PROCEDURE FOR DE-EMPANELLEMENT OF NETWORK PROVIDER Sample Clauses

PROCEDURE FOR DE-EMPANELLEMENT OF NETWORK PROVIDER. Steps 1 - Putting the Provider on “Watch-list”
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PROCEDURE FOR DE-EMPANELLEMENT OF NETWORK PROVIDER. The following procedure shall be followed for de-empanelment of Network Provider: Steps 1 - Putting the Network Provider on “Watch-list” Based on the claims data analysis and / orthe Network Provider visits, ifthereisany doubt on the performance of a Network Provider, the InsuranceCompany can put that Network Provider on the watch list. Thedataof suchNetworkProvidershallbeanalyzedverycloselyon adailybasis by the Insurance Company for patterns, trends and anomalies. Step 2 - Suspension of the Network Provider A Network Provider can be temporarily suspended in the following cases: FortheNetworkProviderswhichareinthe “Watch-list”iftheInsuranceCompanyobservescontinuouspatterns or strong evidence of irregularity based oneitherclaimsdataorfieldvisitofNetwork Provider,theNetwork Provider shallbesuspendedfromprovidingservicestobeneficiariesandaformal investigation shall be instituted. Ifa Network Provider isnotinthe “Watch-list”,buttheInsuranceCompany observesatany stagethat it has data / evidence that suggests thatthe Network Provider is involved in any unethical practice/ or is not adhering to the Agreement or involvedinfinancial fraudrelated to health insurance Beneficiaries, it mayimmediately suspend the NetworkProvider fromprovidingservicestoBeneficiaries andaformalinvestigationshallbe instituted. Aformalletter shallbesenttothe Network Provider regarding its suspension withmentioningthetimeframewithinwhichtheformalinvestigationwillbe completed. Step 3 - Detailed Investigation The Insurance Company can launch a detailed investigation into the activities of a Network Provider in the following conditions: For the Network Provider which have been suspended. Receipt of complaint of a serious nature from any of the stakeholders. ThedetailedinvestigationmayincludefieldvisitstotheNetworkProvider, examinationofcasepapers,talkingwiththeInsuredPerson / Member(if needed), examination of Network Provider records etc. Iftheinvestigationrevealsthatthereport / complaint / allegationagainstthe NetworkProviderisnotsubstantiated,theInsuranceCompanywouldimmediatelyrevokethesuspension (in case it is suspended). A letter regarding revocation of suspension shall be sent to the Network Provider within 24 hours of that decision.
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Related to PROCEDURE FOR DE-EMPANELLEMENT OF NETWORK PROVIDER

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