Common use of Provider Discrimination Clause in Contracts

Provider Discrimination. ‌ Neither Contractor, Subcontractor, nor representatives of Contractor shall provide false or misleading information to providers in an attempt to recruit providers for Contractor’s network. The Contractor shall not discriminate against providers with respect to participation, reimbursement, or indemnification for any provider acting within the scope of that provider’s license or certification under applicable State law or regulation solely on the basis of the provider’s license or certification. Contractor shall not discriminate for the 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 the license or certification. Contractor shall not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. If Contractor declines to include individual or groups of providers in its network, it must provide the affected providers written notice of the reason for its decision. Denials of provider enrollment due to excess network capacity must receive DOM approval prior to provider notification. Nothing in this provision, however, shall preclude Contractor from using a fee schedule for different specialties or for different practitioners in the same specialty, or preclude Contractor from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to Members. Contractor shall not employ or contract with providers excluded from participation in Federal health care programs under either Section 1128 or Section 1128A of the Act. Contractor is prohibited from employing or contracting a provider that has been excluded by DOM, other state Medicaid agencies, or other state CHIP.

Provider Discrimination. ‌ Neither Contractor, Subcontractor, nor representatives of Contractor shall provide false or misleading information to providers in an attempt to recruit providers for Contractor’s network. The Contractor shall not discriminate against providers with respect to participation, reimbursement, or indemnification for any provider acting within the scope of that provider’s license or certification under applicable State law or regulation solely on the basis of the provider’s license or certification. Contractor shall not discriminate for the 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 the license or certification. Contractor shall not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. If Contractor declines to include individual or groups of providers in its network, it must provide the affected providers written notice of the reason for its decision. Denials of provider enrollment due to excess network capacity must receive DOM approval prior to provider notification. Nothing in this provision, however, shall preclude Contractor from using a fee schedule for different specialties or for different practitioners in the same specialty, or preclude Contractor from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to Members. Contractor shall not employ or contract with providers excluded from participation in Federal health care programs under either Section 1128 or Section 1128A of the Social Security Act. Contractor is prohibited from employing or contracting a provider that has been excluded by DOM, other state Medicaid agencies, or other state CHIP.