Common use of Participating Provider Practice Guidelines, General Standards Clause in Contracts

Participating Provider Practice Guidelines, General Standards. (A) The Contractor and its Participating Providers shall develop or adopt practice guidelines consistent with current standards of care. The practice guidelines shall meet the following requirements: (1) Guidelines shall be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field; (2) Guidelines shall consider the needs of the Contractor’s Health Plan Enrollees; (3) Guidelines shall be adopted in consultation with contracting health care professionals; and (4) Guidelines shall be reviewed and updated periodically as appropriate. (B) The Contractor shall disseminate the practice guidelines to all affected Participating Providers and, upon request, to Enrollees. (C) The Contractor shall ensure that decisions for utilization management, Enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the practice guidelines.