Common use of Provider Services Department Clause in Contracts

Provider Services Department. The MCO must maintain a Provider Services Department and operate a toll-free provider phone line for at least eight (8) hours a day during regular business hours. 3.6.1.1 The MCO Provider Services Department is responsible for the following, but not limited to: 1. Assisting providers with questions concerning enrollee eligibility status; 2. Assisting providers with plan prior authorization and referral procedures; 3. Assisting providers with claims payment procedures; 4. Handling provider complaints; 5. Providing and encouraging training to providers to promote sensitivity to the special needs of this population; 6. Educating providers on the program; and 7. Educating providers in regards to the MCO’s written policies on the False Claims Act, including policies and procedures for detecting and preventing waste, fraud, and abuse. This requirement is pursuant to the Deficit Reduction Act of 2005, Section 6032. The MCO must ensure that after regular business hours the line is answered by an automated system with the capability to provide callers with operating hours, information and instructions on how to verify enrollment for a member with an Urgent Condition or an Emergency Medical Condition.