PROVIDER NETWORK AND ACCESS REQUIREMENTS Sample Clauses
The "Provider Network and Access Requirements" clause defines the obligations of a service provider to maintain a network of qualified professionals or facilities and to ensure that users have reasonable access to these services. Typically, this clause outlines standards for the size, composition, and geographic distribution of the provider network, and may require timely access to care or services. Its core function is to guarantee that users or beneficiaries can obtain necessary services without undue delay or hardship, thereby ensuring adequate coverage and preventing gaps in service availability.
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The PIHP must provide medical care to its FCMH members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHP.
A. Use of Medicaid Enrolled Providers Except in emergency situations, the PIHP must use only Medicaid enrolled providers for the provision of covered services. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-enrolled providers, at the FFS rate for those services, unless the PIHP can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled at the time the PIHP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI).
B. Protocols/Standards to Ensure Access The PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under the FCMH program. The PIHP’s protocols must include methods for identification, outreach to and screening/assessment of members with special health care needs, including mental health and substance abuse. The PIHP must identify and provide care coordination to those children with no formally diagnosed medical condition who are nevertheless “at increased risk” for chronic physical, developmental, behavioral or emotional conditions. The health care professionals involved in this process must be trained in trauma-informed care and must have expertise in the care of children with chronic conditions.
C. Written Standards for Accessibility of Care
1. The PIHP must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the PIHP. The standards must include the following:
a. Waiting times for care at facilities;
b. Waiting times for appointments;
c. Statement that providers’ hours of operation do not discriminate against FCMH members; and
d. Whether or not provider(s) speak the member’s language.
2. The PIHP’s standards for waiting times for appointments must be as follows for the indicated provider types:
a. To b...
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The HMO must provide medical care to its Medicaid and BadgerCare enrollees that is as accessible to them, in terms of timeliness, amount, duration, and scope, as those services are to non-enrolled Medicaid and BadgerCare recipients within the area served by the HMO.
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The PIHP must provide medical care to its FCMH members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the PIHP.
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The County must provide medical care to its BadgerCare Plus members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus members within the area served by the County.
A. Protocols/Standards to Ensure Access The County must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under BadgerCare Plus programs. The County’s protocols must include training and information for providers in their network, in order to promote and develop provider skills in responding to the needs of persons with limited English proficiency, mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, where a course of treatment or regular case monitoring is needed, the County must have mechanisms in place to allow members to directly access a specialist, as appropriate, for the member’s condition and identified needs.
B. Written Standards for Accessibility of Care
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The County must provide medical care to its BadgerCare Plus members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus members within the area served by the County.
A. Protocols/Standards to Ensure Access The County must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under BadgerCare Plus programs. The County’s protocols must include training and information for providers in their network, in order to promote and develop provider skills in responding to the needs of persons with limited English proficiency, mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, where a course of treatment or regular case monitoring is needed, the County must have mechanisms in place to allow members to directly access a specialist, as appropriate, for the member’s condition and identified needs.
B. Written Standards for Accessibility of Care
1. The County must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the County. The standards must include the following:
a. Waiting times for care at facilities;
b. Waiting times for appointments;
c. Statement that providers’ hours of operation do not discriminate against BadgerCare Plus members; and
d. Whether or not provider(s) speak the member’s language.
2. The County may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient, for the following:
a. The enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self- administered.
b. Any information the enrollee needs in order to decide among all relevant treatment options.
c. The risks, benefits, and consequences of treatment or non- treatment.
d. The enrollee’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions. These minimum requirements shall not release the County from the requirement to provide or arrange for the provision of any medically necessary covered service required...
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The County must provide medical care to its BadgerCare Plus members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus members within the area served by the County.
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The HMO must provide medical care to its BadgerCare Plus and/or Medicaid SSI members that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non-enrolled BadgerCare Plus and/or Medicaid SSI members within the area served by the HMO.
A. Use of BadgerCare Plus and/or Medicaid SSI Certified Providers
B. Protocols/Standards to Ensure Access
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The PIHP must demonstrate covered services within the provider network are available and accessible to members per 42 CFR § 438.206, 438.68, and 438.14 and has the capacity to serve expected enrollment in its service area per 42 CFR § 438.207. The PIHP must establish provider network access, availability, and capacity expectations within provider’s contracts, to include standards, protocols, methods of monitoring, reporting, and remediation.
A. Availability and Accessibility The PIHP must establish mechanisms to ensure compliance by network providers; regularly monitor to determine compliance; take corrective action if there is a failure to comply by a network provider; and make readily available to the department upon request records of such actions. Provider Network The PIHP must:
a. Maintain and monitor a network of appropriate providers that is supported by written agreements and is sufficient to provide adequate access to all services covered under the contract for all members, including those with limited English proficiency or physical or mental disabilities.
b. Provide female members with direct access to a women's health specialist within the provider network for covered care necessary to provide women's routine and preventive health care services. This is in addition to the member's designated source of primary care if that source is not a women's health specialist.
c. Provide for a second opinion from a network provider or arranges for the member to obtain one outside the network, at no cost to the member.
d. Provide necessary services, covered under the contract, to a particular enrollee, the PIHP must adequately and timely cover these services out of network for the member, for as long as the PIHP’s provider network is unable to provide them.
e. Coordinate with out-of-network providers for payment and ensure the cost to the member is no greater than it would be if the services were furnished within the network.
f. Reimburse for emergency services provided out-of-network at a cost to the member no greater than if the services were provided in-network.
g. Demonstrates network providers are credentialed as required by 42 CFR § 438.214.
h. Demonstrates network providers are credentialed as required by 42 CFR § 438.214. Furnishing of Services and Timely Access The PIHP must:
a. Require network providers meet standards for timely access to care and services, considering the urgency of the need for services.
b. Ensure network providers offer hours ...
PROVIDER NETWORK AND ACCESS REQUIREMENTS. The County PIHP must provide services covered by this Contract to itsmembers that are accessible to them, in terms of timeliness, amount, duration, and scope, as those services to non- enrolled Medicaid members within the area served by the County PIHP.
A. Use of Medicaid Enrolled Providers Except in emergency situations, the County PIHP must use only Medicaid enrolled providers for the provision of covered services. The Department reserves the right to withhold from the capitation development the costs related to services provided by non- enrolled providers, at the FFS rate for those services, unless the County PIHP can demonstrate that it reasonably believed, based on the information provided by the Department, that the provider was Medicaid enrolled at the time the County PIHP reimbursed the provider for service provision. The Wis. Adm. Code, Ch. DHS 105 and the ForwardHealth Handbook, contains information regarding provider certification requirements. The County PIHP must require every physician providing services to members to have a Provider Number or National Provider Identifier (NPI). The Department requires that Medicaid-enrolled providers undergo periodic revalidation. During revalidation, providers update their enrollment information with ForwardHealth, and sign the Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation. Providers who fail to revalidate are terminated from Wisconsin Medicaid.
B. Protocols/Standards to Ensure Access The County PIHP must have written protocols to ensure that members have access to screening, diagnosis and referral and appropriate treatment for those conditions and services covered under the County PIHP. The County PIHP’s protocols must include training and information for providers in their network, in order to promote and develop provider skills in responding to the needs of persons with limited English proficiency, mental, physical and developmental disabilities. Training should include clinical and communication issues and the role of care coordinators. For members with special health care needs, where a course of treatment or regular case monitoring is needed, the County PIHP must have mechanisms in place to allow members to directly access a specialist, as appropriate, for the member’s condition and identified needs.
C. Written Standards for Accessibility of Care
1. The County PIHP must have written standards for the accessibility of care and services. These standards must be co...