Dental Plan with Health Insurance Marketplace (HIM) 7.2

DPHIM-NM 12 - Provider Network Disclosures

Submited by: Tom Goddard

The Basics

The standard is intended to address the situation of "silent PPOs".  
URAC provides the following definition and explanation of silent PPOs:
[A] PPO brokers access to its provider network to other PPOs or payers without providers’ knowledge. For example, PPO X may sell access to its provider network to PPO Y. When an eligible person from PPO Y receives service from a physician in PPO X’s network, PPO Y takes the contract discount, although the physician never signed a contract with PPO Y.
First, if your organization does not operate a silent PPO, this standard is "not applicable."  In such a case, submit the official URAC attestation to that affect, which you can find in the Documents tab for this standard.
Second, it is important to know that this standard does not prohibit silent PPOs. It simpler requires that you have a process for disclosing to inquiring providers how that silent PPO affects the provider. That information can be delivered in response to one of two types of questions from the provider:

  • First, the provider might be interested to know how a particular claim was paid under your silent PPO or arrangement.
  • Second, the provider may want a more generalized understanding of your silent PPO arrangement by requesting a list of clients or other pairs that are entitled to any contract rate under the contract between you and the provider.
If your organization does operate a silent PPO, you will need to find the policy and procedure that describes your mechanism for responding to these two types of inquiries.

Management Tips

If you do have a silent PPO in your organization, you will need to have an explicit policy and procedure that describes how your staff members should respond to the two types of provider inquiries described in this standard. The policy and procedure should be explicit about what types of information you will provide and who will provide it. We recommend that you develop a standardized written response to providers who ask for your client/payer list. In addition, your staff member should be trained in how to answer the question of how a particular claim was paid under the contract.

Accreditation Tips

Desktop Review
In the event of this is a non-applicable standard does you do not operate a silent PPO, you will simply submit an attestation to URAC explaining that you not operate as a silent PPO. If you do operate a silent PPO, submit the policy and procedure that describes your response mechanism, along with any standardized template written responses or scripts you prepare for the implementation of that policy and procedure.
Validation Review
Document Review
During the on-site review, the reviewer will want to look at a list of payers entitled to any contract rate under your contract with participating providers.
In addition, he/she will interview managers in charge of response to provider inquiries described by this standard..

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