Subchapter J. HEALTH CARE PROVIDER CONTRACTS


Sec.


9.721.    Applicability.
9.722.    Plan and health care provider contracts.
9.723.    IDS.
9.724.    Plan-IDS contracts.
9.725.    IDS-provider contracts.

Authority

   The provisions of this Subchapter J issued under Article XXI of The Insurance Company Law (40 P. S. § §  991.2101—991.2193); the HMO Act (40 P. S. § §  1551—1568); and section 630 of the PPO Act (40 P. S. §  764a), unless otherwise noted.

Source

   The provisions of this Subchapter J adopted June 8, 2001, effective June 9, 2001, 31 Pa.B. 3043, unless otherwise noted.

Cross References

   This subchapter cited in 28 Pa. Code §  9.601 (relating to applicability); and 28 Pa. Code §  9.635 (relating to issuance of a certificate of authority to a foreign HMO).

§ 9.721. Applicability.

 This subchapter shall apply to provider contracts between plans subject to Act 68 and health care providers; plans and IDSs; and IDSs and health care providers.

§ 9.722. Plan and health care provider contracts.

 (a)  A plan shall submit the standard form of each type of health care provider contract, including any document incorporated by reference into that contract, to the Department for review and approval. The plan shall be responsible for assuring that the provider contract meets the requirements of all applicable laws. The Department will review a provider contract within 45 days of receipt of the contract. If the Department does not approve or disapprove the contract within 45 days of receipt, the plan may use the contract and it shall be presumed to meet the requirements of all applicable laws. If, at any time, the Department finds that a contract is in violation of law, the plan shall correct the violation.

 (b)  The plan shall submit any material change or amendment to a standard health care provider contract, including a material change or amendment to any document incorporated by reference into the contract, to the Department 10 days before implementation of the change or amendment except for changes required by law or regulation.

 (c)  To be approved by the Department, a standard health care provider contract may not contain provisions permitting the plan to sanction, terminate or fail to renew a health care provider’s participation for any of the following reasons:

   (1)  Advocating for medically necessary and appropriate health care services for an enrollee.

   (2)  Filing a grievance on behalf of and with the written consent of an enrollee, or helping an enrollee to file a grievance.

   (3)  Protesting a plan decision, policy or practice the health care provider believes interferes with its ability to provide medically necessary and appropriate health care.

   (4)  Taking another action specifically permitted by sections 2113, 2121 and 2171 of the act (40 P. S. § §  991.2113, 991.2121 and 991.2171).

 (d)  To be approved by the Department, a standard health care provider contract may not contain any provision permitting the plan to penalize or restrict a health care provider from discussing any of the information health care providers are permitted to discuss under section 2113 of the act or other information the health care provider reasonably believes is necessary to provide to an enrollee full information concerning the health care of the enrollee.

 (e)  To be approved by the Department, a standard health care provider contract shall include the following consumer protection provisions:

   (1)  Enrollee hold harmless language which survives the termination of the health care provider contract regardless of the reason for termination, and includes the following:

     (i)   A statement that the hold harmless language is construed for the benefit of the enrollee.

     (ii)   A statement that the hold harmless language supersedes any written or oral agreement currently in existence, or entered into at a later date, between the health care provider and enrollee, or persons acting in their behalf.

     (iii)   If the provider contract is a contract that affects plan enrollees, language to the following effect:

 ‘‘In no event including, but not limited to, non-payment by the plan, plan insolvency, or a breach of this contract, shall the provider bill, charge, collect a deposit from, seek compensation or reimbursement from, or have any recourse against the enrollee or persons other than the plan acting on the behalf of the enrollee for services listed in this agreement. This provision does not prohibit collecting supplemental charges or co-payments in accordance with the terms of the applicable agreement between the plan and the enrollee. ’’

   (2)  Language stating that enrollee records shall be kept confidential by the plan and the health care provider in accordance with section 2131 of the act (40 P.S §  991.2131) and all applicable State and Federal laws and regulations, which include:

     (i)   Language permitting the Department, the Insurance Department, and, when necessary, the Department of Public Welfare, access to records for the purpose of quality assurance, investigation of complaints or grievances, enforcement or other activities related to compliance with Article XXI, this chapter and other laws of the Commonwealth.

     (ii)   Language which states that records are only accessible to Department employees or agents with direct responsibilities under subparagraph (i).

   (3)  Language requiring the health care provider to participate in and abide by the decisions of the plan’s quality assurance, UR and enrollee complaint and grievance systems.

   (4)  Language addressing any alternative dispute resolution systems.

   (5)  Language requiring the health provider to adhere to State and Federal laws and regulations.

   (6)  Language concerning prompt payment of claims consistent with the requirements of section 2166 of the act (40 P. S. §  991.2166) and 31 Pa. Code §  154.18 (relating to prompt payment of claims).

   (7)  Language requiring that if the plan and the health care provider agree to include a termination without cause provision in the contract, neither party shall be permitted to terminate the contract without cause upon less than 60 days prior written notice.

   (8)  Language requiring the plan to give at least 30 days prior written notice of any changes to contracts, policies or procedures affecting health care providers or the provision or payment of health care services to enrollees, unless the change is required by law or regulation.

 (f)  To be approved by the Department, a health care provider contract shall satisfy the following:

   (1)  Include the reimbursement method being used to reimburse a participating provider under the contract. If a provider reimbursement is subject to variability due to economic incentives, including bonus incentive systems, withhold pools or similar systems, the plan shall describe the systems and the factors being employed by the plan to determine reimbursement when the contract is submitted to the Department for review.

   (2)  Include no incentive reimbursement system for licensed professional health care providers which shall weigh utilization performance as a single component more highly than quality of care, enrollee services and other factors collectively.

   (3)  Include no financial incentive that compensates a health care provider for providing less than medically necessary and appropriate care to an enrollee.

Cross References

   This section cited in 28 Pa. Code §  9.652 (relating to HMO provision of other than basic health services to enrollees); 28 Pa. Code §  9.723 (relating to IDS); and 28 Pa. Code §  9.724 (relating to plan-IDS contracts).

§ 9.723. IDS.

 (a)  Standard IDS contracts between the IDS and the plan and between the IDS and the health care provider shall meet the standards of health care provider contracts in §  9.722 (relating to plan and health care provider contracts).

 (b)  A plan and an IDS entering into an arrangement under this subchapter shall notify the Department in writing in advance of any action which could result in the IDS’s participating providers being unavailable to provide covered services to enrollees.

§ 9.724. Plan-IDS contracts.

 (a)  A plan may contract with an IDS for the provision of care by IDS participating health care providers to plan enrollees. The contract between the plan and the IDS shall be in compliance with the requirements of this subchapter.

 (b)  The plan shall provide a copy of the IDS contract to the Department for review and approval. An IDS contract not based on an approved standard contract shall be submitted to the Department for review and approval. An IDS contract shall be reviewed by the Department in accordance with §  9.722(a) (relating to plan and health care provider contracts). If the IDS contract is based on a standard form contract, the plan shall provide the Department with notice of the contract, including the name, address and description of the IDS, before the effective date of the contract.

 (c)  The plan shall submit the IDS’s standard provider contract to the Department for review and approval before the effective date of the IDS contract. If an IDS’s providers have executed plan-provider contracts instead of IDS-provider contracts, the plan shall provide the Department with written notice of those contracts before the effective date of the IDS contract.

 (d)  For the Department to approve a contract between the plan and the IDS, the contract must meet the following standards:

   (1)  An IDS, assuming financial risk from a plan, is not required to obtain its own license to assume the risk, provided that the ultimate responsibility for benefits and services to enrollees, as set forth in the enrollee contract, remains the responsibility of the plan.

   (2)  If a person or entity is delivering prepaid basic health care services to enrollees, but not soliciting or enrolling members in a plan, that person or entity is not required to obtain a certificate of authority. If the person or entity is delivering prepaid basic health care services and performing administrative services or other similar functions, but not soliciting or enrolling plan members, that person or entity is not required to obtain a certificate of authority.

   (3)  The IDS shall acknowledge and agree that under no circumstance shall provision of covered services to enrollees be delayed, reduced, denied or otherwise hindered because of the financial or contractual relationship between the plan and the IDS or between the IDS and the participating health care providers.

   (4)  The IDS shall acknowledge and agree that only those IDS participating health care providers who meet the plan’s credentialing and provider contracting standards may participate and provide services to enrollees and that the ultimate authority to approve or terminate IDS health care providers is retained by the plan.

   (5)  The IDS shall acknowledge and agree that the plan is required to establish, operate and maintain a health care services delivery system, quality assurance system, provider credentialing system, enrollee complaint and grievance system, and other systems meeting Department standards and that the plan is directly accountable to the Department for compliance with the standards and for provision of quality, cost-effective care to plan enrollees. Nothing in the plan-IDS contract may limit the plan’s authority or responsibility to meet standards or to take prompt corrective action to address a quality of care problem, resolve an enrollee complaint or grievance, or to comply with a regulatory requirement of the Department.

   (6)  The IDS shall agree to provide the plan and the Department with access to medical and other records concerning the provision of services to enrollees by the IDS through its participating health care providers. The IDS shall agree to permit and cooperate with onsite reviews by the Department for purposes of monitoring the effectiveness of the IDS performance of any plan-delegated functions.

   (7)  The IDS shall agree that any delegation of authority or responsibility, in part or in full, for provider credentialing and relations, quality assessment, UR and other plan functions to the IDS shall be subject to performance monitoring by the plan and Department, and is subject to independent validation by the plan, the Department, or an independent quality review organization or CRE approved by the Department.

   (8)  The IDS shall agree to collect and provide the plan with utilization, financial and other data for the purposes of monitoring and comparative performance analysis.

   (9)  The IDS shall agree to comply with data reporting requirements, including encounter, utilization and reimbursement methodology required by the Department.

   (10)  The IDS shall obtain and maintain Department certification as a CRE if performing UR activities in Subchapter K (relating to CREs) and sections 2151 and 2152 of the act (40 P. S. § §  991.2151 and 2152).

   (11)  The IDS contract shall contain enrollee financial hold-harmless provisions acceptable to the Department which prevent the IDS and IDS participating health care providers from billing plan enrollees for covered services (other than authorized co-payments, co-insurance, or deductibles) under any circumstances including insolvency of the plan or the IDS.

   (12)  The IDS contract shall safeguard patient access to care and avoid significant disruption of service delivery by adequately providing for continuation of services by IDS participating health care providers to plan enrollees if the IDS contractual agreement is in any way jeopardized, suspended, terminated or unexpectedly not renewed. In the event of termination, the plan shall ensure continuity of care for those affected enrollees, under Act 68 and §  9.684 (relating to continuity of care).

   (13)  If the plan and IDS agree to include a termination without cause provision in the contract between the plan and the IDS, neither party shall be permitted to terminate the contract without cause upon less than 60 days prior written notice.

   (14)  Any delegation of medical management shall meet the requirements of §  9.675 (relating to delegation of medical management).

§ 9.725. IDS-provider contracts.

 In addition to the IDS contract, the health care provider contracts between the IDS and its participating health care providers shall be submitted by the plan for review and approval to the Department. For this purpose, the IDS shall provide the plan with a copy of these contracts. To secure Department approval of a contract between the plan and the IDS, an IDS-health care provider contract shall meet the following standards:

   (1)  The health care provider shall acknowledge and agree that nothing contained in the IDS-provider contract limits the following:

     (i)   The authority of the plan to ensure the health care provider’s participation in and compliance with the plan’s quality assurance, utilization management, enrollee complaint and grievance systems and procedures or limits.

     (ii)   The Department’s authority to monitor the effectiveness of the plan’s system and procedures or the extent to which the plan adequately monitors any function delegated to the IDS, or to require the plan to take prompt corrective action regarding quality of care or consumer grievances and complaints.

     (iii)   The plan’s authority to sanction or terminate a health care provider found to be providing inadequate or poor quality care or failing to comply with plan systems, standards or procedures as agreed to by the IDS.

   (2)  An IDS health care provider shall acknowledge and agree that any delegation by the plan to the IDS for performance of quality assurance, utilization management, credentialing, provider relations and other medical management systems shall be subject to the plan’s oversight and monitoring of IDS performance.

   (3)  An IDS health care provider shall acknowledge and agree that the plan, upon failure of the IDS to properly implement and administer the systems, or to take prompt corrective action after identifying quality, enrollee satisfaction or other problems, may terminate its contract with the IDS, and that as a result of the termination, the health care provider’s participation in the plan may also be terminated.

   (4)  The IDS provider contract shall contain enrollee financial hold-harmless provisions acceptable to the Department which prevent the IDS and an IDS participating health care provider from billing plan enrollees for covered services (other than authorized co-payments, co-insurance, or deductibles) under any circumstances including insolvency of the plan or the IDS.



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