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Provider Manual

Provider Contracting

Last Updated on January 24, 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

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.