Common use of GENERAL NETWORK REQUIREMENTS Clause in Contracts

GENERAL NETWORK REQUIREMENTS. ‌ Insurer shall maintain a network of Providers sufficient to meet the requirements of this Contract and to adequately serve the needs of the Enrollees. Insurer shall allow Enrollee choice of network Providers to the extent possible and appropriate. Insurer’s Provider network shall be supported by written agreements. Insurer shall establish mechanisms to: a. Ensure network Provider compliance with required terms; b. Monitor Providers regularly to determine compliance; c. Take corrective action should a network Provider fail to comply; and d. Handle Provider complaints. Insurer shall not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification, including Providers that serve high- risk populations or specialize in conditions that require costly treatment. This provision does not: a. Require Insurer to contract with Providers beyond the number necessary to meet the needs of the Enrollees; b. Preclude Insurer from using different reimbursement amounts for different specialties or different Providers of the same specialty; or c. Preclude Insurer from establishing measures designed to maintain quality of services or control costs and are consistent with Insurer’s responsibilities to Enrollees. Insurer shall promptly notify FHKC when Insurer receives information about a change in a network Provider’s information that may affect the Provider’s eligibility to participate in the Program. Insurer shall provide FHKC with a monthly list of Providers leaving and entering the network the previous month. The monthly network change report shall include each Provider’s NPI, name, address(es), specialty type, telephone number, whether the Provider is entering or leaving the network, an indicator showing whether the Provider should appear in the Provider director or be suppressed, and indicators for any Providers removed from the network for ineligibility to participate in Medicare, Medicaid or CHIP or for Fraud or Abuse. Upon FHKC request, Insurer shall provide its complete network Provider data in the format, timeframe and frequency required by FHKC. Insurer shall provide FHKC with sixty (60) Calendar Days advance written notice of any anticipated termination of large Provider groups, hospitals, or any independently practicing Provider if the independently practicing Provider has at least fifty (50) Enrollees on its patient panel.

GENERAL NETWORK REQUIREMENTS. ‌ Insurer shall maintain a network of Providers sufficient to meet the requirements of this Contract and to adequately serve the needs of the Enrollees. Insurer shall allow Enrollee choice of network Providers to the extent possible and appropriate. Insurer’s Provider network shall be supported by written agreements. Insurer shall establish mechanisms to: a. Ensure network Provider compliance with required terms; b. Monitor Providers regularly to determine compliance; c. Take corrective action should a network Provider fail to comply; and d. Handle Provider complaints. Insurer shall not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification, including Providers that serve high- risk populations or specialize in conditions that require costly treatment. This provision does not: a. Require Insurer to contract with Providers beyond the number necessary to meet the needs of the Enrollees; b. Preclude Insurer from using different reimbursement amounts for different specialties or different Providers of the same specialty; or c. Preclude Insurer from establishing measures designed to maintain quality of services or control costs and are consistent with Insurer’s responsibilities to Enrollees. Insurer shall promptly notify FHKC when Insurer receives information about a change in a network Provider’s information that may affect the Provider’s eligibility to participate in the Program. Insurer shall provide FHKC with a monthly list of Providers leaving and entering the network the previous month. The monthly network change report shall include each Provider’s NPI, name, address(es), specialty type, telephone number, whether the Provider is entering or leaving the network, an indicator showing whether the Provider should appear in the Provider director directory or be suppressed, and indicators for any Providers removed from the network for ineligibility to participate in Medicare, Medicaid Medicaid, or CHIP or for Fraud or Abuse. Upon FHKC request, Insurer shall provide its complete network Provider data in the format, timeframe and frequency required by FHKC. Insurer shall provide FHKC with sixty (60) Calendar Days advance written notice of any anticipated termination of large Provider groups, hospitals, or any independently practicing Provider if the independently practicing Provider has at least fifty (50) Enrollees on its patient panel.