LC-DraftRevisedProvider Contract Matrix9208final (2)

CMS PROVIDER PARTICIPATION CONTRACTS AND/OR AGREEMENTS MATRIX- 1

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IPA/Group/Provider Name First Tier & Downstream Contracts and/or Agreements
CMS REGULATIONS – 42 CFR 422 * In addition to the CFR citations provided below, the following contract provisions are required in agreements between MA organizations and provider and suppliers of health care as stated in Chapter 11 of the Medicare Managed Care Manual Section 100.4.		Section/Page	Section/Page	Section/Page	Section/Page	Section/Page
All Provider Contracts
HHS, the Comptroller General or their designees have the right to inspect, evaluate and audit any pertinent contracts, books, papers, and records for a period of 10 years from the final date of the contract period or the completion of any audit, whichever is later. 422.504(i)(2)(i) and (ii);
Proviiders and suppliers agree to safeguard beneficiary privacy and confidentiality and assure the accuracy of beneficiary health records. Chapter 11, Medicare Managed Care Manual
Hold Harmless Provisions - Providers may not hold beneficiary liable for payment of fees that are the legal obligation of the MAO. 422.504(g)(1)(i); 422.504(i)(3)(i)
Accordance with MAO’s contractual obligationsA provision requiring that any services performed will be in consistent and comply with the MA organization’s contractual obligations 422.504(i)(3)(iii);)
Prompt Payment The agreement specifies a prompt payment requirement, the terms and conditions of which are developed and agreed to by the Mao and contracted providers and suppliers. Chapter 11, Medicare Managed Care Manual
Accountability provision – Reporting Responsibilities Delegated activities and reporting responsibilities must be specified. 422.504(i)(3)(ii); 422.504(i)(4)(i) Accountability Provision – Revocation. Agreement provides for the revocation of the delegated activities and reporting requirements or specify other remedies in instances when CMS or the MA organization determine that such parties have not performed satisfactorily. 422.504(i)(3)(ii); 422.504(i)(4)(ii) Accountability Provision - Monitoring Agreement provides that the performance of the parties is monitored by the MA organization on an ongoing basis 422.504(i)(3)(ii); 422.504(i)(4)(iii) Accountability Provision - Credentialing The credentials of medical professionals affiliated with the party or parties will either be reviewed by the MA organization or the credentialing process will be reviewed and approved by the MA organization; OR the MA organization must audit the credentialing process on an ongoing basis 422.504(i)(3)(ii); 422.504(i)(4)(iiv)
Comply with applicable Medicare laws and Regulations Must comply with all applicable Medicare laws, regulations, and CMS instructions 422.504(i)(4)(v)
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Draft 4-18-08 Provider Matrix Template

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