Contract Questions
What questions should I ask the MCO?
|
Contractual limits
• What is your fee schedule? Is it negotiable?
• What are the claims filing limits?
• What is the payment time frame?
• What are your appeals time frames?
Prior Authorization/Referral issues
• What services need plan (program) prior authorization (pre cert)?
• How do I obtain a program authorization?
• Are there any plan guidelines I need to follow before referring a patient to another
provider?
• When can I refer out of network?
• Am I penalized for referring out of network?
• Are there any benefits to my practice regarding referral requirements if we contract?
• What if I already have a PA from Health care Excel or another MCO, will it be honored?
• What is required for proof of the previous PA?
• What if I change my mind and want to terminate the contract? (term clause)
General plan questions :
• Should the RID number or your plan ID# be used when filing claims?
• Where do I send claims I'm submitting?
• Do you accept electronic claims?
• What happens if the primary payer doesn't respond in time?
• Does my hospital need to be contracted with the same MCO? And a specialist to whom I refer?
• What happens if the hospital or specialist is signed up with a different MCO?
• What is your provider-to-patient ratio?
• Is there a maximum panel size that can be assigned to me? If so what is it? What is the
minimum?
• What about panel transfers if I am already a PCCM PMP prior to signing with an MCO?
• How do I verify eligibility? Will I still need to check eligibility using EDS's verification
methods?
• Will I be given a Providers Manual?
• How can I access your PDL?
• What if a patient's medication is not on the PDL?
• What is your Web site address and what information can be found on the site?
• What are the contact numbers and the hours for calling in? |
