SHJ25-014 MOLINA HEALTHCARE RENEWAL - PARTIALLY EXECUTED

Home Browse Search

2.2 Standards for Provision of Care. a. Provision of Covered Services. Provider shall provide Covered Services to Members, within the scope of Provider's business and practice, in accordance with this Agreement, Health Plan's policies and procedures, the terms and conditions of the Health Plan Product which covers the Member, and the requirements of any applicable government sponsored program. b. Standard of Care. Provider shall provide Covered Services to Members at a level of care and competence that equals or exceeds the generally accepted and professionally recognized standard of practice at the time of treatment, all applicable rules and/or standards of professional conduct, and any controlling governmental licensing requirements. c. Facilities, Equipment, and Personnel. Provider's facilities, equipment, personnel and administrative services shall be at a level and quality as necessary to perform Provider's duties and responsibilities under this Agreement and to meet all applicable legal requirements, including the accessibility requirements of the Americans with Disabilities Act. d. Prior Authorization. If Provider determines that it is Medically Necessary to consult or obtain services from other health professionals that are Medically Necessary, Provider shall obtain the prior authorization of Health Plan in accordance with Health Plan's Provider Manual unless the situation is one involving the delivery of Emergency Services. Upon and following such referral, Provider shall coordinate the provision of such Covered Services to Members and ensure continuity of care. The approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization (WAC 182- 500-0085). e. Contracted Providers. Except in the case of Emergency Services or upon prior authorization of Health Plan, Provider shall use only those health professionals, hospitals, laboratories, skilled nursing and other facilities and providers which have contracted with Health Plan ("participating providers"). f. Member Eligibility Verification. Provider shall verify eligibility of Members prior to rendering services. g. Admissions. Provider shall cooperate with and comply with Health Plan's hospital admission and prior authorization procedures. h. Prescriptions. Except with respect to prescriptions and pharmaceuticals ordered for in -patient hospital services, Provider shall abide by Health Plan's drug formularies and prescription policies, including those regarding the prescription of generic or lowest cost alternative brand name pharmaceuticals. Provider shall obtain prior authorization from Health Plan if Provider believes a generic equivalent or formulary drug should not be dispensed. Provider acknowledges the authority of Health Plan contracting pharmacists to substitute generics for brand name pharmaceuticals unless counter indicated on the prescription by the Provider. i. Subcontract Arrangements. Any subcontract arrangement entered into by Provider for the delivery of Covered Services to Members shall be in writing, consistent with the provisions of 42 CFR 434.6, and shall bind Provider's subcontractors to the terms and conditions of this Agreement including, but not limited to, terms relating to licensure, insurance, and billing of Members for Covered Services. j. Availability of Services. Provider shall make necessary and appropriate arrangements to ensure the availability of Covered Services to Members on twenty-four (24) hours a day, seven (7) days a week basis, including arrangement to ensure coverage of Member patient visits after hours. Provider shall meet the applicable standards for timely access to care and services, taking into account the urgency of the need for the services. Provider will make necessary and appropriate arrangements to ensure the availability of non -emergent Covered Services during Provider's normal business hours, unless otherwise required by Laws or Government Program Requirements. k. Treatment Alternatives. Health Plan encourages open Provider -Member communication regarding appropriate treatment alternatives. Health Plan promotes open discussion between Provider and Members regarding Medically Necessary or appropriate patient care, regardless of Covered Services MFIWPROV22.3 MHWHA/Revised Jan 2024 Page 5 of25