CREDENTIALING PROVIDER HEALTH CARE DELIVERY ORGANIZATIONS Sample Clauses

CREDENTIALING PROVIDER HEALTH CARE DELIVERY ORGANIZATIONS. The MCO must have policies and procedures for credentialing health care delivery organizations, including but not limited to, hospitals, home health agencies, freestanding surgical centers, laboratories, and subcontracted networks of providers. Every three years after the effective date of the initial contract the MCO must confirm the following: - That the organizations are in good standing with state and federal regulatory bodies. - That the organizations have been reviewed and approved by an accreditation body before contracting with the MCO. - That the organizations conform to the previously mentioned requirements. The MCO must also develop standards of participation and assess these providers accordingly if the provider has not received accreditation. The MCO is prohibited from contracting with or paying (except in the case of emergency situations) providers that are excluded from participation in Federal health care programs. The MCO must credential and recredential all providers. The MCO is required to report on the credentialing status of its providers, as required in the Reporting Manual. In accordance with 42 CFR 438.214, the credentialing and re-credentialing policies and procedures must be uniformly applied to all contracted providers. The MCO may not discriminate against providers serving high-risk populations or specializing in conditions requiring costly treatment. If the MCO declines to include an individual or group of providers in its network, the MCO must furnish written notice to the provider of the reason for its decision. The health plan must have written policies and procedures for monitoring its providers and for sanctioning providers who are out of compliance with the plan's medical management standards. In accordance with 42 CFR 438.12, the MCO is not required to contract with providers beyond the number necessary to meet the needs of its member. The MCO may choose to use different reimbursement amounts for different specialties or for different practitioners in the same specialty. The MCO is also permitted to establish measures that are designed to maintain quality of services and control
Sample 1
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