Participant Providers and Preferred Clause Samples
The 'Participant Providers and Preferred' clause defines which healthcare providers are considered part of a plan's network and which are designated as preferred providers. In practice, this clause outlines the criteria for a provider to be classified as a participant or preferred, and may specify the benefits or reimbursement rates applicable when members use these providers. Its core function is to guide plan members in selecting providers to maximize their benefits and to help the plan manage costs by steering utilization toward preferred providers.
Participant Providers and Preferred. Providers Section 4.01 General
A. The ACO shall contract with one or more Participant Providers. The ACO shall ensure that each Participant Provider:
1. Is a Medicare-enrolled provider (as defined at 42 CFR § 400.202) or supplier (as defined at 42 CFR § 400.202);
2. Bills for items and services it furnishes to Beneficiaries under a Medicare billing number assigned to a TIN in accordance with applicable Medicare regulations;
3. Is not a Preferred Provider;
4. Is not a Prohibited Participant;
5. Has agreed to participate in the Model pursuant to a written arrangement meeting the requirements of Section 3.04; and
6. Is identified on the Participant Provider List in accordance with this Article IV.
B. The ACO may contract with one or more Preferred Providers. The ACO shall ensure that each Preferred Provider:
1. Is a Medicare-enrolled provider (as defined at 42 CFR § 400.202) or supplier (as defined at 42 CFR § 400.202);
2. Bills for items and services it furnishes to Beneficiaries under a Medicare billing number assigned to a TIN in accordance with applicable Medicare regulations;
3. Is not a Participant Provider;
4. Is not a Prohibited Participant;
5. Has agreed to participate in the Model pursuant to a written arrangement meeting the requirements of Section 3.04; and
6. Is identified on the Preferred Provider List in accordance with this Article IV.
C. Participant Providers and Preferred Providers will be included on the Participant Provider List or Preferred Provider List only upon the prior written approval of CMS.
D. CMS shall maintain the Participant Provider List and Preferred Provider List in a manner that permits the ACO to review the lists.
E. The ACO shall maintain current and historical Participant Provider Lists and Preferred Provider Lists in accordance with Section 16.02.
F. CMS may periodically monitor the program integrity history of the ACO’s Participant Providers and Preferred Providers. CMS may remove an individual or entity from the Participant Provider List or Preferred Provider List or subject the ACO to additional monitoring pursuant to Section 17.01, on the basis of the results of a Program Integrity Screening or information obtained regarding an individual’s or entity’s history of program integrity issues, including but not limited to a Participant Provider’s or Preferred Provider’s licensure status and ongoing investigations by law enforcement, program integrity, or state licensure bodies. CMS shall notify the ACO if CMS chooses to ...