Common use of Participation and Compliance Clause in Contracts

Participation and Compliance. 6.3.1 Participating Provider shall, in good faith: (a) participate in UM and QM programs established by QualCare or Payor, as applicable; (b) submit and participate in performance reviews by QualCare or Payor, as applicable; and (c) provide access to all pertinent documents and information necessary for QualCare or Payor, as applicable, to perform its UM and QM programs and administrative functions. 6.3.2 Participating Provider shall be bound by, comply with, and perform under, subject to Participating Provider’s right of complaint and appeal hereunder, the UM and QM programs established by QualCare or Payor, as applicable. Participating Provider acknowledges and agrees that: a. Adverse Benefit Determinations of the UM and QM committee may be used to deny or reduce payment for those Covered Services provided to Members. A Member may not be billed for the amount of any such payment that is so denied. Reimbursement will not be denied retroactively for a Covered Service provided to a Member where Participating Provider relied upon the written or oral Authorization of QualCare or Payor, as applicable, prior to providing services to the Member, except in cases of misrepresentation or fraud, or in cases of Member ineligibility under the applicable Plan. b. Adverse Benefit Determinations made under the UM and QM programs are for purposes of determining whether services are Covered Services under the terms and conditions of the applicable Health Benefits Plan and the extent to which benefit payments will be made. Unless otherwise expressly set forth below, Adverse Benefit Determinations shall be made as required by the exigencies of the situation – within seventy two (72) hours of receipt of a claim for Urgently Needed Services, within fifteen (15) days of receipt of a claim for all other non- Urgently Needed Services, such as pre-authorizations, and within thirty (30) days of receipt of a post-service claim. Adverse Benefit Determinations shall be provided within two (2) business days. Such Adverse Benefit Determinations shall in no way affect the responsibility of Participating Provider to provide appropriate services to Members. c. Failure to comply with any requirements of the UM or QM programs may be deemed by QualCare to be a material breach of this Agreement and may constitute additional grounds for termination of this Agreement.

Participation and Compliance. 6.3.1 Participating Provider shall, in good faith: (a) participate in UM and QM programs established by QualCare or Payor, as applicable; (b) submit and participate in performance reviews by QualCare or Payor, as applicable; and (c) provide access to all pertinent documents and information necessary for QualCare or Payor, as applicable, to perform its UM and QM programs and administrative functions. 6.3.2 Participating Provider shall be bound by, comply with, and perform under, subject to Participating Provider’s right of complaint and appeal hereunder, the UM and QM programs established by QualCare or Payor, as applicable. Participating Provider acknowledges and agrees that: a. Adverse Benefit Determinations Decisions of the UM and QM committee may be used to deny or reduce payment for those Covered Services provided to MembersMembers which were determined not to be properly Authorized or Medically Necessary, or which were inappropriately or inaccurately coded or reported. A Member may not be billed for the amount of any such payment that is so denied. Reimbursement will not be denied retroactively for a Covered Service provided to a Member where Participating Provider relied upon the written or oral Authorization of QualCare or Payor, as applicable, prior to providing services to the Member, except in cases of misrepresentation or fraud, or in cases of Member ineligibility under the applicable Plan. b. Adverse Benefit Determinations Claim determinations made under in connection with the UM and QM programs are for purposes of determining whether services are Covered Services under the terms and conditions of the applicable Health Benefits Plan and the extent to which benefit payments will be made. Unless otherwise expressly set forth below, Adverse Benefit Determinations shall be made as required by the exigencies of the situation – within seventy two (72) hours of receipt of a claim for Urgently Needed Services, within fifteen (15) days of receipt of a claim for all other non- Urgently Needed Services, such as pre-authorizations, and within thirty (30) days of receipt of a post-service claim. Adverse Benefit Determinations shall be provided within two (2) business days. Such Adverse Benefit Determinations determinations shall in no way affect the responsibility of Participating Provider to provide appropriate services to Members. c. Failure to comply with any requirements of the UM or QM programs may be deemed by QualCare to be a material breach of this Agreement and may constitute additional grounds for termination of this Agreement.