Common use of ADDITIONAL REQUIREMENTS FOR AN INTEGRATED DELIVERY SYSTEM Clause in Contracts

ADDITIONAL REQUIREMENTS FOR AN INTEGRATED DELIVERY SYSTEM. If Provider is an Integrated Delivery System (“IDS”), as defined in 28 Pa. Code § 9.602, the following additional provisions shall apply pursuant to 28 Pa. Code §§ 9.724 and 9.725 and 31 Pa. Code § 301.314. 4.1. Provider acknowledges and agrees that under no circumstance shall provision of Covered Services to Covered Persons be delayed, reduced, denied or otherwise hindered because of the financial or contractual relationship between Health Plan or Subcontractor and Provider or between Provider and the health care providers that participate in Provider’s IDS. 4.2. Provider acknowledges and agrees that only those IDS participating health care providers who meet Health Plan’s credentialing and provider contracting standards may participate and provide services to Covered Persons and that the ultimate authority to approve or terminate IDS health care providers is retained by Health Plan. 4.3. Provider acknowledges and agrees that Health Plan is required to establish, operate and maintain a health care services delivery system, quality assurance system, provider credentialing system, Covered Person complaint and grievance system, and other systems meeting DOH standards and that Health Plan is directly accountable to DOH for the standards and for provision of quality, cost-effective care to Covered Persons. Nothing in the Agreement or this Appendix does or shall be construed to limit Health Plan’s authority or responsibility to meet such standards or to take prompt corrective action to address a quality of care problem, resolve a Covered Person compliant or grievance, or to comply with a regulatory requirement of DOH. 4.4. Provider agrees to provide Health Plan and DOH with access to medical and other records concerning the provision of services to Covered Persons by the IDS through its participating health care providers. Provider agrees to permit and cooperate with onsite reviews by DOH for purposes of monitoring the effectiveness of Provider’s performance of any Health Plan or Subcontractor delegated functions. 4.5. Provider agrees that any delegation of authority or responsibility, in part or in full, for provider credentialing and relations, quality assessment, utilization review (“UR”) and other plan functions to Provider shall be subject to performance monitoring by Health Plan, Subcontractor and DOH, and subject to independent validation by Health Plan, Subcontractor, DOH, or an independent quality review organization or Certified Utilization Review Entity (“CRE”) approved by DOH. 4.6. Provider agrees to collect and provide Health Plan and Subcontractor with utilization, financial and other data for the purposes of monitoring and comparative performance analysis. 4.7. Provider shall comply with all data reporting requirements, including encounter, utilization and reimbursement methodology, required by DOH. 4.8. Provider shall obtain and maintain DOH certification as a CRE if performing UR activities as set forth in Subchapter K (relating to CREs) and sections 2151 and 2152 of Act 68 (40 P.S. §§ 991.2151 and 991.2152). 4.9. Provider agrees that the continuation of care and hold harmless provisions of this Appendix shall apply with equal force to IDS participating health care providers. 4.10. If the Agreement includes a termination without cause provision, neither Health Plan, Subcontractor nor Provider shall terminate the Agreement without cause upon less than sixty (60) days prior written notice. 4.11. Health Plan, Subcontractor and Provider agree that any delegation of medical management shall meet the requirements of 28 Pa. Code § 9.

ADDITIONAL REQUIREMENTS FOR AN INTEGRATED DELIVERY SYSTEM. If Provider is an Integrated Delivery System (“IDS”), as defined in 28 Pa. Code § 9.602, the following additional provisions shall apply pursuant to 28 Pa. Code §§ 9.724 and 9.725 and 31 Pa. Code § 301.314. 4.1. Provider acknowledges and agrees that under no circumstance shall provision of Covered Services to Covered Persons Customers be delayed, reduced, denied or otherwise hindered because of the financial or contractual relationship between Health Plan or Subcontractor United and Provider or between Provider and the health care providers that participate in Provider’s IDS. 4.2. Provider acknowledges and agrees that only those IDS participating health care providers who meet Health PlanUnited’s credentialing and provider contracting standards may participate and provide services to Covered Persons Customers and that the ultimate authority to approve or terminate IDS health care providers is retained by Health PlanUnited. 4.3. Provider acknowledges and agrees that Health Plan United is required to establish, operate and maintain a health care services delivery system, quality assurance system, provider credentialing system, Covered Person Customer complaint and grievance system, and other systems meeting DOH PID’S BMC standards and that Health Plan United is directly accountable to DOH PID’S BMC for the standards and for provision of quality, cost-effective care to Covered PersonsCustomers. Nothing in the Agreement or this Appendix does or shall be construed to limit Health PlanUnited’s authority or responsibility to meet such standards or to take prompt corrective action to address a quality of care problem, resolve a Covered Person Customer compliant or grievance, or to comply with a regulatory requirement of DOHPID’S BMC. 4.4. Provider agrees to provide Health Plan United and DOH PID’S BMC with access to medical and other records concerning the provision of services to Covered Persons Customers by the IDS through its participating health care providers. Provider agrees to permit and cooperate with onsite reviews by DOH PID’S BMC for purposes of monitoring the effectiveness of Provider’s performance of any Health Plan or Subcontractor United delegated functions. 4.5. Provider agrees that any delegation of authority or responsibility, in part or in full, for provider credentialing and relations, quality assessment, utilization review (“UR”) and other plan functions to Provider shall be subject to performance monitoring by Health Plan, Subcontractor United and DOHPID’S BMC, and subject to independent validation by Health PlanUnited, Subcontractor, DOHPID’S BMC, or an independent quality review organization or Certified Utilization Review Entity (“CRE”) approved by DOHPID’S BMC. 4.6. Provider agrees to collect and provide Health Plan and Subcontractor United with utilization, financial and other data for the purposes of monitoring and comparative performance analysis. 4.7. Provider shall comply with all data reporting requirements, including encounter, utilization and reimbursement methodology, required by DOHPID’S BMC. 4.8. Provider shall obtain and maintain DOH PID’S BMC certification as a CRE if performing UR activities as set forth in Subchapter K (relating to CREs) and sections 2151 and 2152 of Act 68 (40 P.S. §§ 991.2151 and 991.2152). 4.9. Provider agrees that the continuation of care and hold harmless provisions of this Appendix shall apply with equal force to IDS participating health care providers. 4.10. If the Agreement includes a termination without cause provision, neither Health Plan, Subcontractor United nor Provider shall terminate the Agreement without cause upon less than sixty (60) days prior written notice. 4.11. Health Plan, Subcontractor United and Provider agree that any delegation of medical management shall meet the requirements of 28 Pa. Code § 9.