Common use of CONTRACTOR Provider Network Clause in Contracts

CONTRACTOR Provider Network. The CONTRACTOR shall establish and maintain, through written agreements, an appropriate Provider network necessary for the provision of the services under this contract. This includes but is not limited to primary care Providers (PCPs), specialty Providers, hospitals and other health care service Providers as identified by the Department. For geographic areas lacking Providers sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the Service Area, the Department at its sole discretion may waive requirements. (42 CFR § 438.207(a); 42 CFR § 438.68; 42 CFR § 438.206(c)(1); 42 CFR § 438.206(b)(1)) 6.2.1 The Contractor shall contract with required Providers based on the standards outlined within the Managed Care Process and Procedure Manual. 6.2.2 The Contractor may execute network Provider agreements, pending the outcome of screening, enrollment, and revalidation process, of up to one-hundred twenty (120) days but must terminate a network Provider immediately upon notification from the Department that the network Provider cannot be enrolled, or the expiration of one (1) one-hundred twenty (120) day period without enrollment of the Provider. 6.2.2.1 The CONTRACTOR shall monitor the SCDHHS NPI Junction file on a routine basis to ensure that Providers ultimately become enrolled as a South Carolina Medicaid Provider. 6.2.2.2 The CONTRACTOR must notify affected Members using the normal notification process and requirements described in this agreement in addition to termination of the In Network Provider. (42 CFR § 438.602(b)(2)). 6.2.3 Primary Care Providers (PCP) The CONTRACTOR shall: 6.2.3.1 Implement procedures to ensure that each Medicaid Managed Care Member has a person or entity, formally designated, as a PCP, primarily responsible for coordinating their health care services. 6.2.3.2 Ensure each Member has access to at least one PCP with an open panel. Additional guidance is contained within the Managed Care Process and Procedure Manual. 6.2.3.3 Ensure its contracted PCPs have an appointment system that meets the following access standards: 6.2.3.3.1 Routine visits scheduled within four (4) to six (6) weeks. 6.2.3.3.2 Urgent, Non-Emergent visits within forty- eight (48) hours. 6.2.3.3.3 Emergent visits immediately upon presentation at a service delivery site. 6.2.3.3.4 Waiting times that do not exceed forty-five (45) minutes for a scheduled appointment of a routine nature. 6.2.3.3.5 Walk-in patients with non-urgent needs should be seen if possible or scheduled for an appointment consistent with written scheduling Procedures. 6.2.3.3.6 Provide twenty-four (24) hour coverage by direct access or through arrangement with a triage system. 6.2.3.3.7 The CONTRACTOR must monitor the adequacy of its appointment processes. 6.2.3.4 If the Contractor is not an ICME, the Contractor shall ensure any Indian Member is eligible to receive services from an Indian Health Care Provider (IHCP) PCP participating as a network provider, is permitted to choose that IHCP as their PCP, as long as the provider has capacity to provide the services, in accordance with American Reinvestment and Recovery Act (ARRA) 5006(d), SMDL 10-00, 42 CFR § 438.14(b)(3). 6.2.4 Specialists

CONTRACTOR Provider Network. The CONTRACTOR shall establish and maintain, through written agreements, an appropriate Provider network necessary for the provision of the services under this contract. This includes ; this includes, but is not limited to to, primary care Providers (PCPs), specialty Providers, hospitals and other health care service Providers as identified by the Department. For geographic areas lacking Providers sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the Service Area, the Department at its sole discretion may waive requirements. (42 CFR § 438.207(a); 42 CFR § 438.68; 42 CFR § 438.206(c)(1); 42 CFR § 438.206(b)(1)) 6.2.1 The Contractor shall contract with required Providers are designated a status based on upon taxonomy as outlined in the standards outlined within Network Adequacy Chart found in the Managed Care Process Report Companion Guide. The Department has four status designations that inform access and Procedure Manualadequacy requirements. Any changes to a Provider’s status designation shall be at the sole discretion of the Department. 6.2.2 The Contractor may execute network Provider agreements, pending the outcome of screening, enrollment, and revalidation process, of up to one-hundred twenty (120) days but must terminate a network Provider immediately upon notification from the Department that the network Provider cannot be enrolled, or the expiration of one 6.2.1 Status One (1) one-hundred twenty (120) day period without enrollment of the Provider. 6.2.2.1 The CONTRACTOR shall monitor the SCDHHS NPI Junction file on a routine basis to ensure that Providers ultimately become enrolled as a Status One providers are South Carolina Medicaid Providernetwork Providers that the Contractor is required to have an executed contract with. These providers have defined adequacy standards. 6.2.2.2 The CONTRACTOR must notify affected Members using the normal notification process and requirements described in this agreement in addition to termination of the In Network Provider. (42 CFR § 438.602(b)(2)). 6.2.3 6.2.1.1 Primary Care Providers (PCP) ) 6.2.1.1.1 Access Standards for Primary Care Providers The CONTRACTOR shall: 6.2.3.1 6.2.1.1.1.1 Implement procedures to ensure that each Medicaid Managed Care Member has a person or entity, formally designated, as a PCP, primarily responsible for coordinating their health care services. 6.2.3.2 6.2.1.1.1.2 Ensure each Member has access to at least one PCP with an open panel. Additional guidance is contained within the Managed Care Process and Procedure Manual. 6.2.3.3 6.2.1.1.1.3 Ensure its contracted PCPs have an appointment system that meets the following access standards: 6.2.3.3.1 6.2.1.1.1.3.1 Routine visits for established patients scheduled within four (4) to six (6) weeksf15 Business days. 6.2.3.3.2 6.2.1.1.1.3.2 Urgent, Non-Emergent visits within forty- eight (48) hours. 6.2.3.3.3 6.2.1.1.1.3.3 Emergent visits immediately upon presentation at a service delivery site. 6.2.3.3.4 6.2.1.1.1.3.4 Waiting times that do not exceed forty-five (45) minutes for a scheduled appointment of a routine nature. 6.2.3.3.5 6.2.1.1.1.3.5 Walk-in patients with non-urgent needs should be seen if possible or scheduled for an appointment consistent with written scheduling Procedures. 6.2.3.3.6 6.2.1.1.1.3.6 Provide twenty-four (24) hour coverage by direct access or through arrangement with a triage system. 6.2.3.3.7 The CONTRACTOR must monitor 6.2.1.1.1.4 Monitor the adequacy of its appointment processes. 6.2.3.4 If the Contractor is not an ICME, the Contractor shall ensure any Indian Member is eligible to receive services from an Indian Health 6.2.1.1.2 Adequacy Standards for Primary Care Provider (IHCP) PCP participating as a network provider, is permitted to choose that IHCP as their PCP, as long as the provider has capacity to provide the services, in accordance with American Reinvestment and Recovery Act (ARRA) 5006(d), SMDL 10-00, 42 CFR § 438.14(b)(3). 6.2.4 SpecialistsProviders

CONTRACTOR Provider Network. The CONTRACTOR shall establish and maintain, through written agreements, an appropriate Provider network Network necessary for the provision of the services under this contractContract. This includes includes, but is not limited to primary care Primary Care Providers (PCPs), specialty Specialty Providers, hospitals Hospitals and other health care service Health Care Service Providers as identified by the Department. For geographic areas lacking Providers sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the Service Areaservice area, the Department at its sole discretion may waive requirements. (42 CFR § 438.207(a); 42 CFR § 438.68; 42 CFR § 438.206(c)(1); 42 CFR § 438.206(b)(1)) 6.2.1 The Contractor shall contract with required Providers based on the standards outlined within the Managed Care Process and Procedure Manualdistance requirement. 6.2.2 The Contractor may execute network Provider agreements, pending the outcome of screening, enrollment, and revalidation process, of up to one-hundred twenty (120) days but must terminate a network Provider immediately upon notification from the Department that the network Provider cannot be enrolled, or the expiration of one (1) one-hundred twenty (120) day period without enrollment of the Provider. 6.2.2.1 The CONTRACTOR shall monitor the SCDHHS NPI Junction file on a routine basis to ensure that Providers ultimately become enrolled as a South Carolina Medicaid Provider. 6.2.2.2 The CONTRACTOR must notify affected Members using the normal notification process and requirements described in this agreement in addition to termination of the In Network Provider6.2.1. (42 CFR § 438.602(b)(2)). 6.2.3 Primary Care Providers Provider (PCP) The CONTRACTOR shall: 6.2.3.1 : Implement procedures to ensure that each Medicaid Managed Care Member has a person or entity, formally designated, as a PCP, primarily responsible for coordinating their health care services. 6.2.3.2 . Ensure each Member has access to at least one PCP with an open panel. Additional guidance is contained within the Managed Care Process managed care policy and Procedure Manual. 6.2.3.3 procedure guide. Ensure its contracted PCPs have an appointment system that meets the following access standards: 6.2.3.3.1 Routine 6.2.1.3.1. ▇▇▇▇▇▇▇ visits scheduled within four (4) to six (6) weeks. 6.2.3.3.2 Urgent6.2.1.3.2. ▇▇▇▇▇▇, Nonnon-Emergent emergent visits within forty- forty-eight (48) hours. 6.2.3.3.3 6.2.1.3.3. Emergent visits immediately upon presentation at a service delivery site. 6.2.3.3.4 6.2.1.3.4. Waiting times that do not exceed forty-five (45) minutes for a scheduled appointment of a routine nature. 6.2.3.3.5 6.2.1.3.5. Walk-in patients with non-urgent needs should be seen if possible or scheduled for an appointment consistent with written scheduling Proceduresprocedures. 6.2.3.3.6 6.2.1.3.6. Provide twenty-four (24) hour coverage by direct access or through arrangement with a triage system. 6.2.3.3.7 6.2.1.3.7. The CONTRACTOR must monitor the adequacy of its appointment processes. 6.2.3.4 If 6.2.2. Specialists General Requirements The CONTRACTOR shall: 6.2.2.1.1. Be required to contract with required specialists based on the Contractor is not an ICME, standards outlined within the Contractor shall ensure any Indian Member is eligible to receive services from an Indian Health Managed Care Provider (IHCP) PCP participating as a network provider, is permitted to choose that IHCP as their PCP, as long as the provider has capacity to provide the services, in accordance with American Reinvestment Policy and Recovery Act (ARRA) 5006(d), SMDL 10-00, 42 CFR § 438.14(b)(3)Procedure Manual. 6.2.4 Specialists6.2.2.1.2. Ensure each Member has access to Specialists with an open panel. Additional guidance is stated within the managed care policy and procedure guide. 6.2.2.1.3. Accept the Department’s instruction to include additional specialists for a specific geographic area, when necessary. 6.2.2.1.4. Make available a choice of at least two (2) required contracted specialists and/or subspecialists who are accepting new patients within the geographic area. 6.2.2.1.5. For specialty referrals, provide for: 6.2.2.1.5.1. Emergent visits immediately upon referral. 6.2.2.1.5.2. Urgent medical condition care appointments within forty-eight (48) hours of referral or notification of the Primary Care Physician. 6.2.2.1.5.3. Scheduling of appointments for routine care (non-symptomatic) within four (4) weeks and a maximum of twelve (12) weeks for unique specialists.