CONTRACTOR Provider Network Sample Clauses
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CONTRACTOR Provider Network. The CONTRACTOR shall establish and maintain, through written agreements, an appropriate Provider network necessary for the provision of the services under this contract. This includes, but is not limited to primary care Providers (PCPs), specialty Providers, hospitals and other health care service Providers as identified by the Department. For geographic areas lacking Providers sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the Service Area, the Department at its sole discretion may waive requirements.
6.2.1. Contract with required Providers based on the standards outlined within the Managed Care Policy and Procedure Guide.
6.2.2. Primary Care Providers (PCP) The CONTRACTOR shall:
6.2.2.1. Implement Procedures to ensure that each Medicaid Managed Care Member has a person or entity, formally designated, as a PCP, primarily responsible for coordinating their health care services.
6.2.2.2. Ensure each Member has access to at least one PCP with an open panel. Additional guidance is contained within the Managed Care Policy and Procedure Guide.
6.2.2.3. Ensure its contracted PCPs have an appointment system that meets the following access standards:
6.2.2.3.1. ▇▇▇▇▇▇▇ visits scheduled within four (4) to six (6) weeks.
6.2.2.3.2. Urgent, Non-Emergent visits within forty-eight (48) hours.
6.2.2.3.3. Emergent visits immediately upon presentation at a service delivery site.
6.2.2.3.4. Waiting times that do not exceed forty-five (45) minutes for a scheduled appointment of a routine nature.
6.2.3. Specialists
CONTRACTOR Provider Network. The CONTRACTOR shall establish and maintain, through written agreements, an appropriate Provider network necessary for the provision of the services under this contract. This includes but is not limited to primary care Providers (PCPs), specialty Providers, hospitals and other health care service Providers as identified by the Department. For geographic areas lacking Providers sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the Service Area, the Department at its sole discretion may waive requirements. (42 CFR § 438.207(a); 42 CFR § 438.68; 42 CFR § 438.206(c)(1); 42 CFR § 438.206(b)(1))
6.2.1 The Contractor shall contract with required Providers based on the standards outlined within the Managed Care Process and Procedure Manual.
6.2.2 The Contractor may execute network Provider agreements, pending the outcome of screening, enrollment, and revalidation process, of up to one-hundred twenty (120) days but must terminate a network Provider immediately upon notification from the Department that the network Provider cannot be enrolled, or the expiration of one (1) one-hundred twenty (120) day period without enrollment of the Provider.
6.2.2.1 The CONTRACTOR shall monitor the SCDHHS NPI Junction file on a routine basis to ensure that Providers ultimately become enrolled as a South Carolina Medicaid Provider.
6.2.2.2 The CONTRACTOR must notify affected Members using the normal notification process and requirements described in this agreement in addition to termination of the In Network Provider. (42 CFR § 438.602(b)(2)).
6.2.3 Primary Care Providers (PCP) The CONTRACTOR shall:
6.2.3.1 Implement procedures to ensure that each Medicaid Managed Care Member has a person or entity, formally designated, as a PCP, primarily responsible for coordinating their health care services.
6.2.3.2 Ensure each Member has access to at least one PCP with an open panel. Additional guidance is contained within the Managed Care Process and Procedure Manual.
6.2.3.3 Ensure its contracted PCPs have an appointment system that meets the following access standards:
6.2.3.3.1 Routine visits scheduled within four (4) to six (6) weeks.
6.2.3.3.2 Urgent, Non-Emergent visits within forty- eight (48) hours.
6.2.3.3.3 Emergent visits immediately upon presentation at a service delivery site.
6.2.3.3.4 Waiting times that do not exceed forty-five (45) minutes for a scheduled appointment of a routine nature.
6.2.3.3.5 Walk-in patients with non-urge...
CONTRACTOR Provider Network. The CONTRACTOR shall establish and maintain, through written agreements, an appropriate Provider Network necessary for the provision of the services under this Contract. This includes, but is not limited to Primary Care Providers (PCPs), Specialty Providers, Hospitals and other Health Care Service Providers as identified by the Department. For geographic areas lacking Providers sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area, the Department at its sole discretion may waive the distance requirement.
6.2.1. Primary Care Provider (PCP) The CONTRACTOR shall:
6.2.1.1. Implement procedures to ensure that each Medicaid Managed Care Member has a person or entity, formally designated, as primarily responsible for coordinating their health care services.
6.2.1.2. Ensure each Member has access to at least one PCP with an open panel. Additional guidance is contained within the managed care policy and procedure guide.
6.2.1.3. Ensure its contracted PCPs have an appointment system that meets the following access standards:
6.2.1.3.1. ▇▇▇▇▇▇▇ visits scheduled within four (4) to six (6) weeks.
6.2.1.3.2. ▇▇▇▇▇▇, non-emergent visits within forty-eight (48) hours.
6.2.1.3.3. Emergent visits immediately upon presentation at a service delivery site.
6.2.1.3.4. Waiting times that do not exceed forty-five (45) minutes for a scheduled appointment of a routine nature.
6.2.1.3.5. Walk-in patients with non-urgent needs should be seen if possible or scheduled for an appointment consistent with written scheduling procedures.
6.2.1.3.6. Provide twenty-four (24) hour coverage by direct access or through arrangement with a triage system.
6.2.1.3.7. The CONTRACTOR must monitor the adequacy of its appointment processes.
6.2.2. Specialists
CONTRACTOR Provider Network. The CONTRACTOR shall establish and maintain, through written agreements, an appropriate Provider network necessary for the provision of the services under this contract. This includes but is not limited to primary care Providers (PCPs), specialty Providers, hospitals and other health care service Providers as identified by the Department. For geographic areas lacking Providers sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the Service Area, the Department at its sole discretion may waive requirements.
6.2.1 Contract with required Providers based on the standards outlined within the Managed Care Policy and Procedure Guide.
6.2.2 Primary Care Providers (PCP) The CONTRACTOR shall:
6.2.2.1 Implement procedures to ensure that each Medicaid Managed Care Member has a person or entity, formally designated, as a PCP, primarily responsible for coordinating their health care services.
6.2.2.2 Ensure each Member has access to at least one PCP with an open panel. Additional guidance is contained within the Managed Care Policy and Procedure Guide.
6.2.2.3 Ensure its contracted PCPs have an appointment system that meets the following access standards:
6.2.2.3.1 Routine visits scheduled within four (4) to six (6) weeks.
6.2.2.3.2 Urgent, Non-Emergent visits within forty- eight (48) hours.
6.2.2.3.3 Emergent visits immediately upon presentation at a service delivery site.
6.2.2.3.4 Waiting times that do not exceed forty-five (45) minutes for a scheduled appointment of a routine nature.
6.2.2.3.5 Walk-in patients with non-urgent needs should be seen if possible or scheduled for an appointment consistent with written scheduling Procedures.
6.2.2.3.6 Provide twenty-four (24) hour coverage by direct access or through arrangement with a triage system.
6.2.2.3.7 The CONTRACTOR must monitor the adequacy of its appointment processes.