Direct-Contracting Providers

40.1 – Direct-Contracting Providers (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) A provider is a direct-contracting provider if the provider has a signed contract or agreement with a PFFS plan to deliver covered services to the plan’s members. These providers are also known as network providers. Direct-contracting providers have already agreed to see members of the plan. • Full network PFFS plans must establish direct-contracting providers for all categories of Part A and Part B services in accordance with the access standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. • Partial network PFFS plans may have direct-contracting providers for one or more categories of Part A or Part B services in accordance with the access standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. • Non-network PFFS plans generally do not have direct-contracting providers. However, non-network plans may establish signed contracts or agreements with some providers without meeting the access standards described in section 1852(d)(1) of the Act and section 30.2 of this chapter. The payment rules for direct-contracting providers under the three types of PFFS plans are discussed in section 70 of this chapter.