The Basics

While the previous standard described what must not be in your provider agreements, this standard prescribes what must be in your provider agreements.  It is a rather straightforward checklist:

• the names of the parties to the agreement
• minimum requirements for participating providers
• the contractual obligations of both of the parties to the contract
• events that may lead your organization to modify or terminate the provider's participation in the network
• terms regulating your organization's access to consumer medical records in the possession of the participating provider
• the healthcare services that the participating provider will provide under this agreement
• claims submission requirements and prohibitions (e.g. billing of consumers)
• provider payment methodology and fees
• a description of the provider dispute resolution mechanism
• contract term and termination procedures
• terms describing requirements regarding confidentiality of patient health information
• an antidiscrimination clause

Management Tips

Your provider contracting policy and procedure should explicitly require the elements of the standard for all new contracts.  In addition, you should conduct an audit of your present universe of contracts to get a sense of the extent of your organization's compliance with the standard.  Finally, for reasons we will explain in greater detail in a subsequent page, you should replicate nearly all of these requirements in your provider manual, whether or not that provider manual is incorporated by reference into your provider contracts.

URAC Accreditation Tips

About half of these elements are mandatory.  The rest are weighted between 2 and 4.

See N-NM 7 for a description of the desktop and on-site review requirements.