Provider Network and Access Sample Clauses
The "Provider Network and Access" clause defines the obligations and standards regarding the network of service providers available to participants under an agreement, such as a health plan or managed care contract. It typically outlines requirements for maintaining an adequate number and variety of providers, procedures for updating the network, and participant rights to access necessary services, including provisions for out-of-network care in certain situations. This clause ensures that users have reasonable and timely access to covered services, addressing potential gaps in care and promoting transparency about available provider options.
Provider Network and Access. 4.8.1 General Provisions
4.8.1.1 The Contractor is solely responsible for providing a network of physicians, pharmacies, hospitals, and other health care Providers through whom it provides the items and services included in Covered Services.
4.8.1.2 The Contractor shall ensure that its network of Providers is adequate to assure access to all Covered Services, and that all Providers are appropriately credentialed, maintain current licenses, and have appropriate locations to provide the Covered Services.
4.8.1.3 The Contractor shall notify DCH sixty (60) days in advance when a decision is made to close network enrollment for new provider contracts and also notify DCH when network enrollment is reopened. The Contractor must notify DCH sixty (60) days prior to closing a provider panel.
4.8.1.4 The Contractor shall not include any Providers who have been excluded from participation by the Department of Health and Human Services, Office of Inspector General, or who are on the State’s list of excluded Providers. The Contractor is responsible for routinely checking the exclusions list and shall immediately terminate any Provider found to be excluded and notify the Member per the requirements outlined in this Contract.
4.8.1.5 The Contractor shall require that each Provider have a unique physician identifier number (UPIN). In accordance with 45 CFR 160.103, the Contractor shall require that each Provider have a national Provider identifier (NPI).
4.8.1.6 The Contractor shall have written Selection and Retention Policies and Procedures. These policies shall be submitted to DCH for review and approval as updated. In selecting and retaining Providers in its network the Contractor shall consider the following: · The anticipated GF Enrollment; · The expected Utilization of services, taking into consideration the characteristics and Health Care needs of its Members; · The numbers and types (in terms of training, experience and specialization) of Providers required to furnish the Covered Services; · The numbers of network Providers who are not accepting new GF patients; and · The geographic location of Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities.
4.8.1.7 If the Contractor declines to include individual Providers or groups of Providers in its network, the Contractor shall give the affected Providers written notice of the reas...
Provider Network and Access