18 Del. Admin. Code § 1403-9.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1403-9.0 - Provider Relations

9.1 An MCO shall establish a mechanism by which participating providers will be notified on an ongoing basis of the specific covered health services for which the provider will be responsible, including any limitations or conditions on services.

9.2 An MCO shall establish procedures for resolution of administrative, payment or other disputes between providers and the MCO.

9.3 The MCO shall establish a policy governing termination of providers. The policy shall include at least:

9.3.1 Written notification to each enrollee six weeks prior to the termination or withdrawal from the MCO's provider network of an enrollee's primary care physician except in cases where termination was due to unsafe health care practices; and

9.3.2 Except in cases where termination was due to unsafe health care practices that compromise the health or safety of enrollees, assurance of continued coverage of services at the contract price by a terminated provider for up to 120 calendar days after notification of termination in cases where it is medically necessary for the enrollee to continue treatment with the terminated provider. In cases of the pregnancy of an enrollee, medical necessity shall be deemed to have been demonstrated and coverage shall continue to completion of postpartum care.

18 Del. Admin. Code § 1403-9.0