Cooperation with Protocols. Participating Providers will cooperate with and be bound by United’s and Payers’ Protocols. The Protocols include but are not limited to all of the following:
a) For non-emergency covered Services, Participating Providers will assist Customers to maximize their benefits by referring or directing Customers only to other providers that participate in United’s network, except as otherwise authorized by United through United’s process for approving out-of-network services at in-network benefit levels.
b) If the Customer’s Benefit Plan requires the Customer to receive certain Covered Services from or upon referral by a primary care physician, Organization Professionals must adhere to the following additional protocols:
1) Notify Customer’s primary care physician of referrals to other participating or non- participating providers.
2) Render Covered Services pursuant to the terms and limitations of the referral notification issued by or on behalf of the Customer’s primary care physician.
3) Notify the Customer’s primary care physician of all admissions.
c) As further described in the Protocols, Participating Providers will provide notification and participate in utilization management programs regarding certain Covered Services, accept and return telephone calls from United staff, and respond to United requests for clinical information, as required by United or Payer.
Cooperation with Protocols. Facility will cooperate with and be bound by United’s and Payers’ Protocols. The Protocols include but are not limited to all of the following:
1) Facility will use reasonable commercial efforts to direct Customers only to other providers that participate in United’s network, except as permitted under the Customer’s Benefit Plan or otherwise authorized by United or Payer.
2) Facility will make its best efforts to assure that all Facility-based physician groups participate in United’s network as long as this Agreement is in effect. In the event that a Facility-based physician group is not a participating provider with United, Facility’s Chief Financial Officer or equivalent senior level officer (“Facility Representative”) will assist United in its efforts to negotiate an agreement with such group. Upon request by United, Facility Representative will:
a) meet with Facility-based physician group to encourage participation. Facility Representative shall provide United with meeting minutes of any such meeting within 15 days. Meeting minutes will include a summary of the key discussion points and an outline of any actionable resolution options deemed by Facility Representative.
b) write letter(s) to Facility-based physician group encouraging the group to negotiate in good faith with United. The letter will also outline any contractual requirements in the agreement between Facility and Facility-based physician group that requires Facility-based physician group to (1) negotiate in good faith with third party payers, (2) participate in third party payer networks, and (3) other provisions related to Facility-based physician group’s participation with third party payers.
c) invoke any applicable penalties or other contractual terms in its agreement with Facility-based physician group related to its non-participating status with a third party payer.
d) allow independent legal counsel (mutually agreeable to all relevant parties) to review Facility/Facility-based physician agreement to ensure Facility is fully invoking all the relevant terms and conditions of such agreement to require or promote Facility-based physician group’s participation status with United. United warrants that it will negotiate with Facility-based physician groups in good faith. Facility acknowledges that United will have no responsibility for the credentialing of any employed or sub-contracted Facility-based provider.
3) Facility will provide notification for certain Covered Services, accept and r...
Cooperation with Protocols. Medical Group will cooperate with and be bound by United’s and Payers’ Protocols. The Protocols include but are not limited to all of the following:
Cooperation with Protocols. Medical Group will cooperate with and be bound by United’s and Payers’ Protocols. The Protocols include but are not limited to all of the following:
1. Medical Group will use reasonable commercial efforts to direct Customers only to other providers that participate in United’s network, except as otherwise authorized by United or Payer.
2. If the Customer’s Benefit Plan requires the Customer to receive certain Covered Services from or upon referral by a primary care physician, all referral physicians must adhere to the following additional protocols when those Covered Services are provided:
a. Notify Customer’s primary care physician of referrals to other participating or nonparticipating providers.
b. Covered Services must be provided pursuant to the terms and limitations of the referral notification issued by or on behalf of the Customer’s primary care physician.
c. If the Medical Group Physician providing the Covered Services is a referral physician, the Medical Group Physician must also notify the Customer’s primary care physician of all admissions in accordance with the required time frames.
3. Medical Group will provide notification for certain Covered Services, accept and return telephone calls from United staff, and respond to United requests for clinical information, as required by United or Payer as described in the Protocols. The Protocols will be made available to Medical Group online or upon request. Some or all Protocols also may be disseminated in the form of an administrative manual or guide or in other communications. See Appendix 4 for additional information on the Protocols applicable to Customers enrolled in certain Benefit Plans. United may change the Protocols from time to time. United will use reasonable commercial efforts to inform Medical Group at least 30 days in advance of any material changes to the Protocols. United may implement changes in the Protocols without Medical Group’s consent if such change is applicable to all or substantially all of the medical groups in United’s network located in the same state as Medical Group and that practice the same specialty as Medical Group. Otherwise, changes to the Protocols proposed by United to be applicable to Medical Group are subject to the terms of section 10.2 of this Agreement that are applicable to amendments.
Cooperation with Protocols. Provider and Participating Provider will cooperate with and be bound by Optum’s, Plan’s and Payer’s Protocols. The Protocols will be made available to Provider upon request. Some or all Protocols also may be disseminated in the form of an operations manual or guide or in other communications. This includes the Optum Operations Manual, which is incorporated into this Agreement by reference. The Operations Manual describes, among other things, Optum’s administrative and operational procedures, such as credentialing, claims submission, audit and recovery review, and clinical submission requirements. Optum, Plan and Payer may make changes to the Protocols from time to time. Optum will use reasonable commercial efforts to inform Provider at least 30 days in advance of any material changes to the Protocols.
Cooperation with Protocols. Ancillary Provider will cooperate with and be bound by United’s Protocols. The Protocols include but are not limited to all of the following:
i) Ancillary Provider will use reasonable commercial efforts to direct Customers only to other providers that participate in United’s network, except as permitted under the Customer’s Benefit Plan or otherwise authorized by United.
ii) Ancillary Provider will provide notification for certain Covered Services, accept and return telephone calls from United staff, and respond to United requests for clinical information as required by United as described in the Protocols. The Protocols will be made available to Ancillary Provider online or upon request. Some or all Protocols also may be disseminated in the form of an administrative manual or guide or in other communications. United may change the Protocols from time to time. United will use reasonable commercial efforts to inform Ancillary Provider at least 30 days in advance of any material changes to the Protocols. United may implement changes in the Protocols without Ancillary Provider’s consent if the change is applicable to all or substantially all facilities in United’s network located in the same state as Ancillary Provider. Otherwise, changes to the Protocols proposed by United to be applicable to Ancillary Provider are subject to the terms of section 9.2 of this Agreement applicable to amendments.
