Health Plan Provider Agreement Essentials Checklist

This checklist is designed for attorneys representing health plans who are asked to draft or review an agreement with healthcare providers who will be part of the plan’s provider network. It highlights key legal and business points for you to consider when preparing a provider agreement for use by a plan.

Assemble Your Project Team. Identify someone at the health plan to connect you with appropriate stakeholders who can answer provider network questions as they arise. While there are preferred drafting techniques for provider agreements, some points will require a judgment call based on the plan’s tolerance for risk or its approach to managing provider relationships. You should involve the plan’s decision-makers when drafting those provisions.

Schedule a Meeting. It is often helpful to schedule a kick-off call with the provider network team. Whether you are tasked with drafting a new agreement from scratch or with reviewing and revising an existing one, a discussion with the provider network team can help to clarify the plan’s approach to provider contracting and where you should focus your attention. You may hear about your client’s pain points (i.e., where they have encountered challenges with their network providers in the past) and you can address those issues in the next iteration of the provider agreement.

Obtain Underlying Documents. As you draft or review the provider agreement, you will need to reference some important plan documents:

• ✔Provider manual. Request a copy of the health plan’s provider manual (or manuals, if there are different manuals for different healthcare providers). The provider manual explains in detail the policies and procedures that govern the health plan-provider relationship. The relevant provisions of the provider manual will be either quoted directly or incorporated by reference throughout the provider agreement.
• ✔Policies and procedures. Request copies of the health plan’s policies and procedures relating to its provider network (for example, provider compensation, billing and payment, credentialing, and records retention policies and procedures). They will provide valuable information when drafting, reviewing, or negotiating the provider agreement.

Draft (or Review) the Provider Agreement. The below topic headings reflect essential provisions of a typical provider agreement. Within each topic are consideration points and discussion prompts for the plan’s provider network team. This is not an exhaustive list. Remember to research applicable federal and state laws, administrative agency rules, and guidance materials on these topics to determine if there are specific requirements that need to be addressed in the context of a health plan provider agreement.

• ✔Compensation, billing, and payment
  • Include compensation amounts
  • Require provider to accept the agreed-upon payment amounts from the health plan as payment in full for all services provided to plan members
  • Define clean claims with reference to applicable state insurance laws and regulations
  • Describe healthcare claims submission and provider billing processes
  • Set clear time frames within which a provider must file a clean claim with the insurer with reference to applicable state requirement
  • Prohibit balance-billing of members by providers for amounts beyond what the health plan pays to the providers for the services provided
  • Require providers to collect co-payment from members, where required under the plan design
  • Reference applicable prompt payment timelines as provided in state insurance laws and regulations
  • Clearly set out any recoupment rights that the health plan will have in the event of overpayments to providers
  • Include provisions to allow for suspension of payments as necessary
• ✔Network participation
  • List the specific networks in which the provider agrees to participate • Include language to facilitate the provider’s participation in additional networks, without requiring amendments to the agreement
• ✔Provider licensing and insurance
  • Require provider to maintain professional licenses
  • Specify the minimum professional liability insurance that the provider should maintain
  • Require provider to comply with all applicable federal and state laws
  • Require active medical staff membership on the medical staff of a hospital or other healthcare facility
  • Require a controlled substance license and DEA registration
  • Require any registrations, certifications, and accreditations required by law to render healthcare services in the state in which services are provided to members
  • Require timely reporting of any license limitations, sanctions, or revocations, or loss of insurance, medical staff privileges, registrations, certifications, or accreditations
• ✔Provider credentialing
  • Require provider to cooperate with the health plan’s credentialing process
  • If the agreement is with a provider organization as opposed to an individual provider, identify whether the health plan is responsible for provider credentialing, or if credentialing will be delegated to the provider organization
  • Require delegated entities to adhere to the health plan’s credentialing standards or outside credentialing standards (such as NCQA), where applicable
• ✔Maintenance of records
  • Require provider to create and maintain patient (member) medical records in a manner that meets the standard of care for their profession
  • Require providers to keep medical records for at least 10 years, or for as long as required by applicable law
  • Require the provider to comply with any applicable medical record privacy and confidentiality laws, including HIPAA and state-specific rules
  • Provide health plan with right to access medical records and other books and records relevant to the provider’s participation in the plan
• ✔Termination
  • Retain the right for the health plan to terminate provider or to direct a delegated entity to terminate provider
  • List the most common reasons for termination by the health plan with applicable time frames for notice to provider
  • Enumerate reasons for immediate termination by the health plan
  • Include mutual termination language in the agreement, with special consideration given to the health plan’s need to plan for provider’s departure from its network
  • Enumerate provider appeal rights

Distribute Provider Agreement and Schedule Follow-Up Meeting. When the agreement is in good form, distribute it to the stakeholders on your project team. Additionally, a follow-up meeting may help to identify and iron out any remaining issues. On the agenda should be a discussion about any pain points raised in the kick-off meeting and how you have addressed them.

Finalize Document. After making any final changes to the agreement, circle back with the plan’s provider network team. There may be logistical issues that require legal input, such as the timing and method of distributing the agreements to providers.

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