Common use of Provider Accessibility Clause in Contracts

Provider Accessibility. CONTRACTOR is required to meet the TDI accessibility and availability requirements and the TDI services requirements for HMOs (Title 28, Part I, Chapter 11, Subchapters Q and U of the Texas Administrative Code). Out-of-network and emergency services also must be provided in accordance with the Texas Insurance Code and TDI regulations as they apply to HMOs. CONTRACTOR must have a sufficient number of providers (including pediatric providers) to meet Members' needs in accordance with TDI accessibility and availability requirements. PCPs and specialty care providers with experience in treating children and adolescents must be available to all Members . CONTRACTOR must ensure that CCSHCN have access to treatment by a multidisciplinary team when determined to be medically necessary for effective treatment or to avoid separate and fragmented evaluations and service plans. The teams must include both physician and non-physician providers determined to be necessary by the Member's PCP. CONTRACTOR must assure access to Texas Department of Health (TDH)-designated Level I and Level II trauma centers within the State or hospitals meeting the equivalent level of trauma care, for emergency services only. CONTRACTOR may make out-of-network reimbursement arrangements with the TDH-designated Level I and Level II trauma centers. CONTRACTOR must assure adequate access of all Members to children's hospitals and pediatric health care centers with recognized special expertise in the care of CCSHCN to meet the medically necessary referrals of a PCP as documented in the Member's medical record. TDH-approved pediatric transplant centers and federally qualified hemophilia centers are examples. CONTRACTOR may make out-of-network reimbursement arrangements for treatment in these hospitals or centers.