Common use of Provider Agreements Clause in Contracts

Provider Agreements. The Contractor must have a process in place to review and authorize all network provider contracts. The Contractor must submit a model or sample contract of each type of provider agreement to OMPP for review and approval at least sixty (60) calendar days prior to the Contractor’s intended use. The Contractor must notify OMPP of any changes to the sample contracts within three (3) weeks of the Contract award date. To allow sufficient processing time for the enrollment of the PMP and ensure an effective date of January 1, 2017, the Contractor shall submit the completed PMP enrollment request to the State fiscal agent through the WebInterchange-Provider Healthcare Portal by December 1, 2016. The Contractor shall include in all of its provider agreements provisions to ensure continuation of benefits. The Contractor shall identify and incorporate the applicable terms of its Contract with the State and any incorporated documents. Under the terms of the provider services agreement, the provider shall agree that the applicable terms and conditions set out in the Contract, any incorporated documents, and all applicable state and federal laws, as amended, govern the duties and responsibilities of the provider with regard to the provision of services to members. The requirement set forth in Section 2.7 that subcontractors indemnify and hold harmless the State of Indiana do not extend to the contractual obligations and agreements between the Contractor and health care providers or other ancillary medical providers that have contracted with the Contractor. In addition to the applicable requirements for subcontracts in Section 2.7, the provider agreements shall meet the following requirements:  Describe a written provider claim dispute resolution process.  Require each provider to maintain a current IHCP provider agreement and to be duly licensed in accordance with the appropriate state licensing board and remain in good standing with said board.  Require each provider to submit all claims that do not involve a third party payer for services rendered to the Contractor’s members within ninety (90) calendar days or less from the date of service. The Contractor shall waive the timely filing requirement in the case of claims for members with retroactive coverage, such as presumptively eligible pregnant women and newborns.  Require each provider to utilize the Indiana Health Coverage Program Prior Authorization Request Form available on the Indiana Medicaid website for submission of prior authorization requests to the Contractor.  Include a termination clause stipulating that the Contractor shall terminate its contractual relationship with the provider as soon as the Contractor has knowledge that the provider’s license or IHCP provider agreement has terminated.  Terminate the provider’s agreement to serve the Contractor’s Hoosier Healthwise members at the end of the Contract with the State.  Monitor providers and apply corrective actions for those who are out of compliance with FSSA’s or the Contractor’s standards.  Obligate the terminating provider to submit all encounter claims for services rendered to the Contractor’s members while serving as the Contractor’s network provider and provide or reference the Contractor’s technical specifications for the submission of such encounter data.  Not obligate the provider to participate under exclusivity agreements that prohibit the provider from contracting with other state contractors.  Provide the PMP with the option to terminate the agreement without cause with advance notice to the Contractor. Said advance notice shall not have to be more that ninety (90) calendar days.  Provide a copy of a member’s medical record at no charge upon reasonable request by the member, and facilitate the transfer of the member’s medical record to another provider at the member’s request.  Require each provider to agree that it shall not seek payment from the State for any service rendered to a Hoosier Healthwise member under the agreement.  For behavioral health providers, require that members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge. This treatment must be provided within seven (7) calendar days from the date of the member’s discharge.  Require each provider to agree to use best commercial efforts to collect required copayments for services rendered Package C members. The Contractor shall have written policies and procedures for registering and responding to claims disputes for out-of-network providers, in accordance with the claims dispute resolution process for non-contracted providers outlined in 405 IAC 1-1.6-1.

Provider Agreements. The Contractor must have a process in place to review and authorize all network provider contracts. The Contractor must submit a model or sample contract of each type of provider agreement to OMPP for review and approval at least sixty (60) calendar days prior to the Contractor’s intended use. The Contractor must notify OMPP of any changes to the sample contracts within three (3) weeks of the Contract award date. To allow sufficient processing time for the enrollment of the PMP and ensure an effective date of January 1, 2017, the Contractor shall submit the completed PMP enrollment request to the State fiscal agent through the WebInterchange-Provider Healthcare Portal by December 1, 2016. The Contractor shall include in all of its provider agreements provisions to ensure continuation of benefits. The Contractor shall identify and incorporate the applicable terms of its Contract with the State and any incorporated documents. Under the terms of the provider services agreement, the provider shall agree that the applicable terms and conditions set out in the Contract, any incorporated documents, and all applicable state and federal laws, as amended, govern the duties and responsibilities of the provider with regard to the provision of services to members. The requirement set forth in Section 2.7 that subcontractors indemnify and hold harmless the State of Indiana do not extend to the contractual obligations and agreements between the Contractor and health care providers or other ancillary medical providers that have contracted with the Contractor. In addition to the applicable requirements for subcontracts in Section 2.7, the provider agreements shall meet the following requirements:  ▪ Describe a written provider claim dispute resolution process.  ▪ Require each provider to maintain a current IHCP provider agreement and to be duly licensed in accordance with the appropriate state licensing board and remain in good standing with said board.  ▪ Require each provider to submit all claims that do not involve a third party payer for services rendered to the Contractor’s members within ninety (90) calendar days or less from the date of service. The Contractor shall waive the timely filing requirement in the case of claims for members with retroactive coverage, such as presumptively eligible pregnant women and newborns.  ▪ Require each provider to utilize the Indiana Health Coverage Program Prior Authorization Request Form available on the Indiana Medicaid website for submission of prior authorization requests to the Contractor.  ▪ Include a termination clause stipulating that the Contractor shall terminate its contractual relationship with the provider as soon as the Contractor has knowledge that the provider’s license or IHCP provider agreement has terminated.  ▪ Terminate the provider’s agreement to serve the Contractor’s Hoosier Healthwise members at the end of the Contract with the State.  ▪ Monitor providers and apply corrective actions for those who are out of compliance with FSSA’s or the Contractor’s standards.  ▪ Obligate the terminating provider to submit all encounter claims for services rendered to the Contractor’s members while serving as the Contractor’s network provider and provide or reference the Contractor’s technical specifications for the submission of such encounter data.  ▪ Not obligate the provider to participate under exclusivity agreements that prohibit the provider from contracting with other state contractors.  ▪ Provide the PMP with the option to terminate the agreement without cause with advance notice to the Contractor. Said advance notice shall not have to be more that ninety (90) calendar days.  ▪ Provide a copy of a member’s medical record at no charge upon reasonable request by the member, and facilitate the transfer of the member’s medical record to another provider at the member’s request.  ▪ Require each provider to agree that it shall not seek payment from the State for any service rendered to a Hoosier Healthwise member under the agreement.  ▪ For behavioral health providers, require that members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge. This treatment must be provided within seven (7) calendar days from the date of the member’s discharge.  ▪ Require each provider to agree to use best commercial efforts to collect required copayments for services rendered Package C members. The Contractor shall have written policies and procedures for registering and responding to claims disputes for out-of-network providers, in accordance with the claims dispute resolution process for non-contracted providers outlined in 405 IAC 1-1.6-1.

Provider Agreements. The Contractor must have a process in place to review and authorize all network provider contracts. The Contractor must submit a model or sample contract of each type of provider agreement to OMPP for review and approval at least sixty (60) calendar days prior to the Contractor’s intended use. The Contractor must notify OMPP of any changes to the sample contracts within three (3) weeks of the Contract award date. To allow sufficient processing time for the enrollment of the PMP and ensure an effective date of January 1, 2017, the Contractor shall submit the completed PMP enrollment request to the State fiscal agent through the WebInterchange-Provider Healthcare Portal by December 1, 2016. The Contractor shall include in all of its provider agreements provisions to ensure continuation of benefits. The Contractor shall identify and incorporate the applicable terms of its Contract with the State and any incorporated documents. Under the terms of the provider services agreement, the provider shall agree that the applicable terms and conditions set out in the Contract, any incorporated documents, and all applicable state and federal laws, as amended, govern the duties and responsibilities of the provider with regard to the provision of services to members. The requirement set forth in Section 2.7 that subcontractors indemnify and hold harmless the State of Indiana do not extend to the contractual obligations and agreements between the Contractor and health care providers or other ancillary medical providers that have contracted with the Contractor. In addition to the applicable requirements for subcontracts in Section 2.7, the provider agreements shall meet the following requirements:  Describe a written provider claim dispute resolution process.  Require each provider to maintain a current IHCP provider agreement and to be duly licensed in accordance with the appropriate state licensing board and remain in good standing with said board.  Require each provider to submit all claims that do not involve a third party payer for services rendered to the Contractor’s members within ninety (90) calendar days or less from the date of service. The Contractor shall waive the timely filing requirement in the case of claims for members with retroactive coverage, such as presumptively eligible pregnant women and newborns.  Require each provider to utilize the Indiana Health Coverage Program Prior Authorization Request Form available on the Indiana Medicaid website for submission of prior authorization requests to the Contractor.  Include a termination clause stipulating that the Contractor shall terminate its contractual relationship with the provider as soon as the Contractor has knowledge that the provider’s license or IHCP provider agreement has terminated.  Terminate the provider’s agreement to serve the Contractor’s Hoosier Healthwise members at the end of the Contract with the State.  Monitor providers and apply corrective actions for those who are out of compliance with FSSA’s or the Contractor’s standards.  Obligate the terminating provider to submit all encounter claims for services rendered to the Contractor’s members while serving as the Contractor’s network provider and provide or reference the Contractor’s technical specifications for the submission of such encounter data.  Not obligate the provider to participate under exclusivity agreements that prohibit the provider from contracting with other state contractors.  Provide the PMP with the option to terminate the agreement without cause with advance notice to the Contractor. Said advance notice shall not have to be more that ninety (90) calendar days.  Provide a copy of a member’s medical record at no charge upon reasonable request by the member, and facilitate the transfer of the member’s medical record to another provider at the member’s request.  Require each provider to agree that it shall not seek payment from the State for any service rendered to a Hoosier Healthwise member under the agreement.  For behavioral health providers, require that members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge. This treatment must be provided within seven (7) calendar days from the date of the member’s discharge.  Require each provider to agree to use best commercial efforts to collect required copayments for services rendered Package C members. The Contractor shall have written policies and procedures for registering and responding to claims disputes for out-of-network providers, in accordance with the claims dispute resolution process for non-contracted providers outlined in 405 IAC 1-1.6-1.EXHIBIT 1.E

Provider Agreements. The Contractor must have a process in place to review and authorize all network provider contracts. The Contractor must submit a model or sample contract of each type of provider agreement to OMPP for review and approval at least sixty (60) calendar days prior to the Contractor’s intended use. The Contractor must notify OMPP of any changes to the sample contracts within three (3) weeks of the Contract award date. To allow sufficient processing time for the enrollment of the PMP and ensure an effective date of January 1, 2017, the Contractor shall submit the completed PMP enrollment request to the State fiscal agent through the WebInterchange-Provider Healthcare Portal by December 1, 2016. The Contractor shall include in all of its provider agreements provisions to ensure continuation of benefits. The Contractor shall identify and incorporate the applicable terms of its Contract with the State and any incorporated documents. Under the terms of the provider services agreement, the provider shall agree that the applicable terms and conditions set out in the Contract, any incorporated documents, and all applicable state and federal laws, as amended, govern the duties and responsibilities of the provider with regard to the provision of services to members. The requirement set forth in Section 2.7 that subcontractors indemnify and hold harmless the State of Indiana do not extend to the contractual obligations and agreements between the Contractor and health care providers or other ancillary medical providers that have contracted with the Contractor. In addition to the applicable requirements for subcontracts in Section 2.7, the provider agreements shall meet the following requirements:  ▪ Describe a written provider claim dispute resolution process.  ▪ Require each provider to maintain a current IHCP provider agreement and to be duly licensed in accordance with the appropriate state licensing board and remain in good standing with said board.  ▪ Require each provider to submit all claims that do not involve a third third-party payer for services rendered to the Contractor’s members within ninety (90) calendar days or less from the date of service. The Contractor shall waive the timely filing requirement in the case of claims for members with retroactive coverage, such as presumptively eligible pregnant women and newborns.  Require each provider to utilize the Indiana Health Coverage Program Prior Authorization Request Form available on the Indiana Medicaid website for submission of prior authorization requests to the Contractor.  Include a termination clause stipulating that the Contractor shall terminate its contractual relationship with the provider as soon as the Contractor has knowledge that the provider’s license or IHCP provider agreement has terminated.  Terminate the provider’s agreement to serve the Contractor’s Hoosier Healthwise members at the end of the Contract with the State.  Monitor providers and apply corrective actions for those who are out of compliance with FSSA’s or the Contractor’s standards.  Obligate the terminating provider to submit all encounter claims for services rendered to the Contractor’s members while serving as the Contractor’s network provider and provide or reference the Contractor’s technical specifications for the submission of such encounter data.  Not obligate the provider to participate under exclusivity agreements that prohibit the provider from contracting with other state contractors.  Provide the PMP with the option to terminate the agreement without cause with advance notice to the Contractor. Said advance notice shall not have to be more that ninety (90) calendar days.  Provide a copy of a member’s medical record at no charge upon reasonable request by the member, and facilitate the transfer of the member’s medical record to another provider at the member’s request.  Require each provider to agree that it shall not seek payment from the State for any service rendered to a Hoosier Healthwise member under the agreement.  For behavioral health providers, require that members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge. This treatment must be provided within seven (7) calendar days from the date of the member’s discharge.  Require each provider to agree to use best commercial efforts to collect required copayments for services rendered Package C members. The Contractor shall have written policies and procedures for registering and responding to claims disputes for out-of-network providers, in accordance with the claims dispute resolution process for non-contracted providers outlined in 405 IAC 1-1.6-1.

Provider Agreements. The Contractor must have a process in place to review and authorize all network provider contracts. The Contractor must submit a model or sample contract of each type of provider agreement to OMPP for review and approval at least sixty (60) calendar days prior to the Contractor’s intended use. The Contractor must notify OMPP of any changes to the sample contracts within three (3) weeks of the Contract award date. To allow sufficient processing time for the enrollment of the PMP and ensure an effective date of January 1, 2017, the Contractor shall submit the completed PMP enrollment request to the State fiscal agent through the WebInterchangeWeb Interchange-Provider Healthcare Portal by December 1, 2016. The Contractor shall include in all of its provider agreements provisions to ensure continuation of benefits. The Contractor shall identify and incorporate the applicable terms of its Contract with the State and any incorporated documents. Under the terms of the provider services agreement, the provider shall agree that the applicable terms and conditions set out in the Contract, any incorporated documents, and all applicable state and federal laws, as amended, govern the duties and responsibilities of the provider with regard to the provision of services to members. The requirement set forth in Section 2.7 that subcontractors indemnify and hold harmless the State of Indiana do not extend to the contractual obligations and agreements between the Contractor and health care providers or other ancillary medical providers that have contracted with the Contractor. In addition to the applicable requirements for subcontracts in Section 2.7, the provider agreements shall meet the following requirements:   Describe a written provider claim dispute resolution process.   Require each provider to maintain a current IHCP provider agreement and to be duly licensed in accordance with the appropriate state licensing board and remain in good standing with said board.   Require each provider to submit all claims that do not involve a third party payer for services rendered to the Contractor’s members within ninety (90) calendar days or less from the date of service. The Contractor shall waive the timely filing requirement in the case of claims for members with retroactive coverage, such as presumptively eligible pregnant women and newborns.   Require each provider to utilize the Indiana Health Coverage Program Prior Authorization Request Form available on the Indiana Medicaid website for submission of prior authorization requests to the Contractor.   Include a termination clause stipulating that the Contractor shall terminate its contractual relationship with the provider as soon as the Contractor has knowledge that the provider’s license or IHCP provider agreement has terminated.   Terminate the provider’s agreement to serve the Contractor’s Hoosier Healthwise members at the end of the Contract with the State.   Monitor providers and apply corrective actions for those who are out of compliance with FSSA’s or the Contractor’s standards.   Obligate the terminating provider to submit all encounter claims for services rendered to the Contractor’s members while serving as the Contractor’s network provider and provide or reference the Contractor’s technical specifications for the submission of such encounter data.   Not obligate the provider to participate under exclusivity agreements that prohibit the provider from contracting with other state contractors.   Provide the PMP with the option to terminate the agreement without cause with advance notice to the Contractor. Said advance notice shall not have to be more that ninety (90) calendar days.   Provide a copy of a member’s medical record at no charge upon reasonable request by the member, and facilitate the transfer of the member’s medical record to another provider at the member’s request.   Require each provider to agree that it shall not seek payment from the State for any service rendered to a Hoosier Healthwise member under the agreement.   For behavioral health providers, require that members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge. This treatment must be provided within seven (7) calendar days from the date of the member’s discharge.   Require each provider to agree to use best commercial efforts to collect required copayments for services rendered Package C members. The Contractor shall have written policies and procedures for registering and responding to claims disputes for out-of-network providers, in accordance with the claims dispute resolution process for non-contracted providers outlined in 405 IAC 1-1.6-1.

Provider Agreements. The Contractor must have a process in place to review and authorize all network provider contracts. The Contractor must submit a model or sample contract of each type of provider agreement to OMPP for review and approval at least sixty (60) calendar days prior to the Contractor’s intended use. The Contractor must notify OMPP of any changes to the sample contracts within three (3) weeks of the Contract award date. To allow sufficient processing time for the enrollment of the PMP and ensure an effective date of January 1, 2017, the Contractor shall submit the completed PMP enrollment request to the State fiscal agent through the WebInterchange-Provider Healthcare Portal by December 1, 2016. The Contractor shall include in all of its provider agreements provisions to ensure continuation of benefits. The Contractor shall identify and incorporate the applicable terms of its Contract with the State and any incorporated documents. Under the terms of the provider services agreement, the provider shall agree that the applicable terms and conditions set out in the Contract, any incorporated documents, and all applicable state and federal laws, as amended, govern the duties and responsibilities of the provider with regard to the provision of services to members. The requirement set forth in Section 2.7 that subcontractors indemnify and hold harmless the State of Indiana do not extend to the contractual obligations and agreements between the Contractor and health care providers or other ancillary medical providers that have contracted with the Contractor. In addition to the applicable requirements for subcontracts in Section 2.7, the provider agreements shall meet the following requirements:  ▪ Describe a written provider claim dispute resolution process.  ▪ Require each provider to maintain a current IHCP provider agreement and to be duly licensed in accordance with the appropriate state licensing board and remain in good standing with said board.  ▪ Require each provider to submit all claims that do not involve a third party payer for services rendered to the Contractor’s members within ninety (90) calendar days or less from the date of service. The Contractor shall waive the timely filing requirement in the case of claims for members with retroactive coverage, such as presumptively eligible pregnant women and newborns.  ▪ Require each provider to utilize the Indiana Health Coverage Program Prior Authorization Request Form available on the Indiana Medicaid website for submission of prior authorization requests to the Contractor.  Include a termination clause stipulating that the Contractor shall terminate its contractual relationship with the provider as soon as the Contractor has knowledge that the provider’s license or IHCP provider agreement has terminated.  Terminate the provider’s agreement to serve the Contractor’s Hoosier Healthwise members at the end of the Contract with the State.  Monitor providers and apply corrective actions for those who are out of compliance with FSSA’s or the Contractor’s standards.  Obligate the terminating provider to submit all encounter claims for services rendered to the Contractor’s members while serving as the Contractor’s network provider and provide or reference the Contractor’s technical specifications for the submission of such encounter data.  Not obligate the provider to participate under exclusivity agreements that prohibit the provider from contracting with other state contractors.  Provide the PMP with the option to terminate the agreement without cause with advance notice to the Contractor. Said advance notice shall not have to be more that ninety (90) calendar days.  Provide a copy of a member’s medical record at no charge upon reasonable request by the member, and facilitate the transfer of the member’s medical record to another provider at the member’s request.  Require each provider to agree that it shall not seek payment from the State for any service rendered to a Hoosier Healthwise member under the agreement.  For behavioral health providers, require that members receiving inpatient psychiatric services are scheduled for outpatient follow-up and/or continuing treatment prior to discharge. This treatment must be provided within seven (7) calendar days from the date of the member’s discharge.  Require each provider to agree to use best commercial efforts to collect required copayments for services rendered Package C members. The Contractor shall have written policies and procedures for registering and responding to claims disputes for out-of-network providers, in accordance with the claims dispute resolution process for non-contracted providers outlined in 405 IAC 1-1.6-1.EXHIBIT 1.E