Common use of PROVIDER PANEL REQUIREMENTS Clause in Contracts

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. Failure to contract with, and properly report to the provider network management (PNM) systemMCPN, 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 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. Failure to contract with, and properly report to the provider network management (PNM) systemMCPN, all MCOP contracted providers the minimum necessary panel 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 must provide all medically medically-necessary Medicaid-covered services to their members. The MCOP shall MCOPs must ensure that all network providers follow community standards in the scheduling of routine appointments (i.e., the amount of time members shall must 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 The MCOP shall must comply with all provider network requirements set forth in the Three-Way and the provider network requirements included as part of this appendix except as explicitly noted herein. i. Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs). The MCOP shall must 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 an 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. ii. Vision Care Providers. MCOPs must contract with at least the minimum number of ophthalmologists and optometrists for each specified county and region, all of whom must maintain a full-time practice at a site(s) located in the specified county and region to count toward minimum panel requirements. All ODM-approved vision providers must regularly perform routine eye exams. MCOPs will be expected to contract with an adequate number of ophthalmologists as part of its overall provider panel, but only ophthalmologists who regularly perform routine eye exams can be used to meet the vision care provider panel requirement. If optical dispensing is not sufficiently available in a region through the MCOP’s contracting ophthalmologists/optometrists, the MCOP must separately contract with an adequate number of optical dispensers located in the region. iii. Dental Care Providers. MCOPs must contract with at least the minimum number of dentists. iv. Waiver Providers. The MCOP shall ensure that MyCare HCBS waiver providers listed in the charts within Appendix H meet the requirements set forth in OAC Chapters 173-39 and 5160-45, as appropriate, and have an active Medicaid provider agreement with ODM. The MCOP must have a written policy setting forth a regular payment cycle for clean claims submitted by independent providers. The MCOP must adhere to the policy and any communications from the MCOP to a provider must be consistent with the policy.