Provider Procurement. The PIHP is responsible for the development of the service delivery system and the establishment of sufficient administrative capabilities to carry out the requirements and obligations of this contract. Where the PIHP and affiliated CMHSPs fulfill these responsibilities through subcontracts, they shall adhere to applicable provisions of federal procurement requirements as specified in Attachment P 6. 4.1.1. In complying with these requirements and in accordance with 42 CFR 438.12, the PIHP: a. May not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification; b. Must give those providers not selected for inclusion in the network written notice of the reason for its decision; Is not required to contract with providers beyond the number necessary to meet the needs of its beneficiaries, and is not precluded from using different practitioners in the same specialty. Nor is the PIHP prohibited from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to its beneficiaries. In addition, the PIHP's selection policies and procedures cannot discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatments. Also, the PIHP must ensure that it does not employ or contract with providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act.
Appears in 3 contracts
Samples: Medicaid Managed Specialty Supports and Services Concurrent Waiver Program Agreement, Medicaid Managed Specialty Supports and Services Concurrent Waiver Program Agreement, Medicaid Managed Specialty Supports and Services Concurrent Waiver Program Agreement
Provider Procurement. The PIHP is responsible for the development of the service delivery system and the establishment of sufficient administrative capabilities to carry out the requirements and obligations of this contract. Where the PIHP and affiliated CMHSPs its provider network fulfill these responsibilities through subcontracts, they shall adhere to applicable provisions of federal procurement requirements as specified in Attachment P 6.
4.1.1. In complying with these requirements and in accordance with 42 CFR 438.12, the PIHP:
a. May not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification;
b. Must give those providers not selected for inclusion in the network written notice of the reason for its decision; ;
c. Is not required to contract with providers beyond the number necessary to meet the needs of its beneficiaries, and is not precluded from using different practitioners in the same specialty. Nor is the PIHP prohibited from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to its beneficiaries. In addition, the PIHP's selection policies and procedures cannot discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatments. Also, the PIHP must ensure that it does not employ or contract with providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act.
Appears in 1 contract
Samples: Medicaid Managed Specialty Supports and Services Concurrent Waiver Program Agreement
