Provider Network Information Requirements. The CONTRACTOR’S provider network capabilities shall include, but not be limited to:
Provider Network Information Requirements. The CONTRACTOR’s Provider network capabilities shall include the following, in order to fulfill the Provider credentialing, recredentialing, and enrollment functions described in Section 4.8.16 of this Agreement, as further described in the MCO Systems Manual: Accepting a provider master file from HCA that identifies all Medicaid enrolled Providers; Transmitting a Provider network file to New Mexico Medicaid’s fiscal agent that identifies by Medicaid Provider ID and NPI any Provider enrolled with New Mexico Medicaid who is a Contract Provider. Non-Contract Providers are not to be included on this file. The CONTRACTOR shall include the date on which the Provider's status as a Contract Provider is effective and when the Provider is no longer a Contract Provider, the CONTRACTOR shall include the date the Provider’s status as a Contract Provider ended. The CONTRACTOR shall send this file monthly, due no later than the tenth day of each month, reflecting the Contract Providers for the previous month. This requirement may be modified or deleted with the implementation of MMIS-R. The CONTRACTOR shall adhere to all federal requirements related to the enrollment, identification, and reporting of billing, rendering, furnishing, ordering, referring, prescribing, attending and other Providers, as applicable; Accepting a Provider confirmation update file from New Mexico Medicaid that contains any newly active Contract Providers or changes to Contract Providers that lists, at a minimum, the provider’s NPI or FEIN/SSN, the provider’s Medicaid ID, servicing location zip code, provider type, specialty, and dates of enrollment/termination; Recording each Provider listed on the New Mexico Medicaid provider update confirmation file and the full provider confirmation file in the CONTRACTOR’s system with the Medicaid provider ID, the assigned provider type, specialty (if applicable), and dates of enrollment/termination and using this data to edit Claims and ensure that the appropriate provider taxonomy and provider servicing location zip code is assigned to Encounter Claims; Maintain an accurate and provide timely updates to an online Provider directory for Members as specified in Section 4.15.5 of this Agreement; and Upon HCA direction, the CONTRACTOR agrees to accept a single provider master file from HCA that has all enrolled Providers. This file will be updated on a daily basis with any changes and published monthly as a full file.
