Common use of Provider Agreements Clause in Contracts

Provider Agreements. ‌ Contractor must have written agreements with a sufficient number of providers to ensure Member access to all Medically Necessary Services covered by CHIP. Contracts with all Behavioral Health providers must have provisions that all Members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge from the inpatient psychiatric hospital. Contractor’s provider agreements must include at least the following provisions: 1. A requirement that Contractor must not exclude or terminate a provider from participation in Contractor’s Provider Network due to the fact that the provider has a practice that includes a substantial number of Members with expensive medical conditions. 2. A requirement to ensure that Members are entitled to the full range of their health care providers' opinions and counsel about the availability of Medically Necessary Services under the provisions of this Contract. Any contractual provisions, including gag clauses or rules, that restricts a health care provider's ability to advise Members about medically necessary treatment options violate Federal law and regulations. 3. A requirement that Contractor cannot prohibit or restrict a provider acting within the lawful scope of practice from discussing Medically Necessary care and advising or advocating appropriate medical care with or on behalf of a Member including; information regarding the nature of treatment options; risks of treatment; alternative treatments; or the availability of alternative therapies, consultation or tests that may be self-administered. 4. A requirement that Contractor cannot prohibit or restrict a provider acting within the lawful scope of practice from providing information the Member needs in order to decide among all relevant treatment options and the risks, benefits, and consequences of treatment or non-treatment. 5. A requirement that Contractor cannot terminate a contract or employment with a provider for filing a Grievance or Appeal on a Member’s behalf. 6. A requirement securing cooperation with the QM and UM program standards outlined in Section 9, Quality Management, of this Contract. 7. A requirement that PCPs comply with requirements of Section 7.C, PCP Responsibilities, of this Contract. 8. A requirement that Contractor include in all capitated provider agreements a clause which requires that should the provider terminate its agreement with Contractor, for any reason, the provider will provide services to the Members assigned to the provider under the contract up to the end of the month in which the effective date of termination falls. 9. A requirement that the provider must comply with all applicable laws and regulations pertaining to the confidentiality of Member Medical Records, including obtaining any required written Member consents to disclose confidential Medical Records. 10. A requirement that the provider must make referrals for social, vocational, education or human services when a need for such service is identified. 11. In the event Contractor becomes insolvent or unable to pay the participating provider, a requirement that the provider shall not seek compensation for services rendered from the State, its officers, Agents, or employees, or the Members or their eligible dependents. 12. A requirement that the provider must submit claims within six (6) months from the date of service. Claims filed within the appropriate time frame but denied may be resubmitted to Contractor within ninety (90) calendar days from the date of denial. Contractor may not enter into a provider agreement that prohibits the provider from contracting with another CCO or that prohibits or penalizes Contractor for contracting with other providers. Contractor may not require providers who agree to participate in CHIP to contract with Contractor’s other lines of business.

Provider Agreements. ‌ The Contractor must have written agreements with a sufficient number of providers Providers to ensure Member access to all Medically Necessary Services covered by CHIPthe MississippiCAN Program. Contracts with all Behavioral Health providers Contractor must have provisions ensure that all Members receiving inpatient psychiatric and PRTF services are scheduled for provided with a transitional care plan that includes outpatient follow-up and/or continuing treatment prior to discharge from the inpatient psychiatric hospitalsetting. All new or renewal provider agreements entered into after the effective date of this Contract Amendment must include provisions to this effect. In all Provider agreements, the Contractor must comply with the requirements specified in 42 C.F.R. § 438.214. The Contractor’s provider Provider agreements must include at least the following provisions: 1. A requirement that the Contractor must not exclude or terminate a provider Provider from participation in the Contractor’s Provider Network due to the fact that the provider Provider has a practice that includes a substantial number of Members patients with expensive medical conditions. 2. A requirement to ensure that Members are entitled to the full range of their health care providersProviders' opinions and counsel about the availability of Medically Necessary Services under the provisions of this Contract. Any contractual provisions, including gag clauses or rules, that restricts a health care providerProvider's ability to advise Members patients about medically necessary treatment options violate Federal law and regulations. 3. A requirement that the Contractor cannot prohibit or restrict a provider Provider acting within the lawful scope of practice from discussing Medically Necessary care and advising or advocating appropriate medical care with or on behalf of a Member including; information regarding the nature of treatment options; risks of treatment; alternative treatments; or the availability of alternative therapies, consultation or tests that may be self-administered. 4. A requirement that the Contractor cannot prohibit or restrict a provider Provider acting within the lawful scope of practice from providing information the Member needs in order to decide among all relevant treatment options and the risks, benefits, and consequences of treatment or non-treatment. 5. A requirement that the Contractor cannot terminate a contract or employment with a provider Provider for filing a Grievance Complaint, Grievance, or Appeal on a Member’s behalf. 6. A requirement securing cooperation with the QM and UM program Program standards outlined in Section 9, Quality Management, of this Contract. 7. A requirement that PCPs comply with requirements of Section 7.C, PCP Responsibilities, of this Contract. 8. A requirement that the Contractor include in all capitated provider Provider agreements a clause which requires that should the provider Provider terminate its agreement with the Contractor, for any reason, the provider Provider will provide services to the Members assigned to the provider Provider under the contract up to the end of the month in which the effective date of termination falls. 9. A requirement that the provider Provider must comply with all applicable laws and regulations pertaining to the confidentiality of Member Medical Records, including obtaining any required written Member consents to disclose confidential Medical Records. 10. A requirement that the provider Provider must make referrals for social, vocational, education or human services when a need for such service is identified. 11. In the event the Contractor becomes insolvent or unable to pay the participating providerProvider, a requirement that the provider Provider shall not seek compensation for services rendered from the State, its officers, Agents, or employees, or the Members or their eligible dependents. 12. A requirement that that, effective July 1, 2014, the provider Provider must submit claims within six one hundred eighty (6180) months calendar days from the date of service. Claims filed within the appropriate time frame but denied may be resubmitted to the Contractor within ninety (90) calendar days from the date of denial. The Contractor may not enter into a provider Provider agreement that prohibits the provider Provider from contracting with another CCO or that prohibits or penalizes the Contractor for contracting with other providersProviders. The Contractor may not require providers Providers who agree to participate in CHIP the MississippiCAN Program to contract with the Contractor’s other lines of business.

Provider Agreements. ‌ The Contractor must have written agreements with a sufficient number of providers Providers to ensure Member access to all Medically Necessary Services covered by CHIPthe MississippiCAN Program. Contracts with all Behavioral Health providers behavioral health Providers must have provisions that all Members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge from the inpatient psychiatric hospitalhospital if the Contractor is aware of the Member’s inpatient hospitalization status. The Division’s Utilization Management Contractor will provide daily reports to the Contractor to identify Members admitted to an inpatient facility. In all Provider agreements, the Contractor must comply with the requirements specified in 42 C.F.R. § 438.214. The Contractor’s provider Provider agreements must include at least include, but are not limited to, the following provisions: 1. A requirement that the Contractor must not exclude or terminate a provider Provider from participation in the Contractor’s Provider Network due to the fact that the provider Provider has a practice that includes a substantial number of Members patients with expensive medical conditions. 2. A requirement to ensure that Members are entitled to the full range of their health care providersProviders' opinions and counsel about the availability of Medically Necessary Services under the provisions of this Contract. Any contractual provisions, including gag clauses or rules, that restricts a health care providerProvider's ability to advise Members patients about medically necessary treatment options violate Federal law and regulations. 3. A requirement that the Contractor cannot prohibit or restrict a provider Provider acting within the lawful scope of practice from discussing Medically Necessary care and advising or advocating appropriate medical care with or on behalf of a Member including; information regarding the nature of treatment options; risks of treatment; alternative treatments; or the availability of alternative therapies, consultation or tests that may be self-administered. 4. A requirement that the Contractor cannot prohibit or restrict a provider Provider acting within the lawful scope of practice from providing information the Member needs in order to decide among all relevant treatment options and the risks, benefits, and consequences of treatment or non-treatment. 5. A requirement that the Contractor cannot terminate a contract or employment with a provider Provider for filing a Grievance Complaint, Grievance, or Appeal on a Member’s behalf. 6. A requirement securing cooperation with the QM and UM program Program standards outlined in Section 9, Quality Management, of this Contract. 7. A requirement that PCPs comply with requirements of Section 7.C, PCP Responsibilities, of this Contract. 8. A requirement that the Contractor include in all capitated provider Provider agreements a clause which requires that should the provider Provider terminate its agreement with the Contractor, for any reason, the provider Provider will provide services to the Members assigned to the provider Provider under the contract up to the end of the month in which the effective date of termination falls. 9. A requirement that the provider Provider must comply with all applicable laws and regulations pertaining to the confidentiality of Member Medical Records, including obtaining any required written Member consents to disclose confidential Medical Records. 10. A requirement that the provider Provider must make referrals for social, vocational, education or human services when a need for such service is identified. 11. In the event the Contractor becomes insolvent or unable to pay the participating providerProvider, a requirement that the provider Provider shall not seek compensation for services rendered from the State, its officers, Agents, or employees, or the Members or their eligible dependents. 12. A requirement that the provider Provider must submit claims within a minimum of ninety (90) calendar days and a maximum of six (6) months from the date of service. Claims filed within the appropriate time frame but denied may be resubmitted to the Contractor within ninety (90) calendar days from the date of denial. The Contractor may not enter into a provider Provider agreement that prohibits the provider Provider from contracting with another CCO or that prohibits or penalizes the Contractor for contracting with other providersProviders. The Contractor may not require providers Providers who agree to participate in CHIP the MississippiCAN Program to contract with the Contractor’s other lines of business.

Provider Agreements. ‌ The Contractor must have written agreements with a sufficient number of providers Providers to ensure Member access to all Medically Necessary Services covered by CHIPthe MississippiCAN Program. Contracts with all Behavioral Health providers behavioral health Providers must have provisions that all Members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge from the inpatient psychiatric hospitalhospital if the Contractor is aware of the Member’s inpatient hospitalization status. The Division’s Utilization Management Contractor will provide daily reports to the Contractor to identify Members admitted to an inpatient facility. In all Provider agreements, the Contractor must comply with the requirements specified in 42 C.F.R. § 438.214. The Contractor’s provider Provider agreements must include at least the following provisions: 1. A requirement that the Contractor must not exclude or terminate a provider Provider from participation in the Contractor’s Provider Network due to the fact that the provider Provider has a practice that includes a substantial number of Members patients with expensive medical conditions. 2. A requirement to ensure that Members are entitled to the full range of their health care providersProviders' opinions and counsel about the availability of Medically Necessary Services under the provisions of this Contract. Any contractual provisions, including gag clauses or rules, that restricts a health care providerProvider's ability to advise Members patients about medically necessary treatment options violate Federal law and regulations. 3. A requirement that the Contractor cannot prohibit or restrict a provider Provider acting within the lawful scope of practice from discussing Medically Necessary care and advising or advocating appropriate medical care with or on behalf of a Member including; information regarding the nature of treatment options; risks of treatment; alternative treatments; or the availability of alternative therapies, consultation or tests that may be self-administered. 4. A requirement that the Contractor cannot prohibit or restrict a provider Provider acting within the lawful scope of practice from providing information the Member needs in order to decide among all relevant treatment options and the risks, benefits, and consequences of treatment or non-treatment. 5. A requirement that the Contractor cannot terminate a contract or employment with a provider Provider for filing a Grievance Complaint, Grievance, or Appeal on a Member’s behalf. 6. A requirement securing cooperation with the QM and UM program Program standards outlined in Section 9, Quality Management, of this Contract. 7. A requirement that PCPs comply with requirements of Section 7.C, PCP Responsibilities, of this Contract. 8. A requirement that the Contractor include in all capitated provider Provider agreements a clause which requires that should the provider Provider terminate its agreement with the Contractor, for any reason, the provider Provider will provide services to the Members assigned to the provider Provider under the contract up to the end of the month in which the effective date of termination falls. 9. A requirement that the provider Provider must comply with all applicable laws and regulations pertaining to the confidentiality of Member Medical Records, including obtaining any required written Member consents to disclose confidential Medical Records. 10. A requirement that the provider Provider must make referrals for social, vocational, education or human services when a need for such service is identified. 11. In the event the Contractor becomes insolvent or unable to pay the participating providerProvider, a requirement that the provider Provider shall not seek compensation for services rendered from the State, its officers, Agents, or employees, or the Members or their eligible dependents. 12. A requirement that that, effective July 1, 2014, the provider Provider must submit claims within six (6) months from the date of service. Claims filed within the appropriate time frame but denied may be resubmitted to the Contractor within ninety (90) calendar days from the date of denial. The Contractor may not enter into a provider Provider agreement that prohibits the provider Provider from contracting with another CCO or that prohibits or penalizes the Contractor for contracting with other providersProviders. The Contractor may not require providers Providers who agree to participate in CHIP the MississippiCAN Program to contract with the Contractor’s other lines of business.