Common use of Required Policies and Procedures Clause in Contracts

Required Policies and Procedures. The CONTRACTOR shall: Maintain written policies and procedures on provider recruitment, retention, and termination of Contract Provider participation with the CONTRACTOR. HCA must prior approve these policies and procedures in writing and may review them upon demand. The recruitment policies and procedures shall describe how a CONTRACTOR responds to a change in the network that affects access and its ability to deliver services in a timely manner; Require that each Provider either billing for or rendering services to Members has a unique identifier in accordance with the provisions of Section 1173(b) of the Social Security Act; Require that any Provider, including Providers ordering or referring a Covered Service, have a National Provider Identifier (NPI) to the extent such Provider is not an atypical provider as defined by CMS; Consider, in establishing and maintaining the network of appropriate Providers, its: Anticipated enrollment; Expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the CONTRACTOR’s population; Numbers and types (in terms of training, experience, and specialization) of Providers required to furnish Covered Services; Numbers of Contract Providers who are not accepting new patients; and Geographic location of Contract Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities; Ensure that Contract Providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees; Establish mechanisms such as notices or training materials to ensure that Contract Providers comply with the timely access requirements, monitor such compliance regularly, and take corrective action if there is a failure to comply; Conduct screening of all Major Subcontractors and Contract Providers, in accordance with the Employee Abuse Registry Act, NMSA 1978 § 27-7A-3, the New Mexico Caregivers Criminal History Screening Act, NMSA 1978, 29-17-2 et seq. and NMAC 7.1.9, the New Mexico Children’s and Juvenile Facility and Program Criminal Records Screening Act, NMSA 1978, § 32A-15-1 to 32A-15-4, PPACA (see Section 4.9.2.47 of this Agreement) and ensure that all Major Subcontractor and Contract Providers are screened against the New Mexico “List of Excluded Individuals/Entities” and the Medicare exclusion databases and not employ or contract with entities or Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Provide Members and Contract Providers with clear instructions on how to access Covered Services, including those that require prior approval and referral; Meet all availability, time, and distance standards set by HCA and have a system to track and report compliance with these standards; and Provide Member access to Non-Contract Providers if the CONTRACTOR is unable to provide Medically Necessary services covered under this Agreement in a manner that meets the availability, time, and distance standards under this Agreement. The CONTRACTOR shall continue to authorize the use of Non-Contract Providers for as long as the CONTRACTOR is unable to provide these services through Contract Providers. The CONTRACTOR must ensure that the cost to the Member is no greater than it would be if the services were provided within the CONTRACTOR’s network.

Required Policies and Procedures. The CONTRACTOR shall: Maintain written policies and procedures on provider recruitment, retention, and termination of Contract Provider participation with the CONTRACTOR. HCA HSD must prior approve these policies and procedures in writing and may review them upon demand. The recruitment policies and procedures shall describe how a CONTRACTOR responds to a change in the network that affects access and its ability to deliver services in a timely manner; Require that each Provider either billing for or rendering services to Members has a unique identifier in accordance with the provisions of Section 1173(b) of the Social Security Act; Require that any Provider, including Providers ordering or referring a Covered Service, have a National Provider Identifier (NPI) to the extent such Provider is not an atypical provider as defined by CMS; Consider, in establishing and maintaining the network of appropriate Providers, its: Anticipated enrollment; Expected utilization of services, taking into consideration the characteristics and health care needs of specific populations represented in the CONTRACTOR’s population; Numbers and types (in terms of training, experience, and specialization) of Providers required to furnish Covered Services; Numbers of Contract Providers who are not accepting new patients; and Geographic location of Contract Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities; Ensure that Contract Providers offer hours of operation that are no less than the hours of operation offered to commercial enrollees; Establish mechanisms such as notices or training materials to ensure that Contract Providers comply with the timely access requirements, monitor such compliance regularly, and take corrective action if there is a failure to comply; Conduct screening of all Major Subcontractors and Contract Providers, in accordance with the Employee Abuse Registry Act, NMSA 1978 § 27-7A-3, the New Mexico Caregivers Criminal History Screening Act, NMSA 1978, 29-17-2 et seq. and NMAC 7.1.9, the New Mexico Children’s and Juvenile Facility and Program Criminal Records Screening Act, NMSA 1978, § 32A-15-1 to 32A-15-4, PPACA (see Section 4.9.2.47 of this Agreement) and ensure that all Major Subcontractor and Contract Providers are screened against the New Mexico “List of Excluded Individuals/Entities” and the Medicare exclusion databases and not employ or contract with entities or Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Provide Members and Contract Providers with clear instructions on how to access Covered Services, including those that require prior approval and referral; Meet all availability, time, and distance standards set by HCA HSD and have a system to track and report compliance with these standards; and Provide Member access to Non-Contract Providers if the CONTRACTOR is unable to provide Medically Necessary services covered under this Agreement in a manner that meets the availability, time, and distance standards under this Agreement. The CONTRACTOR shall continue to authorize the use of Non-Contract Providers for as long as the CONTRACTOR is unable to provide these services through Contract Providers. The CONTRACTOR must ensure that the cost to the Member is no greater than it would be if the services were provided within the CONTRACTOR’s network.