§ 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).
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