Library: Policy

317:55-3-12. Provider contracting and network requirements

Revised 7-1-23

(a) Provider contracts. A CE or DBM must provide or arrange for the delivery of covered health care services described in OAC 317:55-3-5 through a provider agreement with SoonerCare-contracted providers. All provider agreements must be in writing and in accordance with the Contract and 42 C.F.R. §§ 434.6 and 438.6. The CE's or DBM's execution of a provider agreement does not terminate the CE's or DBM's legal responsibility to the OHCA to ensure all the CE's and DBM's activities and obligations are performed in accordance with Okla. Admin. Code § 317, as applicable, the CE's or DBM's Contract with the OHCA, and all applicable federal, state, and local regulations. The CE or DBM shall maintain, and have available, written policies and procedures on:

(1) Participating provider selection;

(2) Retention and termination of a provider's participation with the CE or DBM;

(3) Responding to changes in the CE'S or DBM'S network of participating providers that affect access and ability to deliver services in a timely manner; and

(4) Access standards.

(b) Provider network.

(1) The CE and DBM must maintain, in accordance with 42 C.F.R. § 438.206(b)(1), a network of appropriate participating providers that is supported by a signed provider agreement and is sufficient to provide adequate access and availability to all services covered under the Contract with the OHCA, including those with limited English proficiency or physical or mental disabilities.

(2) The CE and DBM must ensure that all requirements found at 42 C.F.R. § 438.3(q)(1) and (q)(3) are met.

(3) The CE and DBM must meet and require its participating providers to meet state standards for timely access to care and services, in accordance with 42 C.F.R. § 438.206(c) and all contractual requirements.

(4) The OHCA shall monitor and review the CE's and DBM's compliance with all standards as part of all ongoing oversight activities.

(1) All CE and DBM must utilize the same single Credential Verification Organization (CVO) that is certified by a CMS-approved accrediting organization and approved by OHCA as part of its provider credentialing and recredentialing process. The CE and DBM credentialing and re-credentialing processes shall comply with relevant state and federal regulations, including, but not limited to, 42 C.F.R. §§ 438.12, 438.206(b)(6), and 438.214, and all applicable contractual requirements.

(2) The CE and DBM must ensure that providers have been properly credentialed to ensure provider facilities, organizations, and staff meet all qualifications and requirements for participation in the Oklahoma Medicaid program. All applications must be credentialed and the CE's or DBM's claim systems must be able to recognize the provider as a SoonerSelect program network provider, within all applicable timeframes as outlined within the Contract with the OHCA.

(3) The recredentialing process must take into consideration provider performance data including Enrollee grievance and appeal, quality of care, and utilization management.

(4) The CE and DBM must review and approve the credentials of all applicable licensed and unlicensed participating and contracted providers who participate in the CE's or DBM's provider network at least once every three (3) years.

(5) If the CE or DBM fails to comply with the credentialing and recredentialing standards per OAC 317:55-5-12(c), the OHCA may impose any or all the CE intermediate sanctions, found at OAC 317:55-5-10 and the CE Contract, or DBM administrative remedies, found at OAC 317:55-5-11 and the DBM Contract.

(d) Non-discrimination against providers.

(1) The CE's and DBM's written policies and procedures shall not discriminate against providers that serve high-risk populations or specialize in conditions that require costly treatment, per 42 C.F.R. §§ 438.12(a)(2) and 438.214(a).

(2) In accordance with 56 O.S. § 4002.4(B), shall not exclude essential community providers, providers who receive directed payments in accordance with 42 C.F.R. Part 438, and such other providers, as directed by OHCA from execution of provider agreements.