Pennsylvania Code & Bulletin

• No statutes or acts will be found at this website.

The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1806 (March 30, 2024).

28 Pa. Code § 9.725. IDS-provider contracts.

§ 9.725. IDS-provider contracts.

 In addition to the IDS contract, the health care provider contracts between the IDS and its participating health care providers shall be submitted by the plan for review and approval to the Department. For this purpose, the IDS shall provide the plan with a copy of these contracts. To secure Department approval of a contract between the plan and the IDS, an IDS-health care provider contract shall meet the following standards:

   (1)  The health care provider shall acknowledge and agree that nothing contained in the IDS-provider contract limits the following:

     (i)   The authority of the plan to ensure the health care provider’s participation in and compliance with the plan’s quality assurance, utilization management, enrollee complaint and grievance systems and procedures or limits.

     (ii)   The Department’s authority to monitor the effectiveness of the plan’s system and procedures or the extent to which the plan adequately monitors any function delegated to the IDS, or to require the plan to take prompt corrective action regarding quality of care or consumer grievances and complaints.

     (iii)   The plan’s authority to sanction or terminate a health care provider found to be providing inadequate or poor quality care or failing to comply with plan systems, standards or procedures as agreed to by the IDS.

   (2)  An IDS health care provider shall acknowledge and agree that any delegation by the plan to the IDS for performance of quality assurance, utilization management, credentialing, provider relations and other medical management systems shall be subject to the plan’s oversight and monitoring of IDS performance.

   (3)  An IDS health care provider shall acknowledge and agree that the plan, upon failure of the IDS to properly implement and administer the systems, or to take prompt corrective action after identifying quality, enrollee satisfaction or other problems, may terminate its contract with the IDS, and that as a result of the termination, the health care provider’s participation in the plan may also be terminated.

   (4)  The IDS provider contract shall contain enrollee financial hold-harmless provisions acceptable to the Department which prevent the IDS and an IDS participating health care provider from billing plan enrollees for covered services (other than authorized co-payments, co-insurance, or deductibles) under any circumstances including insolvency of the plan or the IDS.

No part of the information on this site may be reproduced for profit or sold for profit.

This material has been drawn directly from the official Pennsylvania Code full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.