Health Care Preferred Provider Program Administrator Provider Agreements

Section 2051.290  Health Care Preferred Provider Program Administrator Provider Agreements Administrators shall file a sample of copy of all provider agreements. WC PPPs are exempt from the requirements of this Section, but must instead comply with the requirements of Section 2051.295. The agreements shall contain, at a minimum: a)         A provision identifying the specific covered health care services for which the preferred provider will be responsible, including any discount services, copayments, benefit maximums, limitations and exclusions, as well as any discount amount or discounted fee schedule reflecting discounted rates; b)         A provision requiring the provider to comply with applicable administrative policies and procedures of the administrator including, but not limited to credentialing or recredentialing requirements; and, except for DHCSP administrators, utilization review requirements, and referral procedures; c)         Medical Records 1)         A provision requiring that, when payments are due to the provider for services rendered to a beneficiary, the provider must maintain and make medical records available: A)        To the administrator and/or insurer for the purpose of determining, on a concurrent or retrospective basis, the medical necessity and appropriateness of care provided to beneficiaries; B)        To appropriate State and federal authorities and their agents involved in assessing the accessibility and availability of care or investigating member grievances or complaints; and C)        To show compliance with the applicable State and federal laws related to privacy and confidentiality of medical records. 2)         This subsection (c) does not apply to administrators offering only a DHCSP; d)         A provision requiring providers to be licensed by the State, and to notify the administrator immediately whenever there is a change in licensure or certification status; e)         A provision requiring all physician providers licensed to practice medicine in all its branches to have admitting privileges in at least one hospital with which the administrator has a written provider contract.  The administrator shall be notified immediately of any changes in privileges at any hospital or admitting facility.  Reasonable exceptions shall be made for physicians who, because of the type of clinical specialty, or location or type of practice, do not customarily have admitting privileges. This subsection (e) does not apply to administrators offering only DHCSPs; f)         A provision describing notification procedures for contract termination. Termination provisions shall require: 1)         Not less than 30 days prior written notice by either party who wishes to terminate the contract without cause; 2)         That the administrator may immediately terminate the provider contract for cause; and 3)         If applicable, that a provider, acting as primary care physician under plans requiring a gatekeeper option, must provide the administrator with a list of all patients using that provider as a gatekeeper within 5 working days after the date that the provider either gives or receives notice of termination; g)         A provision explaining the provider responsibilities for continuation of covered services in the event of contract termination, to the extent that an extension of benefits is required by law or regulation, or that continuation is voluntarily provided by the administrator. This subsection (g) does not apply to administrators offering only a DHCSP; h)         A provision stating that the rights and responsibilities under the contract cannot be sold, leased, assigned, assumed or otherwise delegated by either party without the prior written consent of the other party. The provider's written consent must be obtained for any assignment or assumption of the provider contract whenever an administrator or insurer is bought by another administrator or insurer. A clause within the provider contract allowing assignment will be deemed consent so long as the assignment is in accordance with the terms of the contract. The assignee must comply with all the terms and conditions of the contract being assigned, including all checklists, policies and fee schedules; i)          A provision stating that the preferred provider has and will maintain adequate professional liability and malpractice coverage, through insurance, self-funding, or other means satisfactory to the administrator.  The administrator must be notified within no less than 10 days after the provider's receipt of notice of any reduction or cancellation of the required coverage; j)          A provision stating that the provider will provide health care services without discrimination against any beneficiary on the basis of participation in the preferred provider program, source of payment, age, sex, ethnicity, religion, sexual preference, health status or disability; k)         A provision regarding the preferred provider's obligation, if any, to collect applicable copayments, coinsurance and/or deductibles from beneficiaries as provided by the beneficiary's health care services contract, and to provide notice to beneficiaries of their personal financial obligations for non-covered services. This provision shall include any amount of applicable discounts or, alternatively, a fee schedule that reflects any discounted rates. For DHCSPs only, a provision that providers may not charge beneficiaries more than any applicable discounted rates in accordance with payment terms and provisions contained in a DHCSP agreement signed by a beneficiary; l)          A provision regarding any obligation to provide covered health services on a 24 hour per day, 7 day per week basis; m)        A provision clearly describing the administrator's and payor's payment obligations to the provider. For DHCSPs, neither administrators nor payors may pay providers for health care services provided to beneficiaries. For DHCSPs, neither administrators nor payors may accept money from a beneficiary for payment to a provider for specific health care services furnished or to be furnished to the beneficiary; n)         A provision identifying the administrative services, if any, the administrator will perform and the types of information (e.g., financial, enrollment, utilization) that will be submitted to the provider, as well as other information that is accessible to the provider; o)         A provision obligating the administrator to provide a method for providers to access each payor to obtain benefit information and adequate notice of change in benefits and copayments, and a provision obligating the administrator to provide all of the administrator's operational policies. This subsection does not apply to administrators offering only a DHCSP; and p)         A provision identifying applicable internal appeal or arbitration procedures for settling contractual disputes or disagreements between the administrator and preferred provider.