Alabama Administrative Code › Title 420 - ALABAMA STATE BOARD OF HEALTH › Chapter 420-5-6 - HEALTH MAINTENANCE ORGANIZATIONS › Section 420-5-6-.10 - Provider Contracts

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 "Provider contract" means a written agreement executed between a health
			 maintenance organization and a health care provider in which the health care
			 provider agrees to furnish specified services to enrollees of the health
			 maintenance organization. The health maintenance organization retains the
			 responsibility for the arrangement of the provision of those
			 services.
(2) Health maintenance
			 organizations shall include the following in provider contracts in addition to
			 any requirements of the Alabama Department of Insurance. The Health Department
			 may waive one or more of the following as appropriate for type of provider. If
			 a contracted provider utilizes downstream contracts that the health maintenance
			 organization must rely upon, the contracted provider must guarantee that
			 downstream contracts contain the requirements listed below. A copy of the
			 downstream provider contract(s) with a Department of Public Health approval
			 stamp shall constitute such guarantee.
(a)
			 Full identification of the parties of the contract including name, address, and
			 phone number of the provider;
(b)
			 Effective date of the contract and date of execution;
(c) Term, termination, and renewal
			 mechanisms;
(d) Obligation of the
			 health maintenance organization to the provider;
1. Payment/reimbursement methodologies must
			 be described in terms a reasonably prudent layperson could be expected to
			 understand.
2. If utilized,
			 withhold or other incentives or reimbursement arrangement incentives must be
			 clearly defined. The factors that will be measured and the amount of time
			 required by the health maintenance organization to analyze the data and report
			 the outcome to the provider will be clearly described in the contract.
			 Providers will receive a report consistent with the terms of the contract and
			 showing the resulting funds or lack of funds, due to be paid within six (6)
			 months of the conclusion of the withhold period. Full payment of any funds due
			 to the provider will be made at the time of the report.
3. Reimbursements or deductions based on
			 circumstances outside the provider's control, such as plan performance, must be
			 defined as an additional "discount" or a "bonus" and may not be defined as a
			 withhold.
4. Organizations applying
			 for health maintenance organization certification must file contracts and
			 attachments that fully and clearly describe payment methodologies,
			 reimbursement, and incentives in terms a reasonably prudent layperson could be
			 expected to understand.
(e) Services to be provided by the provider
			 including location of services, site phone number, times of availability of
			 services, and provisions for coverage in provider's absence;
(f) Minimum standards of care as established
			 by the health maintenance organization and required of the provider;
(g) Provisions for emergency
			 services;
(h) Provisions for
			 referral services;
(i) A
			 description of the utilization review program and provisions for provider
			 participation in utilization review;
(j) Provisions requiring provider to
			 participate in enrollee grievance procedure;
(k) Provisions requiring sharing of medical
			 records and confidentiality of medical records;
(l) Provisions relating to credentials of
			 provider;
(m) Education
			 requirements relating to the knowledge of operation of the health maintenance
			 organization's provider's role in the health maintenance
			 organization;
(n) Provisions for
			 adequate medical malpractice coverage;
(o) Provisions for dispute
			 mechanism;
(p) A description of
			 quality improvement procedures and provisions for provider participation in
			 quality improvement; and
(q) A
			 provider shall not deny an enrollee's access to quality care by billing the
			 enrollee directly. Therefore, the contract shall contain a clause that the
			 provider will look solely to the health maintenance organization for
			 compensation for services provided to health maintenance organization
			 enrollees. The clause shall not extend to copayments. The clause shall read;
1.
(Provider) hereby agrees that in no event, including but not
				limited to, non-payment, health maintenance organization insolvency, or breach
				of this agreement, shall (provider) bill, charge, collect a deposit from, seek
				compensation, remuneration or reimbursement from, or have any recourse against
				enrollee, or persons other than the health maintenance organization acting on
				behalf of the enrollee for services provided pursuant to this agreement. This
				provision shall not prohibit collection of copayments, deductibles, and
				coinsurances on the health maintenance organization's behalf made in accordance
				with the terms of the (applicable agreement) between the health maintenance
				organization and enrollee.
(Provider) further agrees that (a) this provision shall survive
				the termination of this agreement regardless of the cause giving rise to
				termination and shall be construed to be for the benefit of the health
				maintenance organization subscriber, and that (b) this provision supersedes any
				oral or written contrary agreement now existing or hereafter entered into
				between (Provider) and enrollee, or persons on their behalf.
Provider may not change, amend, or waive any provision of this
				contract without prior written consent of the health maintenance organization.
				Any attempts to change, amend, or waive this contract are void.
(r) Provisions
			 requiring that the provider cooperate with the health maintenance organization
			 in complying with applicable laws relating to health maintenance organizations
			 and provider complies with applicable laws regulating provider.