Common use of Obligation To A Third Party Clause in Contracts

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually OnBase FR-39 FR-39 SUD Reconciliation Report Annual SUD Risk Share Report Annually OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually OnBase FR-41 [RETIRED] FR-42 [RETIRED] FR-43 FR-43 Primary Care Sub-Capitation Payment Tracking Report Primary Care Sub-Capitation Payment Tracking Report Monthly SFTP FR-44 FR-44 Community Partners Financial Report Quarterly and Annual Community Partners Financial Report Quarterly and Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System To be determined.

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually OnBase FR-39 FR-39 SUD Reconciliation Report Annual SUD Risk Share Report Annually OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually OnBase FR-41 [RETIRED] FR-42 [RETIRED] FR-43 FR-43 Primary Care Sub-Capitation Payment Tracking Report Primary Care Sub-Capitation Payment Tracking Report Monthly SFTP FR-44 FR-44 Community Partners Financial Report Quarterly and Annual Community Partners Financial Report Quarterly and Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System To be determined.[RETIRED]

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ad-Hoc OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually OnBase FR-39 FR-39 SUD Reconciliation Report Annual SUD Risk Share Report Annually OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually OnBase FR-41 [RETIRED] FR-42 [RETIRED] FR-43 FR-43-A FR-43 Primary Care Sub-Capitation Payment Tracking Report - Monthly Primary Care Sub-Capitation Payment Tracking Report Monthly SFTP FR-43-B FR-43 Primary Care Sub-Capitation Payment Tracking Report – Ad Hoc Primary Care Sub-Capitation Payment Tracking Report Ad-Hoc SFTP FR-44 FR-44 Community Partners Financial [RETIRED] FR-45 FR-45 Material Subcontractor Medical Loss Ratio (MLR) Identification Report Quarterly Identify and Annual Community Partners Financial report Material Subcontractors subject to CMS STC 8.6(c) MLR reporting requirement Annually OnBase FR-46 FR-46 Material Subcontractor Medical Loss Ratio (MLR) Report Quarterly and Report MLR data for Material Subcontractors subject to CMS STC 8.6(c) Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System To be determined.HQ-23 [RETIRED] HQ-24 HQ-24 ACO/MCO Health Quality and Strategic Plan Ad-Hoc OnBase

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Ad-Hoc No later than 30 days prior to OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually Annual OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually Annual OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually Annual OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually Annual OnBase FR-39 FR-39 SUD Reconciliation Report Annual OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System Annual SUD Risk Share Report Annually OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually Annual OnBase FR-41 RESERVED FR-42 FR-42 Certification on Compliance with Appendix Z Certification on Compliance with Appendix Z Monthly As Instructed ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-01 OP-01 Inbound Pharmacy Co-pay Interface to MMIS per Appendix M Inbound Pharmacy Co-pay Interface to MMIS per Appendix M Notification: Same Day POPS OP-02 OP-02 Inbound Managed Care Provider Directory Interface (ACPD) Inbound Managed Care Provider Directory Interface (ACPD) Monthly POSC OP-03 OP-03 Long-term Care Report Log Long-term Care Report Log Weekly OnBase OP-04 OP-04 Member Discrepancy Report Member Discrepancy Report Monthly OnBase OP-05 OP-05 [RETIRED] FR-42 [RETIRED] FR-43 FR-43 Primary Care SubOP-06 OP-06 Address Change File Address Change File Bi-Capitation Payment Tracking Weekly OnBase OP-07 OP-07 Multiple ID File Multiple ID File Bi-Weekly OnBase OP-08 OP-08 Date of Death Report Primary Care SubDate of Death Report Bi-Capitation Payment Tracking Report Monthly SFTP FR-44 FR-44 Community Partners Financial Report Quarterly and Annual Community Partners Financial Report Quarterly and Annually Weekly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System To be determined.PH-01 PH-01 Pharmacy Claims Level Interface Plans use the Pharmacy Claims Level Interface to submit rebate data for Pharmacy claims. The original claims file submission is due within 5 calendar days following the close of the prior month. Monthly POPS Portal PH-02 PH-02 MassHealth Custom Interface Guide - 837 Medication Claims Plans use the MassHealth Custom Interface Guide - 837 Medication Claims - Paid Claims File Layout for Batch Interface to Pharmacy Systems to submit rebate data for 837 claims. The original claims file submission is due within 15 calendar days following the close of the prior month. Monthly POPS Portal PH-03 PH-03 Pharmacy Provider Network Identification Layout Pharmacy Provider Network Identification Layout Ad-Hoc POPS Portal PH-04-A PH-04-A Drug Utilization Review Report Drug Utilization Review Report (Note: Due by May 1st of each year) Annual Secure Email PH-04-B PH-04-B Clinical Information request for the DUR Board meeting Clinical Information request for the DUR board meeting Ad-Hoc Email PH-04-C PH-04-C Clinical Criteria for Prior Authorization and Utilization Management Clinical Criteria for Prior Authorization and Utilization Management Ad-Hoc Email PH-05-A PH-05-A Pharmacy MassHealth Drug Rebate File Submission Report Pharmacy MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-01 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-01. Monthly Email PH-05-B PH-05-B 837 MassHealth Drug Rebate File Submission Report 837 MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-02 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-02. Monthly Email ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-06 PH-06 837 Registration Form for Access to the MassHealth Drug Rebate Portal 837 Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase PH-07 PH-07 Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase PH-08 PH-08 Clinical Policy Initiative Report Clinical Policy Initiative Report Ad-Hoc OnBase PH-09 PH-09 MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report Ad-Hoc OnBase PH-10 PH-10 Hepatitis C Utilization Report Hepatitis C Utilization Report Ad-Hoc OnBase PH-11 PH-11 Pediatric BH Medication Initiative Report Pediatric BH Medication Initiative Report Ad-Hoc OnBase PH-12-A PH-12-A PBM Pricing Report - Quarterly PBM Pricing Report- Quarterly Quarterly POPS Portal, or as directed by EOHHS PH-12-B PH-12-B PBM Pricing Report - Ad-Hoc PBM Pricing Report- Ad-Hoc Ad-Hoc POPS Portal, or as directed by EOHHS PH-13 PH-13 Mail Order Pharmacy Program Report Mail Order Pharmacy Program Report- Ad-Hoc Ad-Hoc OnBase PH-14 PH-14 Change in BIN/PCN/Group Number Report Change in BIN/PCN/Group Number Report- Ad-Hoc (Note: Due at least 30-days before new BIN/PCN/Group Number is effective) Ad-Hoc OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-15 PH-15 Vitrakvi Monitoring Report Vitrakvi Monitoring Report- Quarterly Quarterly OnBase PH-16-A PH-16-A Zolgensma Monitoring Program- Quarterly Zolgensma Monitoring Program- Quarterly Quarterly OnBase PH-16-B PH-16-B Zolgensma Monitoring Program- Annual Zolgensma Monitoring Program- Annual Annual OnBase PH-17 PH-17 CAR-T Monitoring Program CAR-T Monitoring Program-Quarterly Quarterly OnBase PH-18 PH-18 Controlled Substance Management Program Enrollees Leaving Health Plan Controlled Substance Management Program Enrollees Leaving Health Plan- Monthly Monthly OnBase

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually OnBase FR-39 FR-39 SUD Reconciliation Report Annual SUD Risk Share Report Annually OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually OnBase FR-41 [RETIRED] FR-42 [RETIRED] FR-43 FR-43 Primary Care Sub-Capitation Payment Tracking Report Primary Care Sub-Capitation Payment Tracking Report Monthly SFTP FR-44 FR-44 Community Partners Financial Report Quarterly and Annual Community Partners Financial Report Quarterly and Annually OnBase ACO Contract MCOContract Exhibit Number Name of Report Deliverable Frequency Target System To be determined.

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually Annual OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually Annual OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually Annual OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually Annual OnBase FR-39 FR-39 SUD Reconciliation Report Annual SUD Risk Share Report Annually Annual OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually Annual OnBase FR-41 [RETIRED] RESERVED FR-42 [RETIRED] FR-43 FR-43 Primary Care Sub-Capitation Payment Tracking Report Primary Care Sub-Capitation Payment Tracking Report FR-42 Certification on Compliance with Appendix Z Certification on Compliance With Appendix Z Monthly SFTP FR-44 FR-44 Community Partners Financial Report Quarterly and Annual Community Partners Financial Report Quarterly and Annually OnBase ACO As Instructed MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System To be determined.OP-01 OP-01 Inbound Pharmacy Co-pay Interface to MMIS per Appendix M Inbound Pharmacy Co-pay Interface to MMIS per Appendix M Notification: Same Day POPS OP-02 OP-02 Inbound Managed Care Provider Directory Interface (ACPD) Inbound Managed Care Provider Directory Interface (ACPD) Monthly POSC OP-03 OP-03 Long-term Care Report Log Long-term Care Report Log Weekly OnBase OP-04 OP-04 Member Discrepancy Report Member Discrepancy Report Monthly OnBase OP-05 OP-05 Blank Rate Cell Report [RETIRED] OP-06 OP-06 Address Change File Address Change File Bi-Weekly OnBase OP-07 OP-07 Multiple ID File Multiple ID File Bi-Weekly OnBase OP-08 OP-08 Date of Death Report Date of Death Report Bi-Weekly OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-01 PH-01 Pharmacy Claims Level Interface Plans use the Pharmacy Claims Level Interface to submit rebate data for Pharmacy claims. The original claims file submission is due within 5 calendar days following the close of the prior month. Monthly POPS Portal PH-02 PH-02 MassHealth Custom Interface Guide - 837 Medication Claims Plans use the MassHealth Custom Interface Guide - 837 Medication Claims - Paid Claims File Layout for Batch Interface to Pharmacy Systems to submit rebate data for 837 claims. The original claims file submission is due within 15 calendar days following the close of the prior month. Monthly POPS Portal PH-03 PH-03 Pharmacy Provider Network Identification Layout Pharmacy Provider Network Identification Layout Ad-Hoc POPS Portal MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-04-A PH-04-A Drug Utilization Review Report Drug Utilization Review Report (Note: Due by May 1st of each year) Annual Secure Email PH-04-B PH-04-B Clinical Information request for the DUR Board meeting Clinical Information request for the DUR board meeting Ad-Hoc Email PH-04-C PH-04-C Clinical Criteria for Prior Authorization and Utilization Management Clinical Criteria for Prior Authorization and Utilization Management Ad-Hoc Email PH-05-A PH-05-A Pharmacy MassHealth Drug Rebate File Submission Report Pharmacy MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-01 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-01. Monthly Email PH-05-B PH-05-B 837 MassHealth Drug Rebate File Submission Report 837 MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-02 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-02. Monthly Email PH-06 PH-06 837 Registration Form for Access to the MassHealth Drug Rebate Portal 837 Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase PH-07 PH-07 Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase PH-08 PH-08 Clinical Policy Initiative Report Clinical Policy Initiative Report Ad-Hoc OnBase PH-09 PH-09 MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report Ad-Hoc OnBase PH-10 PH-10 Hepatitis C Utilization Report Hepatitis C Utilization Report Ad-Hoc OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-11 PH-11 Pediatric BH Medication Initiative Report Pediatric BH Medication Initiative Report Ad-Hoc OnBase PH-12-A PH-12-A PBM Pricing Report - Quarterly PBM Pricing Report- Quarterly Quarterly POPS Portal, or as directed by EOHHS PH-12-B PH-12-B PBM Pricing Report - Ad-Hoc PBM Pricing Report- Ad-Hoc Ad-Hoc POPS Portal, or as directed by EOHHS PH-13 PH-13 Mail Order Pharmacy Program Report Mail Order Pharmacy Program Report- Ad-Hoc Ad-Hoc OnBase PH-14 PH-14 Change in BIN/PCN/Group Number Report Change in BIN/PCN/Group Number Report- Ad-Hoc (Note: Due at least 30-days before new BIN/PCN/Group Number is effective) Ad-Hoc OnBase PH-15 PH-15 Vitrakvi Monitoring Report Vitrakvi Monitoring Report- Quarterly Quarterly OnBase PH-16-A PH-16-A Zolgensma Monitoring Program- Quarterly Zolgensma Monitoring Program- Quarterly Quarterly OnBase PH-16-B PH-16-B Zolgensma Monitoring Program- Annual Zolgensma Monitoring Program- Annual (Note: Due February 28 each year) Annual OnBase PH-17 PH-17 CAR-T Monitoring Program CAR-T Monitoring Program-Quarterly Quarterly OnBase PH-18 PH-18 Controlled Substance Management Program Enrollees Leaving Health Plan Controlled Substance Management Program Enrollees Leaving Health Plan - Monthly Monthly OnBase

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System (No later than 30 days prior to execution) FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually OnBase ACO FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annually OnBase MCO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually OnBase FR-39 FR-39 SUD Reconciliation Report Annual SUD Risk Share Report Annually OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually OnBase FR-41 [RETIRED] FR-42 [RETIRED] FR-43 FR-43 Primary Care Sub-Capitation Payment Tracking Report Primary Care Sub-Capitation Payment Tracking Report Monthly SFTP FR-44 FR-44 Community Partners Financial Report Quarterly and Annual Community Partners Financial Report Quarterly and Annually OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System To be determined.[RETIRED]

Obligation To A Third Party. Under This Contract, Or Any Default By A Parent Corporation On Any Financial Obligation To A Third Party That Could In Any Way Affect The Contractor’s Ability To Satisfy Its Payment Or Performance Obligations. (Notification should be given Same Day) Ad-Hoc OnBase FR-25 FR-25 Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures Significant Organizational Changes, New Material Subcontractors, or Potential Business Ventures That May Ad-Hoc No later than 30 days prior to OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System Impact Performance (No later than 30 days prior to execution) Ad-Hoc No later than 30 days prior to execution OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-26 FR-26 Provider Risk Arrangements Provider Risk Arrangements Ad-Hoc OnBase FR-27 FR-27 Changes in Contractor’s Providers’ Risk Arrangements Changes in Contractor’s Providers’ Risk Arrangements (Notification: Same Day) Ad-Hoc OnBase FR-28 FR-28 Working Capital Requirement Notification Working Capital Requirement Notification (“if” working capital falls below 75% below the amount reported on the prior year audited financial reports) (Two Business Days) Ad-Hoc OnBase FR-29 FR-29 Continuing Services Reconciliation Data Continuing Services Reconciliation Data Ad-Hoc OnBase FR-30 FR-30 ABA Reconciliation Report ABA Reconciliation Report Annually Annual OnBase FR-31 FR-31 Medical Loss Ratio (MLR) Report Medical Loss Ratio (MLR) Report Annually OnBase FR-32 FR-32 Alternative Payment Models (APM) Report Alternative Payment Models (APM) Report Quarterly OnBase FR-33 FR-33 Provider Agreements Annual Provider Agreements Annual Annually Annual OnBase FR-34 FR-34 Provider Agreements – Ad-Hoc Provider Agreements – Ad-Hoc Ad-Hoc OnBase FR-35 FR-35 Report on Satisfying Contractor’s Payment Or Performance Obligations Report on Satisfying Contractor’s Payment Or Performance Obligations Ad-Hoc OnBase FR-37 FR-37 IMD Services Report Report on services provided to members with long term IMD stay Quarterly and Annually Annual OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System FR-38 FR-38 Other High Cost Pharmacy Reconciliation Report Annual Other High Cost Pharmacy Risk Share Report Annually Annual OnBase FR-39 FR-39 SUD Reconciliation Report Annual OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System Annual SUD Risk Share Report Annually OnBase FR-40 FR-40 Financial Encounter Validation Report Quarterly Financial Encounter Validation Report Quarterly and Annually Annual OnBase FR-41 RESERVED FR-42 FR-42 Certification on Compliance with Appendix Z Certification on Compliance with Appendix Z Monthly As Instructed ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System OP-01 OP-01 Inbound Pharmacy Co-pay Interface to MMIS per Appendix M Inbound Pharmacy Co-pay Interface to MMIS per Appendix M Notification: Same Day POPS OP-02 OP-02 Inbound Managed Care Provider Directory Interface (ACPD) Inbound Managed Care Provider Directory Interface (ACPD) Monthly POSC OP-03 OP-03 Long-term Care Report Log Long-term Care Report Log Weekly OnBase OP-04 OP-04 Member Discrepancy Report Member Discrepancy Report Monthly OnBase OP-05 OP-05 [RETIRED] FR-42 [RETIRED] FR-43 FR-43 Primary Care SubOP-06 OP-06 Address Change File Address Change File Bi-Capitation Payment Tracking Weekly OnBase OP-07 OP-07 Multiple ID File Multiple ID File Bi-Weekly OnBase OP-08 OP-08 Date of Death Report Primary Care SubDate of Death Report Bi-Capitation Payment Tracking Report Monthly SFTP FR-44 FR-44 Community Partners Financial Report Quarterly and Annual Community Partners Financial Report Quarterly and Annually Weekly OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System To PH-01 PH-01 Pharmacy Claims Level Interface Plans use the Pharmacy Claims Level Interface to submit rebate data for Pharmacy claims. The original claims file submission is due within 5 calendar days following the close of the prior month. Monthly POPS Portal PH-02 [RETIRED] PH-03 PH-03 Pharmacy Provider Network Identification Layout Pharmacy Provider Network Identification Layout Ad-Hoc POPS Portal PH-04-A PH-04-A Drug Utilization Review Report Drug Utilization Review Report (Note: Due by May 1st of each year) Annual Secure Email PH-04-B PH-04-B Clinical Information request for the DUR Board meeting Clinical Information request for the DUR board meeting Ad-Hoc Email PH-04-C PH-04-C Clinical Criteria for Prior Authorization and Utilization Management Clinical Criteria for Prior Authorization and Utilization Management Ad-Hoc Email PH-05-A PH-05-A Pharmacy MassHealth Drug Rebate File Submission Report Pharmacy MassHealth Drug Rebate File Submission Report for the plans to self- report monthly on the upload of the report PH-01 to the POPS Portal. The File Submission Report is due within 3 business days following the upload of PH-01. Monthly Email PH-05-B [RETIRED] PH-06 [RETIRED] PH-07 PH-07 Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Pharmacy Retail Registration Form for Access to the MassHealth Drug Rebate Portal Ad-Hoc OnBase PH-08 PH-08 Clinical Policy Initiative Report Clinical Policy Initiative Report Ad-Hoc OnBase PH-09 PH-09 MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report MassHealth ACO/MCO Uniform Preferred Drug List Compliance Report Ad-Hoc OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-10 PH-10 Hepatitis C Utilization Report Hepatitis C Utilization Report Ad-Hoc OnBase PH-11 PH-11 Pediatric BH Medication Initiative Report Pediatric BH Medication Initiative Report Ad-Hoc OnBase PH-12-A PH-12-A PBM Pricing Report - Quarterly PBM Pricing Report- Quarterly Quarterly POPS Portal, or as directed by EOHHS PH-12-B PH-12-B PBM Pricing Report - Ad-Hoc PBM Pricing Report- Ad-Hoc Ad-Hoc POPS Portal, or as directed by EOHHS PH-13 PH-13 Mail Order Pharmacy Program Report Mail Order Pharmacy Program Report- Ad-Hoc Ad-Hoc OnBase PH-14 PH-14 Change in BIN/PCN/Group Number Report Change in BIN/PCN/Group Number Report- Ad-Hoc (Note: Due at least 30-days before new BIN/PCN/Group Number is effective) Ad-Hoc OnBase PH-15 PH-15 Vitrakvi Monitoring Report Vitrakvi Monitoring Report- Quarterly Quarterly OnBase PH-16-A PH-16-A Zolgensma Monitoring Program- Quarterly Zolgensma Monitoring Program- Quarterly Quarterly OnBase PH-16-B PH-16-B Zolgensma Monitoring Program- Annual Zolgensma Monitoring Program- Annual Annual OnBase PH-17 PH-17 CAR-T Monitoring Program CAR-T Monitoring Program-Quarterly Quarterly OnBase PH-18 PH-18 Controlled Substance Management Program Enrollees Leaving Health Plan Controlled Substance Management Program Enrollees Leaving Health Plan- Monthly Monthly OnBase PH-19 PH-19 Givlaari Monitoring Program Givlaari Monitoring Program - Annual Annual OnBase ACO Contract Exhibit Number Name of Report Deliverable Frequency Target System PH-20 PH-20 Onpattro Monitoring Program PH-20 Onpattro Monitoring Program - Quarterly Quarterly OnBase Payment for COVID-19 Temporary Rate Increases for Inpatient Mental Health Services and Administratively Necessary Days (AND) The tables below include the per inpatient day payment for rate increases to Tier 1 and Tier 2 Hospitals for Contract Year 2020 as described in Sections 2.20.B.2 and 4.3.F of the Contract. Inpatient Mental Health and Administratively Necessary Days (AND) Tier 1 Payment Inpatient Mental Health and Administratively Necessary Days (AND) Tier 2 Payment Inpatient Mental Health and AND Tier 2 Payment For the HIPF for calendar year 2019, EOHHS shall perform the following retrospective add-on adjustment to the Contract Year 2019 Base Capitation Rates, as reflected in Appendix D effective during that period (as incorporated into this Contract through Amendment 1 to the First Amended and Restated Contract). Such adjustment shall be determined.applied to the period of January 1, 2019 – December 31, 2019. Appendix T: Behavioral Health Outpatient and Certain Other Services Minimum Fee Schedule‌ MH and SA OP Services 90791* UG - Doctoral Level (Child Psychiatrist) Psychiatric Diagnostic Evaluation $ 189.34 MH and SA OP Services 90791* U6 - Doctoral Level (MD / DO) Psychiatric Diagnostic Evaluation $ 151.95 MH and SA OP Services 90791* AH - Doctoral Level (PhD, PsyD, EdD) Psychiatric Diagnostic Evaluation $ 130.44 MH and SA OP Services 90791* SA - Nurse Practitioner/Board Certified RNCS and APRN-BC Psychiatric Diagnostic Evaluation $ 131.51 MH and SA OP Services 90791* HO - Master's Level Psychiatric Diagnostic Evaluation $ 117.41 MH and SA OP Services 90791* U3 - Intern (PhD, PsyD, EdD) Psychiatric Diagnostic Evaluation $ 65.22 MH and SA OP Services 90791* U4 - Intern (Master's) Psychiatric Diagnostic Evaluation $ 58.71 MH and SA OP Services 90792 Doctoral Level (Child Psychiatrist) Psychiatric Diagnostic Evaluation with Medical Services $ 119.82 MH and SA OP Services 90792 Doctoral Level (MD / DO) Psychiatric Diagnostic Evaluation with Medical Services $ 103.92 MH and SA OP Services 90792 Nurse Practitioner/Board Certified RNCS and APRN-BC Psychiatric Diagnostic Evaluation with Medical Services $ 95.06 MH and SA OP Services 90832 Doctoral Level (Child Psychiatrist) Individual Psychotherapy, approximately 20-30 minutes $ 52.60 MH and SA OP Services 90832 Doctoral Level (MD / DO) Individual Psychotherapy, approximately 20-30 minutes $ 45.54 MH and SA OP Services 90832 Doctoral Level (PhD, PsyD, EdD) Individual Psychotherapy, approximately 20-30 minutes $ 44.22 MH and SA OP Services 90832 Nurse Practitioner/Board Certified RNCS and APRN-BC Individual Psychotherapy, approximately 20-30 minutes $ 42.96 MH and SA OP Services 90832 Master's Level (Independently Licensed Clinicians and Supervised Master's Level Clinicians) Individual Psychotherapy, approximately 20-30 minutes $ 42.96 MH and SA OP Services 90832 Master's Level (Licensed Alcohol and Drug Counselor 1 and Supervised Master's Level Clinicians) Individual Psychotherapy, approximately 20-30 minutes $ 29.94 MH and SA OP Services 90832 Intern (PhD, PsyD, EdD) Individual Psychotherapy, approximately 20-30 minutes $ 22.11 MH and SA OP Services 90832 Intern (Master's) Individual Psychotherapy, approximately 20-30 minutes $ 21.44 MH and SA OP Services 90833 Doctoral Level (MD / DO) Psychotherapy, 30 minutes, when Performed with an Evaluation and Management Service $ 31.77 MH and SA OP Services 90833 Nurse Practitioner/Board Certified RNCS and APRN-BC Psychotherapy, 30 minutes, when Performed with an Evaluation and Management Service $ 31.77 MH and SA OP Services 90834 Doctoral Level (Child Psychiatrist) Individual Psychotherapy, approximately 45 minutes $ 105.18 MH and SA OP Services 90834 Doctoral Level (MD / DO) Individual Psychotherapy, approximately 45 minutes $ 92.42 MH and SA OP Services 90834 Doctoral Level (PhD, PsyD, EdD) Individual Psychotherapy, approximately 45 minutes $ 87.17 MH and SA OP Services 90834 Nurse Practitioner/Board Certified RNCS and APRN-BC Individual Psychotherapy, approximately 45 minutes $ 85.91 Category of Service Procedure Code Modifier Group Procedure Description Unit Cost MH and SA OP Services 90834 Master's Level (Independently Licensed Clinicians and Supervised Master's Level Clinicians) Individual Psychotherapy, approximately 45 minutes $ 85.91 MH and SA OP Services 90834 Master's Level (Licensed Alcohol and Drug Counselor 1 and Supervised Master's Level Clinicians) Individual Psychotherapy, approximately 45 minutes $ 85.91 MH and SA OP Services 90834 Intern (PhD, PsyD, EdD) Individual Psychotherapy, approximately 45 minutes $ 43.62 MH and SA OP Services 90834 Intern (Master's) Individual Psychotherapy, approximately 45 minutes $ 42.96 MH and SA OP Services 90836 Doctoral Level (MD / DO) Psychotherapy, 45 minutes, when Performed with an Evaluation and Management Service $ 51.58 MH and SA OP Services 90836 Nurse Practitioner/Board Certified RNCS and APRN-BC Psychotherapy, 45 minutes, when Performed with an Evaluation and Management Service $ 51.58 MH and SA OP Services 90837 Doctoral Level (Child Psychiatrist) Psychotherapy, 60 minutes $ 105.18 MH and SA OP Services 90837 Doctoral Level (MD / DO) Psychotherapy, 60 minutes $ 92.42 MH and SA OP Services 90837 Doctoral Level (PhD, PsyD, EdD) Psychotherapy, 60 minutes $115.94 MH and SA OP Services 90837 Nurse Practitioner/Board Certified RNCS and APRN-BC Psychotherapy, 60 minutes $114.26 MH and SA OP Services 90837 Master's Level (Independently Licensed Clinicians and Supervised Master's Level Clinicians) Psychotherapy, 60 minutes $114.26 90837 Master's Level (Licensed Alcohol and Drug Counselor 1 and Supervised Master's Level Clinicians) Psychotherapy, 60 minutes $114.26 MH and SA OP Services 90837 Intern (PhD, PsyD, EdD) Psychotherapy, 60 minutes $ 43.62 MH and SA OP Services 90837 Intern (Master's) Psychotherapy, 60 minutes $ 42.96 MH and SA OP Services 90838 Doctoral Level (MD / DO) Psychotherapy, 60 minutes, when Performed with an Evaluation and Management Service $ 83.11 MH and SA OP Services 90838 Nurse Practitioner/Board Certified RNCS and APRN-BC Psychotherapy, 60 minutes, when Performed with an Evaluation and Management Service $ 83.11 MH and SA OP Services 90846 Doctor Level (Child Psychiatrist) Family Psychotherapy (without patient present) $ 128.56 MH and SA OP Services 90846 Doctor Level (MD/DO) Family Psychotherapy (without patient present) $ 97.84 MH and SA OP Services 90846 Doctoral Level (PhD, PsyD, EdD) Family Psychotherapy (without patient present) $ 91.34 MH and SA OP Services 90846 Nurse Practitioner/Board Certified RNCS and APRN-BC Family Psychotherapy (without patient present) $ 88.68 Category of Service Procedure Code Modifier Group Procedure Description Unit Cost MH and SA OP Services 90846 Master's Level (Independently Licensed Clinicians and Supervised Master's Level Clinicians) Family Psychotherapy (without patient present) $ 88.68 MH and SA OP Services 90846 Master's Level (Licensed Alcohol and Drug Counselor 1 and Supervised Master's Level Clinicians) Family Psychotherapy (without patient present) $ 88.68 MH and SA OP Services 90846 Intern (PhD, PsyD, EdD) Family Psychotherapy (without patient present) $ 45.66 MH and SA OP Services 90846 Intern (Master's) Family Psychotherapy (without patient present) $ 44.34 MH and SA OP Services 90847 Doctoral Level (Child Psychiatrist) Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 128.56 MH and SA OP Services 90847 Doctoral Level (MD / DO) Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 97.84 MH and SA OP Services 90847 Doctoral Level (PhD, PsyD, EdD) Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 91.34 MH and SA OP Services 90847 Nurse Practitioner/Board Certified RNCS and APRN-BC Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 88.68 MH and SA OP Services 90847 Master's Level (Independently Licensed Clinicians and Supervised Master's Level Clinicians) Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 88.68 MH and SA OP Services 90847 Master's Level (Licensed Alcohol and Drug Counselor 1 and Supervised Master's Level Clinicians) Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 88.68 MH and SA OP Services 90847 Intern (PhD, PsyD, EdD) Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 45.66 MH and SA OP Services 90847 Intern (Master's) Family Psychotherapy (conjoint psychotherapy) (with patient present) $ 44.34 MH and SA OP Services 90849 Doctor Level (Child Psychiatrist) Multi-family group psychotherapy 42.08 MH and SA OP Services 90849 Doctor Level (MD/DO) Multi-family group psychotherapy 35.31 MH and SA OP Services 90849 Doctoral Level (PhD, PsyD, EdD) Multi-family group psychotherapy 32.60 MH and SA OP Services 90849 Nurse Practitioner/Board Certified RNCS and APRN-BC Multi-family group psychotherapy 30.00 MH and SA OP Services 90849 Master's Level (Independently Licensed Clinicians and Supervised Master's Level Clinicians) Multi-family group psychotherapy 22.17 MH and SA OP Services 90849 Master's Level (Licensed Alcohol and Drug Counselor 1 and Supervised Master's Level Clinicians) Multi-family group psychotherapy 22.17 MH and SA OP Services 90849 Intern (PhD, PsyD, EdD) Multi-family group psychotherapy 16.33 MH and SA OP Services 90849 Intern (Master's) Multi-family group psychotherapy 15.00 MH and SA OP Services 90853 Doctoral Level (Child Psychiatrist) Group psychotherapy (other than of a multiple-family group) $ 42.08 MH and SA OP Services 90853 Doctoral Level (MD / DO) Group psychotherapy (other than of a multiple-family group) $ 35.31 MH and SA OP Services 90853 Doctoral Level (PhD, PsyD,