Ohio Admin. Code 4123-6-59 - Provider access to the QHP system - QHP provider selection
(A) An employer
that develops a QHP, a vendor within the QHP system, or a QHP shall develop and
implement standards of credentialing of providers in the QHP network that meet
but may exceed the bureau credentialing requirements in the HPP.
(B) An employer that develops a QHP may
selectively contract with providers or contract with a vendor that selectively
contracts with providers.
(C) Only
a bureau certified provider is eligible for selection by an employer that
develops a QHP, by a QHP as a QHP panel provider or by a vendor as a panel
provider to participate in the QHP system. A provider identified by a QHP for
inclusion in its panel of providers that is not a bureau certified provider may
be assisted by the QHP in applying for bureau provider credentialing and
certification.
(D) The bureau, an
employer, a QHP or a vendor shall not discriminate against any category of
health care provider when establishing categories of providers for
participation in the QHP system. However, an employer, a QHP or a vendor is not
required to accept or retain any individual provider in the QHP
system.
(E) The bureau, an
employer, a QHP and a vendor shall comply with state and federal laws
prohibiting discrimination based on, but not limited
to, race, color, religion, sex, age,
disability, military status as defined in section
4112.01 of the Revised
Code, national origin, ancestry, or
color, and shall not discriminate against any health
care provider when establishing categories of providers for participation in
the QHP system on the basis of race, religion, national origin, color,
gender, sexual orientation.
or age.
(F) A QHP shall include in its panel a
substantial number of the medical, professional, and pharmacy providers
currently being utilized by employees. A QHP may limit the number of providers
on its provider panel, but shall do so based upon objective data that
demonstrates that the fundamental needs of the employer and employees are met
based on reasonable standards such as historical claims data or other
geographic information approved by the bureau. In addition, a QHP shall include
in its application for QHP certification information including reasonable
patient access, the potential number of employees the QHP is applying to
service, and other performance criteria, without discrimination by provider
type. A QHP seeking QHP certification may select out-of-state providers as
members of the QHP panel.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Prior Effective Dates: 09/05/1996, 02/01/2010, 11/13/2015
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(A) An employer that develops a QHP , a vendor within the QHP system, or a QHP shall develop and implement standards of credentialing of providers in the QHP network that meet but may exceed the bureau credentialing requirements in the HPP.
(B) An employer that develops a QHP may selectively contract with providers or contract with a vendor that selectively contracts with providers.
(C) Only a bureau certified provider is eligible for selection by an employer that develops a QHP, by a QHP as a QHP panel provider or by a vendor as a panel provider to participate in the QHP system. A provider identified by a QHP for inclusion in its panel of providers that is not a bureau certified provider may be assisted by the QHP in applying for bureau provider credentialing and certification.
(D) The bureau, an employer, a QHP or a vendor shall not discriminate against any category of health care provider when establishing categories of providers for participation in the QHP system. However, an employer, a QHP or a vendor is not required to accept or retain any individual provider in the QHP system.
(E) The bureau, an employer, a QHP and a vendor shall comply with state and federal laws prohibiting discrimination based on, but not limited to, race, color, religion, sex, age, disability, military status as defined in section 4112.01 of the Revised Code, national origin, ancestry, or color, and shall not discriminate against any health care provider when establishing categories of providers for participation in the QHP system on the basis of race, religion, national origin, color, gender, sexual orientation. or age.
(F) A QHP shall include in its panel a substantial number of the medical, professional, and pharmacy providers currently being utilized by employees. A QHP may limit the number of providers on its provider panel, but shall do so based upon objective data that demonstrates that the fundamental needs of the employer and employees are met based on reasonable standards such as historical claims data or other geographic information approved by the bureau. In addition, a QHP shall include in its application for QHP certification information including reasonable patient access, the potential number of employees the QHP is applying to service, and other performance criteria, without discrimination by provider type. A QHP seeking QHP certification may select out-of-state providers as members of the QHP panel.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4121.442, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4121.442
Prior Effective Dates: 09/05/1996, 02/01/2010, 11/13/2015