2021-350-EMS-E-WellCare Health Plans of NC Inc-Medicaid managed care

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Page 23 of 48 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 DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210