Common use of Provider Dispute Resolution System Clause in Contracts

Provider Dispute Resolution System. The PH-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The resolution of all issues regarding the interpretation of Department-approved Provider Agreements must be handled between the two (2) entities and shall not involve the Department; therefore, these are not within the scope of the Department’s BHA. Additionally, the Department’s BHA or its designee is not an appropriate forum for Provider Disputes/Appeals with the PH-MCO. Prior to implementation, the PH-MCO must submit to the Department, their policies and procedures relating to the resolution of Provider Disputes/Provider Appeals for approval. Any changes made to the Provider Disputes/Provider Appeals policies and procedures must be submitted to the Department for approval prior to implementation of the changes. The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by th e Department. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO’s Provider Disputes/Provider Appeals policies and procedures must include at a minimum: • Informal and formal processes for settlement of Provider Disputes; • Acceptance and usage of the Department’s definition of Provider Appeals and Provider Disputes; • Timeframes for submission and resolution of Provider Disputes/Provider Appeals; • Processes to ensure equitability for all Providers; • Mechanisms and time-frames for reporting Provider Appeal decisions to PH-MCO administration, QM, Provider Relations and the Department; and • Establishment of a PH-MCO Committee to process formal Provider Disputes/Provider Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Health Care Providers/peers; – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues; – Access to data necessary to assist committee members in making decisions; and – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution System. The PH-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The resolution of all issues regarding the interpretation of Department-approved Provider Agreements must be handled between the two (2) entities and shall not involve the Department; therefore, these are not within the scope of the Department’s BHA. Additionally, the Department’s BHA or its designee is not an appropriate forum for Provider Disputes/Appeals with the PH-MCO. Prior to implementation, the PH-MCO must submit to the Department, their policies and procedures relating to the resolution of Provider Disputes/Provider Appeals for approval. Any changes made to the Provider Disputes/Provider Appeals policies and procedures must be submitted to the Department for approval prior to implementation of the changes. The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by th e the Department. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO’s Provider Disputes/Provider Appeals policies and procedures must include at a minimum: • Informal and formal processes for settlement of Provider Disputes; • Acceptance and usage of the Department’s definition of Provider Appeals and Provider Disputes; • Timeframes for submission and resolution of Provider Disputes/Provider Appeals; • Processes to ensure equitability for all Providers; • Mechanisms and time-frames for reporting Provider Appeal decisions to PH-MCO administration, QM, Provider Relations and the Department; and • Establishment of a PH-MCO Committee to process formal Provider Disputes/Provider Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Health Care Providers/peers; – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues; – Access to data necessary to assist committee members in making decisions; and – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution System. The PH-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The resolution of all issues regarding the interpretation of Department-approved Provider Agreements must be handled between the two (2) entities and shall not involve the Department; therefore, these are not within the scope of the Department’s 's BHA. Additionally, the Department’s 's BHA or its designee is not an appropriate forum for Provider Disputes/Appeals with the PH-MCO. Prior to implementation, the PH-MCO must submit to the Department, their policies and procedures relating to the resolution of Provider Disputes/Provider Appeals for approval. Any changes made to the Provider Disputes/Provider Appeals policies and procedures must be submitted to the Department for approval prior to implementation of the changes. The PH-MCO’s 's submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by th e Department. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO’s 's Provider Disputes/Provider Appeals policies and procedures must include at a minimum: • Informal and formal processes for settlement of Provider Disputes; • Acceptance and usage of the Department’s 's definition of Provider Appeals and Provider Disputes; • Timeframes for submission and resolution of Provider Disputes/Provider Appeals; • Processes to ensure equitability for all Providers; • Mechanisms and time-frames for reporting Provider Appeal decisions to PH-MCO administration, QM, Provider Relations and the Department; and • Establishment of a PH-MCO Committee to process formal Provider Disputes/Provider Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Health Care Providers/peers; – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues; – Access to data necessary to assist committee members in making decisions; and – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution System. The PH-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The resolution of all issues regarding the interpretation of Department-Department- approved Provider Agreements must be handled between the two (2) entities and shall not involve the Department; therefore, these are not within the scope of the Department’s BHA. Additionally, the Department’s BHA or its designee is not an appropriate forum for Provider Disputes/Appeals with the PH-MCO. Prior to implementation, the PH-MCO must submit to the Department, their policies and procedures relating to the resolution of Provider Disputes/Provider Appeals for approval. Any changes made to the Provider Disputes/Provider Appeals policies and procedures must be submitted to the Department for approval prior to implementation of the changes. The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by th e the Department. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO’s Provider Disputes/Provider Appeals policies and procedures must include at a minimum: •  Informal and formal processes for settlement of Provider Disputes; •  Acceptance and usage of the Department’s definition of Provider Appeals and Provider Disputes; •  Timeframes for submission and resolution of Provider Disputes/Provider Appeals; •  Processes to ensure equitability for all Providers; •  Mechanisms and time-frames for reporting Provider Appeal decisions to PH-MCO administration, QM, Provider Relations and the Department; and •  Establishment of a PH-MCO Committee to process formal Provider Disputes/Provider Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Health Care Providers/peers; – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues; – Access to data necessary to assist committee members in making decisions; and – Documentation of meetings and decisions of the Committee.

Provider Dispute Resolution System. The PH-MCO must develop, implement, and maintain a Provider Dispute Resolution Process, which provides for informal resolution of Provider Disputes at the lowest level and a formal process for Provider Appeals. The resolution of all issues regarding the interpretation of Department-Department- approved Provider Agreements must be handled between the two (2) entities and shall not involve the Department; therefore, these are not within the scope of the Department’s BHA. Additionally, the Department’s BHA or its designee is not an appropriate forum for Provider Disputes/Appeals with the PH-MCO. Prior to implementation, the PH-MCO must submit to the Department, their policies and procedures relating to the resolution of Provider Disputes/Provider Appeals for approval. Any changes made to the Provider Disputes/Provider Appeals policies and procedures must be submitted to the Department for approval prior to implementation of the changes. The PH-MCO’s submission of new or revised policies and procedures for review and approval by the Department shall not act to void any existing policies and procedures which have been prior approved by th e the Department. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the Department approves the new or revised version thereof. The PH-MCO’s Provider Disputes/Provider Appeals policies and procedures must include at a minimum: • Informal and formal processes for settlement of Provider Disputes; • Acceptance and usage of the Department’s definition of Provider Appeals and Provider Disputes; • Timeframes for submission and resolution of Provider Disputes/Provider Appeals; • Processes to ensure equitability for all Providers; • Mechanisms and time-frames for reporting Provider Appeal decisions to PH-MCO administration, QM, Provider Relations and the Department; and • Establishment of a PH-MCO Committee to process formal Provider Disputes/Provider Appeals which must provide: – At least one-fourth (1/4th) of the membership of the Committee must be composed of Health Care Providers/peers; – Committee members who have the authority, training, and expertise to address and resolve Provider Dispute/Provider Appeal issues; – Access to data necessary to assist committee members in making decisions; and – Documentation of meetings and decisions of the Committee.