Provider Contracting Sample Clauses
Provider Contracting a. contracting with health care providers or soliciting such contracts in a Contiguous Area in order to serve its subscribers residing or working in its service area;
b. issuing a small sign containing the legal name or trade name of the Licensee for display by a provider in a Contiguous Area to identify the provider as a participating provider of the Licensee;
c. negotiating case-specific reimbursement rates with a provider that does not have a contract applicable to a specific member’s services rendered or to be rendered with the Licensee (or any of the Licensees in the case of overlapping Service Areas) in whose Service Area the health care provider is located, so long as
(1) the Licensee engaging in the negotiations complies with all applicable Inter- Plan Programs Policies and Provisions and Brand Regulations related to case- specific rate negotiations, and
(2) the Licensee (or all Licensees in the case of overlapping Service Areas) in whose Service Area the health care provider is located provides consent before negotiations commence.
d. contracting with a pharmacy management organization (“Pharmacy Intermediary”) to gain access to a national or regional pharmacy network to provide self-administered prescription drugs to deliver a pharmacy benefit for all of the Licensee’s members nationwide, provided, however, that the Pharmacy Intermediary may not use the Licensed Marks or Name in contracting with the pharmacy providers in such network. Page 3 of 14 e. contracting with the corporate owner of a national or regional retail pharmacy chain to gain access to the pharmacies in the chain to provide self-administered prescription drugs to deliver a pharmacy benefit for all of the Licensee’s members nationwide, provided that (1) the Plan and the Controlled Affiliate may not contract directly with pharmacists or pharmacy stores outside the Plan’s Service Area, and (2) neither the Plan’s or the Controlled Affiliate’s name nor the Licensed Marks or Name may be posted or otherwise displayed at or by any pharmacy store outside the Plan’s Service Area;
Provider Contracting contracting with health care providers or soliciting such contracts in areas contiguous to the Plan's Service Area in order to serve its subscribers or those of such licensed Controlled Affiliates residing or working in its service area;
Provider Contracting. The INSURER will assure that all hospitals facilities, doctors, dentists, and all health care providers are appropriately licensed and in good standing with all their governing bodies and accrediting agencies and meet all practice requirements established by law, the Department of Health, the ADMINISTRATION and other governing agencies, as described in the INSURER's Proposal. The ADMINISTRATION may review participating provider credentials at any time and submit its findings to the INSURER for consideration by the INSURER if necessary. The INSURER shall notify the ADMINISTRATION quarterly of all accepted and non-accepted providers.
Provider Contracting. The Contractor shall enter into written agreements with providers to ensure the provision of all covered services as outlined in this contract. When contracting with providers the Contractor shall have the authority to develop alternative and varying contractual models and relations, and incentives outside of the fee-for-service structure. The Contractor must submit a copy of all base provider agreements to the Department for review and approval.
Provider Contracting a. contracting with health care providers or soliciting such contracts in areas contiguous to the Plan's Service Area in order to serve its subscribers or those of such licensed Controlled Affiliates residing or working in its service area;
b. issuing a small sign containing the legal name or trade name of the Plan or such licensed Controlled Affiliates for display by a provider to identify the latter as a participating provider of the Plan or Controlled Affiliate;
c. negotiating rates with a health care provider for services to a specific member, provided that all of the following conditions are met:
(1) the health care provider does not have a contract, applicable to the services rendered or to be rendered, with the Licensee (or any of the Licensees in the case of overlapping Service Areas) in whose Service Area the health care provider is located; and
(2) the Plan or Controlled Affiliate reasonably determines that the member did/does not have a reasonable opportunity to access a participating provider whose contract applies to the services rendered or to be rendered; and
(3) at least one of the following circumstances exists:
(i) the member received emergency services and the Plan or Controlled Affiliate knows or reasonably anticipates that the charges on the claim will meet or exceed $5,000; or
(ii) a provider, in consultation pre- or post- treatment with the Plan or Controlled Affiliate, makes/made a treatment recommendation or referral to a non-par provider or to a par provider whose contract does not apply to the services to be rendered; or
(iii) the member inadvertently accessed a non-par provider or non-contracted services in the course of receiving services from a par provider (e.g., the member sees a non-par consulting specialist in a participating hospital); and
(4) the Licensee (and in the case of overlapping Service Areas, all of the Licensees) in whose Service Area the health care provider is located consent(s) in advance.
Provider Contracting xxiv. Tobacco-free Policy, a. is revised and restated as follows:
Provider Contracting. The MBHO will assure that all hospitals facilities, doctors, dentists, and all health care providers are appropriately licensed and in good standing with all their governing bodies and accrediting agencies and meet all practice requirements established by law, the Department of Health, the ASSMCA and other governing agencies, as described in the MBHO's Proposal. The ADMINISTRAT1ON may review participating provider credentials at any time and submit its findings to the MBHO. The MBHO shall notify the ADMINISTRATION quarterly of all accepted and non-accepted providers.
Provider Contracting. 3.1 Each party understands and acknowledges that the other party is in the business of providing health care services and, as such, may from time to time enter into contracts with providers currently under contract with the other party.
3.2 HSPC delegates to ACS on a non-exclusive basis provider recruitment and contracting responsibility for those health care services listed in Exhibit A in those geographic regions identified in Schedule 3.2. During the term of this Agreement, ACS agrees to use its commercially reasonable efforts to expand the ACS network [***] in the geographic regions identified in Schedule 3.2 for purposes of enhancing its product offering to HSPC and HSPC's clients. HSPC shall provide ACS with an HSPC letterhead endorsement in a mutually agreed upon format to assist ACS in provider solicitation. Notwithstanding anything in this Agreement to the contrary, HSPC reserves the right to directly contract with any provider providing the health care services listed in Exhibit A within the geographic regions listed in Schedule 3.2 as determined by HSPC in its sole discretion.
3.3 HSPC shall provide ACS with a quarterly claims file indicating all “white space” non-participating providers.
3.4 Periodically at HSPC's discretion, HSPC may provide to ACS, in a format mutually agreed upon by the parties, a list of provider nominations. The list, at a minimum, shall contain the name, address, phone, specialty, and other relevant information sufficient to allow ACS to identify, locate and solicit the nominated provider. ACS shall, [***] following receipt of a provider nomination from HSPC, provide written confirmation to HSPC of its intent to recruit and contract with such provider. ACS shall thereafter use its commercially reasonable efforts to secure a contract with such nominated provider [***]. No later than the fifth (5th) day of each month, ACS shall provide HSPC with its monthly list of active provider solicitations, including, without limitation, the current status of negotiations, as well as the effective date of each completed agreement for HSPC nominated providers. Additionally, upon mutual written agreement, HSPC may engage ACS to conduct network development activities associated with those health care services identified in Exhibit A for additional geographic regions for a period of time to be determined by the parties. For the avoidance of doubt, nothing in this Section 3.4 shall prohibit HSPC from directly contracting with any provider i...
Provider Contracting. ACR Consulting Services has a proven history of handling Single Case Agreements (SCA). Our work frees up insurers to handle other important issues while providing a level of expertise that many providers do not possess. All of which facilitates patient access to out-of-network providers.
Provider Contracting. The DMO must enter into Provider Agreements to ensure Network adequacy under Section