I am a Participating Practitioner employed or otherwise retained by the Provider named below. The
Provider has signed an Agreement (“Agreement”) with Neighborhood Health Plan of Rhode Island,
(“Neighborhood”), a copy of which has been made available to me for my review. I hereby agree to
comply with those provisions of the Agreement that apply to a Participating Practitioner. Capitalized
terms not otherwise defined in this Attachment will have the meanings set forth in the Agreement.
I specifically acknowledge the following:
1. In no event, including, but not limited to non-payment by Neighborhood, Neighborhood’s
insolvency, or its breach of the Agreement, shall I be entitled to bill, charge, collect a deposit from,
or have any recourse against any Neighborhood Member, subscriber or enrollee for services provided under the Agreement, except for Copayments or Deductibles.
2. I will give the Provider at least Sixty (60) days advance written notice prior to terminating my
employment or independent contractor relationship with the Provider.
3. I agree to comply with all applicable state and federal laws and regulations, including without
limitation, rules and regulations promulgated by CMS, the State of Rhode Island pursuant to R.I.
General Laws and the Department of Health amended Rules and Regulations for the Certification of Health Plans (R23-17.13-CHP) and the Neighborhood Policies and Procedures outlined in the
Administrative Guidelines and Provider Manual.
4. I agree to comply with Attachments 3 (Medicaid requirements) and 4 (Medicare and CFAD requirements) as they relate to me personally.
5. I understand the components of Neighborhood’s policy for all adverse decisions resulting in a change of contractual privileges of a credentialed Participating Practitioner. Neighborhood shall be deemed to have met the adequate notice and hearing requirements for due process for a Participating Practitioner if the following conditions are met:
5.1. In the event of any adverse decision by Neighborhood resulting in a change of contractual privileges of the Participating Practitioner, Neighborhood shall notify the Participating Practitioner in writing of the reasons(s) for the proposed actions and Participating Practitioner shall be given the opportunity to appeal the actions prior to the implementation of the proposed action. The Participating Practitioner may waive Neighborhood’s due process in writing. At no time will Neighborhood require their professional Participating Practitioner to waive their rights to appeal as a condition of their contractual agreement with Neighborhood. When Neighborhood has reason to suspect that there is immediate danger to a Member, Neighborhood and/or Plan shall immediately notify the Rhode Island Director of Health and shall take appropriate action to protect Members.
5.2. Neighborhood shall maintain an internal appeal process for the Participating Practitioner that has reasonable time limits for the resolution of such internal appeals.
6. Termination of my participation in Neighborhood shall not affect the method of payment, reduce or increase the amount of reimbursement to the Provider by Neighborhood for any patient in active
treatment for an acute medical condition at the time the patient’s Participating Practitioner terminates participation with Neighborhood until the active treatment is concluded or, if earlier, one (1) year after the termination. During the active treatment period, I understand I will remain subject to all relevant Neighborhood policies and procedures, including but not limited to all of the reimbursement provisions that limit the patient’s liability.
7. I understand that as a Participating Practitioner for Neighborhood, I must abide by the Principles of Medical Ethics and Professional Practice as written in the American Medical Associations Council for Ethical and Judicial Affairs which is updated and distributed annually.
8. I recognize that Neighborhood will have the right to require my compliance with the Agreement.