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<br />1.9. “Covered Services” means those services and items for which benefits are available and payable
<br />under the applicable Coverage Agreement and which are determined, if applicable, to be Medically Necessary.
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<br />1.10. “Medically Necessary” or “Medical Necessity” shall have the meaning defined in the applicable
<br />Coverage Agreement or applicable Regulatory Requirements.
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<br />1.11. “Participating Provider” means, with respect to a particular Product, any physician, hospital,
<br />ancillary, or other health care provider that has contracted, directly or indirectly, with WellCare to provide Covered
<br />Services to Covered Persons, that has been approved for participation by Company, and that is designated by
<br />Company as a “participating provider” in such Product.
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<br />1.12. “Payor” means the entity (including Company where applicable) that bears direct financial
<br />responsibility for paying from its own funds, without reimbursement from another entity, the cost of Covered Services
<br />rendered to Covered Persons under a Coverage Agreement and, if such entity is not Company, such entity contracts,
<br />directly or indirectly, with Company for the provision of certain administrative or other services with respect to such
<br />Coverage Agreement.
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<br />1.13. “Payor Contract” means the contract with a Payor, pursuant to which Company furnishes
<br />administrative services or other services in support of the Coverage Agreements entered into, issued or agreed to by
<br />a Payor, which services may include access to one or more of Company’s provider networks or vendor arrangements,
<br />except those excluded by WellCare. The term “Payor Contract” includes Company’s or other Payor’s contract with
<br />a governmental authority (also referred to herein as a “Governmental Contract”) under which Company or Payor
<br />arranges for the provision of Covered Services to Covered Persons.
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<br />1.14. “Product” means any program or health benefit arrangement designated as a “product” by WellCare
<br />(e.g., WellCare Product, Payor-specific Product, etc.) that is now or hereafter offered by or available from or through
<br />Company (and includes the Coverage Agreements that access, or are issued or entered into in connection with such
<br />product, except those excluded by WellCare).
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<br />1.15. “Product Attachment” means an Attachment setting forth requirements, terms and conditions specific
<br />or applicable to one or more Products, including certain provisions that must be included in a provider agreement
<br />under the Regulatory Requirements, which may be alternatives to, or in addition to, the requirements, terms and
<br />conditions set forth in this Agreement or the Provider Manual.
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<br />1.16. “Provider Manual” means the provider manual and any billing manuals, adopted by Company or
<br />Payor which include, without limitation, requirements relating to utilization management, quality management,
<br />grievances and appeals, and Product-specific, Payor-specific and State-specific requirements, as may be amended
<br />from time to time by Company or Payor.
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<br />1.17. “Regulatory Requirements” means all applicable federal and state statutes, regulations, regulatory
<br />guidance, judicial or administrative rulings, requirements of Governmental Contracts and standards and requirements
<br />of any accrediting or certifying organization, including, but not limited to, the requirements set forth in a Product
<br />Attachment.
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<br />1.18. “State” is defined as the state identified in the applicable Attachment.
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<br />ARTICLE II - PRODUCTS AND SERVICES
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<br />2.1. Contracted Providers. Provider shall, and shall cause each Contracted Provider, to comply with and
<br />abide by the agreements, representations, warranties, acknowledgements, certifications, terms and conditions of this
<br />Agreement (including the provisions of Schedule A that are applicable to Provider, a Contracted Provider, or their
<br />services, and any other Attachments), and the Provider Manual, and fulfill all of the duties, responsibilities and
<br />DocuSign Envelope ID: 2EC1F0FD-FAF9-4B42-B52E-D419F55A6210
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