Provider and Supplier Contract Requirements

100.4 - Provider and Supplier Contract Requirements (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) Contracts or other written agreements between MA organizations and providers and suppliers of health care or health care-related services must contain the following provisions: • Contracting providers agree to safeguard beneficiary privacy and confidentiality and assure accuracy of beneficiary health records; • Contracts must specify a prompt payment requirement, the terms and conditions of which are developed and agreed-to by the MA organization and its contracted providers and suppliers; • Contracts must hold Medicare members harmless for payment of fees that are the legal obligation of the MA organization to fulfill. Such provision will apply, but will not be limited to insolvency of the MA organization, contract breach, and provider billing; • Contracts must contain accountability provisions specifying: o That first tier and downstream entities must comply with Medicare laws, regulations, and CMS instructions (422.504(i)(4)(v)), and agree to audits and inspection by CMS and/or its designees and to cooperate, assist, and provide information as requested, and maintain records a minimum of 10 years; o That the MA organization oversees and is accountable to CMS for any functions and responsibilities described in the MA regulations (422.504(i)(4)(iii)); and o That MA organizations that choose to delegate functions must adhere to the delegation requirements - including all provider contract requirements in these delegation requirements - described in the MA regulations (422.504(i)(3)(iii); 422.504(i)(4)(i)-(v)). • Contracts must specify that providers agree to comply with the MA organization's policies and procedures; In addition to the provisions mentioned above, MA organizations must include certain MA-related provisions in the policies and procedures that are distributed to providers and suppliers that constitute the organizations' health services delivery network. The following table summarizes these provisions. Access the CFR online. CONTRACT REQUIREMENTS THROUGH POLICIES, STANDARDS & MANUALS Safeguard privacy and maintain records accurately and timely 422.118 Permanent "out of area" members to receive benefits in continuation area 422.54(b) Prohibition against discrimination based on health status 422.110(a) Pay for emergency and urgently needed services 422.100(b) Pay for renal dialysis for those temporarily out of a service area 422.100(b)(1)(iv) Direct access to mammography and influenza vaccinations 422.100(g)(1) No copay for influenza and pneumococcal vaccines 422.100(g)(2) Agreements with providers to demonstrate "adequate" access 422.112(a)(1) Direct access to women's specialists for routine and preventive services 422.112(a)(3) Services available 24 hrs/day, 7 days/week 422.112(a)(7) Adhere to CMS marketing provisions 422.80(a), (b), (c) Ensure services are provided in a culturally competent manner 422.112(a)(8) Maintain procedures to inform members of follow-up care or provide training in selfcare as necessary 422.112(b)(5) Document in a prominent place in medial record if individual has executed advance directive 422.128(b)(1)(ii)(E) Provide services in a manner consistent with professionally recognized standards of care 422.504(a)(3)(iii) Continuation of benefits provisions (may be met in several ways, including contract provision) 422.504(g)(2)(i); 422.504(g)(2)(ii); 422.504(g)(3) CONTRACT REQUIREMENTS THROUGH POLICIES, STANDARDS & MANUALS Payment and incentive arrangements specified 422.208 Subject to applicable Federal laws 422.504(h) Disclose to CMS all information necessary to (1) Administer & evaluate the program (2) Establish and facilitate a process for current and prospective beneficiaries to exercise choice in obtaining Medicare services 422.64(a): 422.504(a)(4) 422.504(f)(2) Must make good faith effort to notify all affected members of the termination of a provider contract 30 calendar days before the termination by plan or provider 422.111(e) Submission of data, medical records and certify completeness and truthfulness 422.310(d)(3)-(4), 422.310(e), 422.504(d)- (e), 422.504(i)(3)-(4), 422.504(l)(3) Comply with medical policy, QI and MM 422.202(b); 422.504(a)(5) Disclose to CMS quality & performance indicators for plan benefits re: disenrollment rates for beneficiaries enrolled in the plan for the previous two years 422.504(f)(2)(iv)(A) Disclose to CMS quality & performance indicators for the benefits under the plan regarding enrollee satisfaction 422.504(f)(2)(iv)(B) Disclose to CMS quality & performance indicators for the benefits under the plan regarding health outcomes 422.504(f)(2)(iv)(C) Notify providers in writing for reason for denial, suspension & termination 422.202(c)(1) Provide 60 days notice (terminating contract without cause) 422.202(c)(4) Comply with Federal laws and regulations to include, but not limited to: Federal criminal law, the False Claims Act (31 U.S.C. 3729 et. Seq.) and the anti-kickback statute (section 1128B(b) of the Act) 422.504(h)(1) Prohibition of use of excluded practitioners 422.752(a)(8) Adhere to appeals/grievance procedures 422.562(a)