Common use of Provider Network Requirements Clause in Contracts

Provider Network Requirements. a. The Contractor shall establish and maintain a provider network that is capable of delivering medically necessary Covered Services under this Subcontract, including the provision of care to members with limited proficiency in English, in accordance with required appointment standards, professional requirements and best practices. The provider network shall provide a full continuum of treatment, rehabilitative, supportive and ancillary services for the following populations: i. Title XIX and Non-Title XIX Children; ii. Title XIX and Non-Title XIX Adults with Serious Mental Illness; and iii. Title XIX Adults with general mental health issues and Title XIX Adults with substance abuse/dependence. b. The Contractor shall ensure that Covered Services are provided promptly and are reasonably accessible in terms of location and hours of operation. There shall be sufficient professional personnel for the provision of Covered Services including emergency care on a 24 hours a day, 7 days a week basis. c. Services must be delivered by qualified providers that meet the initial credentialing requirements and are appropriately licensed, insured and operating within the scope of their practice. All providers must be registered with ADHS/DBHS and with AHCCCS for the provision of Title XIX Covered Services to Title XIX enrolled persons. At minimum, qualified providers shall meet the following criteria: i. Covered Services shall be delivered by providers who are appropriately licensed, insured and operating within the scope of their practice; ii. Behavioral health practitioners, other than physicians, nurse practitioners, physician assistants, psychologists and independently contracted Specialty Providers, must be affiliated with an outpatient mental health clinic or rehabilitation agency to provide outpatient services. d. Contractor shall meet and ensure that all of its paid and unpaid personnel who are required or are allowed to provide behavioral health services directly to juveniles have met all fingerprint certification requirements of A.R.S. (S) 36-425.03 prior to providing such services. The Contractor shall have on file and make available to CPSA upon request and/or audit personnel evidence of fingerprint certification. Revised 11-01-01 SCHEDULE I-A Effective 10-3-01 Page 1 of 26

Provider Network Requirements. a. The Contractor shall establish and maintain a provider network that is capable of delivering medically necessary Covered Services under this Subcontract, including the provision of care to members with limited proficiency in English, in accordance with required appointment standards, professional requirements and best practices. The provider network shall provide a full continuum of treatment, rehabilitative, supportive and ancillary services for the following populations: i. Title XIX and Non-Title XIX Children; ii. Title XIX and Non-Title XIX Adults with Serious Mental Illness; and iii. Title XIX Adults with general mental health issues and Title XIX Adults with substance abuse/dependence. b. The Contractor shall ensure that Covered Services are provided promptly and are reasonably accessible in terms of location and hours of operation. There shall be sufficient professional personnel for the provision of Covered Services including emergency care on a 24 hours a day, 7 days a week basis. c. Services must be delivered by qualified providers that meet the initial credentialing requirements and are appropriately licensed, insured and operating within the scope of their practice. All providers must be registered with ADHS/DBHS and with AHCCCS for the provision of Title XIX Covered Services to Title XIX enrolled persons. At minimum, qualified providers shall meet the following criteria: i. Covered Services shall be delivered by providers who are appropriately licensed, insured and operating within the scope of their practice; ii. Behavioral health practitioners, other than physicians, nurse practitioners, physician assistants, psychologists and independently contracted Specialty Providers, must be affiliated with an outpatient mental health clinic or rehabilitation agency to provide outpatient services. d. Contractor shall meet and ensure that all of its paid and unpaid personnel who are required or are allowed to provide behavioral health services directly to juveniles have met all fingerprint certification requirements of A.R.S. (S) 36S)36-425.03 prior to providing such services. The Contractor shall have on file and make available to CPSA upon request and/or audit personnel evidence of fingerprint certification. Revised 11Final Jun 6-01 Effective 7-01-01 SCHEDULE IPage 76 -------------------------------------------------------------------------------- [LOGO] Community Partnership FEE FOR SERVICE and RISK-A Effective 10-3-01 Page 1 BASED of 26Southern Arizona SUBCONTRACT AGREEMENT Regional Behavioral CHILDREN SERVICES Health Authority The Providence Service Corporation ------------------------------------------------- CONTRACT NUMBER: A0108 FY 01/02 -------------------------------------------------------------------------------- e. Contractor shall provide enrolled persons choice within the provider network, subject to reasonable frequency limitations and contingent on the availability within the Contractor's service network of an alternative that is suitable to meet the enrolled member's needs. f. Contractor is encouraged to use consumers of service and their families to provide supportive services to enrolled members including payment, as appropriate, for those services. Consumers and families shall receive appropriate training and must meet requirements for service provision under this Subcontract. g. All material changes in the provider network, during the term of this Subcontract, must be approved in advance by the RBHA. The RBHA will assess proposed changes in the provider network for potential impact on enrolled members health and provide written response to the Contractor within fourteen (14) days of receipt of request. h. The Contractor shall notify the RBHA within one (1) working day of any unforeseen material change in services or personnel. This notification shall include information about how the change will affect the delivery of Covered Services and the Contractor's plans for maintaining quality of care if the provider network change is likely to result in deficient delivery of Covered Services. i. If a Subcontracted Provider subsequently fails to meet licensure criteria, or if a provider subcontract is being terminated or suspended, the Contractor shall notify the RBHA within five (5) days of learning of the deficiency or of deciding to terminate or suspend. j. The Contractor shall ensure that its providers are not restricted or inhibited in any way from communicating freely with eligible or enrolled persons regarding behavioral health care, medical needs, and treatment options, even if the needed services are not covered by the Contractor. k. The Contractor shall monitor timely accessibility for routine and emergency services for Title XIX and Title XXI enrolled persons requiring emergency services. l. The Contractor shall have sufficient numbers of providers including licensed medical professionals and clinician personnel to fulfill the requirements outlined in this Subcontract including, but not limited to, clinicians completing assessments, clinicians completing ALFAs, clinicians designated as Primary Clinicians and medical professionals to provide psychiatric services.