[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR422.202]



[Page 1012]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents

 

                 Subpart E_Relationships With Providers

 

Sec. 422.202  Participation procedures.



    (a) Notice and appeal rights. An MA organization that operates a 

coordinated care plan or network MSA plan must provide for the 

participation of individual physicians, and the management and members 

of groups of physicians, through reasonable procedures that include the 

following:

    (1) Written notice of rules of participation including terms of 

payment, credentialing, and other rules directly related to 

participation decisions.

    (2) Written notice of material changes in participation rules before 

the changes are put into effect.

    (3) Written notice of participation decisions that are adverse to 

physicians.

    (4) A process for appealing adverse participation procedures, 

including the right of physicians to present information and their views 

on the decision. In the case of termination or suspension of a provider 

contract by the MA organization, this process must conform to the rules 

in Sec. 422.202(d).

    (b) Consultation. The MA organization must establish a formal 

mechanism to consult with the physicians who have agreed to provide 

services under the MA plan offered by the organization, regarding the 

organization's medical policy, quality improvement programs and medical 

management procedures and ensure that the following standards are met:

    (1) Practice guidelines and utilization management guidelines--

    (i) Are based on reasonable medical evidence or a consensus of 

health care professionals in the particular field;

    (ii) Consider the needs of the enrolled population;

    (iii) Are developed in consultation with contracting physicians; and

    (iv) Are reviewed and updated periodically.

    (2) The guidelines are communicated to providers and, as 

appropriate, to enrollees.

    (3) Decisions with respect to utilization management, enrollee 

education, coverage of services, and other areas in which the guidelines 

apply are consistent with the guidelines.

    (c) Subcontracted groups. An MA organization that operates an MA 

plan through subcontracted physician groups must provide that the 

participation procedures in this section apply equally to physicians 

within those subcontracted groups.

    (d) Suspension or termination of contract. An MA organization that 

operates a coordinated care plan or network MSA plan providing benefits 

through contracting providers must meet the following requirements:

    (1) Notice to physician. An MA organization that suspends or 

terminates an agreement under which the physician provides services to 

MA plan enrollees must give the affected individual written notice of 

the following:

    (i) The reasons for the action, including, if relevant, the 

standards and profiling data used to evaluate the physician and the 

numbers and mix of physicians needed by the MA organization.

    (ii) The affected physician's right to appeal the action and the 

process and timing for requesting a hearing.

    (2) Composition of hearing panel. The MA organization must ensure 

that the majority of the hearing panel members are peers of the affected 

physician.

    (3) Notice to licensing or disciplinary bodies. An MA organization 

that suspends or terminates a contract with a physician because of 

deficiencies in the quality of care must give written notice of that 

action to licensing or disciplinary bodies or to other appropriate 

authorities.

    (4) Timeframes. An MA organization and a contracting provider must 

provide at least 60 days written notice to each other before terminating 

the contract without cause.



[64 FR 7981, Feb. 17, 1999, as amended at 65 FR 40324, June 29, 2000; 68 

FR 50857, Aug. 22, 2003; 70 FR 4724, Jan. 28, 2005]