Provider Requirements for Medicare, Medicaid and State Government Program Products

In addition to other requirements specified in Medica’s Administrative Requirements, the following requirements (“Requirements”) apply to Medica’s Medicare Advantage products; and, to the extent required by federal and/or state law or Medica’s contracts with the Centers for Medicare and Medicaid Services (“CMS”) and/or the Minnesota Department of Human Services (“DHS”), the Requirements apply to all Medica’s Medicare, Medicaid and state government program products.

1. Provision of Health Services and Quality of Care. Provider will provide Health Services in a manner consistent with professionally recognized standards of care and in accordance with the standard of practice in the community in which such Provider renders Health Services as required pursuant to state and federal law and Medica’s contracts with CMS and DHS, and in a manner so as to assure quality of care and treatment.

2. Access to Health Services. Provider will provide Health Services in a culturally competent manner to all Members, including Members with limited English proficiency or reading skills and diverse cultural and ethnic backgrounds. Provider will not discriminate against any person based on his or her race, color, creed, religion, national origin, gender, health status including mental and physical medical conditions, marital status, status with regard to public assistance, disability, sexual orientation, age, or any other classification protected by law.

3. Data Collection. Provider will submit to Medica all data, including medical records, necessary to characterize the context and purpose of each encounter with a Member in the manner and to the extent required by CMS and DHS. Provider will certify, in writing, the completeness and accuracy of all such data.

4. Member Complaints. Provider will cooperate with Medicare, Medicaid, and state government program products grievance, appeals and expedited appeals procedures.

5. No Relationship with Excluded Providers. Provider will not employ or contract with any individual or entity that is excluded from participation in the Medicare, Medicaid or state government program products, or entity that employs or contracts with an excluded individual or entity.

6. No Opting Out of Medicare; Participation in Medicare. Provider may not employ or contract with any Providers who have opted out of Medicare by filing with a Medicare carrier an affidavit promising to furnish Medicare covered services to Medicare beneficiaries only through private contracts with such beneficiaries. Provider will be certified for participation in Medicare, Medicaid, or state government program products, where such Providers are a provider type eligible to be certified for participation in Medicare, Medicaid, or state government program products.

7. Compliance Requirements. Provider will comply with:

(a) all federal laws and regulations designed to prevent or ameliorate fraud, waste or abuse, including but not limited to, applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. 3729 et. seq.) and the anti-kickback statute (section 1128B(b)) of the Act; and
(b) HIPAA administrative simplification rules at 45 CFR parts 160, 162, and 164 and the Health Care Administrative Simplification Act of 1994, Minnesota Statutes, section 62J.50 et. seq.

8. Access to and Release of Books and Records. Provider will prepare and maintain accurate and timely medical records and information for all Members who receive services from Provider. Provider agrees to document in a prominent place in the Member’s medical record whether or not the Member has executed an Advance Directive.

9. Exception to Protocols. Any protocol that requires a Medicare Advantage Member to obtain a referral from his/her Care System/Primary Care Physician, shall not apply to the following Health Services:

(a) mammography screening;
(b) influenza vaccine; and
(c) preventive and routine services provided by women’s health specialists.

10. Member Protection Provisions. Provider will not hold financially responsible, collect or attempt to collect additional reimbursement for Health Services from any Member, except for (i) Copayments or Coinsurance, (ii) Deductibles, (iii) any service rendered by Provider that is ineligible for coverage under the Member’s Benefit Contract; provided, however, that the Member has been informed, in writing, prior to performance of the service, that the non-covered service or treatment to be rendered will be the Member’s liability and therefore, not covered under the Benefit Contract. Provider must obtain written authorization from the Member, prior to performance of the service, indicating that the Member is fully aware that the services being provided may not or will not be covered by Medica under the Member’s Benefit Contract, and indicating that the Member agrees to be financially responsible for such non-covered service or treatment if rendered.

Members receiving services at hospitals or ambulatory surgical centers may not be held liable for any service provided for an authorized procedure (e.g. anesthesiologist/radiologist).

11. Prompt Payment for Health Services. Medica will pay Provider for Health Services in accordance with applicable state and federal law as it relates to the prompt payment of claims.

12. General Requirements. Provider will allow qualified Members to directly access any Indian Health Services facility operated by a tribe or tribunal organized under funding authorized by 25 U.S.C. Sections 450f through 450n or Title I of the Indian Self-Determination Act, Public Law Number 93-638, for services that would otherwise be covered by the Member’s Benefit Contract. No prior approval or prior authorization may be placed on such services.

13. General Request for Services. As applicable, Provider or Member may make a request for Health Services to the Member’s Medicare Advantage Care System (“System”) or Medica, as appropriate. System will evaluate such request, within a timeframe, at Medica’s discretion, that will allow completion of the initial review within ten (10) working days, or shorter time period as required by law. System will promptly communicate its decision to approve a request to Provider by telephone and in accordance with law, Medica’s contracts with CMS and DHS, and Medica’s Administrative Requirements (collectively referred to as “Utilization Review Requirements”). System will promptly submit requests that it does not approve to Medica for Medica’s review. Medica will notify Provider of an approval of its review of a request by telephone and in accordance with the Utilization Review Requirements. If Medica’s decision is to deny the request, Medica will notify Provider and Member, or his or her authorized representative, in accordance with the Utilization Review Requirements. Each party must notify the other party of any information it has regarding applicable law. The Member, or Provider on behalf of the Member, may appeal Medica’s decision in accordance with the Complaints and Appeals process described in the Benefit Contract and in Medica’s contract with CMS and the DHS Contract.

14. Access to Health Services. Provider will, in accordance with the standards set forth below, provide Health Services:
(a) Emergency Services. Emergency Services and Post-Stabilization Care Services will be available to Members twenty-four (24) hours per day and seven (7) days per week, including a twenty-four (24) hours per day number for Members to call in case of Medical Emergency or an Emergency Medical Condition.
(b) Urgent Services. Urgent Services will be made available to Members twenty-four (24) hours per day and seven (7) days per week. Appointment times for Urgent Services will be made available to Members within twenty-four (24) hours of the time services are requested.
(c) Routine and Preventive Services. Appointment times for routine and preventive services will not exceed forty-five (45) days from the date of a Member’s request for routine and preventive services.
(d) Specialty Care. Appointments for a specialist will be made in accordance with the time frame appropriate for the needs of the Member, or the generally accepted community standards.
(e) Lab and X-Ray Services. Appointment times for lab and x-ray services will not exceed sixty (60) days for regular appointments and forty-eight (48) hours for Urgent Services.

15. Accessibility for Disabled Members. Provider will comply with applicable provisions of the Americans with Disabilities Act of 1990, 42 U.S.C. §12101. et. seq., and regulations promulgated pursuant to it. Provider will also comply with 28 CFR 35.130(d), which requires that services, programs, and activities be provided in the most integrated setting appropriate to the needs of Members with disabilities. Provider also will take reasonable steps to ensure meaningful access by Limited English Proficient Persons (LEPs). The following four factors should be considered: (1) the number or proportion of LEP persons eligible to be served; (2) the frequency with which LEP individuals come in contact with the Provider; (3) the nature and importance of the program, activity, or service provided by the program to people's lives; and (4) the resources available to the Provider, and costs.

16. Member Rights. Provider will comply with any applicable state and federal laws that pertain to Member rights and, when providing services to a Member, ensure the Member’s right to:

(a) Receive information pursuant to 42 CFR 438.10;
(b) Be treated with respect and with due consideration for the Member's dignity and privacy;
(c) Receive information on available treatment options and alternatives, presented in a manner appropriate to the Member’s condition and ability to understand;
(d) Participate in decisions regarding his or her health care, including the right to refuse treatment;
(e) Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other Federal regulations on the use of restraints and seclusion;
(f) Request and receive a copy of his or her medical records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;
(g) Be furnished health care services in accordance with 42 CFR 438.206 through 438.210; and
(h) Be free to exercise his or her rights and that the exercise of these rights will not adversely affect the way the Member is treated.

For more information on Member Rights as they apply to Medica’s Medicare, Medicaid and state government program products click on the links below: