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Provider Responsibilities
The Provider Shall:
- Provide 24 hour a day, 7 day a week call
coverage for members.
- Agree to comply with the appointment access
standards, as defined by the plan.
- Provide appropriate, medically necessary
services to the members, and work collaboratively with all members of
the health care team in treating the member.
- Use best efforts in the referral of all members
to an in-network provider. Should an out-of-network referral be made,
the member shall be informed of such and made aware of any in-network
providers that are available.
- Agree to obtain all necessary precertification
on the member’s behalf.
- Understand the benefit design of the plan, and
seek the members written authorization for non-covered/ excluded
services prior to treatment. Should the provider provide such services
without the members written acknowledgement and authorization to pay,
the member will not be responsible and held harmless.
- Agree to bill all services to the claims
administrator on the appropriate form, and collect only the
copay/coinsurance/deductible as necessary at the time of service.
- Agree NOT
to balance bill the members for any services unless identified on the
remittance advice for the carrier as member liability.
- Participate in and cooperate with all the
Utilization Management and Quality Management Program requirements.
- Cooperate and comply with all the credentialing
requirements of the network. Failure to do so will result in the removal
from the plan.
- Agree to comply with all policies and
procedures of the network and the claims administrator as defined in the
provider manual and the members benefit materials.
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