Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part I - General Health › Chapter 9 - MANAGED CARE ORGANIZATIONS › Subchapter J - HEALTH CARE PROVIDER CONTRACTS › Section 9.724 - Plan-IDS contracts

Current through Register Vol. 54, No. 28, July 13, 2024
(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).