Participant Provider definition

Participant Provider means an individual or entity that satisfies the requirements of Section 4.01.A.
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Participant Provider means an individual or entity that: (1) is a Medicare- enrolled provider or supplier (as described in 42 C.F.R. § 400.202); (2) is identified on the DCE’s list of Participant Providers by name, individual National Provider Identifier (“NPI”), tax identification number (“TIN”), Legacy TIN or CMS Certification Number (“CCN”) (if applicable); (3) bills for items and services it furnishes to Medicare FFS beneficiaries under a Medicare billing number assigned to a TIN in accordance with applicable Medicare regulations; (4) is not a Preferred Provider nor a Prohibited Participant (as defined below); and (5) has agreed to participate in the Direct Contracting Model pursuant to a written agreement with the DCE.
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Participant Provider means a provider who has entered into a service agreement with a service corporation;
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Examples of Participant Provider in a sentence

  • For each Performance Year that the ACO selects to participate in the APO, the arrangement prohibits a Participant Provider that is added to the Participant Provider List during the Performance Year or a Preferred Provider that is added to the Preferred Provider List during a Performance Year from participating in the APO for the Performance Year in which the Participant Provider or the Preferred Provider is so added.

  • By a date specified by CMS, the ACO shall furnish written notification to the executive of any TIN through which an individual or entity on the Proposed Revised Participant Provider List or Proposed Revised Preferred Provider List bills Medicare.

  • The arrangement requires the Participant Provider or Preferred Provider to complete a close-out process upon termination or expiration of the arrangement that requires the Participant Provider or Preferred Provider to furnish all data required by the ACO to participate in the Model and any data required by CMS to monitor or evaluate the Model.

  • If the ACO selects to provide a Benefit Enhancement for a Performance Year, the ACO’s Participant Providers and Preferred Providers, as indicated on the relevant Participant Provider List and Preferred Provider List under Article IV, may submit claims for services furnished pursuant to such Benefit Enhancement as described in this Article X during the Performance Year for which the ACO selected to provide the Benefit Enhancement.

  • The notice must include the date on which the individual or entity will cease to be a Participant Provider or Preferred Provider and the basis for removal (i.e., the requirements of Section 4.01.A or Section 4.01.B, as applicable, that the individual or entity no longer satisfies).

  • The ACO shall not take, and shall ensure that its Participant Providers and Preferred Providers do not take, any action to limit the ability of a Participant Provider or Preferred Provider to make decisions in the best interests of a Beneficiary, including the selection of devices, supplies and treatments used in the care of the Beneficiary.

  • If the ACO has selected PCC Payment as its Capitation Payment Mechanism, the arrangement prohibits a Participant Provider that is added to the Participant Provider List during a Performance Year or a Preferred Provider that is added to the Preferred Provider List during a Performance Year from participating in the ACO’s selected Capitation Payment Mechanism for the Performance Year in which the Participant Provider or Preferred Provider is so added.

  • If the ACO has selected TCC Payment as its Capitation Payment Mechanism, the arrangement prohibits a Participant Provider that is added to the Participant Provider List during a Performance Year or a Preferred Provider that is added to the Preferred Provider List during a Performance Year from participating in the ACO’s selected Capitation Payment Mechanism for the Performance Year in which the Participant Provider or Preferred Provider is so added.

  • In offering this Beneficiary-identifiable data, CMS does not represent that the ACO or any Participant Provider or Preferred Provider has met all applicable HIPAA requirements for requesting data under 45 CFR 164.506(c)(4).

  • In a form and manner specified by CMS, except as otherwise specified in Section 4.03.B.2, the ACO shall provide advance notice to CMS in accordance with the List Addition and Removal Schedule before an individual or entity ceases to be a Participant Provider or Preferred Provider.