Common use of Required Provisions in Provider Contracts Clause in Contracts

Required Provisions in Provider Contracts. 10.3.1 All Provider Contracts shall be labeled with the Provider’s NPI, if applicable. In general, the Contractor’s Provider Contracts shall: 10.3.1.1 Include a section summarizing the Contractor’s obligations under this Contract, as they affect the delivery of Health Care services under MiSalud, and describing Covered Services and populations (or, include the Provider guidelines as an attachment); 10.3.1.2 Require that the Provider cooperate and collaborate with the MBHO in serving Enrollees, and work to advance the integrated model of physical and behavioral health services; 10.3.1.3 Require that the Provider comply with the federal and Puerto Rico laws, rules, regulations, statutes, policies or procedures, including but not limited to those listed in Attachment 1 to this Contract, to the extent applicable, and with all CMS requirements; 10.3.1.4 Require that the Provider verify the Enrollee’s Eligibility before providing services or making a Referral; 10.3.1.5 Prohibit any unreasonable denial, delay, or rationing of Covered Services to Enrollees, and provide that any violation of this prohibition shall be subject to the provisions of Article VI, Section 6 of Act 72 and of 42 CFR Part 438, Subpart I (Sanctions); 10.3.1.6 Prohibit the Provider from claiming for any non-allowed administrative expenses, as listed in Article 21; 10.3.1.7 Prohibit the unauthorized sharing or transfer of ASES Data, as defined in Section 27.1 of this Contract; 10.3.1.8 Notify the Provider that the terms of the contract for services under the MiSalud Program are subject to subsequent changes in legal requirements that are outside of the control of ASES; 10.3.1.9 Require the Provider to comply with all reporting requirements contained in Article 18 of this Contract, and particularly with the requirements to submit Encounter Data for all services provided, and to report all instances of suspected Fraud or Abuse; 10.3.1.10 Require the Provider to acknowledge that ASES Data (as defined in Section 27.1.1 of this Contract) belongs exclusively to ASES, and that the Provider may not give access to, assign, or sell such data to third parties, without prior authorization from ASES. The Contractor shall include penalty clauses in its Provider Contracts to prohibit this practice, and require that the fines be paid to ASES; 10.3.1.11 Prohibit the Provider from seeking payment from the Enrollee for any Covered Services provided to the Enrollee within the terms of the Contract, and require the Provider to look solely to the Contractor for compensation for services rendered to Enrollees, with the exception of any nominal cost-sharing, as provided in Section 7.11 of this Contract; 10.3.1.12 Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Management activities; 10.3.1.13 Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of an Enrollee for the Enrollee’s health status, medical care, or treatment or non-treatment options; 10.3.1.14 Not prohibit a Provider from advocating on behalf of the Enrollee in any Grievance System or Utilization Management process, or individual authorization process to obtain necessary health care services; 10.3.1.15 Require Providers to meet the timeframes for Access to services pursuant to Sections 9.8 and 9.9 of this Contract; 10.3.1.16 Provide for continuity of treatment in the event that a Provider’s participation in the Contractor’s Network terminates during the course of an Enrollee’s treatment by that Provider; 10.3.1.17 Require Providers to monitor Enrollee patients to determine whether they have a Medical Condition that suggests Case Management or Disease Management services are warranted; 10.3.1.18 Prohibit Provider discrimination against high-risk populations or Enrollees requiring costly treatments;

Required Provisions in Provider Contracts. 10.3.1 All Provider Contracts shall be labeled with the Provider’s NPI, if applicable. In general, the Contractor’s Provider Contracts shall: 10.3.1.1 Include a section summarizing the Contractor’s obligations under this Contract, as they affect the delivery of Health Care services under MiSaludMI Salud, and describing Covered Services and populations (or, include the Provider guidelines as an attachment); 10.3.1.2 Require that the Provider cooperate and collaborate with the MBHO in serving Enrollees, and work to advance the integrated model of physical and behavioral health services; 10.3.1.3 Require that the Provider comply with the federal and Puerto Rico laws, rules, regulations, statutes, policies or procedures, including but not limited to those listed in Attachment 1 to this Contract, to the extent applicable, and with all CMS requirements; 10.3.1.4 Require that the Provider verify the Enrollee’s Eligibility before providing services or making a Referral; 10.3.1.5 Prohibit any unreasonable denial, delay, or rationing of Covered Services to Enrollees, and provide that any violation of this prohibition shall be subject to the provisions of Article VI, Section 6 of Act 72 and of 42 CFR Part 438, Subpart I (Sanctions); 10.3.1.6 Prohibit the Provider from claiming for any non-allowed administrative expenses, as listed in Article 2122; 10.3.1.7 Prohibit the unauthorized sharing or transfer of ASES Data, as defined in Section 27.1 28.1 of this Contract; 10.3.1.8 Notify the Provider that the terms of the contract for services under the MiSalud MI Salud Program are subject to subsequent changes in legal requirements that are outside of the control of ASES; 10.3.1.9 Require the Provider to comply with all reporting requirements contained in Article 18 of this Contract, and particularly with the requirements to submit Encounter Data for all services provided, and to report all instances of suspected Fraud or Abuse; 10.3.1.10 Require the Provider to acknowledge that ASES Data (as defined in Section 27.1.1 28.1.1 of this Contract) belongs exclusively to ASES, and that the Provider may not give access to, assign, or sell such data to third parties, without prior authorization from ASES. The Contractor shall include penalty clauses in its Provider Contracts to prohibit this practice, and require that the fines be paid to ASES; 10.3.1.11 Prohibit the Provider from seeking payment from the Enrollee for any Covered Services provided to the Enrollee within the terms of the Contract, and require the Provider to look solely to the Contractor for compensation for services rendered to Enrollees, with the exception of any nominal cost-sharing, as provided in Section 7.11 of this Contract; 10.3.1.12 Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Management activities; 10.3.1.13 Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of an Enrollee for the Enrollee’s health status, medical care, or treatment or non-treatment options; 10.3.1.14 Not prohibit a Provider from advocating on behalf of the Enrollee in any Grievance System or Utilization Management process, or individual authorization process to obtain necessary health care services; 10.3.1.15 Require Providers to meet the timeframes for Access to services pursuant to Sections 9.8 and 9.9 of this Contract; 10.3.1.16 Provide for continuity of treatment in the event that a Provider’s participation in the Contractor’s Network terminates during the course of an Enrollee’s treatment by that Provider; 10.3.1.17 Require Providers to monitor Enrollee patients to determine whether they have a Medical Condition that suggests Case Management or Disease Management services are warranted; 10.3.1.18 Prohibit Provider discrimination against high-risk populations or Enrollees requiring costly treatments;