JLN Process - Provider agreement

Process Group

Provider Management

Objective

Establish legal binding documents between health provider and health insurance payer
This agreement may include:
a) What services the provider is authorized to deliver (credentialing data)
b) What fees the provider will receive for delivering services
c) Agreement about how quickly the provider will be paid
d) Any other agreement which the payer and provider agree to as part of the provision of service

Input

• Provider identifier

• Privacy restrictions

• Fee schedule

• Previous agreement/ contract

• agreement template

• Region of the provider (there may be rural differentials in the fee schedule)

• Specialty of the provider (there may be a difference in fee amount based on the specialty)

Output

• New agreement/ contract for a particular time period

• Signature on agreement by provider and health insurance payer

Measurable Outcomes

• Provider and health insurance payer to abide by a set of established rules, regulations, and fee schedule

Sources

• Joint Learning Network, 2012