Provision of Covered Services. Contractor shall undertake commercially reasonable efforts to ensure that each Participating Provider Agreement and each subcontracting arrangement entered into by each Participating Provider complies with the applicable terms and conditions set forth in this Agreement, as mutually agreed upon by Covered California and Contractor, and which may include the following:
i. Coordination with Covered California and other programs and stakeholders;
ii. Relationship of the parties as independent contractors (Section 1.3(a)) and Contractor’s exclusive responsibility for obligations under the Agreement (Section 1.3(b)); iii. Participating Provider Directory requirements (Section 3.4.4);
Provision of Covered Services. Contractor shall cause each Participating Provider to assure that each Participating Provider Agreement and each subcontracting arrangement entered into by each Participating Provider shall comply with, the applicable terms and conditions set forth in the Agreement, as mutually agreed upon by the Exchange and Contractor, and which may include the following: • Coordination with the Exchange and other programs and stakeholders (Section 1.06); • Relationship of the parties as independent contractors (Section 1.08(a)) and Contractor’s exclusive responsibility for obligations under the Agreement (Section 1.08(b)); • Participating Provider directory requirements (Section 3.05(c)); • Implementation of processes to enhance stability and minimize disruption to provider network (Section 3.05(d) and (e); • Notice, network requirements and other obligations relating to costs of out-of-network and other benefits (Section 3.1); • Credentialing, including, maintenance of licensure and insurance (Section 3.16); • Customer service standards (Section 3.18); • Utilization review and appeal processes (Section 3.17); • Maintenance of a corporate compliance program (Section 3.19); • Enrollment and eligibility determinations and collection practices (Sections 3.20 to 3.25) • Appeals and grievances (Section 3.26); • Enrollee and marketing materials (Section 3.27); • Disclosure of information required by the Exchange, including, financial and clinical (Section 3.31; Quality, Network Management and Delivery System Standards (Article 4 ) and other data, books and records (Article 10)); • Nondiscrimination (Section 3.32); • Conflict of interest and integrity (Section 3.33); • Other laws (Section 3.35); • Quality, Network Management and Delivery System Standards to the extent applicable to Participating Providers (Article 4), including, disclosure of contracting arrangements with Participating Providers as required under Section 7.01 of the Quality, Network Management and Delivery System Standards; • Performance Measures, to the extent applicable to Participating Providers (Article 6) • Continuity of care, coordination and cooperation upon termination of Agreement and transition of Enrollees (Article 7); • Security and privacy requirements, including, compliance with HIPAA (Article 9); and • Maintenance of books and records (Article 10).
Provision of Covered Services. Medical Group and its Participating Providers shall provide Covered Services to Commercial Plan Members pursuant to the terms of the Base Agreement and this Product Attachment A.
Provision of Covered Services. MCP is responsible for authorizing Medically Necessary Covered Services, including NSMHS, ensuring MCP’s Network Providers coordinate care for Members as provided in the applicable Medi-Cal Managed Care Contract, and coordinating care from other providers of carve-out programs, services, and benefits.
Provision of Covered Services. Provider may not refuse to provide Medically Necessary or preventive Covered Services to a child under the age of twenty-one (21) or other Covered Persons for non-medical reasons. Provider is not required to accept or continue treatment of a patient with whom Provider feels he or she cannot establish and/or maintain a professional relationship. Provider shall follow the applicable CRA’s requirements for the provision of Covered Services. Provider’s decisions affecting the delivery of acute or chronic care services to Covered Persons shall be made on an individualized basis and in accordance with the following definitions:
Provision of Covered Services. Provider shall furnish to Medi-Cal Members those services which is authorized to provide under this Agreement, consistent with the scope of Provider’s license, certification or accreditation, and in accordance with professionally recognized standards. Provider shall provide services to Medi-Cal Members in accordance with, and shall otherwise comply with, all of the provisions of the Plan Contract, including but not limited to all Exhibits, with respect to Medi-Cal Members enrolled in Health Plan through the Local Initiative.
Provision of Covered Services. Provider shall provide Covered Services to Members, within the scope of Provider’s license, in accordance with this Agreement, Health Plan’s policies and procedures, the terms and conditions of the Health Plan product which covers the Member, and the requirements of any applicable government sponsored program.
Provision of Covered Services. Participating Provider agrees to and shall participate in all Health Benefits Plans as may be required by QualCare hereunder. Participating Provider agrees to and shall provide, and arrange for the provision of, Covered Services, including without limitation Emergency services and Urgently Needed Services, as applicable, to Members pursuant to such Plans, pursuant to such Payor Agreements entered into between QualCare and the applicable Payors, pursuant to this Agreement, and pursuant to the Provider Manual, and shall comply with, and shall arrange for compliance with, all of the terms and conditions of each Payor Agreement, this Agreement, and the Provider Manual; provided, however, that the Payor Agreement, this Agreement, or the Provider Manual shall not require Participating Provider to provide services, charge of a fee, or engage in activities that would cause Participating Provider to be in violation of any applicable law, rule, or regulation. Such Covered Services shall be within the Participating Provider’s license, certification, and authorization as well as scope of service or specialty, consistent with standards prevailing in the community at the time the Covered Services are rendered.
Provision of Covered Services. Provider agrees to render Covered Services to Members eligible for coverage under Title XVIII of the Social Security Act, as amended, in accordance with the terms and conditions of the MA PPO Program and BCBSM MA PPO Program requirements. Such BCBSM MA PPO Program requirements include the provisions of BCBSM’s applicable EOC, operational policies and procedures, utilization management program and quality management program requirements with which Provider shall comply in rendering Covered Services. BCBSM shall supply Provider with the MA PPO Program requirements not set forth in this Agreement through its MA PPO Provider Manual and any amendments thereto. Determination of Covered Services shall be governed by coverage guidelines established by BCBSM and the MA PPO Program, with BCBSM being solely responsible for final coverage determination, subject to the applicable appeal procedures.
Provision of Covered Services a. Contractor may not deny or reduce the amount, duration, or scope of a Covered Service solely because of the diagnosis, type of illness, or condition, subject to the Prioritized List of Health Services.
b. Contractor shall ensure all Medically Appropriate Covered Services are furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to Clients under Fee-for-Service and as set forth in 42 CFR § 438.210. Contractor shall also ensure that the Covered Services are sufficient in amount, duration, and scope as necessary
(1) The prevention, diagnosis, and treatment of a disease, condition, or disorder that results in health impairments or disability;
(2) The ability to achieve age-appropriate growth and development; and
(3) The ability to attain, maintain, or regain functional capacity.
c. Contractor shall create a written Utilization Management (UM) Handbook that sets forth Contractor’s utilization management policies, procedures, and criteria for Covered Services. The UM Handbook must comply with the utilization control requirements set forth in 42 CFR Part 456, including, without limitation, the minimum health record requirements set forth in 42 CFR
(1) Identification of the Member;
(2) Physician name;
(3) Date of admission, dates of application for, and authorization of, Medicaid benefits if application is made after admission;
(4) The plan of care (as required under 45 CFR § 456.180 for mental Hospitals or 45 CFR §
(5) Initial and subsequent continued stay review dates (described under 42 CFR § 456.233 and § 456.234 for mental Hospitals and 42 CFR § 456.128 and § 456.133 for Hospitals);
(6) Reasons and plan for continued stay if the attending physician determines continued stay is necessary;
(7) Other supporting material the Hospital’s utilization review committee believes appropriate to include; and
(8) For non-mental Hospitals only:
(a) Date of operating room reservation; and
(b) Justification of emergency admission, if applicable.
d. Contractor’s utilization management policies, procedures, and criteria shall not be structured so as to provide incentives for its Provider Network, employees, or other Utilization Reviewers to inappropriately deny, delay, limit, or discontinue Medically Appropriate services to any Member.
e. Contractor shall ensure that medical necessity determination standards and any other quantitative or Non-Quantitative Treatment Limitations applied to Covered Servi...
