Common use of Provider Responsibility Clause in Contracts

Provider Responsibility. Wellpoint shall not be liable for, nor will it exercise control or direction over, the manner or method by which Provider provides Health Services to Medicaid Members. Provider shall be solely responsible for all medical advice and services provided by Provider to Medicaid Members. Provider acknowledges and agrees that Wellpoint may deny payment for services rendered to a Medicaid Member which it determines are not Medically Necessary, are not Health Services under the applicable Medicaid Program(s), or are not otherwise provided or billed in accordance with the Agreement and/or this Attachment. A denial of payment or any action taken by Wellpoint pursuant to a utilization review, referral, discharge planning program, or claims adjudication shall not be construed as a waiver of Provider's obligation to provide appropriate Health Services to a Medicaid Member under applicable Regulatory Requirements and any code of professional responsibility. Provider may discuss treatment or non-treatment options with Medicaid Member irrespective of whether such treatment options are Health Services covered under the Agreement. However, this provision does not require Provider to provide Health Services if Provider objects to such service on moral or religious grounds. 2.3.1 No health carrier subject to the jurisdiction of the state of Washington may in any way preclude or discourage their providers from informing patients of the care they require, including various treatment options, and whether in their view such care is consistent with Medical Necessity, medical appropriateness, or otherwise covered by the patient's service agreement with the health carrier. No health carrier may prohibit, discourage, or penalize a provider otherwise practicing in compliance with the law from advocating on behalf of a patient with a health carrier. Nothing in this section shall be construed to authorize Provider to bind health carriers to pay for any service. 2.3.2 No health carrier may preclude or discourage Members or those paying for their coverage from discussing the comparative merits of different health carriers with their providers. This prohibition specifically includes prohibiting or limiting providers participating in those discussions even if critical of a carrier.

Provider Responsibility. Wellpoint shall not be liable for, nor will it exercise control or direction over, the manner or method by which Provider provides Health Services to Medicaid Members. Provider shall be solely responsible for all medical advice and services provided by Provider to Medicaid Members. Provider acknowledges and agrees that Wellpoint may deny payment for services rendered to a Medicaid Member which it determines are not Medically Necessary, are not Health Medicaid Covered Services under the applicable Medicaid Program(s), or are not otherwise provided or billed in accordance with the Agreement and/or this Attachment. A denial of payment or any action taken by Wellpoint pursuant to a utilization review, referral, discharge planning program, program or claims adjudication shall not be construed as a waiver of Provider's obligation to provide appropriate Health Services to a Medicaid Member under applicable Regulatory Requirements and any code of professional responsibility. Provider may discuss treatment or non-treatment options with Medicaid Member irrespective of whether such treatment options are Health Services covered under the AgreementMedicaid Covered Services. However, this provision does not require Provider to provide Health Services if Provider objects to such service on moral or religious grounds. 2.3.1 No health carrier subject to the jurisdiction of the state of Washington may in any way preclude or discourage their providers from informing patients of the care they require, including various treatment options, and whether in their view such care is consistent with Medical Necessity, medical appropriateness, or otherwise covered by the patient's service agreement with the health carrier. No health carrier may prohibit, discourage, or penalize a provider otherwise practicing in compliance with the law from advocating on behalf of a patient with a health carrier. Nothing in this section shall be construed to authorize Provider to bind health carriers to pay for any service. 2.3.2 No health carrier may preclude or discourage Members or those paying for their coverage from discussing the comparative merits of different health carriers with their providers. This prohibition specifically includes prohibiting or limiting providers participating in those discussions even if critical of a carrier.