Common use of Provider Selection Clause in Contracts

Provider Selection. a. The Contractor may not preclude any potential provider who is acting within the scope of his or her license or certification under state law from participating in the Network or refuse to make payments to a Provider, solely on the basis of that license or certification. b. The Contractor must submit written policies and procedures for the selection and retention of Network Providers within fifteen (15) days after signing this Agreement for approval by the Department. Those policies and procedures must include standards and procedures for credentialing and recredentialing Network Providers that are consistent with this Section and include the following criteria: a. Network Providers must have applicable licenses or certifications as required by Pennsylvania law. b. Network Providers must have board certification or eligibility, as applicable. c. Network Providers must not have been excluded from participating in Medicare or any State Medicaid or other health care program. d. Network Providers must be enrolled in the Medical Assistance Program. e. Network Providers must have malpractice/liability insurance. f. Network Providers must disclose any past or pending lawsuits or litigation. c. The Contractor may not discriminate against potential providers who serve high-risk populations or specialize in conditions that require costly treatment. d. In establishing and maintaining a Network sufficient to provide prompt access to Capitation Services and other Covered Services, the Contractor must consider the following: a. The anticipated number of Participants. b. The expected utilization of services considering the needs of the population being served. c. The numbers and types (in terms of training, experience, and specialization) of Network Providers required to furnish Capitation Services and other Covered Services in a timely manner. d. The geographic location of Network Providers compared to Participants, considering distance, travel time, the means of transportation ordinarily used by Medical Assistance recipients, and whether the location provides physical access for Medical Assistance recipients with disabilities. e. The number of Network Providers who are not accepting new Participants. f. The ability of Network Providers to communicate with limited English proficient Participants in their preferred language. g. The ability of Network Providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment to Participants with physical or mental disabilities. h. The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, or other evolving and innovative technological solutions. e. The Network established and maintained by the Contractor must meet the following access standard for Capitation Services and other Covered Services: a. The Contractor must maintain a Network sufficient to provide prompt access to Capitation Services and Covered Services that are not required to be delivered directly by the Contractor, including LTSS that are not provided in the Provider’s office. The Contractor must offer Participants a choice of at least two (2) Network Providers for each service or Provider type. The Contractor shall enter into written agreements with all Network Providers as specified in Section 2.5. b. The access standard for ambulatory services to which the Participant travels, including PCPs, OB/GYNs, and LTSS, is at least two (2) Providers: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The access standard for inpatient and residential services, including LTSS, is at least two (2) Providers one (1) of which must be located: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The Contractor must obtain Department approval for network exception requests to cover situations in which the Contractor determines that a Participant is in need of a specialized service and a Network Provider is not available within the above listed travel timeframes. The network exception request must provide for the appropriate delivery of services and the availability of local supports for the Participant. The Department will review and approve network exception requests based on the number of Network Providers in that specialty practicing in the Service Area. The Contractor must comply with additional access standards for Network Providers if CMS determines that it will promote the objectives of the Medicaid program for a level of care to be subject to an access standard. f. The Contractor may use different payment amounts for different specialties or for different practitioners in the same specialty. g. The Contractor shall notify providers in writing when they are denied participation in the Contractor's Network. Notification must include the reason for the denial.

Provider Selection. a. The Contractor may not preclude any potential provider who is acting within the scope of his or her license or certification under state law from participating in the Network or refuse to make payments to a Provider, solely on the basis of that license or certification. b. The Contractor must submit written policies and procedures for the selection and retention of Network Providers within fifteen (15) days after signing this Agreement for approval by the Department. Those policies and procedures must include standards and procedures for credentialing and recredentialing Network Providers that are consistent with this Section and include the following criteria: a. Network Providers must have applicable licenses or certifications as required by Pennsylvania law. b. Network Providers must have board certification or eligibility, as applicable. c. Network Providers must not have been excluded from participating in Medicare or any State Medicaid or other health care program. d. Network Providers must be enrolled in the Medical Assistance Program. e. Network Providers must have malpractice/liability insurance. f. Network Providers must disclose any past or pending lawsuits or litigation. c. The Contractor may not discriminate against potential providers who serve high-risk populations or specialize in conditions that require costly treatment. d. In establishing and maintaining a Network sufficient to provide prompt access to Capitation Services and other Covered Services, the Contractor must consider the following: a. The anticipated number of Participants. b. The expected utilization of services considering the needs of the population being served. c. The numbers and types (in terms of training, experience, and specialization) of Network Providers required to furnish Capitation Services and other Covered Services in a timely manner. d. The geographic location of Network Providers compared to Participants, considering distance, travel time, the means of transportation ordinarily used by Medical Assistance recipients, and whether the location provides physical access for Medical Assistance recipients with disabilities. e. The number of Network Providers who are not accepting new Participants. f. The ability of Network Providers to communicate with limited English proficient Participants in their preferred language. g. The ability of Network Providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment to Participants with physical or mental disabilities. h. The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, or other evolving and innovative technological solutions. e. The Network established and maintained by the Contractor must meet the following access standard for Capitation Services and other Covered Services: a. The Contractor must maintain a Network sufficient to provide prompt access to Capitation Services and Covered Services that are not required to be delivered directly by the Contractor, including LTSS that are not provided in the Provider’s office. The Contractor must offer Participants a choice of at least two (2) Network Providers for each service or Provider type. The Contractor shall enter into written agreements with all Network Providers as specified in Section 2.5. b. The access standard for ambulatory services to which the Participant travels, including PCPs, OB/GYNs, and LTSS, is at least two (2) Providers: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The access standard for inpatient and residential services, including LTSS, is at least two (2) Providers one one (1) of which must be located: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The Contractor must obtain Department approval for network exception requests to cover situations in which the Contractor determines that a Participant is in need of a specialized service and a Network Provider is not available within the above listed travel timeframes. The network exception request must provide for the appropriate delivery of services and the availability of local supports for the Participant. The Department will review and approve network exception requests based on the number of Network Providers in that specialty practicing in the Service Area. The Contractor must comply with additional access standards for Network Providers if CMS determines that it will promote the objectives of the Medicaid program for a level of care to be subject to an access standard. f. The Contractor may use different payment amounts for different specialties or for different practitioners in the same specialty. g. The Contractor shall notify providers in writing when they are denied participation in the Contractor's Network. Notification must include the reason for the denial.

Provider Selection. a. The Contractor may not preclude any potential provider who is acting within the scope of his or her license or certification under state law from participating in the Network or refuse to make payments to a Provider, solely on the basis of that license or certification. b. The Contractor must submit written policies and procedures for the selection and retention of Network Providers within fifteen (15) days after signing this Agreement for approval by the Department. Those policies and procedures must include standards and procedures for credentialing and recredentialing re- credentialing Network Providers that are consistent with this Section and include the following criteria: a. Network Providers must have applicable licenses or certifications as required by Pennsylvania law. b. Network Providers must have board certification or eligibility, as applicable. c. Network Providers must not have been excluded from participating in Medicare or any State Medicaid or other health care program. d. Network Providers must be enrolled in the Medical Assistance Program. e. Network Providers must have malpractice/liability insurance. f. Network Providers must disclose any past or pending lawsuits or litigation. c. The Contractor may not discriminate against potential providers who serve high-risk populations or specialize in conditions that require costly treatment. d. In establishing and maintaining a Network sufficient to provide prompt access to Capitation Services and other Covered Services, the Contractor must consider the following: a. The anticipated number of Participants. b. The expected utilization of services considering the needs of the population being served. c. The numbers and types (in terms of training, experience, and specialization) of Network Providers required to furnish Capitation Services and other Covered Services in a timely manner. d. The geographic location of Network Providers compared to Participants, considering distance, travel time, the means of transportation ordinarily used by Medical Assistance recipients, and whether the location provides physical access for Medical Assistance recipients with disabilities. e. The number of Network Providers who are not accepting new Participants. f. The ability of Network Providers to communicate with limited English proficient Participants in their preferred language. g. The ability of Network Providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment to Participants with physical or mental disabilities. h. The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, or other evolving and innovative technological solutions. e. The Network established and maintained by the Contractor must meet the following access standard for Capitation Services and other Covered Services: a. The Contractor must maintain a Network sufficient to provide prompt access to Capitation Services and Covered Services that are not required to be delivered directly by the Contractor, including LTSS that are not provided in the Provider’s office. The Contractor must offer Participants a choice of at least two (2) Network Providers for each service or Provider type. The Contractor shall enter into written agreements with all Network Providers as specified in Section 2.5. b. The access standard for ambulatory services to which the Participant travels, including PCPs, OB/GYNs, and LTSS, is at least two (2) Providers: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The access standard for inpatient and residential services, including LTSS, is at least two (2) Providers one (1) of which must be located: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The Contractor must obtain Department approval for network exception requests to cover situations in which the Contractor determines that a Participant is in need of a specialized service and a Network Provider is not available within the above listed travel timeframes. The network exception request must provide for the appropriate delivery of services and the availability of local supports for the Participant. The Department will review and approve network exception requests based on the number of Network Providers in that specialty practicing in the Service Area. The Contractor must comply with additional access standards for Network Providers if CMS determines that it will promote the objectives of the Medicaid program for a level of care to be subject to an access standard. f. The Contractor may use different payment amounts for different specialties or for different practitioners in the same specialty. g. The Contractor shall notify providers in writing when they are denied participation in the Contractor's Network. Notification must include the reason for the denial.

Provider Selection. a. 1. The Contractor may not preclude any potential provider who is acting within the scope of his or her license or certification under state law from participating in the Network or refuse to make payments to a Provider, solely on the basis of that license or certification. b. 2. The Contractor must submit written policies and procedures for the selection and retention of Network Providers within fifteen (15) days after signing this Agreement for approval by the Department. Those policies and procedures must include standards and procedures for credentialing and recredentialing re- credentialing Network Providers that are consistent with this Section and include the following criteria: a. Network Providers must have applicable licenses or certifications as required by Pennsylvania law. b. Network Providers must have board certification or eligibility, as applicable. c. Network Providers must not have been excluded from participating in Medicare or any State Medicaid or other health care program. d. Network Providers must be enrolled in the Medical Assistance Program. e. Network Providers must have malpractice/liability insurance. f. Network Providers must disclose any past or pending lawsuits or litigation. c. 3. The Contractor may not discriminate against potential providers who serve high-risk populations or specialize in conditions that require costly treatment. d. 4. In establishing and maintaining a Network sufficient to provide prompt access to Capitation Services and other Covered Services, the Contractor must consider the following: a. The anticipated number of Participants. b. The expected utilization of services considering the needs of the population being served. c. The numbers and types (in terms of training, experience, and specialization) of Network Providers providers required to furnish Capitation Services and other Covered Services in a timely mannerServices. d. The geographic location of Network Providers compared to Participants, considering distance, travel time, the means of transportation ordinarily used by Medical Assistance recipients, and whether the location provides physical access for Medical Assistance recipients with disabilities. e. The number of Network Providers who are not accepting new Participants. f. The ability of Network Providers to communicate with limited English proficient Participants in their preferred language. g. The ability of Network Providers to ensure physical access, reasonable accommodations, culturally competent communications, and accessible equipment to Participants with physical or mental disabilities. h. The availability of triage lines or screening systems, as well as the use of telemedicine, e-visits, or other evolving and innovative technological solutions. e. The Network established and maintained by the Contractor must meet the following access standard for Capitation Services and other Covered Services: a. The Contractor must maintain a Network sufficient to provide prompt access to Capitation Services and Covered Services that are not required to be delivered directly by the Contractor, including LTSS that are not provided in the Provider’s office5. The Contractor must offer Participants a choice of at least two (2) Network Providers for each service or Provider type. The Contractor shall enter into written agreements with all Network Providers as specified in Section 2.5. b. The access standard for ambulatory services to which the Participant travels, including PCPs, OB/GYNs, and LTSS, is at least two (2) Providers: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The access standard for inpatient and residential services, including LTSS, is at least two (2) Providers one (1) of which must be located: i. Within thirty (30) minutes travel time in Urban areas. ii. Within sixty (60) minutes travel time in Rural areas. The Contractor must obtain Department approval for network exception requests to cover situations in which the Contractor determines that a Participant is in need of a specialized service and a Network Provider is not available within the above listed travel timeframes. The network exception request must provide for the appropriate delivery of services and the availability of local supports for the Participant. The Department will review and approve network exception requests based on the number of Network Providers in that specialty practicing in the Service Area. The Contractor must comply with additional access standards for Network Providers if CMS determines that it will promote the objectives of the Medicaid program for a level of care to be subject to an access standard. f. The Contractor may use different payment amounts for different specialties or for different practitioners in the same specialty. g. 6. The Contractor shall notify providers in writing when they are denied participation in the Contractor's Network. Notification must include the reason for the denial.