Provider Network Services. The PIHP is responsible for maintaining and continually evaluating an effective provider network adequate to fulfill the obligations of this contract. The PIHP remains the accountable party for the Medicaid beneficiaries in its service area, regardless of the functions it has delegated to its provider networks. In this regard and in compliance with 42 CFR Parts 438.414; 438.10(g)(2)(xi)(C)(D)(E) and 457.1260, the PIHP agrees to: 1. Maintain a regular means of communicating and providing information on changes in policies and procedures to its providers. This may include guidelines for answering written correspondence to providers, offering provider-dedicated phone lines, and a regular provider newsletter. 2. Have clearly written mechanisms to address provider grievances and complaints, and an appeal system to resolve disputes. 3. Provide a copy of the PIHP's prior authorization policies to the provider when the provider joins the PIHP's provider network. The PIHP must notify providers of any changes to prior authorization policies as changes are made. 4. Provide a copy of the PIHP's grievance, appeal and fair hearing procedures and timeframes to the provider when the provider joins the PIHP's provider network. The PIHP must notify providers of any changes to those procedures or timeframes. Please see attachment P6. 3.1.1 GA Technical Requirement for Grievance & Appeal timeframes and State Fair Hearing process for further detail. 5. Provide to MDHHS in the format specified by MDHHS, provider agency information profiles that contain a complete listing and description of the provider network available to recipients in the service area. 6. Assure that services are accessible, taking into account travel time, availability of public transportation, and other factors that may determine accessibility. 7. Assure that network providers do not segregate PIHP individuals in any way from other people receiving their services. In addition, the PIHP agrees upon request from MDHHS either through an RFP or other means to: 1. Provide documentation on which the state bases its certification that the MCP complied with the state’s requirements for availability and accessibility of services, including the adequacy of the provider network as referenced in 42 CFR Parts 438.604(a)(5); 438.606; 438.207(b) and 438.206. 2. Submit any other data, documentation, or information relating to the performance of the entity’s obligations as required by the state or Secretary as referenced in 42 CFR Parts 438.604(b) and 438.606.
Appears in 3 contracts
Samples: Agreement Between Michigan Department of Health and Human Services and Pihp, Medicaid Managed Specialty Supports and Services Program, Amendment No. 3 to the Agreement Between Michigan Department of Health and Human Services and Pihp
Provider Network Services. The PIHP is responsible for maintaining and continually evaluating an effective provider network adequate to fulfill the obligations of this contract. The PIHP remains the accountable party for the Medicaid beneficiaries in its service area, regardless of the functions it has delegated to its provider networks. In this regard and in compliance with 42 CFR Parts 438.414; 438.10(g)(2)(xi)(C)(D)(E) and 457.1260regard, the PIHP agrees to:
1. Maintain a regular means of communicating and providing information on changes in policies and procedures to its providers. This may include guidelines for answering written correspondence to providers, offering provider-dedicated phone lines, and a regular provider newsletter.
2. Have clearly written mechanisms to address provider grievances and complaints, and an appeal system to resolve disputes.
3. Provide a copy of the PIHP's prior authorization policies to the provider when the provider joins the PIHP's provider network. The PIHP must notify providers of any changes to prior authorization policies as changes are made.
4. Provide a copy of the PIHP's grievance, appeal and fair hearing procedures and timeframes to the provider when the provider joins the PIHP's provider network. The PIHP must notify providers of any changes to those procedures or timeframes. Please see attachment P6.
3.1.1 GA Technical Requirement for Grievance & Appeal timeframes and State Fair Hearing process for further detail.
5. Provide to MDHHS in the format specified by MDHHS, provider agency information profiles that contain a complete listing and description of the provider network available to recipients in the service area.
6. Assure that services are accessible, taking into account travel time, availability of public transportation, and other factors that may determine accessibility.
7. Assure that network providers do not segregate PIHP individuals in any way from other people receiving their services. In addition, addition the PIHP agrees upon request from MDHHS either through an RFP or other means to:
1. : 1 Provide documentation on which the state bases its certification that the MCP complied with the state’s requirements for availability and accessibility of services, including the adequacy of the provider network as referenced in 42 CFR Parts 438.604(a)(5); 438.606; 438.207(b) and 438.206.
2network. 2 Submit any other data, documentation, or information relating to the performance of the entity’s obligations as required by the state or Secretary as referenced in 42 CFR Parts 438.604(b) and 438.606Secretary.
Appears in 1 contract
