Common use of Obligations of Provider Clause in Contracts

Obligations of Provider. 3.1 Provider shall submit information to InterWest, upon request, as may be required to support InterWest’s provider credentialing process. Provider warrants and represents that all such information is true, accurate, and complete and shall notify InterWest promptly of any changes. 3.2 Provider shall accept as patients those Enrollees of Health Benefit Plans that provide access to Health Care Networks in which Provider has agreed to participate, as identified by the Schedules incorporated as attachments to this Agreement. This obligation does not prohibit Provider from refusing to render non-Emergency services to any Enrollee that demonstrates violent, threatening, abusive, or otherwise inappropriate behavior. Provider may close his or her practice to new Enrollees upon ninety (90) days’ advance written notice to InterWest. 3.3 Provider shall provide Covered Services to Enrollees within the scope of his or her license, certification, and specialty. Provider shall make best efforts to ensure that such services are Medically Necessary and are provided in a cost effective manner consistent with quality of care. 3.4 Provider shall make best efforts to provide Covered Services in the same manner, with the same availability, and in accordance with the same standards as provided to other patients, without regard to an Enrollee’s participation as a private purchaser or as a participant in a publicly financed program of health care services. Provider shall not discriminate against an Enrollee on the basis of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, handicap, source of payment, or lawful employment. 3.5 Provider shall make best efforts to cooperate with the utilization management requirements of Payors, as documented on Enrollees’ ID cards and other materials issued by Payors or by InterWest on a Payor’s behalf. Such requirements include, but are not limited to, preadmission certification, emergency admission notification, continued stay review, discharge planning, prior approval for outpatient procedures, and case management. 3.6 Provider shall submit claims data to Payors for Covered Services rendered to Enrollees. Such data shall be submitted electronically or on UB-04 or CMS 1500 claim forms (or successor forms) in accordance with: (a) Procedures established by Payors or by InterWest on a Payor’s behalf; and (b) Standard industry conventions for CPT, HCPCS, ICD-9, and other coding. Claims shall be submitted as promptly as possible, preferably within ninety (90) days following the date of service. Claims submitted after one (1) year may be denied for lack of timely filing. If a Payor makes an error repricing a claim, Provider may contact InterWest or the Payor directly to request that the claim be adjusted. Requests for adjustment shall be submitted as promptly as possible, preferably within ninety (90) days but no later than one (1) year following the date the claim was processed. All other appeals shall be submitted directly to Payors in accordance with Payor procedures. 3.7 Provider shall make best efforts to refer Enrollees to other Participating Providers where medically feasible, when requested by the Enrollee or required under the terms of an Enrollee’s Health Benefit Plan. 3.8 Provider shall establish and maintain medical and other records for Enrollees who receive services under the terms of this Agreement. It is understood that medical records are the property of Provider and shall not be removed or transferred from Provider’s premises, except as required or permitted under applicable State and Federal law. 3.9 Provider shall make all records relating to this Agreement available to InterWest, Payors, and governmental authorities having jurisdiction over this Agreement for inspection and copying at reasonable times upon receipt of at least 24 hours prior written notice. Provider is under no obligation to release medical information to any party without a proper written release from the Enrollee. InterWest warrants that prior to requesting a medical record, it will obtain a valid written release from the Enrollee or his or her legal representative authorizing InterWest to obtain the medical record and will hold Provider harmless from any liability incurred as a result of the release of the medical record, including, but not limited to, any attorney fees paid or incurred by Provider. InterWest agrees to reimburse Provider for all reasonable costs that he or she incurs in copying records that InterWest requests. 3.10 Provider shall maintain at Provider’s expense professional malpractice insurance in the minimum amount specified in InterWest’s provider credentialing standards. 3.11 Provider shall allow InterWest to use his or her name, address, specialty, and other relevant information in marketing and enrollment materials and to release information to Payors regarding Provider’s credentials and malpractice insurance. The parties agree not to use any symbols, trademarks, service marks, or other similar devices of the other party without the party’s prior written consent.

Obligations of Provider. 3.1 Provider shall submit information to InterWest, upon request, as may be required to support InterWest’s provider credentialing process. Provider warrants and represents that all such information is true, accurate, and complete and shall notify InterWest promptly of any changes. 3.2 Provider shall accept as patients those Enrollees of Health Benefit Plans that provide access to Health Care Networks in which Provider has agreed to participate, as identified by the Schedules incorporated as attachments to this Agreement. This obligation does not prohibit Provider from refusing to render non-Emergency services to any Enrollee that demonstrates violent, threatening, abusive, or otherwise inappropriate behavior. Provider may close his or her practice to new Enrollees upon ninety (90) days’ advance written notice to InterWest. 3.3 Provider shall provide Covered Services to Enrollees within the scope of his or her license, certification, and specialty. Provider shall make best efforts to ensure that such services are Medically Necessary and are provided in a cost effective manner consistent with quality of care. 3.4 Provider shall make best efforts to provide Covered Services in the same manner, with the same availability, and in accordance with the same standards as provided to other patients, without regard to an Enrollee’s participation as a private purchaser or as a participant in a publicly financed program of health care services. Provider shall not discriminate against an Enrollee on the basis of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, handicap, source of payment, or lawful employment. 3.5 Provider shall make best efforts to cooperate with the utilization management requirements of Payors, as documented on Enrollees’ ID cards and other materials issued by Payors or by InterWest on a Payor’s behalf. Such requirements include, but are not limited to, preadmission certification, emergency admission notification, continued stay review, discharge planning, prior approval for outpatient procedures, and case management. 3.6 Provider shall submit claims data to Payors for Covered Services rendered to Enrollees. Such data shall be submitted electronically or on UB-04 or CMS 1500 claim forms (or successor forms) in accordance with: (a) Procedures established by Payors or by InterWest on a Payor’s behalf; and (b) Standard industry conventions for CPT, HCPCS, ICD-9, and other coding. Claims shall be submitted as promptly as possible, preferably within ninety (90) days following the date of service. Claims submitted after one (1) year may be denied for lack of timely filing. If a Payor makes an error repricing a claim, Provider may contact InterWest or the Payor directly to request that the claim be adjusted. Requests for adjustment shall be submitted as promptly as possible, preferably within ninety (90) days but no later than one twenty four (124) year months following the date the claim was processed or, where coordination of benefits is involved, thirty (30) months following the date the claim was processed. All other appeals shall be submitted directly to Payors in accordance with Payor procedures. 3.7 Provider shall make best efforts to refer Enrollees to other Participating Providers where medically feasible, when requested by the Enrollee or required under the terms of an Enrollee’s Health Benefit Plan. 3.8 Provider shall establish and maintain medical and other records for Enrollees who receive services under the terms of this Agreement. It is understood that medical records are the property of Provider and shall not be removed or transferred from Provider’s premises, except as required or permitted under applicable State and Federal law. 3.9 Provider shall make all records relating to this Agreement available to InterWest, Payors, and governmental authorities having jurisdiction over this Agreement for inspection and copying at reasonable times upon receipt of at least 24 hours prior written notice. Provider is under no obligation to release medical information to any party without a proper written release from the Enrollee. InterWest warrants that prior to requesting a medical record, it will obtain a valid written release from the Enrollee or his or her legal representative authorizing InterWest to obtain the medical record and will hold Provider harmless from any liability incurred as a result of the release of the medical record, including, but not limited to, any attorney fees paid or incurred by Provider. InterWest agrees to reimburse Provider for all reasonable costs that he or she incurs in copying records that InterWest requests. 3.10 Provider shall maintain at Provider’s expense professional malpractice insurance in the minimum amount specified in InterWest’s provider credentialing standards. 3.11 Provider shall ensure that all subcontracted providers who render Covered Services to Enrollees under the terms of this Agreement abide by the terms of the Agreement. 3.12 Provider shall allow InterWest to use his or her name, address, specialty, and other relevant information in marketing and enrollment materials and to release information to Payors regarding Provider’s credentials and malpractice insurance. The parties agree not to use any symbols, trademarks, service marks, or other similar devices of the other party without the party’s prior written consent. 3.13 Except in the case of fraud, Provider may not request additional payment from Payor to satisfy a claim unless he or she does so in writing to Payor within twenty-four

Obligations of Provider. 3.1 In addition to any and all other obligations of the Provider set forth herein, Provider agrees to follow all policies and procedures provided by SHBB which may change from time to time. SHBB shall submit information provide thirty (30) days’ prior Notice to InterWestProvider. Such policies and procedures are included as Exhibit A to this Agreement and, upon requestby way of Provider’s signature hereto, as may be required to support InterWestshall evidence Provider’s provider credentialing processacknowledgement and receipt of the Policies and Procedures. Provider warrants and represents that all such information is trueagrees to maintain the Safety Device in good working order, accuratethe costs of which are to be borne by Provider. Provider agrees to not change, and complete and shall notify InterWest promptly of any changes. 3.2 Provider shall accept as patients those Enrollees of Health Benefit Plans that provide access to Health Care Networks in which Provider has agreed to participateadd to, as identified by the Schedules incorporated as attachments to this Agreement. This obligation does not prohibit Provider from refusing to render non-Emergency services to any Enrollee that demonstrates violentsubtract from, threateningalter, abusiverebrand, or otherwise inappropriate behaviormodify the Safety Device and accompanying signage as set forth in Exhibit A in any manner whatsoever without the prior written approval of SHBB. Provider may close his agrees to use best efforts to prevent any third parties from adding to, subtracting from, altering, rebranding, or her practice otherwise modifying the Safety Device and accompanying materials/signage as set forth in Exhibit A in any manner whatsoever without prior written approval by SHBB. Provider agrees to new Enrollees upon ninety (90) days’ advance written notice immediately notify SHBB of any modification to InterWest. 3.3 the Safety Device. Provider shall provide Covered Services agrees to Enrollees within accept complete liability for any and all unapproved modifications to the scope Safety Device and any and all unapproved modifications to accompanying parts of his the Safety Device, including required signage/materials. Provider agrees to accept complete liability for modifications to the Safety Device which are the result of: its own actions, omissions, and/or failure to use best efforts to maintain the Safety Device in good working order or her license, certification, and specialtybest efforts to prevent any modifications to the Safety Device by a third party. Provider shall make best efforts refer to ensure the Safety Device as a “Safe Haven Baby Box”. Further, Provider shall procure and maintain a twenty-four (24) hour alarm monitoring of the Safety Device at all times and shall confirm with SHBB that such services are Medically Necessary and are provided in a cost effective manner consistent with quality of care. 3.4 service is acceptable. Should alarm monitoring service be disconnected for any reason, Provider shall make best efforts immediately notify SHBB and shall secure the Safety Device by locking its exterior door and removing all signage and materials related to provide Covered Services in the same manner, with the same availability, its use and in accordance with the same standards as provided to other patients, without regard to an Enrollee’s participation as a private purchaser or as a participant in a publicly financed program of health care servicesfunctionality. Provider shall not discriminate against an Enrollee on the basis of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, handicap, source of payment, or lawful employment. 3.5 Provider shall make best efforts to cooperate with the utilization management requirements of Payors, as documented on Enrollees’ ID cards and other materials issued by Payors or by InterWest on a Payor’s behalf. Such requirements includeSHBB may, but are is not limited required to, preadmission certification, emergency admission notification, continued stay review, discharge planning, prior approval for outpatient procedures, and case management. 3.6 Provider shall submit claims data to Payors for Covered Services rendered to Enrollees. Such data shall be submitted electronically or on UB-04 or CMS 1500 claim forms (or successor forms) in accordance with: (a) Procedures established by Payors or by InterWest on a Payor’s behalf; and (b) Standard industry conventions for CPT, HCPCS, ICD-9, and other coding. Claims shall be submitted as promptly as possible, preferably within ninety (90) days following inspect the date of service. Claims submitted after one (1) year may be denied for lack of timely filing. If a Payor makes an error repricing a claim, Provider may contact InterWest or the Payor directly to request that the claim be adjusted. Requests for adjustment shall be submitted as promptly as possible, preferably within ninety (90) days but no later than one (1) year following the date the claim was processed. All other appeals shall be submitted directly to Payors in accordance with Payor procedures. 3.7 Provider shall make best efforts to refer Enrollees to other Participating Providers where medically feasible, when requested by the Enrollee or required under the terms of an Enrollee’s Health Benefit Plan. 3.8 Provider shall establish and maintain medical and other records for Enrollees who receive services under the terms of this Agreement. It is understood that medical records are the property of Provider and shall not be removed or transferred from Provider’s premises, except as required or permitted under applicable State and Federal law. 3.9 Provider shall make all records relating to this Agreement available to InterWest, Payors, and governmental authorities having jurisdiction over this Agreement for inspection and copying Safety Device at reasonable times upon receipt of at least 24 hours prior written notice. Provider is under no obligation to release medical information to any party without a proper written release from the Enrollee. InterWest warrants that prior to requesting a medical record, it will obtain a valid written release from the Enrollee or his or her legal representative authorizing InterWest to obtain the medical record and will hold Provider harmless from any liability incurred as a result of the release of the medical recordtime, including, but not limited to: to ensure that it is in good working order, any attorney fees paid or incurred by Provider. InterWest agrees to reimburse Provider for all reasonable costs that he or she incurs in copying records that InterWest requests. 3.10 Provider shall maintain at Provider’s expense professional malpractice insurance in the minimum amount specified in InterWest’s provider credentialing standards. 3.11 Provider shall allow InterWest to use his or her name, address, specialtyensure proper branding and signage is being displayed, and other relevant information in marketing to conduct tests related to its functionality and enrollment materials monitoring and to release information to Payors regarding Provider’s credentials and malpractice insurancealarm systems. The parties agree not to use any symbols, trademarks, service marks, or other similar devices of the other party without the party’s prior written consentIT IS IMPERATIVE THAT ANY MALFUNCTION IDENTIFIED WITH RESPECT TO THE SAFETY DEVICE OR ANY DISCONNECTION IN THE SAFETY DEVICE MONITORING SYSTEM RESULT IN THE IMMEDIATE SECURING AND LOCKING OF THE SAFETY DEVICE SO THAT IT MAY NOT BE USED BY THE PUBLIC DURING THIS TIME PERIOD. FAILURE TO DO SO MAY RESULT IN A THREAT OF BODILY HARM OR DEATH TO AN INFANT PLACED IN THE SAFETY DEVICE DURING ANY PERIOD OF TIME IN WHICH THE SAFETY DEVICE IS MALFUNCTIONING OR NOT.

Obligations of Provider. 3.1 2.1 Throughout the term of this Agreement, Provider shall submit information have and maintain, without restriction, all licenses, certificates, registrations and permits as are required under applicable State and federal statutes and regulations to InterWest, upon request, as may be required to support InterWest’s provider credentialing process. provide the Covered Services furnished by Provider warrants and represents that all such information is true, accurate, and complete and shall notify InterWest promptly of any changes. 3.2 Provider shall accept as patients those Enrollees of Health Benefit Plans that provide access to Health Care Networks in which Provider has agreed to participate, as identified and/or other related activities delegated by the Schedules incorporated as attachments to ACDE under this Agreement. This obligation does not prohibit Provider from refusing shall obtain a unique identifier (national provider identifier) in accordance with the system established under Section 1173(b) of the Social Security Act, submit such identifier number to render non-Emergency ACDE, and include such identifier on all claims. At all times during the term of this Agreement, Provider shall be eligible for participation in the Delaware Medicaid program; and, if required by the Delaware Medicaid program as a condition of furnishing services to any Enrollee Delaware Medicaid recipients, Provider shall participate in the Delaware Medicaid program. To the extent that demonstrates violentCovered Services are furnished to Medicare beneficiaries under this Agreement, threatening, abusive, or otherwise inappropriate behaviorProvider shall also participate in the Medicare program. Provider may close his or her practice shall ensure that all services provided pursuant to new Enrollees upon ninety (90) days’ advance written notice to InterWestthis Agreement are within the Provider’s scope of professional responsibility. 3.3 2.2 Provider shall provide to Members the Covered Services described in Appendix A hereto; provided, however, that Provider shall only be obligated to provide Covered Services to Enrollees within a Member in accordance with ACDE’s pre-authorization and other Utilization Management Program policies as described in the scope Provider Manual, other than Emergency Services, which will be provided as needed. In providing Covered Services, Provider agrees to abide by the relevant standards, policies and procedures of his or her licenseACDE, certificationincluding, but not limited to administrative, credentialing, quality management, utilization management, and specialtyMember Appeal Procedures set forth in the Provider Manual and other ACDE notices. Provider shall make best efforts to ensure that such services are Medically Necessary and are provided in a cost effective manner consistent with quality of care. 3.4 Provider shall make best efforts to provide Covered Services in the same manner, manner and with the same availability, availability as services provided to other patients without regard to reimbursement and shall further provide these services in the most cost effective setting in accordance with the same appropriate quality of care and performance standards which are professionally recognized as industry standards and/or otherwise adopted, accepted or established by ACDE. 2.3 Provider shall provide ACDE with complete and accurate statements of all Covered Services provided to other patientsMembers in conformance with ACDE billing procedures as set forth in the applicable Program manuals, without regard to an Enrollee’s participation as a private purchaser or as a participant in a publicly financed program of health care services. the Provider shall not discriminate against an Enrollee on the basis of race, color, national origin, ancestry, religion, sex, marital status, sexual orientation, age, handicap, source of payment, or lawful employment. 3.5 Provider shall make best efforts to cooperate with the utilization management requirements of Payors, as documented on Enrollees’ ID cards Manual and other materials issued by Payors or by InterWest on a Payor’s behalfwritten ACDE billing guidelines. Such requirements include, but ACDE will not be liable for any bills relating to services that are not limited to, preadmission certification, emergency admission notification, continued stay review, discharge planning, prior approval for outpatient procedures, and case management. 3.6 Provider shall submit claims data to Payors for Covered Services rendered to Enrollees. Such data shall be submitted electronically or on UB-04 or CMS 1500 claim forms (or successor forms) in accordance with: the later of: (a) Procedures established by Payors after twelve (12) months from the date the services were provided (consistent with 42 CFR §447.45(d)), or by InterWest on a Payor’s behalf; and (b) Standard industry conventions for CPT, HCPCS, ICD-9, and other coding. Claims shall be submitted as promptly as possible, preferably within ninety after sixty (9060) days following of the date of servicethe Explanation of Benefits from another payor when services are first billed by Provider to another payor. Claims submitted after one (1) year may be denied for lack of timely filing. If a Payor makes an error repricing a claim, Provider may contact InterWest Any appeal or the Payor directly to request that the claim be adjusted. Requests for adjustment shall of a payment by Provider must be submitted as promptly as possible, preferably within ninety (90) days but no later than one (1) year following the date the claim was processed. All other appeals shall be submitted directly to Payors made in accordance with Payor procedures. 3.7 applicable provisions of the Provider shall make best efforts to refer Enrollees to other Participating Providers where medically feasibleManual and ACDE policies and procedures and, when requested in any case, must be received by ACDE within sixty (60) days of the Enrollee original payment or required under the terms of an Enrollee’s Health Benefit Plan. 3.8 Provider shall establish and maintain medical and other records for Enrollees who receive services under the terms of this Agreement. It is understood that medical records are the property of Provider and shall not be removed or transferred from Provider’s premises, except as required or permitted under applicable State and Federal law. 3.9 Provider shall make all records relating to this Agreement available to InterWest, Payors, and governmental authorities having jurisdiction over this Agreement for inspection and copying at reasonable times upon receipt of at least 24 hours prior written noticedenial. Provider is under no obligation to release medical information to any party without a proper written release from may not bring legal action on claims which have not been appealed through the Enrollee. InterWest warrants that prior to requesting a medical record, it will obtain a valid written release from the Enrollee or his or her legal representative authorizing InterWest to obtain the medical record and will hold Provider harmless from any liability incurred as a result of the release of the medical record, including, but not limited to, any attorney fees paid or incurred by Provider. InterWest agrees to reimburse Provider for all reasonable costs that he or she incurs in copying records that InterWest requestsappeal mechanisms described herein. 3.10 Provider shall maintain at Provider’s expense professional malpractice insurance in the minimum amount specified in InterWest’s provider credentialing standards. 3.11 Provider shall allow InterWest to use his or her name, address, specialty, and other relevant information in marketing and enrollment materials and to release information to Payors regarding Provider’s credentials and malpractice insurance. The parties agree not to use any symbols, trademarks, service marks, or other similar devices of the other party without the party’s prior written consent.