Provider Network Requirements. The Contractor shall develop and maintain a provider network in compliance with the terms of this section. The Contractor shall ensure that its provider network is supported by written provider agreements, is available and geographically accessible and provides adequate numbers of facilities, physicians, pharmacies, ancillary providers, service locations and personnel for the provision of high-quality covered services for its members, in accordance with 42 CFR 438.206, which relates to availability of services. The Contractor shall also ensure that all of its contracted providers can respond to the cultural, racial and linguistic needs of its member populations. The network shall be able to handle the unique needs of its members, particularly those with special health care needs. The Contractor will be required to participate in any state efforts to promote the delivery of covered services in a culturally competent manner. The Contractor shall ensure all network providers who, in accordance with IHCP policy, are provider types eligible and required to enroll as an IHCP provider, are enrolled IHCP providers. In some cases, members may receive out-of-network services. In order to receive reimbursement from the Contractor, out-of-network providers shall be IHCP providers. The Contractor shall encourage out-of-network providers to enroll in the IHCP, particularly emergency services providers, as well as providers based in non-traditional urgent health care settings such as retail clinics. An out-of-network provider shall be enrolled in the IHCP in order to receive payment from the Contractor. Further information about IHCP Provider Enrollment is located at:
Provider Network Requirements. 1. Geographic Access Standards In addition to maintaining in its network a sufficient number of Providers to provide all services to its Members, the Contractor shall meet the geographic access standards for all Members set forth in Table 6.
Provider Network Requirements. The Contractor shall develop and maintain a provider network in compliance with the terms of this section. Individuals with disabilities and chronic health conditions often spend years finding providers with the appropriate clinical knowledge and competencies to meet their needs. The Contractor shall implement strategies to ensure the maintenance of these established provider relationships and develop a network able to handle the special health care needs of the Hoosier Care Connect population. In accordance with 42 CFR 438.3(l) the Contractor must allow each member to choose his or her health professional to the extent possible and appropriate. The Contractor must ensure that its provider network is supported by written provider agreements, is available and geographically accessible and provides an adequate number of facilities, physicians, pharmacies, ancillary providers, service locations and personnel for the provision of high-quality covered services for its members, in accordance with 42 CFR 438.206. The Contractor must also ensure that all of its contracted providers can respond to the cultural, racial and linguistic needs of its members. The Contractor must ensure all network providers who, in accordance with IHCP policy, are provider types eligible and required to enroll as an IHCP provider, are enrolled IHCP providers. In some cases, members may receive out-of-network services. In order to receive reimbursement from the Contractor, out-of-network providers must be IHCP providers. The Contractor shall encourage out-of- network providers, particularly emergency services providers, to enroll in the IHCP. Further information about IHCP Provider Enrollment is located at: xxxx://xxxxxxxx.xxxxxxxxxxxxxxx.xxx/become-a-provider/ihcp-provider-enrollment- transactions.aspx
Provider Network Requirements. The Contractor shall develop and maintain a provider network in compliance with the terms of this section. The Contractor shall ensure that its provider network is supported by written provider agreements, is available and geographically accessible and provides adequate numbers of facilities, physicians, pharmacies, ancillary providers, service locations and personnel for the provision of high-quality covered services for its members, in accordance with 42 CFR 438.206, which relates to availability of services. The Contractor shall also ensure that all of its contracted providers can respond to the cultural, racial and linguistic needs of its member populations. The network shall be able to handle the unique needs of its members, particularly those with special health care needs. The Contractor will be required to participate in any state efforts to promote the delivery of covered services in a culturally competent manner.
Provider Network Requirements. 7.1 PROVIDER ACCESSIBILITY ----------------------
7.1.1 HMO must enter into written contracts with properly credentialed health care service providers. The names of all providers must be submitted to TDH as part of HMO subcontracting process. HMO must have its own credentialing process to review, approve and periodically recertify the credentials of all participating providers in compliance with 28 TAC 11.1902, relating to credentialing of providers in HMOs.
7.1.2 HMO must require tax I.D. numbers from all providers. HMO is required to do backup withholding from all payments to providers who fail to give tax I.D. numbers or who give incorrect numbers.
Provider Network Requirements. Provider networks and all provider types within the network shall be reviewed on a county basis, i.e., must be located within the county except where indicated. (See also Section 4.8.8.
Provider Network Requirements. When a mobile dental van’s use is associated with health fairs or other one-time events, services will be limited to oral screenings, exams, fluoride varnish, prophylaxis and palliative care to treat an acute condition. State Board regulations must still be followed. The MCO must maintain documentation for all locations served to include schedule of time and days. Multilingual--at a minimum, English and Spanish and any other language which is spoken by 200 enrollees or five percent of the enrolled Medicaid population of the Contractor’s plan, whichever is greater. NCQA--the National Committee for Quality Assurance. Newborn--an infant born to a mother enrolled in a Contractor’s plan at the time of birth. New Jersey State Plan or State Plan--the DHS/DMAHS document, filed with and approved by CMS, that describes the New Jersey Medicaid/NJ FamilyCare program. N.J.A.C.--New Jersey Administrative Code. NJ Choice Assessment System--consists of the interRAI Home Care, Version 9.1 assessment form with NJ specific revisions (NJ Choice), Home Care Clinical Assessment Protocols (CAPS), Home Care case mix categories (RUG-III/HC), and the NJ specific Interim Plan of Care (IPOC) form. This standardized NJ FamilyCare Program Eligibility Groups Include:
Provider Network Requirements a. The Contractor shall establish and maintain a provider network that is capable of delivering medically necessary Covered Services under this Subcontract, in accordance with required appointment standards, professional requirements and best practices. The provider network shall provide a full continuum of treatment, rehabilitative, supportive and ancillary services for the following populations:
i. Title XIX and Non-Title XIX Children;
ii. Title XIX and Non-Title XIX Adults with Serious Mental Illness; and
iii. Title XIX Adults with general mental health issues and Title XIX Adults with substance abuse/dependence.
b. The Contractor shall ensure that Covered Services are provided promptly and are reasonably accessible in terms of location and hours of operation. There shall be sufficient professional personnel for the provision of Covered Services including emergency care on a 24 hours a day, 7 days a week basis.
c. Services must be delivered by qualified providers that meet the initial credentialing requirements and are appropriately licensed, insured and operating within the scope of their practice. All providers must be registered with ADHS/DBHS and with AHCCCS for the provision of Title XIX Covered Services to Title XIX enrolled persons. At minimum, qualified providers shall meet the following criteria:
i. Covered Services shall be delivered by providers who are appropriately licensed, insured and operating within the scope of their practice;
ii. Behavioral health practitioners, other than physicians, nurse practitioners, physician assistants, psychologists and independently contracted Specialty Providers, must be affiliated with an outpatient mental health clinic or rehabilitation agency to provide outpatient services.
d. Contractor shall meet and ensure that all of its paid and unpaid personnel who are required or are allowed to provide behavioral health services directly to juveniles have met all fingerprint certification requirements of A.R.S. (S)36-425.03 prior to providing such services. The Contractor shall have on file and make available to CPSA upon request and/or audit personnel evidence of fingerprint certification. Final Jun 6-01 Effective 7-01-01 Page 76 -------------------------------------------------------------------------------- [LOGO] Community Partnership FEE FOR SERVICE and RISK-BASED of Southern Arizona SUBCONTRACT AGREEMENT Regional Behavioral CHILDREN SERVICES Health Authority The Providence Service Corporation ----------------...
Provider Network Requirements. 1. Network Development, monitoring and maintenance
a. Contractor shall establish and maintain a community-based governing or advisory board for local decision-making and input into service delivery and network development.
b. The Contractor shall establish, maintain and monitor a provider network that is capable of delivering a full continuum of treatment, rehabilitative and supportive services for children and adults. The continuum of care may be provided directly or through contractual arrangements with qualified providers (Subcontracted Providers). The Contractor shall provide technical assistance to its providers regarding Covered Services, encounter submission and documentation requirements on an as needed basis.
c. The Contractor’s network must meet the Minimum Network Standards and Staff Inventory requirements established by CPSA. Contractor must submit quarterly reports documenting these minimum standards in the format prescribed by CPSA and on the time schedule enunciated in Schedule III, Subcontract Deliverables.
d. The Contractor’s network must be sufficient to ensure that:
i. Capacity to serve eligible and enrolled persons of non-dominant culture and ethnicity is demonstrated;
ii. Unnecessary use of emergency departments and urgent care centers is reduced;
iii. Use of jail and detention centers is reduced;
iv. Covered Services, including emergency care, are provided promptly and are reasonably accessible in terms of location and hours of operation and are delivered in compliance with ADHS/DBHS/CPSA Provider Manual, Section 3.2, Appointment Standards and Timeliness of Service.
v. Children with special health care needs have adequate access to behavioral health practitioners with experience in treating the child’s diagnosed condition.
e. The Contractor’s network must include intake sites and capacity adequate to ensure the following:
i. Scheduled hours for intake appointments must ensure accessibility and ease of entry into the behavioral health system.
ii. All service sites must be staffed adequately to complete SMI determinations within time frames established by ADHS/DBHS/CPSA Provider Manual Section 3.10, SMI Eligibility Determination.
iii. Financial assessments must be conducted at each intake site by a staff person trained in financial screening and dedicated to the completion of applications for public benefits according to ADHS/DBHS/CPSA Provider Manual, Section 3.1, Accessing and Interpreting Eligibility and Enrollment Information and Sc...
Provider Network Requirements. Provider networks and all provider types within the network shall be reviewed on a county basis, i. e., must be located within the county except where indicated. The contractor shall monitor the capacity of each of its providers and decrease ratio limits as needed to maintain appointment availability standards.
A. Primary Care Provider Ratios PCP ratios shall be reviewed and calculated by provider specialty on a county basis and on an index city basis, i. e., the major city of each county where the majority of the Medicaid and NJ FamilyCare beneficiaries reside. Physician A primary care physician shall be a General Practitioner, Family Practitioner, Pediatrician, or Internist. Obstetricians/Gynecologists and other physician specialists may also participate as primary care providers providing they participate on the same contractual basis as all other PCPs and contractor enrollees are enrolled with the specialists in the same manner and with the same PCP/enrollee ratio requirements applied.
