Common use of Referral Process Clause in Contracts

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on file) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU Exhibit F and any policies and procedures related thereto must comply with Section 13 12 of this MOU.Exhibit F. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer Members using a patient-centered, shared decision- making process. iii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations C.F.R. Section 431.635(c) and any relevant DHCS guidance. iii. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 twelve (12) months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) ECM or Complex Case ManagementCCM. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU Exhibit F does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations C.F.R. Section 246.7(f) and Title 22 of the California Code of Regulations, Title 22, Regulations Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (“PA”) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Medi- Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer Members using a patient-centered, shared decision-making process. iii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer Members using a patient-centered, shared decision-making process. iii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s MCPs’ Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP MCPs must refer Members using a patient-centered, shared decision-making process. iii. MCPs must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP MCPs must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP MCPs must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP MCPs must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP MCPs must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP MCPs must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP MCPs must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP MCPs for MCP’s MCPs Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP MCPs and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP MCPs that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and Docusign Envelope ID: D85E852F-3FA1-4F3C-9872-E9693CE3488A Docusign Envelope ID: 88C58D28-A927-464D-AE1D-1FD0A0AFE8F4 assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP MCPs with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCPMCPs, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Medi- Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, Date of Birth, a qualifying medical diagnosis, the name and type of the therapeutic medical formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WICWIG-eligible Members are referred to the appropriate WIC Services and MCP’s MCPs Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP MCPs must refer Members using a patient-centered, shared decision-makLng process. iii. MCPs must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP MCPs must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP MCPs must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s 's name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s 's phone/email on fileemail) as well as a copy of the Member’s 's current (within the past 12 months) hemoglobin months)_hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP MCPs must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP MCPs must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must Agency.:..MCPs_must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP MCPs must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP MCPs for MCP’s MCPs Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“"ECM”") or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP MCPs and Agency for Community Supports or ECM services, this MOU does not govern Agency’s 's provision of Community Supports or ECM services. vi. Upon notification from MCP MCPs that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services.governing vii. Agency must provide MCP MCPs with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCPMCPs, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s 's first and last name, a qualifying medical diagnosis, the name of the therapeutic medical formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s 's signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer Members using a patient-centered, shared decision-making process. iii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services.. DRAFT 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675.. DRAFT ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer Members using a patient-centered, shared decision-making process iii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iiiiv. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on file) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. v. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. vi. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vivii. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. viiviii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viiiix. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. x. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto there to must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer Members using a patient-centered, shared decision-making process. iii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCP’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 of this MOU. i. The Parties must facilitate referrals to Agency for Members who may meet the eligibility criteria for WIC Services. ii. MCP must refer Members using a patient-centered, shared decision- making process. iii. MCP must refer and document the referral to Agency of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency those Members who may be eligible for WIC Services. 1. As part of the referral, or as soon as possible thereafter, MCP must assist the Network Provider, Member, and Agency, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency as soon as possible. If the Member has not yet had these laboratory tests, MCP must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. 2. MCP must ensure its Network Providers share with Agency relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency and/or when requested by Agency. MCP must also ensure that its Network Providers share with Agency all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP must collaborate with Agency to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency should refer Members to MCP for MCP’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP and Agency for Community Supports or ECM services, this MOU does not govern Agency’s provision of Community Supports or ECM services. vi. Upon notification from MCP that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency must provide MCP with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to Agency. Agency must work with MCP, as necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. As Agency is the payor of last resort, MCP and Agency must coordinate to ensure MCP understands Agency’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: (1) a copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and (2) a completed WIC Medical Formula and Nutritionals Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.

Referral Process. The Parties must work collaboratively to develop policies and procedures that ensure WIC-eligible Members are referred to the appropriate WIC Services and MCPHPSM’s Covered Services. Referrals made pursuant to this MOU and any policies and procedures related thereto must comply with Section 13 8 of this MOU. i. i) The Parties must facilitate referrals to Agency Other Party for Members who may meet the eligibility criteria for WIC Services. ii. MCP ) HPSM must refer Members using a patient-centered, shared decision-making process. iii) HPSM must refer and document the referral to Agency Other Party of Members who are Pregnant Women, Breastfeeding Women, Postpartum Women, or the legal guardians of Members who are Infants or Children, including referrals made as part of the initial evaluation of newly pregnant individuals, pursuant to 42 Code of Federal Regulations Section 431.635(c) and any relevant DHCS guidance. iii. MCP HPSM must have policies and procedures to identify and refer, and to ensure its Network Providers identify and refer, to Agency Other Party those Members who may be eligible for WIC Services. (1. ) As part of the referral, or as soon as possible thereafter, MCP HPSM must assist the Network Provider, Member, and AgencyOther Party, as necessary, with sharing the Member’s name, address, relevant portions of the medical record, Medi-Cal number, and contact information (such as the Member’s phone/email on fileemail) as well as a copy of the Member’s current (within the past 12 months) hemoglobin and hematocrit laboratory values with Agency Other Party as soon as possible. If the Member has not yet had these laboratory tests, MCP HPSM must coordinate with the Network Provider and Member to assist the Member with obtaining such laboratory tests as soon as possible. 1 Additional guidance is available at All-Plan Letter (“APL”) 22-016, APL 22-031, and APL 22- 029. (2. MCP ) HPSM must ensure its Network Providers share with Agency Other Party relevant information from patient visits, including, without limitation, height and weight measurements, hemoglobin/hematocrit values, blood lead values, immunization records for Infants and Children, and health conditions when referring their patients to Agency Other Party and/or when requested by AgencyOther Party. MCP HPSM must also ensure that its Network Providers share with Agency Other Party all WIC Program documentation, including necessary CDPH WIC Program forms. iv. MCP ) HPSM must collaborate with Agency Other Party to update referral processes and policies designed to address barriers and concerns related to referrals and delays in service delivery. v. Agency v) Other Party should refer Members to MCP HPSM for MCPHPSM’s Covered Services, including any Community Supports services or care management programs for which Members may qualify, such as Enhanced Care Management (“ECM”) or Complex Case Management. However, if Agency Other Party is also a Community Supports Provider or an ECM Provider pursuant to a separate agreement between MCP HPSM and Agency Other Party for Community Supports or ECM services, this MOU does not govern AgencyOther Party’s provision of Community Supports or ECM services. vi. ) Upon notification from MCP HPSM that a Member may be eligible for WIC Services, and in accordance with its normal practices and procedures governing WIC application and certification, Agency Other Party must conduct the applicable screening and assessments to determine whether the Member is eligible for WIC Services. vii. Agency ) Other Party must provide MCP HPSM with current information about WIC referral process(es), including referral forms, links, fax numbers, email addresses, and other means of making and sending referrals to AgencyOther Party. Agency Other Party must work with MCPHPSM, as Docusign Envelope ID: D704F5A3-1FAF-499F-B725-E1CD5B84B766 necessary, to revise referral processes and address barriers and concerns related to referrals. viii. Agency ) Other Party is responsible for the timely enrollment of, and follow-up with, Members eligible for WIC Services in accordance with the processing standards set forth in 7 Code of Federal Regulations Section 246.7(f) and California Code of Regulations, Title 22, Section 40675. ix. ) As Agency Other Party is the payor of last resort, MCP HPSM and Agency Other Party must coordinate to ensure MCP HPSM understands AgencyOther Party’s processes and procedures for providing Members with therapeutic formula as appropriate. MCP HPSM must ensure its Network Providers are informed of and follow the requirements for assisting Members in obtaining therapeutic formula from Agency Other Party as appropriate. The following information must be included with the WIC referral after submitting a prior authorization (PA) to Medi-Cal Rx for provision of therapeutic formula, including submission of the following information with the referral: : (1) a A copy of the Medi-Cal Rx PA denial notification upon receipt from Medi-Cal Rx or an attestation from the Provider that the request has been submitted to and denied by Medi-Cal Rx, and and (2) a A completed WIC Medical Formula and Nutritionals Nutritional Request Form or a prescription or hospital discharge papers that contain: the WIC Participant’s first and last name, a qualifying medical diagnosis, the name of the therapeutic formula or medical nutritional, amount required per day, length of time prescribed in months, WIC authorized food restrictions (if applicable), the Network Provider’s signature or signature stamp, contact information of the Network Provider who wrote the medical documentation, and the date the Network Provider signed the medical documentation.