PROVIDER PROTECTIONS. 1. The M+C Organization agrees to comply with all applicable provider requirements in subpart E of part 422, including provider certification requirements, anti-discrimination requirements, provider participation and consultation requirements, the prohibition on interference with provider advice, limits on provider indemnification, rules governing payments to providers, and limits on physician incentive plans. [422.502(A)(6)]
2. Prompt Payment.
(a) The M+C Organization must pay 95 percent of the "clean claims" within 30 days of receipt if they are claims for covered services that are not furnished under a written agreement between the organization and the provider.
(i) The M+C Organization must pay interest on clean claims that are not paid within 30 days in accordance with sections 18l6(c)(2)(B) and l842(c)(2)(B) of the Act.
(ii) All other claims must be paid or denied within 60 calendar days from the date of the request. [422.520(A)]
(b) Contracts or other written agreements between the M+C Organization and its providers must contain a prompt payment provision, the terms of which are developed and agreed to by both the M+C Organization and the relevant provider. [422.520(B)]
(c) If CMS determines, after giving notice and opportunity for hearing, that the M+C Organization has failed to make payments in accordance with paragraph (2)(a) of this section, CMS may provide--
(i) For direct payment of the sums owed to providers; and
(ii) For appropriate reduction in the amounts that would otherwise be paid to the M+C Organization, to reflect the amounts of the direct payments and the cost of making those payments. [422.520(C)]
PROVIDER PROTECTIONS. 3.1 This guarantee is and shall at all times be a continuing security and shall cover the ultimate balance from time to time owing to the Provider by the Resident in respect of the Guaranteed Obligations.
3.2 The liability of the Guarantor under this guarantee shall not be reduced, discharged or otherwise adversely affected by:
(a) any intermediate payment, settlement of account or discharge in whole or in part of the Guaranteed Obligations;
(b) any variation, extension, discharge, compromise, dealing with, exchange or renewal of any right or remedy which the Provider may now or after the date of this guarantee have from or against any of the Resident and any other person in connection with the Guaranteed Obligations;
(c) any act or omission by the Provider or any other person in taking up, perfecting or enforcing any Security, indemnity, or guarantee from or against the Resident or any other person;
(d) any termination, amendment, variation, novation, replacement or supplement of or to any of the Guaranteed Obligations including without limitation any change in the purpose of, any increase in or extension of the Guaranteed Obligations and any addition of new Guaranteed Obligations;
(e) any grant of time, indulgence, waiver or concession to the Resident or any other person;
(f) any insolvency, bankruptcy, liquidation, administration, winding up, incapacity, limitation, disability, the discharge by operation of law, or any change in the constitution, name or style of the Resident or any other person;
(g) the death or incapacity (whether mental or physical) of the Guarantor, or any notice of his or her death or incapacity; or
(h) any invalidity, illegality, unenforceability, irregularity or frustration of any actual or purported obligation of, or Security held from, the Resident or any other person in connection with the Guaranteed Obligations;
(k) any claim or enforcement of payment from the Resident or any other person; or any act or omission which would not have discharged or affected the liability of the Guarantor had he or she been a principal debtor instead of a guarantor; or any other act or omission except an express written release by deed of the Guarantor by the Provider.
3.3 The Provider shall not be obliged, before taking steps to enforce any of its rights and remedies under this guarantee, to:
(a) take any action or obtain judgment in any court against the Resident or any other person;
(b) make or file any claim in a bankruptcy, liquidation, adm...
PROVIDER PROTECTIONS. (a) ACDE shall not exclude or terminate Provider or a Group Physician from ACDE’s provider network because the Provider or Group Physician advocated on behalf of a Member including in the context of a utilization management appeal or another dispute with ACDE over appropriate medical care, provided that such advocacy is consistent with the degree of learning and skill ordinarily possessed by a health care provider practicing in accordance with the applicable standard of care.
(b) Provider shall not be excluded or terminated from participation with ACDE due to the fact that the Provider may have a practice that includes a substantial number of patients with expensive medical conditions.
(c) Provider shall not be excluded from participation, nor shall this Agreement be terminated, because Provider objects to the provision of or refuses to provide a healthcare service on moral or religious grounds.
PROVIDER PROTECTIONS. (a) ACOH shall not exclude or terminate Provider from ACOH’s provider network because the Provider advocated on behalf of a Member including in the context of a utilization management appeal or another dispute with ACOH over appropriate medical care, provided that such advocacy is consistent with the degree of learning and skill ordinarily possessed by a health care provider practicing in accordance with the applicable standard of care.
(b) No Provider shall be excluded or terminated from participation with ACOH due to the fact that the Provider has a practice that includes a substantial number of patients with expensive medical conditions.
(c) Provider shall not be excluded from participation, nor shall this Agreement be terminated, because Provider objects to the provision of or refuses to provide a healthcare service on moral or religious grounds.
PROVIDER PROTECTIONS. 3.1 This guarantee is and shall at all times be a continuing security and shall cover the ultimate balance from time to time owing to the Provider by the Resident in respect of the Guaranteed Obligations.
3.2 The liability of the Guarantor under this guarantee shall not be reduced, discharged or otherwise adversely affected by:
PROVIDER PROTECTIONS. ACIA shall not exclude or terminate Provider or a Group Physician from ACIA’s provider network because the Provider or Group Physician advocated on behalf of a Member including in the context of a utilization management appeal or another dispute with ACIA over appropriate medical care, provided that such advocacy is consistent with the degree of learning and skill ordinarily possessed by a health care provider practicing in accordance with the applicable standard of care. Provider shall note be excluded or terminated from participation with ACIA due to the fact that the Provider may have a practice that includes a substantial number of patients with expensive medical conditions.
PROVIDER PROTECTIONS. 2.7.1. Provider shall not be penalized or the Agreement or this Appendix terminated by Horizon because Provider acts as an advocate for a Member in seeking appropriate, medically necessary health care services.
2.7.2. Provider shall not be penalized or the Agreement or this Appendix terminated by Horizon because Provider files a complaint or appeal as permitted by applicable Law.
2.7.3. Provider shall not be penalized or the Agreement or this Appendix terminated by Horizon because Provider expresses disagreement with Horizon’s decision to deny or limit benefits to a Member or because Provider assists a Member to seek reconsideration of Horizon’s decision.
2.7.4. Provider shall not be penalized or the Agreement or this Appendix terminated by Horizon because Provider discusses with a current, former, or prospective patient any aspect of the patient’s medical condition, any proposed treatments or treatment alternatives, whether covered by Horizon or not, policy provisions of a plan, or Provider’s personal recommendation regarding selection of a health plan based on Provider’s personal knowledge of the health needs of such patients.
2.7.5. Nothing in the Agreement or this Appendix constitutes a financial incentive for Provider to withhold medically necessary Covered Services.
2.7.6. Nothing in the Agreement or this Appendix shall impair or limit the right of Provider to communicate openly with a Member about (a) the Member’s health status, medical care, and all appropriate diagnostic testing and treatment options (including alternative treatments that may be self-administered), including the provision of sufficient information to provide an opportunity for the Member to decide among all relevant treatment options; (b) the risks, benefits, and consequences of treatment or non-treatment; and (c) the opportunity for the Member to refuse treatment and to express preferences about future treatment decisions.
2.7.7. Nothing in the Agreement or this Appendix shall be construed to impose obligations or responsibilities upon Provider which require Provider to violate the statutes or rules governing Provider’s licensure.
