Common use of Provider Qualifications Clause in Contracts

Provider Qualifications. (1) Those subcontractors who have medicaid provider agreements with ODJFS must be providers in good standing. Providers who do not have medicaid provider agreements with ODJFS must not have previously had a medicaid provider agreement with ODJFS that was terminated, suspended, denied, or not renewed as a result of any action in accordance with the Revised Code, the Administrative Code, CMS, or the medicaid fraud unit of the office of the Ohio attorney general. Providers who are not in good standing are not allowed to treat or be reimbursed for treating medicaid patients. ODJFS will notify the MCP of medicaid providers who do not meet the qualifications as specified in this rule. (2) An MCP may not discriminate in regard to 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 on the basis of that license or certification. If an MCP declines to include individual or groups of providers in its network, it must give the affected providers written notice of the reasons for its decision. This paragraph may not be construed to: (a) Require the MCP to contract with providers beyond the number necessary to meet the needs of its members. (b) Preclude the MCP from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or (c) Preclude the MCP from establishing measures that are designated to (3) MCPs must have written policies and procedures for the selection and retention of providers which cannot discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. (4) MCPs must credential/recredential all providers using the standardized credentialing form and process as prescribed by the Ohio department of insurance under section 173.03 of the Revised Code, when initially credentialing and recredentialing providers in connection with policies, contracts, and agreements providing basic health care services. Upon ODJFS' request, MCPs must demonstrate the record keeping associated with maintaining this documentation. (5) If any MCP delegates the credentialing/recredentialing of providers to another entity, the MCP must retain the authority to approve, suspend, or terminate any providers.