2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Legalcomply with all state and federal laws regarding theprivacy, security, confidentiality and disclosure ofMA Plan Enrollees’ health information. The providerwill ensure maintenance of such information in anaccurate and timely manner and ensure thatenrollees may timely access such information uponrequest. (Source: 42 CFR § 422.118.)Cooperation with Presbyterian’s ProgramsProvider shall use their best efforts to cooperatewith and participate in, and to require allSubcontractors to cooperate with and participate in,Presbyterian’s quality improvement programs,member grievance systems, medication therapymanagement, and utilization managementprograms to the extent applicable to the Servicesprovided by Provider, including, but not limited to,credentialing, recredentialing, quality assurance,prospective, concurrent, and retrospective utilizationreview and management, medical recordsmaintenance, claims payment review andmanagement peer review, and provider andmember grievance procedures. Provider shall bebound by the appeal procedures of Presbyterian’sutilization review and quality assurance program.(Source: 42 CFR §§ 422.152, 422.202(c).)Communication with MA Plan EnrolleesPresbyterian encourages the provider, and providershall encourage subcontractors, to freelycommunicate with plan enrollees regardingappropriate treatment alternatives, regardless ofbenefit limitations, in a culturally competent mannerand in compliance with requirements of 42 USC §12101, as amended (otherwise known as the“American with Disabilities Act of 1990”).Presbyterian shall not penalize its employees,contractors, or subcontractors for discussingmedically necessary or appropriate care withenrollees. (Source: 42 CFR § 422.206(a)(1) & (2).)IndemnityProvider shall indemnify, defend and holdPresbyterian responsible for any loss, damage, orcosts (including reasonable attorneys’ fees)incurred in connection with claims arising out of orresulting from provider’s or a subcontractor’s failureto comply with all applicable Medicare Advantagerequirements.MA Plan Enrollee Hold HarmlessProvider hereby agrees, and will require allsubcontractors to agree, to seek payment forcovered prescription drug services only fromPresbyterian. In no event, including, but not limitedto, termination of the Agreement(s) or thisAmendment, non-payment by Presbyterian,Presbyterian’s insolvency or breach of theAgreement(s) or this Amendment, shall a provideror a subcontractor bill, charge, collect a depositfrom; seek compensation, remuneration, orreimbursement from; or have any recourse againstenrollees, their families, or people acting on theirbehalf for covered prescription drug services. Theforegoing sentence shall not prohibit collection byprovider or a Subcontractor of applicable copayments,co-insurance, and cost-sharing chargesfor non-covered services. (Source: 42 CFR §422.504(g)(1)(i) & (i)(3).)14-102014 Practitioner and Provider Manual - Ver. 3