Provider tools

Provider rights and responsibilities

Network Provider Participation

MCC of VA is dedicated to selecting healthcare professionals, groups, agencies and facilities to provide
member care and treatment across a range of covered services as defined by Virginia Department of
Medical Assistance Services (DMAS).

To be a network provider of healthcare services with MCC of VA under the CCC Plus and Medallion, you
must be credentialed and contracted according to MCC of VA and DMAS standards. Providers are
subject to applicable licensing requirements.

Your responsibilities

Your responsibility, as a network provider of healthcare services, is to:

  • Provide medically necessary covered services to members whose care is managed by MCC of
    VA; Comply with all applicable non-discrimination requirements
  • Maintain eligibility to participate in Medicare/Medicaid or other federal or state health
    programs; you may not be excluded from participation while under agreement with MCC of VA
  • Comply with all terms of your Participating Agreement. In the event there is a conflict between
    the terms of your Agreement and the terms of the CCC Plus or Medallion, the DMAS contract
    will apply
  • Follow the policies and procedures outlined in this handbook, any applicable supplements and
    your provider participation agreement(s) as well as DMAS policies and regulations
  • Provide services in accordance with applicable Commonwealth of VA and federal laws and
    licensing and certification bodies. Contracted providers for the CCC Plus or Medallion networks
    are required to abide by DMAS regulations and manuals, and maintain active licensure for their
    contracted provider type and specialty at each service location
  • Provide covered services to MCC of VA members as outlined in this handbook and applicable
    supplements and your provider agreement(s), as well as DMAS policies and regulations without
    exclusion or restriction on the basis of religious or moral objections
  • Agree to cooperate and participate with all system of care coordination, quality improvement,
    outcomes measurement, peer review, and appeal and grievance procedures
  • Make sure only providers currently credentialed with MCC of VA render services to MCC of VA
    members
  • Follow MCC of VA’s credentialing and re-credentialing policies and procedures
  • Participate and collaborate in Value-based payment programs and strategies (as agreed upon in your Participating Provider Agreement) that contribute and align with MCC of VA and DMAScare goals and outcomes for members

 

MCC of VA’s responsibility is to:

  • Offer assistance with your administrative questions during normal business hours, Monday
    through Friday
  • Not prohibit, or otherwise restrict health care providers acting within the lawful scope of
    practice, from advising or advocating on behalf of the member who is the provider’s patient, for
    the member’s health status, medical care, or treatment options, including any alternative
    treatments that may be self-administered, any information the member may need in order to
    decide among all relevant treatment options, the risks, benefits, and consequences of
    treatment or non-treatment. And not prohibit nor restrict the member’s right to participate in
    decisions regarding his or her health care, including the right to refuse treatment, and to
    express preferences about future treatment decisions
  • Ensure health equity in the coverage and provision of services. This includes parity in process
    and coverage policy between covered medical and Behavioral health service needs
  • Ensure member’s access to Native American and/or other Indian Health Services Providers (IHS)
    providers, where available.
  • Assist providers in understanding and adhering to our policies and procedures, the payer’s
    applicable policies and procedures, and other requirements including but not limited to those
    of the National Committee for Quality Assurance (NCQA)
  • Maintain a credentialing and recredentialing process to evaluate and select network providers
    that does not discriminate based on a member’s benefit plan coverage, race, color, creed,
    religion, gender, sexual orientation, marital status, age, national origin, ancestry, citizenship,
    physical disability or other status protected by applicable law

 

 

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