Material Modification of Provider Sample Clauses
The Material Modification of Provider clause defines the conditions under which significant changes to the service provider or their operations must be disclosed or approved. Typically, this clause applies when there is a substantial alteration in the provider’s ownership, management, or the nature of services delivered, such as a merger, acquisition, or outsourcing of key functions. Its core practical function is to ensure that the client is informed of and can respond to major changes that could impact service quality or contractual obligations, thereby managing risk and maintaining transparency in the business relationship.
Material Modification of Provider. Network means 1) a change that would result in an Enrollee having only three remaining choices of a Primary Care Provider within thirty (30) miles or thirty (30) minutes; 2) a change that results in the discontinuation of a Primary Care Provider who is responsible for Primary Care for one third (1/3) or more of the Enrollees in the applicable area (the same area from which the affected Enrollee chose their Primary Care Provider or sole source Provider, prior to the Material Modification); 3) a change that involves a termination of a sole source Provider where the termination is for cause. Such changes include both Medicare and Medicaid Providers, and pharmacy benefit managers as applicable, or 4) loss of the contractual agreement with a major subcontractor providing a network of providers, including but not limited to the MCO’s dental or behavioral health network, pharmacy benefit manager, care systems and care coordination entities. For purposes of this section, termination of a Provider for cause does not include the inability to reach agreement on contract terms.
Material Modification of Provider. Network means 1) a change that would result in an Enrollee having only three remaining choices of a Primary Care Provider within thirty (30) miles or thirty (30) minutes; or 2) a change that results in the discontinuation of a Primary Care Provider who is responsible for Primary Care for one third (1/3) or more of the Enrollees in the applicable area (the same area from which the affected Enrollee chose their Primary Care Provider or sole source Provider, prior to the Material Modification); or 3) a change that involves a termination of a sole source Provider where the termination is for cause. Such changes include both Medicare and Medicaid Providers, and pharmacy benefit managers as applicable. For purposes of this section, termination of a Provider for cause does not include the inability to reach agreement on contract terms.
Material Modification of Provider. Network means 1) a change that would result in an Enrollee having only three remaining choices of a Primary Care Provider within thirty (30) miles or thirty (30) minutes; or 2) a change which results in the discontinuation of a Primary Care Provider who is responsible for Primary Care for one third (1/3) or more of the Enrollees in the applicable area (the same area from which the affected Enrollee chose their Primary Care Provider or sole source Provider, prior to the Material Modification); or 3) a change which involves a termination of a sole source Provider; and 4) such changes include both Medicare and Medicaid Providers and pharmacy benefit managers. For purposes of this section, termination of a Provider for cause does not include the inability to reach agreement on contract terms.