Compliance and Participation. 1. Practitioner shall be bound by and comply with the provisions of applicable state and federal laws and regulations.
Compliance and Participation. 4.1.1 Physician shall use his/her best efforts to comply fully with and participate in the implementation of CCPA’s or the Payor’s (as applicable) written policies and programs as set forth in the Policy and Procedure Manual, to control the cost and utilization of health services that are consistent with sound medical practice and as described in the Product Descriptions, including but not limited to, written policies and programs regarding: (i) quality assurance; (ii) utilization management; (iii) claims payment review; (iv) beneficiary grievances; and (v) credentialing and re-credentialing.
Compliance and Participation. Physician agrees to comply fully with and participate in the implementation of the Payer's and PHO’s policies and programs to control the cost and utilization of medical services as described in the Product Description, including, but not limited to, policies and programs regarding:
Compliance and Participation. Pharmacy shall comply fully with and be bound by the Participation Criteria described in the PARTICIPATION CRITERIA SCHEDULE (attached hereto and made a part hereof), the Provider Policies and Services Manual, and shall also abide by the rules, policies and procedures that Company has and will establish, including but not limited to, those regarding (a) quality improvement/management; (b) utilization management; (c) claims payment review; (d) Member grievances; (e) provider credentialing; and (f) electronic submission of encounter data, claims and other data required by Company. In addition to the aforementioned, Pharmacy agrees to comply with precertification and other requirements which are applicable to the dispensing of certain drugs. Such requirements may include, but are not limited to, forwarding physician supplied documentation to Company for review and approval, follow up with physician, and return of prescriptions to Members with appropriate explanation when certification for dispensing is denied by Company. Pharmacy shall not return unfilled any prescription to a Member unless Pharmacy provides a written explanation to Member the reason for the return of the prescription. If Pharmacy receives an on-line response that a prescription cannot be filled for reasons other than the drug is not covered, Pharmacy shall contact either the Member or the prescribing physician optometrist, physician assistant or dentist. Pharmacy acknowledges and agrees that failure to comply with the terms of the PARTICIPATION CRITERIA and Company's other rules, policies and procedures may adversely affect any compensation due hereunder and could lead to sanctions including, without limitation, termination of this Agreement. Company may at any time modify the Participation Criteria and all Company rules, policies and procedures.
