Provider Contracts and Payments. 4.10.1 Provider Contracts 4.10.1.1 The Contractor shall comply with all DCH procedures for contract review and approval submission. Memoranda of Agreement (MOA) shall not be permitted. Letters of Intent shall only be permitted in accordance with Section 4.8.1.10. 4.10.1.2 The Contractor shall submit to DCH for review and approval a model for each type of Provider Contract as updated. 4.10.1.3 Any significant changes to the model Provider Contract shall be submitted to DCH for review and approval no later than thirty (30) Calendar Days prior to the Enrollment of Members into the CMO plan. 4.10.1.4 Upon request, the Contractor shall provide DCH with free copies of all executed Provider Contracts. 4.10.1.5 The Contractor shall not require providers to participate or accept other plans or products offered by the care management organization unrelated to providing care to members, nor reduce the funding available for members as a result of payment of such penalties.. Any care management organization which violates this prohibition shall be subject to a penalty of $1,000.00 per violation. 4.10.1.6 The Contractor shall not enter into any exclusive contract agreements with providers than exclude other health care providers from contract agreements for network participation. 4.10.1.7 Health care providers may not, as a condition of contracting with a CMO, require the CMO to contract with or not contract with another health care provider. A provider who violates this probation will be subject to a $1,000 per violation penalty. 4.10.1.8 If a provider has complied with all of DCH’s published procedures for verifying a patient’s eligibility for Medicaid benefits through the established common verification process, DCH must reimburse the provider for all covered services provided to the patient within the 72 hours following the verification, if such services are denied by a CMO or DCH because the patient is not enrolled as shown in the verification process. DCH would be able to pursue a case of action against a person who had contributed to the incorrect verification. 4.10.1.9 In addition to addressing the CMO plan licensure requirements, the Contractor’s Provider Contracts shall: · Prohibit the Provider from seeking payment from the Member for any Covered Services provided to the Member within the terms of the Contract and require the Provider to look solely to the Contractor for compensation for services rendered, with the exception of nominal cost sharing pursuant to the Georgia State Medicaid Plan, the Georgia State Medicaid Policies and Procedures Manuals, and the GF Contract; · Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Review and management activities; · Include provisions for the immediate transfer to another PCP or Contractor if the Member’s health or safety is in jeopardy; · Not prohibit a Provider from discussing treatment or non-treatment options with Members that may not reflect the Contractor’s position or may not be covered by the Contractor; · Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of a Member for the Member’s health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered; · Not prohibit a Provider from advocating on behalf of the Member in any Grievance System or Utilization Review process, or individual authorization process to obtain necessary Health Care services; · Require Providers to meet appointment waiting time standards pursuant to Section 4.8.14.2 of this Contract; · Provide for continuity of treatment in the event a Provider’s participation terminates during the course of a Member’s treatment by that Provider; · Prohibit discrimination with respect to participation, reimbursement, or indemnification of any Provider who is acting within the scope of his or her license or certification under applicable State law, solely based on such license or certification. This provision should not be construed as any willing provider law, as it does not prohibit Contractors from limiting Provider participation to the extent necessary to meet the needs of the Members. Additionally, this provision shall not preclude the Contractor from using different reimbursement amounts for different specialties or for different practitioners in the same specialty. This provision also does not interfere with measures established by the Contractor that are designed to maintain Quality and control costs; · Prohibit discrimination against Providers serving high-risk populations or those that specialize in Conditions requiring costly treatments; · Specify that CMS and DCH will have the right to inspect, evaluate, and audit any pertinent books, financial records, documents, papers, and records of any Provider involving financial transactions related to the GF Contract; · Specify Covered Services and populations; · Require Provider submission of complete and timely Encounter Data, pursuant to Section 4.17.4.2 of the GF Contract; · Include the definition and standards for Medical Necessity, pursuant to the definition in Section 4.5.4 of this Contract; · Specify rates of payment. The Contractor ensures that Providers will accept such payment as payment in full for Covered Services provided to Members, as deemed Medically Necessary and appropriate under the Contractor’s Quality Improvement and Utilization Management program, less any applicable Member cost sharing pursuant to the GF Contract; · Provide for timely payment to all Providers for Covered Services to Members. Pursuant to O.C.G.A. 33-24-59.5(b) (1) once a clean claim has been received, the CMO(s) will have 15 Business Days within which to process and either transmit funds for payment electronically for the claim or mail a letter or notice denying it, in whole or in part giving the reasons for such denial. · Specify acceptable billing and coding requirements; · Require that Providers comply with the Contractor’s Cultural Competency plan; · Require that any marketing materials developed and distributed by Providers be submitted to the Contractor to submit to DCH for approval; · Specify that in the case of newborns the Contractor shall be responsible for any payment owed to Providers for services rendered prior to the newborn’s Enrollment with the Contractor; · Specify that the Contractor shall not be responsible for any payments owed to Providers for services rendered prior to a Member’s Enrollment with the Contractor, even if the services fell within the established period of retroactive eligibility; · Comply with 42 CFR 434 and 42 CFR 438.6; · Require Providers to collect Member co-payments as specified in Attachment K; · Not employ or subcontract with individuals on the State or Federal Exclusions list; · Prohibit Providers from making Referrals for designated health services to Health Care entities with which the Provider or a Member of the Provider’s family has a Financial Relationship. · Require Providers of transitioning Members to cooperate in all respects with Providers of other CMO plans to assure maximum health outcomes for Members; · Not require that Providers sign exclusive Provider Contracts with the Contractor if the Provider is a CAH, FQHC, or RHC; · Contain a provision stating that in the event DCH is due funds from a Provider; who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment by one hundred percent (100%) to that Provider until such time as the amount owed to DCH is recovered; and · Contain a provision giving notice that the Contractor’s negotiated rates with Providers shall be adjusted in the event the Commissioner of DCH directs the Contractor to make such adjustments in order to reflect budgetary changes to the Medical Assistance program. 4.10.2 Provider Termination 4.10.2.1 The Contractor shall comply with all State and federal laws regarding Provider termination. In its Provider Contracts the Contractor shall: · Specify that in addition to any other right to terminate the Provider Contract, and notwithstanding any other provision of this Contract, DCH may request Provider termination immediately, or the Contractor may immediately terminate on its own, a Provider’s participation under the Provider Contract if a Provider fails to abide by the terms and conditions of the Provider Contract, as determined by DCH, or, in the sole discretion of DCH, fails to come into compliance within fifteen (15) Calendar Days after a receipt of notice from the Contractor specifying such failure and requesting such Provider to abide by the terms and conditions hereof; · Specify that any Provider whose participation is terminated under the Provider Contract for any reason shall utilize the applicable appeals procedures outlined in the Provider Contract. No additional or separate right of appeal to DCH or the Contractor is created as a result of the Contractor’s act of terminating, or decision to terminate any Provider under this Contract. Notwithstanding the termination of the Provider Contract with respect to any particular Provider, this Contract shall remain in full force and effect with respect to all other Providers; 4.10.2.2 The Contractor shall notify DCH at least forty-five (45) Calendar Days prior to the effective date of the suspension, termination, or withdrawal of a Provider from participation in the Contractor’s network. If the termination was “for cause”, the Contractor may terminate, suspend, or withdraw the provider immediately and shall notify DCH in writing within one business day of the termination with the reasons for termination. 4.10.2.3 The Contractor shall notify the Members pursuant to Section 4.10.2 of this Contract.
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Provider Contracts and Payments. 4.10.1 Provider Contracts
4.10.1.1 The Contractor shall comply with all DCH procedures for contract review and approval submission. Memoranda of Agreement (MOA) shall not be permitted. Letters of Intent shall only be permitted in accordance with Section 4.8.1.10.
4.10.1.2 The Contractor shall submit to DCH for review and approval a model for each type of Provider Contract as updated.
4.10.1.3 Any significant changes to the model Provider Contract shall be submitted to DCH for review and approval no later than thirty (30) Calendar Days prior to the Enrollment of Members and P4HB Participants into the CMO plan.
4.10.1.4 Upon request, the Contractor shall provide DCH with free copies of all executed Provider Contracts.
4.10.1.5 The Contractor shall not require providers Providers to participate or accept other plans or products offered by the care management organization unrelated to providing care to membersmembers and P4HB Participants, nor reduce the funding available for members and P4HB Participants as a result of payment of such penalties.. Any care management organization which violates this prohibition shall be subject to a penalty of $1,000.00 per violation.
4.10.1.6 The Contractor shall not enter into any exclusive contract agreements with providers than that exclude other health care providers from contract agreements for network participation.
4.10.1.7 Health care providers may not, as a condition of contracting with a CMO, require the CMO to contract with or not contract with another health care provider. A provider who violates this probation will be subject to a $1,000 per violation penalty.
4.10.1.8 If a provider Provider has complied with all of DCH’s published procedures for verifying a patient’s eligibility for Medicaid benefits through the established common verification process, DCH must reimburse the provider Provider for all covered services provided to the patient within the 72 hours following the verification, if such services are denied by a CMO or DCH because the patient is not enrolled as shown in the verification process. DCH would be able to pursue a case of action against a person who had contributed to the incorrect verification.
4.10.1.9 In addition to addressing the CMO plan licensure requirements, the Contractor’s Provider Contracts shall: · Prohibit the Provider from seeking payment from the Member for any Covered Services provided to the Member and P4HB Participant within the terms of the Contract and require the Provider to look solely to the Contractor for compensation for services rendered, with the exception of nominal cost sharing pursuant to the Georgia State Medicaid Plan, the Georgia State Medicaid Policies and Procedures Manuals, and the GF Contract; · Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Review and management activities; · Include provisions for the immediate transfer to another PCP or Contractor if the Member’s and P4HB Participants health or safety is in jeopardy; · Not prohibit a Provider from discussing treatment or non-treatment options with Members and P4HB Participants that may not reflect the Contractor’s position or may not be covered by the Contractor; · Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of a Member for the Member’s and P4HB Participants health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered; · Not prohibit a Provider from advocating on behalf of the Member and P4HB Participant in any Grievance System or Utilization Review process, or individual authorization process to obtain necessary Health Care services; · Require Providers to meet appointment waiting time standards pursuant to Section 4.8.14.2 of this Contract; · Provide for continuity of treatment in the event a Provider’s participation terminates during the course of a Member’s or P4HB Participants treatment by that Provider; · Prohibit discrimination with respect to participation, reimbursement, or indemnification of any Provider who is acting within the scope of his or her license or certification under applicable State law, solely based on such license or certification. This provision should not be construed as any willing provider law, as it does not prohibit Contractors from limiting Provider participation to the extent necessary to meet the needs of the Members. Additionally, this provision shall not preclude the Contractor from using different reimbursement amounts for different specialties or for different practitioners in the same specialty. This provision also does not interfere with measures established by the Contractor that are designed to maintain Quality and control costs; · Prohibit discrimination against Providers serving high-risk populations or those that specialize in Conditions requiring costly treatments; · Specify that CMS and DCH will have the right to inspect, evaluate, and audit any pertinent books, financial records, documents, papers, and records of any Provider involving financial transactions related to the GF Contract; · Specify Covered Services and populations; · Require Provider submission of complete and timely Encounter Data, pursuant to Section 4.17.4.2 of the GF Contract; · Include the definition and standards for Medical Necessity, pursuant to the definition in Section 4.5.4 of this Contract; · Specify rates of payment. The Contractor ensures that Providers will accept such payment as payment in full for Covered Services provided to MembersMembers and P4HB Participants, as deemed Medically Necessary and appropriate under the Contractor’s Quality Improvement and Utilization Management program, less any applicable Member and P4HB Participants cost sharing pursuant to the GF Contract; · Provide for timely payment to all Providers for Covered Services to MembersMembers and P4HB Participants. Pursuant to O.C.G.A. 33-24-59.5(b) (1) once a clean claim has been received, the CMO(s) will have 15 Business Days within which to process and either transmit funds for payment electronically for the claim or mail a letter or notice denying it, in whole or in part giving the reasons for such denial. · Specify acceptable billing and coding requirements; · Require that Providers comply with the Contractor’s Cultural Competency plan; · Require that any marketing materials developed and distributed by Providers be submitted to the Contractor to submit to DCH for approval; · Specify that in the case of newborns the Contractor shall be responsible for any payment owed to Providers for services rendered prior to the newborn’s Enrollment with the Contractor; · Specify that the Contractor shall not be responsible for any payments owed to Providers for services rendered prior to a Member’s or P4HB Participants Enrollment with the Contractor, even if the services fell within the established period of retroactive eligibility; · Comply with 42 CFR 434 and 42 CFR 438.6; · Require Providers to collect Member and P4HB Participant co-payments as specified in Attachment K; · Not employ or subcontract with individuals on the State or Federal Exclusions list; · Prohibit Providers from making Referrals for designated health services to Health Care entities with which the Provider or a Member or P4HB Participant of the Provider’s family has a Financial Relationship. · Require Providers of transitioning Members and P4HB Participants to cooperate in all respects with Providers of other CMO plans to assure maximum health outcomes for MembersMembers and P4HB Participants; · Not require that Providers sign exclusive Provider Contracts with the Contractor if the Provider is a CAH, FQHC, or RHC; · Contain a provision stating that in the event DCH is due funds from a Provider; who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment by one hundred percent (100%) to that Provider until such time as the amount owed to DCH is recovered; and · Contain a provision giving notice that the Contractor’s negotiated rates with Providers shall be adjusted in the event the Commissioner of DCH directs the Contractor to make such adjustments in order to reflect budgetary changes to the Medical Assistance program; and · Require the Contractor to notify the Provider in writing no less than thirty (30) calendar days prior to any adjustments to the Provider's contracted reimbursement rates.
4.10.2 Provider Termination
4.10.2.1 The Contractor shall comply with all State and federal laws regarding Provider termination. In its Provider Contracts the Contractor shall: · Specify that in addition to any other right to terminate the Provider Contract, and notwithstanding any other provision of this Contract, DCH may request Provider termination immediately, or the Contractor may immediately terminate on its own, a Provider’s participation under the Provider Contract if a Provider fails to abide by the terms and conditions of the Provider Contract, as determined by DCH, or, in the sole discretion of DCH, fails to come into compliance within fifteen (15) Calendar Days after a receipt of notice from the Contractor specifying such failure and requesting such Provider to abide by the terms and conditions hereof; · Specify that any Provider whose participation is terminated under the Provider Contract for any reason shall utilize the applicable appeals procedures outlined in the Provider Contract. No additional or separate right of appeal to DCH or the Contractor is created as a result of the Contractor’s act of terminating, or decision to terminate any Provider under this Contract. Notwithstanding the termination of the Provider Contract with respect to any particular Provider, this Contract shall remain in full force and effect with respect to all other Providers;
4.10.2.2 The Contractor shall notify DCH at least forty-five (45) Calendar Days prior to the effective date of the suspension, termination, or withdrawal of a Provider from participation in the Contractor’s network. If the termination was “for cause”, the Contractor may terminate, suspend, or withdraw the provider Provider immediately and shall notify DCH in writing within one business day of the termination with the reasons for termination.
4.10.2.3 The Contractor shall notify the Members pursuant to Section 4.10.2 of this Contract.
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Sources: Contract (Centene Corp)