Dental Plan with Health Insurance Marketplace (HIM) 7.2

DPHIM-NM 13 - Participating Provider Violation Mechanism

Submited by: Tom Goddard

The Basics

The standard requires that your organization implement a means of addressing alleged violations by participating providers in its network of the organization's requirements for providers. The standard applies only to providers already in your network, not merely applicants for participation in the network. 

Management Tips

Standard is the first in a series of standards addressing provider dispute resolution. The standards apply only to participating providers. Furthermore, the standards do not require of the organization to provide dispute resolution mechanisms if the contract with the provider is clear and states that in the event of the revocation of medical licensure is not subject to the dispute resolution process.
It is also important to note that this standard and the ones that follow do not apply to appeals of denials of requests for certification legalization management process. Those disputes are handled in the health utilization management accreditation standards.

Accreditation Tips

Desktop Review
Submit your policies and procedures for provider dispute resolution.
Validation Review
The reviewer will conduct interviews of the medical directors overseeing provider dispute resolution, as well as other members of network management in order to assess whether they understand the dispute resolution processes of your organization.
Document Reviews
You will need to provide your reviewer with a list of provider disputes within the scope of this standard and the ones that follow. Be sure that such a list allows the reviewer to distinguish between disputes arising out of purely administrative matters from disputes involving quality of care, professional conduct, or participation in the provider network. From that list, the reviewer will select files of both types in order to see if you're implementing policies and procedures that comply with URAC's requirements.

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