Provider Contract Requirements. The HMO is prohibited from requiring a provider or provider group to enter into an exclusive contracting arrangement with the HMO as a condition for participation in its Provider Network. The HMO’s contract with health care Providers must be in writing, must be in compliance with applicable federal and state laws and regulations, and must include minimum requirements specified in the Uniform Managed Care Contract Terms and Conditions (Attachment A) and HHSC’s Uniform Managed Care Manual. The HMO must submit model Provider contracts to HHSC for review during Readiness Review. HHSC retains the right to reject or require changes to any model Provider contract that does not comply with HMO Program requirements or the HHSC-HMO Contract.
Provider Contract Requirements. The MCO is prohibited from requiring a provider or provider group to enter into an exclusive contracting arrangement with the MCO as a condition for Network participation. The MCO’s contract with health care Providers must be in writing, must be in compliance with applicable federal and state laws and regulations, and must include minimum requirements specified in Attachment A, "Uniform Managed Care Contract Terms and Conditions," and Uniform Managed Care Manual Chapter 8.1 “Provider Contract Checklist.” As described in Section 7, the MCO must submit model Provider contracts to HHSC for review during Readiness Review. The MCO must resubmit the model Provider contracts any time it makes substantive modifications to such agreements. HHSC retains the right to reject or require changes to any Provider contract that does not comply with MCO Program requirements or the HHSC-MCO Contract.
Provider Contract Requirements. 1. The Health Plan shall comply with all Agency procedures for provider contract review and approval submission.
a. All provider contracts must comply with 42 CFR 438.230, 42 CFR 455.104, 42 CFR 455.105, and 42 CFR 455.106.
b. If the Health Plan is capitated, it shall ensure that all providers are eligible for participation in the Medicaid program. If a provider is currently suspended or involuntarily terminated from the Florida Medicaid program whether by contract or WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract sanction, other than for purposes of inactivity, that provider is not considered an eligible Medicaid provider. If the Health Plan is not capitated, its providers shall be enrolled as Florida Medicaid providers. Suspension and termination are described further in Rule 59G-9.070, F.A.C. The Health Plan is responsible for this provision within five (5) calendar days after notification of a provider’s ineligibility to participate in the Medicaid program (by its own or outside source, by communication from the Agency, by listing in an Agency website or other forum designated by the Agency).
c. The Health Plan shall not employ or contract with individuals on the state or federal exclusions list.
d. No provider contract that the Health Plan enters into with respect to performance under this Contract shall in any way relieve the Health Plan of any responsibility for the provision of services or duties under this Contract. The Health Plan shall assure that all services and tasks related to the provider contract are performed in accordance with the terms of this Contract. The Health Plan shall identify in its provider contract any aspect of service that may be subcontracted by the provider.
2. All provider contracts and amendments executed by the Health Plan shall be in writing, signed, and dated by the Health Plan and the provider, and shall meet the following requirements:
a. Prohibit the provider from seeking payment from the enrollee for any covered services provided to the enrollee within the terms of the Contract;
b. Require the provider to look solely to the following for compensation for services rendered, with the exception of nominal cost sharing, pursuant to the Medicaid State Plan and the Florida Coverage and Limitations Handbooks:
(1) If a capitated Health Plan, then to the capitated Health Plan for compensation;
(2) If a FFS Health Plan, then to the Agency or its Agent, unless the service is one for which the Health Plan receive...
