Participating Provider Responsibilities
Below outlines important contract reminders for participating providers. Please note this is an overview and not intended to include all contractual provider obligations.
Access to Care & Services
Provider will offer 24/7 telephone access to patients for their safety and protection, and will have procedures in place to respond to patients’ calls and requests after normal business hours.
Access to Care at In-Network Providers for Alliance Enrollees
Participating Providers acknowledge that Alliance enrollees have the right to freedom of choice of providers, including, without limitation, primary care and specialty providers. Participating Providers acknowledge and agree that the provision of care for an enrollee will not be conditioned on the enrollee first receiving primary care or other healthcare services from the participating provider’s choice of providers. For example, if an enrollee is referred to a participating provider for specialty services, the provider will not condition such specialty services on the enrollee first receiving primary care from a primary care practitioner that is employed by, contracted with, affiliated with, or otherwise selected by the provider.
Provider will not balance bill the member beyond patient responsibility, such as co-payments, coinsurance, and deductibles.
Facilities (and other designated providers) will send The Alliance information regarding any modifications related to their charge master.
Claims Processing Errors
Provider will notify The Alliance in a timely manner of claim(s) processed or submitted incorrectly.
Provider will submit claims according to regulations and in a timely manner to The Alliance.
Provider will comply with the requirements of The Alliance’s Provider Credentialing Program, including the timely completion of a credentialing application if requested.
Provider will provide services to all individuals in a prompt manner, consistent with professional, clinical, and ethical standards and without bias.
Using the Provider Update Form, provider will notify The Alliance 30 business days prior to a change in the following:
- Ownership (mergers, acquisitions, sale)
- Tax identification numbers
- Specialty designation of a practitioner
- Practice locations
- New practitioners
- Other demographic information, including changes to individual providers