Provider Network Information Requirements. The CONTRACTOR’s Provider network capabilities shall include the following, in order to fulfill the Provider credentialing, recredentialing, and enrollment functions described in Section 4.8.16 of this Agreement, as further described in the MCO Systems Manual: Accepting a provider master file from HCA that identifies all Medicaid enrolled Providers; Transmitting a Provider network file to New Mexico Medicaid’s fiscal agent that identifies by Medicaid Provider ID and NPI any Provider enrolled with New Mexico Medicaid who is a Contract Provider. Non-Contract Providers are not to be included on this file. The CONTRACTOR shall include the date on which the Provider's status as a Contract Provider is effective and when the Provider is no longer a Contract Provider, the CONTRACTOR shall include the date the Provider’s status as a Contract Provider ended. The CONTRACTOR shall send this file monthly, due no later than the tenth day of each month, reflecting the Contract Providers for the previous month. This requirement may be modified or deleted with the implementation of MMIS-R. The CONTRACTOR shall adhere to all federal requirements related to the enrollment, identification, and reporting of billing, rendering, furnishing, ordering, referring, prescribing, attending and other Providers, as applicable; Accepting a Provider confirmation update file from New Mexico Medicaid that contains any newly active Contract Providers or changes to Contract Providers that lists, at a minimum, the provider’s NPI or FEIN/SSN, the provider’s Medicaid ID, servicing location zip code, provider type, specialty, and dates of enrollment/termination; Recording each Provider listed on the New Mexico Medicaid provider update confirmation file and the full provider confirmation file in the CONTRACTOR’s system with the Medicaid provider ID, the assigned provider type, specialty (if applicable), and dates of enrollment/termination and using this data to edit Claims and ensure that the appropriate provider taxonomy and provider servicing location zip code is assigned to Encounter Claims; Maintain an accurate and provide timely updates to an online Provider directory for Members as specified in Section 4.15.5 of this Agreement; and Upon HCA direction, the CONTRACTOR agrees to accept a single provider master file from HCA that has all enrolled Providers. This file will be updated on a daily basis with any changes and published monthly as a full file.
Provider Network Information Requirements. The CONTRACTOR’S provider network capabilities shall include, but not be limited to:
A. maintaining complete provider information for all providers contracted with the CONTRACTOR and its subcontractors and any other non-contracted providers who have provided services to date;
B. transmitting a Provider Network File to HSD/MAD on a monthly basis, no later than the 28th day of each month, which must be sent along with encounter files, to include all contracted providers, non-contracted providers who have provided service to date, and providers who have been terminated. The file is a general replacement file each month with no deletions from the file until three (3) years past the date of the provider’s termination or denied status. Once a provider is shown on the file, the provider should continue to be reported regardless of whether any encounters are reported;
C. providing a complete and accurate designation of each provider according to the data elements and definitions included in the Medicaid Systems Manual, including assignment of unique provider numbers to each type of certification the provider organization has, according to HSD/MAD classification of provider type; and
D. providing automated access to members and providers of a member’s PCP assignment.
Provider Network Information Requirements. The CONTRACTOR’s provider network capabilities shall include, but not be limited, to:
(1) maintaining complete provider information for all Network Providers with the CONTRACTOR and its subcontractors and any other non-Network Providers who have provided services to date, including the provider’s Medicare number for processing Medicare crossover claims;
(2) transmitting an initial Provider Network File, if the CONTRACTOR has not previously submitted a Provider Network File to HSD/MAD and on an ongoing basis, which must be sent along with encounter files, to include new Network Providers, new non-Network servicing providers, changes to existing providers and termination of provider status including provider type and specialties assigned according to HSD/MAD criteria and definitions;
(3) providing a complete and accurate designation of each Network Provider according to data elements and definitions included in the MCO/CSP Systems Manual, including assignment of unique provider numbers to each type of certification the provider organization has, according to national standards (National Provider Identifier (NPI));
(4) providing automated access to Members and providers of a Member’s PCP assignment;
(5) using the NPI to identify health care providers and send a separate provider network file record for each unique combination of NPI, provider type, and ZIP code;
(6) sending the tax ID (FEIN or SSN) for all providers and, for atypical providers, send a separate network file record for each unique combination of FEIN/SSN, provider type, and ZIP code;
(7) ensuring that the provider type file contains no duplicate combinations of NPI or FEIN/SSN, provider type, and ZIP code; and
(8) determining and reporting both billing and servicing provider types and specialties according to Medicaid provider type and specialty codes which are based on the provider’s licensure/certification and not the service that the provider is rendering.
Provider Network Information Requirements. The CONTRACTOR’S provider network capabilities shall include, but not be limited to:
A. Maintaining complete provider information for all providers contracted with the CONTRACTOR and its subcontractors and any other non-contracted providers who have provided services to date;
B. Transmitting a Provider Network File to HSD on a monthly basis, no later than the 28th day of each month, to include all contracted providers, non-contracted providers who have provided service to date, providers who have applied for contract and are pending, providers whose application has been denied, and providers who have been terminated from contract. The file is a general replacement file each month with no deletions from the file until 3 years past the date of the provider’s termination or denied status. Once a provider is shown on the file, the provider should continue to be reported regardless of whether any encounters are reported for that provider or not;
C. Providing a complete and accurate designation of each provider according to the data elements and definitions included in the SALUD! Systems Manual; and
D. Providing automated access to members and providers of a member’s PCP assignment.
Provider Network Information Requirements. The CONTRACTOR’s provider network capabilities shall include, but not be limited, to:
