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Provider Manual

Provider Contracting

Last Updated on February 28, 2019

Agreement with contracting and subcontracting entities

When the provider or contracted entity provides services under the affiliated provider agreement through subcontracts with other individuals or entities, the provider shall require those individuals or entities to meet the requirements as outlined in the CMS Operational Policy Letter 98.077 (OPL 77) set forth in the Affiliated Provider Agreement.

Termination of provider or contracting entity

Consistent with Security Health Plan’s contract with CMS and related affiliated provider agreements, Security Health Plan reserves the right to terminate or nonrenew a contract with any provider or other contracted entity for failure to be compliant with any of the following:

  • Persistent noncompliance with Security Health Plan policies and/or procedures
  • Breach of the provider agreement without remedy of such breach after 60-day notification
  • Upon receipt of written notice that the provider can no longer meet the obligations required under the agreement including but not limited to suspension, revocation, or expiration of any license or certificate that is necessary to perform required obligations under this affiliated provider agreement
  • Upon notification of bankruptcy or insolvency
  • Notification of any sanction, remedial actions or revocation of Medicare participation, or that of applicable state or federal agency
  • In the event that in the judgment of Security Health Plan, continuation of the agreement would jeopardize the health and welfare of Medicare Advantage members

Medicare Preclusion List

Starting January 1, 2019, The Centers for Medicare and Medicaid Services (CMS) started issuing a list of providers and prescribers who are precluded from receiving payment for Medicare Advantage items and services, or Part D drugs furnished or prescribed to Medicare beneficiaries. CMS will make the preclusion list available to Part D sponsors and Medicare Advantage plans, starting January 1, 2019, and effective April 1, 2019.

  • Part D sponsors will be required to reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by an individual on the preclusion list.
  • Medicare Advantage plans will be required to deny payment for a health care item or service furnished by an individual or entity on the preclusion list.

Why was the list created?

  • To replace the Medicare Advantage and prescriber enrollment requirements
  • To ensure patient protections and safety, and to protect the Trust Funds from prescribers and providers identified as “bad actors”

Who is on the list?

Individuals or entities who meet the following criteria:

  • Are currently:
    • Revoked from Medicare
    • Under an active reenrollment bar
    • AND determined by CMS that the underlying conduct, which led to the revocation, is detrimental to the best interests of the Medicare program

    OR

  • Have engaged in behavior for which CMS could have revoked the individual or entity to the extent applicable if they had been enrolled in Medicare
  • AND CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare program

For Providers on the Preclusion List

  • You will receive an email and letter from CMS/Medicare Administrative Contractors in advance of your inclusion on the preclusion list.
  • The email and letter will be sent to your Provider Enrollment Chain and Ownership System (PECOS) address or National Plan and Provider Enumeration System (NPPES) mailing.
  • The letter will contain the reason you are precluded, the effective date of your preclusion, and your applicable rights to appeal.

For Security Health Plan Affiliated Medicare Advantage Providers or Facilities on the Preclusion List

  • You will be removed from printing in the SHP Medicare Advantage provider directories immediately.\
  • You will be terminated from SHP’s Medicare Advantage products 90 days from the date you are listed on the Preclusion list
  • You will receive a notice from Security Health Plan outlining your termination from its Medicare Advantage plans.
  • After the 90 days, claims will be denied to the provider/practice responsibility, not to the member responsibility.  Providers cannot bill members for these denied claims.
  • If Provider and/or facility is removed from the Preclusion list, they will need to reapply for affiliation with Security Health Plan’s Medicare Advantage product. Provider and/or facility will remain affiliated for its other contracted SHP product lines and reapplication for those plans will not be necessary.

    In the event of termination, Security Health Plan will do all of the following:

    • notify the provider or contracting entity of termination, including effective date and, if applicable, reasons for termination, right to appeal decision, and obligations of the provider in the termination process
    • notify Medicare Advantage members and coordinate transfer of member care to other Security Health Plan providers
    • notify any state, federal or regulatory agency, if applicable

    Termination of providers will be consistent with Security Health Plan’s policies and procedures and any
    applicable state or federal laws.