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, national origin, 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. Subject to the provisions of rules 4123-6-67 and 4123-6-68 of the Administrative Code, a QHP seeking QHP certification may select out-of-state providers as members of the QHP panel.

Effective: 02/01/2010
R.C. 119.032 review dates: 11/17/2009 and 11/01/2014
Promulgated Under: 119.03
Statutory Authority: 4121.12 , 4121.30 , 4121.31 , 4123.05
Rule Amplifies: 4121.121 , 4121.44 , 4121.441 , 4121.442 , 4123.66
Prior Effective Dates: 9/5/96