In developing and managing its network for physical health and pharmacy services, Alliance Health (Alliance) will make a Good Faith Effort to contract for Medicaid, NC Health Choice and State-funded services as applicable with Essential Providers, and with any willing physical health, pharmacy or Indian Health Care Provider (IHCP). Alliance shall exercise its statutory authority to maintain a closed network with regard to Behavioral Health (BH), Intellectual/Developmental Disability (I/DD) and Traumatic Brain Injury (TBI) services as set forth in NCGS § 108D-23. The purpose of this policy is to provide a framework that identifies a Good Faith Effort to contract with providers, as defined by the North Carolina Department of Health and Human Services (NCDHHS), that request to join our network or are recruited into our Network.
- Alliance will offer to contract with a provider in writing using a NCDHHS approved provider agreement (Medicaid, NC Health Choice and State-funded) including the required provisions within and will consider all facts and circumstances surrounding a provider’s willingness to contract before determining that the provider has refused the health plan’s “good faith” contracting effort.
- Alliance will accept provider credentialing and verified information from the NCDHHS, or designated NCDHHS vendor, and shall not request any additional credentialing information from a provider without the NCDHHS’ written prior approval. Alliance may collect other information from providers as necessary for the contracting process.
- Alliance will make timely network contracting decisions using the process outlined in the Credentialing and Re-credentialing operational policy #202.
- Alliance shall not solicit or accept provider credentialing or verified information from any source other than NCDHHS, or designated NCDHHS vendor, except as expressly permitted by NCDHHS.
- Alliance is prohibited from using, disclosing, or sharing provider credentialing information for any purpose other than use in Medicaid Managed Care without the express, written consent of the provider and NCDHHS.
- Alliance shall not require individual practitioners to agree to participate or accept other products offered by Alliance nor shall Alliance automatically enroll the provider in any other product offered by Alliance. This requirement shall not apply to facility providers. This requirement shall not preclude Alliance from requiring individual practitioners, as a condition of contracting with Alliance, to provide State-funded services.
- Alliance shall evaluate a contracted provider’s continued eligibility for contracting by validating the information of the provider on the daily Provider Enrollment File. Alliance’s process shall occur every 3 years consistent with NCDHHS policy and procedure, unless otherwise notified by NCDHHS.
- Alliance will reimburse an out-of-network provider who is not excluded for quality reasons or refused a “good faith” contract at either 90% or 100% as follows:
- Situations in which Alliance will pay no more than 90% to out of network providers:
- A “good faith” effort to contract with a provider was made, but the provider has refused that contract.
- The provider was excluded from the network for failure to meet objective quality standards.
- Situation in which Alliance will pay 100% to out of network providers:
- The provider has not been offered a contract or is still engaged in good faith negotiations.
- All family planning providers
- Out of state providers that deliver emergency and post-stabilization services
- In state providers that deliver emergency and post-stabilization services
- Out of network providers will receive 100% of Medicaid reimbursement during transition coverage, ninety (90) days after go-live.
- Under Transition of Care requirements, services shall be reimbursed at 100% of the Medicaid Fee for Service rate.
- If a good faith effort has not been made, services shall be reimbursed at 100% of the Medicaid Fee for Service rate.
- Out of state services shall be reimbursed at 100% of the Medicaid Fee for Service rate when:
- The rate is more reasonable than an in-state network provider, or
- In response to an emergency medical condition, or
- The health of the member would be endangered if services were postponed until return to North Carolina, or
- The health of the member would be endangered if the member traveled to North Carolina.
- Out-of-network services shall be no greater than if the services were to be provided in network.
- Emergency and post stabilization payments
- Alliance shall reimburse without regard to contract or prior authorization.
- Alliance shall reimburse due to an emergency medical condition or under instruction to seek emergency services by Alliance.
- iii. Alliance shall not hold a member responsible for charges related to screening and treatment necessary to diagnose or stabilize.
- Alliance shall reimburse until the attending physician or provider treating member determines the member is stabilized for transfer or discharge.
- Services shall be reimbursed at no more than 100% of the Medicaid Fee for Service rate including out of state hospitals.
- For post stabilization services, Alliance shall:
- Reimburse for services that are pre-approved by Alliance.
- Reimburse for services that are not pre-approved but provided within one hour of request to Alliance.
- Reimburse for services that are not pre-approved but are administered when:
- Alliance could not be contacted
- Alliance did not respond within one hour
- Alliance and the treating physician do not agree concerning the care and an Alliance physician is not available for consultation
- The treating physician must be given an opportunity for consultation and may continue with treatment until consultation is available.
- For post-stabilization services, Alliance shall NOT reimburse for services it has not preapproved when:
- Member treatment begins under a network physician with privileges at the treating hospital
- A network physician assumes care through a transfer
- Once Alliance and treating physician reach an agreement regarding the care, or
- Once the member is discharged
- Alliance shall limit charges to no more than what charges would be under an in-network provider.
- Situations in which Alliance will pay no more than 90% to out of network providers:
- Alliance’s Provider Network Specialist team will make attempts to contract in good faith with any out of network provider rendering care to a member and will work with provider to join the Network.
- Alliance will make a minimum of 3 documented attempts, by phone or email (or any number designated by the State) at least once every 10 days to encourage Network participation. These attempts will be documented in Salesforce, Alliance’s provider recruiting management software. The provider will have 30 calendar days from the first attempt to respond.
- Once the provider has been approved to be in the network, the provider will have 30 calendar days to accept the contract. The 30-day period starts upon the provider’s receipt of the contract. Alliance will make a minimum of 3 documented attempts, by phone or email (or any number designated by the State) at least once every 10 days to encourage Network participation. These attempts will be documented in Salesforce, Alliance’s provider recruiting management software. If within 30 calendar days the potential network provider rejects the request or fails to respond in writing, Alliance may consider the request for inclusion in the Alliance network as rejected by the provider. If discussions are ongoing, or the contract is under legal review, Alliance will not consider the request rejected.
- Alliance shall give written notice to any provider whom it declines to contract within 5 business days after Alliance’s final decision. The notice shall include the reason for Alliance’s decision, the provider’s right to appeal that decision, and how to request an appeal.
- Alliance will meet availability, accessibility, and quality goals and requirements. In developing the physical health network, Alliance will negotiate with any willing provider in good faith regardless of provider or Alliance affiliation. Alliance will continue to operate a closed network for behavioral health services but will follow the reimbursement requirements outlined in section 7. of this policy and the contract process in section 8. of this policy. Alliance will perform ongoing activities to recruit new providers including physical health to retain providers currently participating in the Alliance network. Alliance will not enact any recruitment or retention activity that is or could potentially be discriminatory of providers that serve high-risk populations or specialize in complex conditions that require costly treatment. Alliance will not discourage its network providers from contracting with other Managed Care Organizations.
- Alliance or its delegated vendors will not include exclusivity or non-compete provisions in contracts with providers, including non-medical service providers, for example non-emergency medical transportation drivers, require a provider to participate in the governance of a Provider Lead Entities, or otherwise prohibit a provider from providing services for or contracting with any other Prepaid Health Plan. Alliance will conduct a good faith effort to contract with North Carolina or contiguous county providers who are credentialed and enrolled with NCDHHS as Medicaid, NC Health Choice, and State-funded providers within the state of North Carolina, using DocuSign, emails, ongoing negotiations, and continuing communications with the provider to receive a completed network agreement.
- Alliance will meet availability, accessibility, and quality goals and requirements. Alliance will continue to operate a closed network for BH, I/DD, and TBI services.
- The Senior Director of Provider Network Operations or designee will conduct random reviews of provider records in the Alliance provider tracking database to ensure compliance with this policy. Provider reimbursement shall be made in accordance with the Alliance Provider Reimbursement operational policy #201.
Provider: Individual practitioners and facilities, entities, organizations, atypical organizations/providers, and institutions, including Essential Providers and IHCPs, unless otherwise noted.
Out-of-Network: A provider that has not executed a Network Participating Provider Contract with Alliance or its Tailored Plan subcontractors.
Provider Enrollment File: File provided by the State to Alliance that provides provider Medicaid enrollment information from NCTracks.
Good Faith Effort: Means that Alliance has:
- Extended a Contract offer to a provider in writing using a NCDHHS-approved Network Participating Provider Contract; and
- Considered all available facts and circumstances surrounding a provider’s willingness to contract; and
- Adhered to the procedures outlined in Paragraphs 1-9 above.
Essential Provider: Federally qualified health centers, rural health centers, free clinics, local health departments, State Veteran’s Homes, and any other providers as designated by NCDHHS in accordance with N.C. Gen. Stat. § 108D-22(b).