PROVIDER PANEL REQUIREMENTS Clause Samples
The PROVIDER PANEL REQUIREMENTS clause sets out the standards and criteria that service providers must meet to be included on an approved panel or list. Typically, this clause outlines qualifications, experience, compliance with regulations, and ongoing performance expectations for providers. For example, it may require providers to maintain certain certifications or adhere to specific service protocols. Its core function is to ensure that only qualified and reliable providers are selected, thereby maintaining quality and consistency in the services delivered.
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PROVIDER PANEL REQUIREMENTS. Failure to contract with, and properly report to the MCPN, all MCOP contracted providers will result in sanctions as outlined in Appendix N. ODM will grant an ‘exception to the issuance of sanction’ only when an action taken by ODM has adversely impacted a plan’s ability to meet the provider panel network or when a provider is not available in the required zip code, county, and/or region.
PROVIDER PANEL REQUIREMENTS. The provider network criteria that must be met by each MCP are as follows:
PROVIDER PANEL REQUIREMENTS. Failure to contract with, and properly report to the provider network management (PNM) system, all MCOP contracted providers will result in sanctions as outlined in Appendix N. ODM will grant an ‘exception to the issuance of sanction’ only when an action taken by ODM has adversely impacted a plan’s ability to meet the provider panel network or when a provider is not available in the required zip code, county, and/or region.
a. All MCOPs shall provide all medically necessary Medicaid-covered services to their members. The MCOP shall ensure all network providers follow community standards in the scheduling of routine appointments (i.e., the amount of time members shall wait from the time of their request to the first available time when the visit can occur).
b. In addition to requirements set forth in the Three-Way, the MCOP shall comply with all provider network requirements set forth in this appendix except as explicitly noted herein.
i. Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs). The MCOP shall ensure access to CNM and CNP services in the region if such provider types are present within the region. The MCOP may contract directly with the CNM or CNP providers, or with a physician or other provider entity which is able to obligate the participation of a CNM or CNP. If the MCOP does not contract for CNM or CNP services and such providers are present within the region, the MCOP will be required to allow members to receive CNM or CNP services outside of the MCOP’s provider network.
PROVIDER PANEL REQUIREMENTS. The provider network criteria that must be met by each MCP are as follows:
a. Primary Care Physicians (PCPs) Primary Care Physicians (PCPs) may be individuals or group practices/clinics [Primary Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general practice, internal medicine, pediatrics and obstetrics/gynecology(OB/GYNs). Acceptable PCCs include FQHCs, RHCs and the acceptable group practices/clinics specified by ODJFS. As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP. The capacity-by-site requirement must be met for all ODJFS-approved PCPs. Appendix H Covered Families and Children (CFC) population Page 3 In determining whether an MCP has sufficient PCP capacity for a region, ODJFS considers a physician who can serve as a PCP for 2000 Medicaid MCP members as one full-time equivalent (FTE). ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated capacity for all MCP networks added together exceeds 2000 Medicaid members (i.e., 1 FTE). Where indicated, ODJFS may set a cap on the maximum amount of capacity that we will recognize for a specific PCP. ODJFS may allow up to an additional 750 member capacity for each nurse practitioner or physician's assistant that is used to provide clinical support for a PCP. For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP's capacity figure to determine if an MCP meets the provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS recognizes that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not...
PROVIDER PANEL REQUIREMENTS. The provider network criteria that must be met by each MCP are as follows:
a. Primary Care Physicians (PCPs)
PROVIDER PANEL REQUIREMENTS a) PROVIDER shall specify a capacity of members he/she is willing to accept under this Agreement; the maximum capacity is two thousand five hundred (2,500) for each full-time physician in the PROVIDER group; for each full-time physician assistant or advanced registered nurse practitioner in the PROVIDER group, the maximum is one thousand two hundred fifty (1,250); for each medical resident in the PROVIDER group, enrollment shall not exceed eight hundred seventy-five (875) members. If PROVIDER has both Choice and IO panels, PROVIDER shall not exceed these capacities for both panels combined.
b) OHCA does not guarantee PROVIDER an enrollment level nor will OHCA pay for members who are not eligible or excluded from enrollment.
c) PROVIDER may request a change in his/her capacity by submitting a written request signed by authorized representative of PROVIDER group. This request is subject to review according to program standards. In the event PROVIDER requests a lower capacity, OHCA may lower the capacity by dis-enrolling members to achieve that number or allowing the capacity to adjust as members change their PCP/CM or lose eligibility;
d) Unless approved by OHCA, PROVIDER must accept members in the order in which they apply without restriction up to the capacity established by this Agreement. PROVIDER may not refuse an assignment or will not discriminate against members on the basis of health status or need for health care services. PROVIDER will not use any policy or practice that has the effect of discriminating on the basis of race, color, or national origin, unless superseded by another Federal statute.
e) PROVIDER shall provide medically necessary health care for any member who has selected or been assigned to PROVIDER’s panel until OHCA officially reassigns the member. PROVIDER shall not notify the member of a change of PCP/CM until PROVIDER has received notification from OHCA;
f) PROVIDER may request that OHCA disenroll a member for cause. OHCA will give written notice of the disenrollment request to the member. If OHCA approves a disenrollment request for a Choice member, OHCA will enroll the member in SoonerCare Traditional for a period not to exceed six months. During this period, PROVIDER must continue to provide services to the member as necessary for continuity of care.
PROVIDER PANEL REQUIREMENTS. The provider network criteria that shall be met by the MCP is as follows:
a. Primary Care Providers (PCPs). PCP means an individual physician (M.D. or D.O.), certain physician group practice/clinic (Primary Care Clinics [PCCs]), physician assistants, or an advanced practice registered nurse (APRN) as defined in ORC section 4723.43 or advanced practice nurse group practice within an acceptable specialty, contracting with the MCP to provide services as specified in OAC rule 5160-26-03.
1. Acceptable specialty types for PCPs include family/general practice, internal medicine, and pediatrics. Acceptable PCCs include FQHCs, RHCs, and the acceptable group practices/clinics specified by ODM. In order for the PCP to count toward minimum provider panel requirement, as part of the MCP’s subcontract with a PCP, the MCP shall ensure the total Medicaid member capacity is not greater than 2,000 for that individual PCP. The PCP capacity for a county is the total amount of members that all of the PCPs in the MCP agree to serve in that county. ODM will determine the PCP capacity based on information submitted by the MCP through the MCPN. The PCP capacity shall exceed by at least 5% the total number of members enrolled in the MCP during the preceding month in the same county. ODM will determine the MCP’s compliance with the PCP capacity requirement each quarter using the ODM enrollment report for the previous month. For example, in April, ODM will review the MCP’s countable PCP capacity using one of the April MCPN reports. The countable capacity will be compared to the finalized enrollment report for March. ODM recognizes that some members needing specialized care will use specialty providers as PCPs. In these cases, the MCP will submit the specialist to the MCPN database as a PCP. However, the specialist serving as a PCP will not count toward minimum provider panel PCP requirements, even though they are coded as a PCP. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for the MCP. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. In addition to the PCP capacity requirement, the MCP shall also contract with the specified number of pediatric PCPs for each region. These pediatric PCPs will have their stated capacity counted toward the PCP capacity requirement. A pediatric PCP shall maintain a general pediatric practice (e.g., a pediatric neu...