Member Rights & Responsibilities

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Provider Bill of Rights

1.1 Provider is assured of the following rights:
   a. A healthcare professional, acting within the lawful scope of practice, shall not be prohibited from advising or advocating on behalf of a Member, for the following:
        i. The Member’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered
       ii. Any information the Member needs in order to decide among all relevant treatment options
      iii. The risks, benefits, and consequences of treatment or non-treatment
      iv. The Member’s right to participate in decisions regarding his or her healthcare, including the right to refuse treatment, and to express preferences about          future treatment decisions

  b. To receive information on the grievance, appeal and fair hearing procedures;

  c. To have access to the Health Plan’s policies and procedures covering the authorization of services;

  d. To be notified of any decision by the Health Plan to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested;

  e. To challenge, on behalf of the Members, the denial of coverage of, or payment for, medical assistance;

  f. Health Plan’s participating provider selection policies and procedures must not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment; and

  g. To be free from discrimination for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state Law, solely on the basis of that license or certification.

1.2 Availability of Services. Providers will offer hours of operation that are no less than the hours of operation offered to commercial enrollees or, if the Provider serves only Medicaid managed care members, comparable to Medicaid Fee for Service enrollees. Provider will ensure all Covered Services included in the Agreement are made available twenty-four (24) hours a day, seven (7) days a week, when Medically Necessary.

1.3 Exclusions.

   a. Provider must be enrolled with the SCDHHS as a qualified Medicaid provider.

   b. Provider will possess a current license to practice or operate in the state in which the Covered Service is delivered. If Provider is not appropriately licensed at any time during the term of the Agreement, Health Plan will remove the Provider from its Participating Provider list and Provider will discontinue providing services to Members. Health Plan may withhold payment for any period that Provider is not licensed to practice or operate.

   c. Health Plan will not make any payments or pay any Claim, nor does Health Plan have any obligation to make any payment or pay any Claim, to a Provider for items or services provided to any financial institution or entity located outside of the United States (U.S.) in accordance with Section 6505 of the Affordable Care Act amends section 1902(a) of the Social Security Act. Health Plan will not pay for claims for services, including, but not limited to telemedicine and pharmacy, submitted by Providers.

   d. Health Plan will not make any payments or pay any Claim, nor does Health Plan have any obligation to make any payment or pay any Claim, to a Provider excluded, terminated, suspended, or disbarred from the Medicare program, Medicaid program, or any other state or federally funded health care programs. This includes, but is not limited to, Providers excluded for fraud, abuse, or waste.

1.4  Records. Provider will maintain individual medical records for each Member. Such records shall be readily available to the SCDHHS and/or its designee and contain all information necessary for the medical management of each Member. Procedures shall also exist to facilitate the prompt transfer of patient care records to other Participating Providers or non-Participating Providers.

1.5 Compliance with Laws. Provider will comply with all applicable statutory and regulatory requirements of the Medicaid program and be eligible to participate in the Medicaid program during the term of this Agreement.

1.6 Delegation. The following provisions apply to subcontractors:

   a. Health Plan maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of Health Plan’s contract with SCDHHS (“State Contract”). However, Provider will adhere to all applicable requirements set forth in the State Contract to the extent that Provider is utilized to carry out the terms of the State Contract.

   b. Health Plan’s rights and obligations will not be amended or altered if Provider subcontracts any delegated activity to another, and all subcontractors and sub-subcontractors remain subject to the terms of the State Contract.

1.7 Right to Audit. The following provisions apply to subcontractors:

   a. Provider agrees the State, CMS, the United States Department of Health and Human Service (“HHS”) Office of Inspector General, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any books, records, contracts, computer or other electronic systems of the subcontractor, or of the subcontractor's contractor, that pertain to any aspect of services and activities performed, or determination of amounts payable under Health Plan’s contract with the State.

   b. Provider will make available, for purposes of an audit, evaluation, or inspection, its premises, physical facilities, equipment, books, records, contracts, computer or other electronic systems relating to its Medicaid enrollees.

   c. The right to audit will exist through ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later. If the State, CMS, or the HHS Inspector General determines that there is a reasonable possibility of fraud or similar risk, the State, CMS, or the HHS Inspector General may inspect, evaluate, and audit the subcontractor at any time.