| Better Medical Necessity Definition . Patients will be entitled to receive medically necessary care as determined by a physician exercising clinically prudent judgment in accordance with generally accepted standards of medical practice, and cheaper alternatives are permissible only when they are "at least as likely to produce equivalent therapeutic or diagnostic results." |
7.16
|
7.16
|
7.16
|
7.16
|
| Payment of Vaccines and Vaccine Administration. Recommended vaccines and injectibles and the administration of such vaccines and injectibles, will be reimbursed. |
7.14
|
7.14
|
7.14
|
7.14
|
| Reduced Downcoding . Evaluation and management CPT codes will not be automatically downcoded or reassigned. |
7.19
|
7.19
|
7.19
|
7.19
|
| Fewer Contract Changes . No material adverse change to a contract may be made on less than 90 days written notice. |
7.6
|
7.6
|
7.6
|
7.6
|
| Fairer Payment Rules . CPT coding edits will comply with most of the guidelines contained in the AMA CPT Manual. |
7.20
|
7.20
|
7.20
|
7.20
|
| Most Favored Nation Clauses Prohibited. Health Plan will not include any "most favored nation clause" in its contracts with physicians. |
_____
|
_____
|
_____
|
7.29
|
| Disclosure of Fee Schedules. Physician Fee Schedules will be available on the internet. |
7.3, 7.14
|
7.3, 7.14
|
7.3, 714
|
7.3, 7.14
|
Consistency and Disclosure of Payment Rules. Payment rules will become consistent across all of Health Plan's products. Moreover, most reimbursement edits and claims adjudication logic will be disclosed.
|
7.8
|
7.2, 7.8
|
7.8
|
7.8
|
Capitation from Date of Enrollment. Capitation fees will be paid when the patient chooses a PCP or is assigned to a PCP, retroactive to date of enrollment.
|
7.28
|
7.28
|
7.28
|
7.28
|
Assignment of Benefits Accepted. Health plan will recognize an assignment of benefits.
|
7.15
|
7.15
|
_____
|
7.15
|
All Products Clauses Limited. Health Plan generally will not require physicians to participate in products they do not want to participate in.
|
7.13
|
7.13
|
7.13
|
7.13
|
Stop-loss Insurance May be Purchased Elsewhere. Health Plan will not restrict physicians from purchasing stop-loss coverage from other insurers.
|
7.29
|
7.29
|
7.29
|
7.29
|
Faster Credentialing. New physician group members will be generally credentialed within 90 days of application, which physician groups can submit prior to their employment, and little or no additional credentialing will be required when already credentialed physicians change employment or location.
|
7.13
|
7.13
|
7.13
|
7.13
|
Arbitration Fees Capped. For solo and small group physicians arbitration fees will be capped at $1000.
|
7.29
|
7.29
|
_____
|
7.29
|
Arbitration Reform. Health Plan's participation contracts will not require overreaching arbitration provisions as specified.
|
_____
|
_____
|
7.29
|
7.29
|
Prompt, external dispute resolution mechanism for physician disputes. A streamlined, external review system will be established enabling physicians to dispute Health Plan's decisions on billing or medical records requests (Billing Dispute External Review Board) and on medical necessity (Medical Necessity External Review Process).
|
7.10, 7.11
|
7.10, 7.11
7.12
|
7.10, 7.11
|
7.10, 7.11
|
Gag clauses prohibited. "Gag" clauses will be prohibited.
|
7.29
|
7.29
|
7.29
|
7.29
|
Non-participating physicians protected. Disparaging language will be removed from EOBs, and the Agreement will not change or alter the rights of non-participating physicians to balance bill patients or to avoid dealing with Health Plan. Moreover, Health Plans (except) are required to disclose information concerning its "UCR" calculations.
|
7.21, 7.29
|
7.14, 7.21, 7.29
|
7.14, 7.21, 7.29
|
7.14, 7.21, 7.29
|
Limitation on Rental Networks. Health Plan will disclose on each EOB or remittance advice the identity of any PPO discount it is claiming, and within 30 days of a physician's request, will provide the physician with a copy of the signed agreement between the physician and that PPO, or else Health Plan will not be entitled to that discount.
|
_____
|
_____
|
_____
|
7.29
|
No HIPAA Mandate. Non-participating physicians will not be forced to use electronic transactions or otherwise become HIPAA compliant, and Health Plan agrees to continue to accept paper claims.
|
7.17
|
7.17
|
7.17
|
7.17
|
Restrictive Endorsements Limited. When the check is a partial payment of allowable charges, physicians may cash a check with "Payment in Full" on it without waiving the right to pursue a remedy under the Settlement.
|
_____
|
7.29
|
7.29
|
7.29
|
Better Mental Health Coverage . Health Plan will generally apply the §7.16 definition of medical necessity described above to mental health care, including treatment for psychiatric illness and substance abuse, it will treat its participating psychiatrists like its other participating physicians with respect to its provider directories and referrals, and it will adhere to the "prudent lay person standard" for emergency services, including admission, or physical or chemical restraints.
|
_____
|
7.33
|
7.33
|
7.33
|
Better state and federal law supersedes the Agreement . Settlement agreed does not supersede better federal or state law, or future legislative reform efforts.
|
7.29
|
7.29
|
7.29
|
7.29
|