Provider Manuals Sample Clauses

Provider Manuals. The TPA shall develop, distribute, and maintain provider manuals. In addition, the TPA will be expected to notify network providers of subsequent contract clarifications and procedural changes. The provider manual will include at least the following information: 1. An introduction to the Plan which explains the TPA’s organization and administrative structure; 2. A description of the Plan’s case management process; 3. A description of covered medical services, excluded medical services, and benefit limitations; 4. Billing and encounter submission information indicating which form (e.g. UB92, HCFA 1500) is to be used for services and which fields and codes are required for a claim to be considered acceptable by the TPA, or the necessary protocol and procedural information for a provider to submit claims electronically in accordance with HIPAA and HITECH EDI standards; 5. Provider performance expectations including disclosure of medical management and quality assurance criteria and processes; 6. Emergency room utilization (appropriate and non-appropriate use of the emergency room);

Provider Manuals. AMERICAID shall provide Group with a Provider Manual, to be periodically updated, which details policies and procedures of AMERICAID, and the terms of which are incorporated herein by reference.