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304.17A-525 Standards for provider participation -- Mechanisms for
consideration of provider applications -- Policy for removal or withdrawal.
(1)
(2)
(3)
(4)
Insurers shall establish relevant, objective standards for initial consideration of
providers and for providers to continue as a participating provider in the plan.
Standards shall be reasonably related to services provided. Selection or
participation standards based on the economics or capacity of a provider's
practice shall be adjusted to account for case mix, severity of illness, patient
age and other features that may account for higher-than- or
lower-than-expected costs. All data profiling or other data analysis pertaining to
participating providers shall be done in a manner which is valid and
reasonable. Plans shall not use criteria that would allow an insurer to avoid
high-risk populations by excluding providers because they are located in
geographic areas that contain populations or providers presenting a risk of
higher-than-average claims, losses, or health services utilization or that would
exclude providers because they treat or specialize in treating populations
presenting a risk of higher-than-average claims, losses, or health services
utilization.
Each insurer shall establish mechanisms for soliciting and acting upon
applications for provider participation in the plan in a fair and systematic
manner. These mechanisms shall, at a minimum, include:
(a) Allowing all providers who desire to apply for participation in the plan an
opportunity to apply at any time during the year or, where an insurer does
not conduct open continuous provider enrollment, conducting a provider
enrollment period at least annually with the date publicized to providers
located in the geographic service area of the plan at least thirty (30) days
in advance of the enrollment periods; and
(b) Making criteria for provider participation in the plan available to all
applicants.
If a managed care plan terminates the participation of an enrollee's primary
care provider, the plan shall provide notice to the enrollee and arrange for the
enrollee's continuity of care with an approved primary care provider.
An insurer that offers a managed care plan shall establish a policy governing
the removal of and withdrawal by health care providers from the provider
network that includes the following:
(a) The insurer shall inform a participating health care provider of the
insurer's removal and withdrawal policy at the time the insurer contracts
with the health care provider to participate in the provider network, and
when changed thereafter;
(b) If a participating health care provider's participation will be terminated or
withdrawn prior to the date of the termination of the contract as a result of
a professional review action, the insurer and participating health care
provider shall comply with the standards in 42 U.S.C. sec. 11112; and
(c) If the insurer finds that a health care provider represents an imminent
danger to an individual patient or to the public health, safety, or welfare,
the medical director shall promptly notify the appropriate professional
state licensing board.
Effective:April 10, 1998
History: Created 1998 Ky. Acts ch. 496, sec. 30, effective April 10, 1998.
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