse. WellCare will offer Provider an in-person or telephone hearing when Provider
is appealing whether WellCare has good cause to withhold or suspend payments to Provider. WellCare will schedule
such hearing and issue a written decision regarding whether WellCare had good cause to suspend or withhold
payments within fifteen (15) business days of receiving Provider’s appeal. Upon a finding that WellCare did not have
good cause to suspend or withhold payments, WellCare will reinstate any payments that were withheld or suspended
within five (5) business days. WellCare will pay interest and penalties for overturned denials, underpayments, or
findings that it did not have good cause to suspend or withhold payment from the original Date of Payment,
suspension, withhold or denial. (Attachment G-1.q)
32. Material Changes to Provider Manual, Reimbursement Policies or Clinical Policies. WellCare shall notify
Participating Provider of updates to WellCare’s clinical policies electronically no later than 30 calendar days prior to
the effective date of the policy, or at a date defined by the NC DHHS, directed to Participating Provider’s contact for
notices under this Agreement via WellCare’s provider portal. Participating Provider may request written notification,
at no additional cost, to be mailed no later than 30 days prior to the effective date of the policy, or at a date defined
by the NC DHHS, of the policy. WellCare shall not implement any material changes to the clinical policies without
express approval from the NC DHHS. (Section VII, Attachment G(3)(i))
33. Contract Amendments with Individual Providers. For the purposes of this Section 33 only, the following
terms shall have the following definitions:
(i) “Amendment” shall mean any change to the terms of this Medicaid Product Attachment, including
terms incorporated by reference, that modifies fee schedules. A change required by federal or State law, rule,
regulation, administrative hearing, or court order is not an Amendment.
(ii) “Contract” shall mean this Agreement, which is an agreement between WellCare and Provider for
the provision of health care services by the provider on a preferred or in-network basis.
(iii) “Health Benefit Plan” shall mean a policy, certificate, contract, or plan as defined in N.C. Gen. Stat.
§58-3-167.
(iv) “Health Care Provider” shall mean Provider if Provider is an individual who is licensed, certified,
or otherwise authorized under Chapter 90 or Chapter 90B of the General Statutes or under the laws of another state
to provide health care services in the ordinary course of business or practice of a profession or in an approved
education or training program and a facility that is licensed under Chapter 131E or Chapter 122C of the General
Statutes or is owned or operated by the State of North Carolina in which health care services are provided to patients.
(v) “Insurer” shall mean WellCare (as otherwise defined herein), which is an entity as defined in N.C.
Gen. Stat. §58-3-227(a)(4).
Insurer shall send any proposed Contract Amendment to the notice contact of Health Care Provider pursuant to N.C.
Gen. Stat. §58-50-275. The proposed Amendment shall be dated, labeled “Amendment,” signed by the Insurer, and
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include an effective date for the proposed Amendment. Health Care Provider receiving a proposed Amendment shall
be given at least sixty (60) days from the date of receipt to object to the proposed Amendment. The proposed
Amendment shall be effective upon Health Care Provider failing to object in writing within sixty (60) days. If Health
Care Provider objects to a proposed Amendment, then the proposed Amendment is not effective and the initiating
Insurer shall be entitled to terminate the Contract upon sixty (60) days written notice to Health Care Provider. Nothing
in this Part prohibits Health Care Provider and Insurer from negotiating Contr act terms that provide for mutual
consent to an Amendment, a process for reaching mutual consent, or alternative notice contacts. (Attachment G-
1.x.iii)
34. Exemption from Notification of Emergent or Observation Admissions. For all contracts with a hospital who
attests live in production status with North Carolina HealthConnex, the contract shall indicate the provider is
exempted from reporting any emergent or observation admissions to the PHP, and that the PHP shall utilize
NC*Notify for such admission information. Except the exemption from notification shall not apply when the hospital
has technical or data quality issues, in which case the hospital shall notify the PHP directly.
35. Incident Reporting Procedures and Peer Review Process. Providers rendering Covered Services to Members
or Covered Persons shall report critical incidents to Health Plan and to the Department in accordance with all
applicable Laws and Governmental Authority’s mandated requirements and procedures for reporting such incidents,
and Providers shall cooperate with Health Plan in its investigation of critical incidents. Notwithstanding the foregoing,
nothing in this Agreement shall require Providers who participate in Health Plan’s peer review, medical review, or
quality review committees to take any actions that are contrary to the confidentiality and liability protections afforded
such Providers under N.C. Gen. Stat. §§90-21.22A, 131E-76, or 131E-95, as applicable.
36. Patient Choice Counseling Limitations. Nothing in this Agreement shall be construed to limit the ability of
Provider to inform its patients of Provider or its Contracted Provider’s participation or non-participation in specific
Medicaid Managed Care health plans. Provider may also inform its patients of the categories of Medicaid participants
remaining in North Carolina Medicaid Direct.
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Attachment A: Medicaid
APPENDIX A TO
SCHEDULE A
GOVERNMENTAL PROGRAM REQUIREMENTS
Section VII Attachment M.2. Table 1: Required Preventive Services
Required for providers who serve the following age ranges (The age ranges are not displayed to the
provider on this screen. The age ranges will be used in PEGA workflow for approval and
verification purposes.)
Reference
Number
AMH Preventative
Health Requirements
0 to
3
0 to
6
0 to
11
0 to
18
0 to
21
0 to
121
3 to
17
7 to
120
11 to
18
11 to
121
18 to
121
21 to
121
1 Adult Preventative and
Ancillary Health
Assessment
Y Y Y Y Y
2 Blood Lead Level
Screening
Y Y Y Y Y Y
3 Cervical Cancer
Screening (applicable
to Females only)
Y Y Y Y Y
4 Diphtheria, Tetanus
Pertussis Vaccine
(DTaP)
Y Y Y Y Y Y Y
5 Haemophilus
Influenzae Type B
Caccine Hib
Y Y Y Y Y Y Y
6 Health Check
Screening Assessment
Y Y Y Y Y Y Y Y Y Y Y
7 Hearing Y Y Y Y Y Y Y Y Y
8&9 Hemoglobin or
Hematocrit
Y Y Y Y Y Y Y Y Y Y Y Y
10 Hepatitis B Vaccine Y Y Y Y Y Y Y
11 Inactivated Polio
Vaccine (IPV)
Y Y Y Y Y Y Y
12 Influenza Vaccine Y Y Y Y Y Y Y Y Y Y Y Y
13 Measles, Mumps,
Rubella Vaccine
(MMR)
Y Y Y Y Y Y Y
14 Pneumococcal Vaccine Y Y Y Y Y Y Y Y Y Y Y
15 Standardized Written
Developmental
Y Y Y Y Y Y Y
16 Tetanus Y Y Y Y Y Y Y Y Y Y
17 Tuberculin Testing
(PPD Intradermal
Injection/Mantoux
Method)
Y Y Y Y Y Y Y Y Y Y Y Y
18 Urinalysis Y Y Y Y
19 Varicella Vaccine Y Y Y Y Y Y Y
20 Vision Assessment Y Y Y Y Y Y Y Y Y Y
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Attachment A: Medicaid
EXHIBIT 1
COMPENSATION SCHEDULE
ANCILLARY SERVICES
PUBLIC AMBULANCE
_ Orange County, a local political subdivision of the State of North Carolina
____________________________________________
This compensation schedule (“Compensation Schedule”) sets forth the maximum reimbursement amounts for
Covered Services provided by Contracted Providers to Covered Persons enrolled in a Medicaid Product. Where the
Contracted Provider’s tax identification number (“TIN”) has been designated by the Payor as subject to this
Compensation Schedule, Payor shall pay or arrange for payment of a Clean Claim for Covered Services rendered by
the Contracted Provider according to the terms of, and subject to the requirements set forth in, the Agreement and
this Compensation Schedule. Payment under this Compensation Schedule shall consist of the Allowed Amount as set
forth herein less all applicable Cost-Sharing Amounts. All capitalized terms used in this Compensation Schedule
shall have the meanings set forth in the Agreement, the applicable Product Attachment, or the Definitions section set
forth at the end of this Compensation Schedule.
The compensation for ambulance Covered Services rendered to a Covered Person shall be the “Allowed Amount.”
Except as otherwise provided in this Compensation Schedule, the Allowed Amount for ambulance Covered Services
is 100% of the amount payable based on the Medicaid Managed Care Ambulance Fee Schedule set forth by the North
Carolina Division of Health Benefits (“NCDHB”) at the date of service.
Additional Directed Payments. WellCare shall make additional payments as directed and determined by NCDHB
and approved by CMS.
Additional Provisions:
1. Code Change Updates. Payor utilizes nationally recognized coding structures (including, without limitation,
revenue codes, CPT codes, HCPCS codes, ICD codes, national drug codes, ASA relative values, etc., or their
successors) for basic coding and descriptions of the services rendered. Updates to billing-related codes shall become
effective on the date (“Code Change Effective Date”) that is the later of: (i) the first day of the month following sixty
(60) days after publication by the governmental agency having authority over the applicable Product of such
governmental agency’s acceptance of such code updates, (ii) the effective date of such code updates as determined
by such governmental agency or (iii) if a date is not established by such governmental agency or the applicable
Product is not regulated by such governmental agency, the date that changes are made to nationally recognized codes.
Such updates may include changes to service groupings. Claims processed prior to the Code Change Effective Date
shall not be reprocessed to reflect any such code updates.
2. Fee Change Updates. Updates to the fee schedule shall become effective on the effective date of such fee
schedule updates, as determined by the Payor (“Fee Change Effective Date”). The date of implementation of any fee
schedule updates, i.e. the date on which such fee change is first used for reimbursement (“Fee Change Implementation
Date”), shall be the later of: (i) the first date on which Payor is reasonably able to implement the update in the claims
payment system; or (ii) the Fee Change Effective Date. Clai ms processed prior to the Fee Change Implementation
Date shall not be reprocessed to reflect any updates to such fee schedule, even if service was provided after the Fee
Change Effective Date.
3. Billing Requirements. Contracted Provider must bill HCPCS codes in addition to revenue code for services
specified within this Compensation Schedule. Failure to submit a HCPCS code may result in a claim denial.
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4. Date of Service Requirements. Contracted Provider is required to identify each date of service on claims for
multiple dates of service.
5. Carve-Out Services. With respect to any “Carve-Out” Covered Services as contemplated in this Agreement,
any payment arrangement entered into between Provider and a third party vendor of such services shall supersede
compensation hereunder.
6. Payment under this Compensation Schedule. All payments under this Compensation Schedule are subject to
the terms and conditions set forth in the Agreement, the Provider Manual and any applicable billing manual and claim
processing policies.
Definitions:
a. Allowed Amount means the amount designated in this Compensation Schedule as the maximum amount
payable to a Contracted Provider for any particular Covered Service provided to any particular Covered
Person, pursuant to this Agreement or its Attachments.
b. Allowable Charges means a Contracted Provider’s billed charges for services that qualify as Covered
Services.
c. Cost-Sharing Amounts means any amounts payable by a Covered Person, such as copayments, cost-
sharing, coinsurance, deductibles or other amounts that are the Covered Person’s financial responsibility
under the applicable Coverage Agreement, if applicable.
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