PROVIDER SUBSYSTEM. The provider subsystem accepts and maintains comprehensive, current and historical information about Providers eligible to participate in the Contractor’s Network. The maintenance of provider data is required to support Claims and encounter processing, utilization/quality processing, financial processing and report functions. The Contractor shall electronically transmit provider enrollment information to the Department on a monthly basis, by the first Friday of the month following the month reported. The Contractor’s provider subsystem shall contain such items as demographic data, identification of provider type, specialty codes, maintenance of payment information, identification of licensing, credentialing/re-credentialing information, and monitoring of Primary Care Provider capacity for enrollment purposes. The Contractor shall demonstrate compliance with standards of provider network capacity and member access to services by producing reports illustrating that services, service locations, and service sites are available and accessible in terms of timeliness, amount, duration and personnel sufficient to provide all Covered Services on an emergency or urgent care basis, 24 hours a day, seven days a week. The Department shall monitor the Contractor’s Network capacity and member access by use of a Decision Support System. The Encounter Record submitted will be used to display Primary Care Provider location, Service Location, Member distribution, patterns of referral, quality measures, and other analytical data.
PROVIDER SUBSYSTEM. 97 10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM..........................................98 10.6
PROVIDER SUBSYSTEM. The provider subsystem must accept, process, store and retrieve current and historical data on providers, including services, payment methodology, license information, service capacity, and facility linkages.
PROVIDER SUBSYSTEM. Subparts 7 and 8 of Section 10.4 are replaced with the following language:
PROVIDER SUBSYSTEM. The provider subsystem must accept, process, store and retrieve current and historical data on providers, including services, payment methodology, license information, service capacity, and facility linkages. 1999 Renewal Contract Harrxx Xxxvice Area 104 August 9, 1999 105 Functions and Features:
(1) Identify specialty(s), admission privileges, enrollee linkage, capacity, facility linkages, emergency arrangements or contact, and other limitations, affiliations, or restrictions.
(2) Maintain provider history files to include audit trails and effective dates of information.
(3) Maintain provider fee schedules/remuneration agreements to permit accurate payment for services based on the financial agreement in effect on the date of service.
(4) Support HMO credentialing, recredentialing, and credential tracking processes; incorporates or links information to provider record.
(5) Support monitoring activity for physician to enrollee ratios (actual to maximum) and total provider enrollment to physician and HMO capacity.
(6) Flag and identify providers with restrictive conditions (e.g., limits to capacity, type of patient, age restrictions, and other services if approved out- of-network).
(7) Support national provider number format (UPIN, NPIN, CLIA, etc., as required by TDH).
(8) Provide provider network files 90 days prior to implementation and updates monthly. Format will be provided by TDH to contracted entities.
(9) Support the national CLIA certification numbers for clinical laboratories.
(10) Exclude providers from participation that have been identified by TDH as ineligible or excluded. Files must be updated to reflect period and reason for exclusion.
PROVIDER SUBSYSTEM. (A) The System implemented by CONTRACTOR must include a Provider Subsystem that accepts, processes, stores and retrieves current and historical data on health care providers in CONTRACTOR's network, including, but not limited to, the following data:
(i) Services offered or provided;
(ii) Payment methodology;
(iii) License/credentialing information;
(iv) Service capacity and facility linkages; and
(v) If required by HHSC, information concerning excluded providers.
(B) The functions and/or features of the Provider Subsystem must achieve the following:
(i) Identify network providers, specialty or specialties by:
a. The appropriate regulatory board certification/eligibility;
b. Admission privileges;
c. Member linkage;
PROVIDER SUBSYSTEM. 23 (3) Claims/Services Data Subsystem.................................................................24 (4)
PROVIDER SUBSYSTEM. The provider subsystem must accept, process, store and retrieve current and historical data on providers, including services, payment methodology, license information, service capacity, and facility linkages. Functions and Features:
1. Identify specialty(s), admission privileges, enrollee linkage, capacity, facility linkages, emergency arrangements or contact, and other limitations, affiliations, or restrictions;
2. Maintain provider history files to include audit trails and effective dates of information;
3. Maintain provider fee schedules/remuneration agreements to permit accurate payment for services based on the financial agreement in effect on the date of service;
4. Support HMO credentialing, recredentialing, and credential tracking processes; incorporates or links information to provider record;
5. Support monitoring activity for physician to enrollee ratios (actual to maximum) and total provider enrollment to physician and HMO capacity;
6. Flag and identify providers with restrictive conditions (e.g., limits to capacity, type of patient, age restrictions, and other services if approved out- of-network);
7. Support national provider number format (UPIN, NPIN, CLIA, TPI, etc., as required by HHSC);
8. Provide Provider Network and Affiliation files 90 days prior to implementation and updates monthly. Format will be provided by HHSC to contracted entities;
9. Support the national CLIA certification numbers for clinical laboratories; and
10. Exclude providers from participation that have been identified by HHSC as ineligible or excluded. Files must be updated to reflect period and reason for exclusion.
PROVIDER SUBSYSTEM. 81 10.5 ENCOUNTER/CLAIMS PROCESSING SUBSYSTEM................81 TDHS/HMO CONTRACT August 11, 1999
PROVIDER SUBSYSTEM. (A) The System implemented by CONTRACTOR must include a Provider Subsystem that accepts, processes, stores and retrieves current and historical data on health care providers in CONTRACTOR's network, including, but not limited to, the following data:
(i) Services offered or provided;
(ii) Payment methodology;
(iii) License/credentialing information;
(iv) Service capacity and facility linkages; and
(v) If required by HHSC, information concerning excluded providers.
(B) The functions and/or features of the Provider Subsystem must achieve the following:
(i) Identify network providers, specialty or specialties by:
a. The appropriate regulatory board certification/eligibility;
b. Admission privileges;
c. Member linkage;
d. Capacity;
e. Facility linkages;
f. Emergency arrangements or contact; and
g. Other limitations, affiliations, or restrictions specified by HHSC;
(ii) Maintain provider history files to include audit trails and effective dates of information;
(iii) Maintain provider fee schedules/remuneration agreements to permit accurate payment for services based on the financial agreement in effect on the date of service;
(iv) Support CONTRACTOR's credentialing, re-credentialing, and credential-tracking processes;
(v) Incorporate or link appropriate billing, client, and other information to the provider record;
(vi) Flag and identify providers with restrictive conditions (e.g. limits to capacity, type of patient, and other services if approved out of network, age restrictions, exclusion, etc.);
(vii) Support national and state provider number formats (such as UPIN, NPI, CLIA, Medicaid, TPI, etc.) as required by HHSC;
(viii) Identify providers excluded from participation by HHSC as ineligible or excluded and update Provider Subsystem and other files to reflect period and reason for exclusion;
(ix) Capture provider complaints;
(x) Provide geographical mapping of provider network and assessment of network's capabilities to meet client needs; and
(xi) Update provider information (e.g. provider addresses).
