PAM Section 11: Network Participation Responsibilities

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Overview

Mount Carmel MediGold Health Plan contracts with a variety of physicians and other health care professionals to provide primary and specialty care, as well as ancillary services to members.

Mount Carmel MediGold Health Planpublishes and distributes a directory of network providers and is available online at [link]. If you have any questions regarding the current Provider/Pharmacy Directory, please contact the Provider Service Center at 1-800-991-9907 (TTY 771).

How to Become a Participating Provider with Mount Carmel MediGold Health Plan

To join Mount Carmel MediGold Health Plan, please visit the Join the Network page on our website or email MediGoldContracting@mchs.com.

Mount Carmel MediGold Health Plan's Code of Conduct

As part of Mount Carmel MediGold Health Plan's Integrity and Compliance Program, Mount Carmel MediGold Health Plan has a Code of Conduct that describes expected behaviors and actions. While not intended to address all possible legal, regulatory or ethical issues, our Code of Conduct addresses the more common issues and questions that someone might encounter. It provides resources to assist you if you have questions or need further assistance and it explains your duty to speak up and report, without fear of retaliation, any matters you believe may be a violation of our Code of Conduct. The Mount Carmel MediGold Health Plan Code of Conduct can be found on the Legal page of our website.

Credentialing Process

Providers applying for network participation have the following rights regarding the credentialing process:

To review the information submitted to support your credentialing application.
To correct erroneous information.
To be informed of the status of your credentialing application, upon request.

Physician Credentialing

All credentialing activities are administered through Mount Carmel MediGold Health Plan's credentials committee, which reports its activities to the Mount Carmel MediGold Health Plan Board of Directors. The credentials committee is comprised of network primary care providers (PCPs) and specialists, in addition to the physician chairperson. The committee has the responsibility to establish, adapt, and adopt, as necessary, Mount Carmel MediGold Health Plan Board of Directors-approved criteria for participation and termination of physician participation. The committee also directs credentialing and recredentialing policies and procedures, including participation, denial and termination of physician participation.

Credentialing is an ongoing process, where a provider must first complete initial credentialing and, at a minimum of every three years, undergo recredentialing. Therefore, initial credentials will be valid for a period of 36 months.

New physician and other professional provider applicants will be reviewed within 180 days of gathering and verifying all necessary information. Review of all terminations, denials and renewals of participation shall occur within thirty (30) days of gathering and verifying all necessary information. Mount Carmel MediGold Health Plan utilizes the Council for Affordable Quality Healthcare (CAQH) for all initial credentialing and recredentialing of physicians. Please ensure that your information is up to date and your attestation current before applying for participation.

Initial Credentialing

Initial credentialing is a process of evaluating and determining a provider’s qualifications for participation with Mount Carmel MediGold Health Plan. The process includes screening and verifying provider applicants’ credentials and investigating any areas of potential concern. An office site audit and medical record review may be performed within six (6) months after the initial credentialing process has been completed. The process of evaluating credentials is based on predetermined credentialing and recredentialing criteria that Mount Carmel MediGold Health Plan has established for review of provider applicants. The credentialing and recredentialing criteria are available upon request.

Recredentialing

Recredentialing is the re-evaluation, at a minimum of every three years, of network providers to ensure their credentials still meet approved standards for participation and that their Mount Carmel MediGold Health Plan utilization and quality performance is acceptable. The credentials committee and the quality management committee work together to monitor important aspects of quality related to access, satisfaction, medical record review activities and peer review activities.

Mount Carmel MediGold Health Plan accesses CAQH’s Universal Provider Datasource^® for credentialing and recredentialing purposes. As long as you meet the recredentialing criteria, you will be successfully recredentialed. In the event any of the recredentialing criteria has not been met, the credentials committee may impose adverse action, including termination of your participation with Mount Carmel MediGold Health Plan. Written notification, via certified mail, will be sent by the chief executive officer within thirty (30) days of any adverse action stating the reasons for termination, the consequences thereof and your appeal rights pursuant to the Mount Carmel MediGold Health Plan Formal Appeals Process Plan for providers (policy available upon request).

Facility Credentialing and Recredentialing

Credentialing and recredentialing of network facilities plays an important part in the Mount Carmel MediGold Health Plan QM Program. Credentialing, as a structural aspect of QM, is an ongoing process. All network facilities must meet Mount Carmel MediGold Health Plan state and federal quality standards prior to entering into a contractual agreement. Ongoing assessments are completed every three (3) years. Reassessment will be done more frequently if problems are identified.

Summary Suspension

Mount Carmel MediGold Health Plan, including its board of directors and credentials committee shall have the authority to summarily suspend a provider from participation with Mount Carmel MediGold Health Plan. A summary suspension may only be imposed when you, the provider, willfully disregard Mount Carmel MediGold Health Plan policies, whenever your conduct requires that immediate action be taken by the Plan to protect the life of a member, or to reduce the substantial likelihood of immediate injury or damage to the health or safety of any member.

The summary suspension shall become effective immediately upon imposition. Written notification will be sent via certified mail to your address of record with Mount Carmel MediGold Health Plan within thirty (30) days by the chief executive officer on behalf of the imposer of such suspension. The notification will detail the summary suspension decision and your appeal rights pursuant to the Mount Carmel MediGold Health Plan Formal Appeals Process Plan for providers.

Within ten (10) days after such summary suspension, a meeting of the credentials committee shall be convened to review and consider the action taken. The committee may recommend modification, continuation, or termination of the terms of the summary suspension and any further or additional corrective action. This shall not constitute a hearing. You are entitled to an appeal pursuant to the formal appeals process plan policy, unless the credentials committee recommends immediate termination of the suspension or cessation of all further corrective action. The terms of the summary suspension, as sustained or as modified, shall remain in effect pending a final decision by the Mount Carmel MediGold Health Plan Board of Directors.

Immediately upon the imposition of a summary suspension, the medical director shall have the authority to provide for alternative medical coverage of your members who are in a hospital at the time of such suspension. The wishes of the member(s) shall be considered in the selection of such an alternate provider. In the case of an immediate suspension of a PCP, non-hospitalized members of the suspended PCP will be assigned to alternate network PCPs.

Provide Official Notice

You must immediately notify us, in writing, at the address in your provider agreement or located on the contact page of this manual of the following events:

Material changes in, cancellation or termination of liability insurance.
Bankruptcy or insolvency.
Any indictment, arrest or conviction for a felony or any criminal charge related to your practice or profession.
Any suspension, exclusion, disbarment or sanction from a state or federally funded health care program.
Loss or suspension of federal Drug Enforcement Administration registration.
- Loss of Medicare participation status.
- Loss of a medical license, certificate or other legal credential authorizing the ability to practice or provide care.
- Loss, suspension or revocation of staff privileges in your specialty or medical staff membership with at least one Mount Carmel MediGold Health Plannetwork hospital (except chiropractors). In extenuating circumstances, Mount Carmel MediGold Health Plan may accept into the network physicians who do not have active hospital privileges. These physicians must indicate in writing the coverage arrangements with network physician(s) who will admit and follow Mount Carmel MediGold Health Plan patients on their behalf; or
- Loss of board certification or board eligibility in your medical specialty.

Mount Carmel MediGold Health Plan, including its board of directors and credentials committee shall have the authority to automatically and immediately suspend a provider’s participation with Mount Carmel MediGold Health Plan for any of the above instances.

The chief executive officer will notify you in writing, via certified mail, within thirty (30) days of the automatic suspension decision and of your appeal rights, pursuant to the Mount Carmel MediGold Health Plan Formal Appeals Process Plan for providers.

All such official notices must be in writing and sent by certified or registered mail or personally delivered to Mount Carmel MediGold Health Plan at:

Attn: President & Chief Executive Officer
Mount Carmel MediGold Health Plan
3100 Easton Square Place
Third Floor – Health Plan
Columbus, Ohio 43219

Transition of Member Care Following Termination of Your Participation

You must make a good faith effort to notify all affected members at least thirty (30) calendar days prior to your termination of participation. If your network participation terminates for any reason, you are required to participate in the transition of your patient with timely and effective care.

Performance Assessment

Principles for performance assessment are derived from Mount Carmel MediGold Health Plan's philosophies and business strategies for improving the quality of clinical care and to support providers in their practice of evidence-based and efficient health care delivery. In general, evaluation of provider practices is based upon the comparison of observed practice patterns with expected published patterns. Our goal is to improve healthcare quality and efficiency and reduce variation in outcomes by promoting the practice of evidence-based medicine. The performance assessments include benchmarking to national data and peers.

We require cooperation with our performance assessments and improvement activities (including, but not limited to, requests for telephone or face-to-face discussions and requests for additional information).

Provisions of Access to Your Facility

In support of Mount Carmel MediGold Health Plan's clinical and quality initiatives, including care coordination, and concurrent review activities, you will provide us access to your facilities, including the emergency room, our members and their medical records, as well as your hospital and medical staff for purposes of obtaining necessary clinical information regarding our member’s condition or treatment plan. In addition, you will participate in discharge planning activities.

Physician Incentive Plan Regulation Compliance

The purpose of the federal Physician Incentive Plan (PIP) regulation is to allow CMS to determine if contracted Medicare managed care plans are making payments to physicians as an inducement for limiting medically necessary covered services to members. To make this determination, Mount Carmel MediGold Health Plan is required to provide information to CMS on whether its contractual relationships place physicians at substantial financial risk for referral services. CMS has complicated regulations defining a PIP and for calculating substantial financial risk. These regulations require a physician group or individual physician who is placed at substantial financial risk to purchase stop loss insurance and conduct member satisfaction surveys.

Remediation Policy

It is the policy of Mount Carmel MediGold Health Plan to maintain an adequate provider network and enforce the terms and conditions of its provider agreements and operating documents. Mount Carmel MediGold Health Plan will implement progressive disciplinary steps with Mount Carmel MediGold Health Plan participating providers who do not comply with the contractual requirement to refer members to Mount Carmel MediGold Health Plan participating providers or fail to obtain prior authorization from Mount Carmel MediGold Health Plan for services listed on Mount Carmel MediGold Health Plan's Prior Authorization List. These disciplinary steps include focused review, monetary penalties and adverse participation decisions.

The following delineates the disciplinary steps taken upon each occurrence during the previous rolling twelve (12) month time period:

Step one: The Mount Carmel MediGold Health Plan participating provider will be mailed the “First Warning Letter” attached hereto and made a part hereof, along with a copy of this policy, the Mount Carmel MediGold Health Plan Prior Authorization List, instructions on how to access the provider directory and/or related provider communications.
Step two: The Mount Carmel MediGold Health Plan participating provider will be mailed the “Second Warning Letter,” attached hereto and made a part hereof, describing the potential for a reduction in reimbursement for a period of six (6) months upon another occurrence. A copy of the policy, the Mount Carmel MediGold Health Plan Prior Authorization List, instructions on how to access the provider directory and/ or related communications may accompany this letter.
Step three: The Mount Carmel MediGold Health Plan participating provider will be mailed the “Payment Reduction Letter” notifying them that (i) the non-participating provider or the unauthorized services has been paid by Mount Carmel MediGold Health Plan and (ii) that the Mount Carmel MediGold Health Plan participating provider will be reimbursed at the lesser of (i) eighty percent (80%) of the current Medicare fee schedule on the date of service, or (ii) actual billed charges, less applicable copayments, deductibles and coinsurance, for a period of six (6) months from the date of the payment reduction letter. A copy of the policy, the Mount Carmel MediGold Health Plan Prior Authorization List, instructions on how to access the provider/pharmacy directory and/or related communications may accompany this letter. The participating provider will be re-evaluated by Mount Carmel MediGold Health Plan during the six (6) months to determine if the provider has come into compliance. Reduced reimbursement may continue beyond the six (6) months at the discretion of Mount Carmel MediGold Health Plan. A memo will be placed in the QMACS system to explain the reduction.
Step four: The Mount Carmel MediGold Health Plan participating provider will be mailed the “Final Warning Letter” indicating that the Mount Carmel MediGold Health Plan participating provider’s noncompliance with the Mount Carmel MediGold Health Plan provider agreement and operating documents will be brought to a Mount Carmel MediGold Health Plan Committee and/or the Mount Carmel MediGold Health Plan Board for an adverse participation decision or other corrective action as deemed appropriate.

Medicare Advantage Participation Provisions

If you are contracted to participate in the network for Mount Carmel MediGold Health Plan (referred to below as Plan), you are required to follow a number of Medicare laws, regulations and CMS guidelines and instructions. These program requirements are stated in your provider agreement with us and listed below.

You must provide covered health care services in a manner consistent with professionally recognized standards of health care.
You may not discriminate against Medicare beneficiaries in any way based upon health status.
You must cooperate with Plan in allowing Mount Carmel MediGold Health Plan members to directly access screening mammography and influenza vaccination services.
You must cooperate with Plan in not imposing cost-sharing on Mount Carmel MediGold Health Plan members for influenza vaccine or pneumococcal vaccine.
You must cooperate with Plan in providing female Mount Carmel MediGold Health Plan members with direct access to a woman’s health specialist for routine and preventive health care services.
You must assist us in providing our Mount Carmel MediGold Health Plan members with timely and adequate access to covered health services. You must ensure that your hours of operation are convenient, you do not discriminate against members and that medically necessary services are available to Mount Carmel MediGold Health Plan members 24 hours a day, 7 days a week. Arrangements for coverage after hours and while off duty (weekends, sick times, vacations, etc.) must be made with other network providers. A current listing of network providers is available on our website at [link] or by calling provider services.
You must provide information regarding treatment options, including the option of no treatment, to Mount Carmel MediGold Health Plan members in a culturally competent manner, taking into account limited English proficiency or reading skills, hearing or vision impairment and diverse cultural and ethnic backgrounds. Members with disabilities must have effective means of communication to make informed decisions about treatment options.
You must abide by our procedures to ensure effective and continuous patient care and quality review including our procedures to ensure the performance of an initial health assessment within 90 days of a member’s effective date of enrollment.
You will cooperate with Plan’s efforts to maintain procedures to identify Mount Carmel MediGold Health Plan members with complex or serious medical conditions, assess those conditions using medical procedures to diagnose and monitor the conditions on an ongoing basis and establish, implement and periodically update treatment plans for those members. You will maintain procedures to inform Mount Carmel MediGold Health Plan members of follow up care or provide training in self-care as necessary.
You must document in a Mount Carmel MediGold Health Plan member’s medical record whether they have executed an advance directive.
You must comply with Plan’s medical policies, quality improvement programs and medical management procedures. Plan will consult with providers when developing, reviewing and communicating them to providers in accordance with federal and state laws and regulations.
You will continue to provide covered services to members in the event of Plan’s insolvency, discontinuance of operations or termination of its contract with CMS, for the duration of the contract period for which CMS payments have been made to Plan and, for Mount Carmel MediGold Health Plan members who are hospitalized, until such time as the member is appropriately discharged from the hospital.
With respect to covered services which are not provided in a health care facility, notwithstanding anything herein to the contrary, you shall continue to provide covered services until the earlier of: (a) thirty (30) days following the entry of a liquidation order under applicable state law; (b) the end of the member’s period of coverage for a contractual prepayment or Plan premium; (c) the date the Mount Carmel MediGold Health Plan member obtains equivalent coverage from an alternative payor; (d) the date the Mount Carmel MediGold Health Planmember or the member’s employer terminates coverage under its agreement with Mount Carmel MediGold Health Plan; or (e) the date Mount Carmel MediGold Health Plan's obligations under the Participating Provider agreement are transferred by a liquidator pursuant to applicable state law.
You will maintain Mount Carmel MediGold Health Plan members’ medical and other records in an accurate and timely manner and in accordance with accepted industry professional standards and applicable federal and state laws and regulations. Members shall be given timely access to their medical records and information that pertains to them. Any charges to Mount Carmel MediGold Health Plan members for copies of the records shall not exceed the reasonable and customary charges in the professional community, or the maximum amount allowed by applicable law.
You must safeguard the privacy and confidentiality of all information that identifies a particular Mount Carmel MediGold Health Plan member and abide by all applicable federal and state laws and regulations regarding privacy, confidentiality and disclosure of mental health records, medical records, other health information and enrollment and member information.
Information from, or copies of, medical, enrollment and other records may be released only to authorized individuals in accordance with applicable federal and state laws and regulations. When required by law, you must secure a signed release from a member prior to disclosure of the member’s medical records and health information. You also will take reasonable precautions to ensure that unauthorized individuals cannot gain access to or alter member records.
You must cooperate with Plan procedures for handling grievances, determination appeals and expedited determinations and expedited appeals. This includes complying with all final determinations made by Plan, CMS, CMS’ contracted independent agency or the local quality improvement organization (QIO) pursuant to grievance and appeals procedures. Members are entitled to appeal denial and discharge decisions to an independent entity contracted by CMS or to the QIO. Upon request by Plan, you will promptly deliver to a member any required denial letter and cooperate in the delivery of a notice of Medicare non-coverage (NOMNC) or other materials from Plan containing members’ appeal rights and with the parties responsible for performing the review and reconsideration. In addition, you must notify Plan promptly of any decision not to furnish to a member a health care service requested by a member or to terminate or discontinue a health care service being provided to a member which termination or discontinuation is contrary to the member’s wishes and of any member grievances and appeals known to you. Plan and the QIO will review members’ grievances concerning quality of care. Upon request of Plan, you will investigate and respond promptly to all quality issues related to care provided to members and cooperate with the QIO and Plan to resolve such issues in the best interest of members.
You must provide requested records and documentation to the Plan or the QIO as requested no later than by close of business of the day that you are notified by Plan or the QIO if the member has requested a fast track or expedited appeal at no cost to the Plan.
You will cooperate with any QIO review and other QIO activities pertaining to the provision of services to members.
In the event that Plan suspends and/or terminates your participation, Plan will deliver to you written notice of the reason(s) for the suspension and/or termination including, if relevant, the standards and profiling data used to evaluate you and the number and mix of providers needed by Plan. If applicable, the notice will also include the right to appeal the action taken by Plan and the process and timing for requesting a hearing in accordance with Plan’s policies and procedures. You acknowledge that if Plan suspends and/ or terminates your participation because of deficiencies in the quality of care, Plan is required by federal regulations to provide written notice of such action to licensing or disciplinary bodies or to other appropriate authorities.
You must cooperate with Plan’s processes for notifying Mount Carmel MediGold Health Plan members of provider agreement terminations.
You may not distribute marketing materials or forms to Medicare beneficiaries without CMS approval of those materials or forms. If approved by CMS, you must display the approval number at the bottom of the form.
You must follow CMS marketing guidelines found in the Medicare Managed Care Manual if you are marketing this Plan to your Medicare eligible patients.
In no event, including, but not limited to, non-payment by the Plan, Plan’s insolvency or breach of your provider agreement, can you bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Mount Carmel MediGold Health Plan member, or person other than Plan acting on a Mount Carmel MediGold Health Plan member’s behalf, for services provided pursuant to your provider agreement. You are not prohibited from collecting supplemental charges or copayments on Plan’s behalf made in accordance with the terms of any agreement between Plan and its members. Further, this does not prohibit the collection of charges for services rendered by you but not covered under the subscriber or member agreement and benefits schedule. You further agree that (1) this provision shall survive the termination of your contract, regardless of the cause giving rise to the termination and shall be construed to be for the benefit of Plan’s members and (2) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between you and the member or persons acting on the member’s behalf.
You may not hold any Mount Carmel MediGold Health Plan member liable for payment of any fees that are the legal obligation of the Plan.
You must contact Mount Carmel MediGold Health Plan Utilization Management before providing a service if you feel that such a service will not be covered by the Plan and wish to bill the member for that service. If the service is not covered by Plan, utilization management will issue an integrated denial notice (IDN). The member must receive this IDN with sufficient advance notice to make an informed decision on whether to receive the non-covered and/or not medically necessary service. If you perform a non-covered service on a member without requesting an IDN sufficiently in advance for the member to make such a decision, then the service will be denied, and you may not hold the member liable for the non-covered and/or “not medically necessary” service. For more details, see the Provider Policies and Protocols section in this manual for more details.
You will be paid by the Plan in a prompt manner according to the terms of your provider agreement with Plan and applicable federal and state laws and regulations. You must cooperate with Plan in ensuring that any payment and incentive arrangements with subcontractors are specified in a written contract, that such arrangements do not encourage reductions in medically necessary services and that any physician incentive plans comply with CMS standards.
You understand that you are subject to laws and regulations applicable to persons or entities receiving federal funds and must notify all subcontractors that they are also subject to these laws and regulations.
You will comply with all applicable federal laws and regulations including Medicare, Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, the Rehabilitation Act of 1973, the False Claims Act, the Anti-Kickback statute, and all other laws applicable to recipients of federal funds.
You will inform Plan immediately upon your exclusion from participation in the Medicare program. According to section 42 CFR 422.204(b)(4), an MA organization must follow a documented process with respect to providers and suppliers who have signed contracts or provider agreements that ensures compliance with the requirements at § 422.752(a)(8) that prohibit employment or contracts with individuals (or with an entity that employs or contracts with such an individual) excluded from participation under Medicare and with the requirements at § 422.220 regarding physicians and practitioners who opt out of Medicare.
You understand and acknowledge that Plan is ultimately accountable to CMS for any functions and responsibilities described in the Medicare Advantage regulations. You will cooperate with Plan in prohibiting the use of Medicare excluded practitioners. If you are delegated an administrative function by the Plan, you must adhere to all delegation requirements set forth in the Medicare Advantage regulations and your provider agreement. All delegated activities are routinely monitored by Plan. You may not delegate any function under your provider agreement with the Plan to a Medicare excluded practitioner.
You must cooperate with Plan processes to disclose to CMS all information necessary for CMS to administer and evaluate the MA program, and all information necessary for CMS to permit beneficiaries and prospective beneficiaries to exercise an informed choice in obtaining Medicare services.
You will cooperate with us in fulfilling our responsibility to disclose to CMS quality, performance, enrollee satisfaction, health outcomes and disenrollment rates for beneficiaries enrolled in Mount Carmel MediGold Health Plan for the previous two years, and other indicators as specified by CMS.
Subject to applicable patient confidentiality laws and regulations, you must submit to Plan, upon our request, or the request of our designees, within fifteen (15) calendar days of the request, medical records necessary to characterize the content/purpose of each encounter with a member. In the event that you are paid under a capitated arrangement, you must submit to Plan or our designee, within fifteen (15) calendar days of the request, all encounter data including medical records necessary to characterize the content/purpose of each encounter with a member in such frequency, formats and type as reasonably requested by Plan for compliance with reporting requirements of federal and state government agencies and Plan’s utilization programs. Upon request by Plan or CMS, you are required to certify to CMS the accuracy, completeness and truthfulness of the encounter data submitted to Plan or our designee.
You acknowledge and agree that, as a contractor of Plan, you give Plan, the U.S. Department of Health and Human Services, the comptroller general, the general accounting office, other federal agencies and state and local regulatory agencies and their designees the right to inspect, evaluate and audit any pertinent contracts, books, documents, papers and records involving any aspect of services performed for members for a period of ten (10) years from the final date of the contract between CMS and Plan or the date of completion of an audit, whichever is later. The right to audit your records may be extended if CMS determines there is a special need to retain a particular record or group of records for a longer period and notifies you at least thirty (30) days prior to the normal disposition date or if there is a reasonable possibility of fraud. Your obligations herein survive the termination or expiration of your provider agreement.
Your books, provider agreement, documents, papers, medical records, patient care documentation, and any other records that pertain to any aspect of services performed for members must be maintained for ten (10) years or the date of completion of any federal or state government audit, whichever is later. You must retain such records beyond such period upon direction from CMS or other government agency.

Last updated: 03/2024