Title: Provider Appeal for Network Exclusion Policy Application: Zenith Insurance Company and All Affiliated Entities
Policy Number: CA011
Issued: October 15, 2008
Michael Jansen, EVP and General Counsel Bernyce Peplowski, DO, MS, EVP and National Medical Director
It is Zenith’s policy to:
with applicable contract provisions, laws, rules to Exclude a Provider from a Zenith Network; (2)
Providers fair and adequate notice of the reasons for Exclusion from a Zenith give Providers a fair and reasonable opportunity to respond to and appeal an Zenith Network.
Network; and (3) Exclusion from a
This policy sets forth the appeal rights of Providers to dispute Zenith’s decisions to Exclude Providers from Zenith’s networks. This policy applies only to Exclusion decisions made by Zenith staff, unless otherwise indicated. Decisions made by a contracted network vendor to Exclude a provider from the vendor’s global network will be subject to the dispute resolution processes provided by the contracted network vendor. This policy does not replace Zenith Provider dispute mechanisms in place for other types of Provider disputes including utilization review determinations.
If Zenith receives a dispute resolution request that should be handled by a contracted network vendor or credentialing vendor, Zenith will forward the dispute to the appropriate vendor and notify the applicable Provider.
“Exclude”, “Excluded” or “Exclusion” as used in this policy means that a Provider is either not included in a Zenith Network following a request for inclusion by the Provider or is not being retained in a Zenith Network following a period of participation in a Zenith Network.
“Excluded Provider” means a Provider that was Excluded from a Zenith Network under either a Qualitative Exclusion or an Objective Exclusion.
“Objective Considerations” means that Zenith based its Exclusion of the Provider upon one or more objective factors based upon supportable documentation or data including but not limited to: (1) volume of injured workers treated during a given period; (2) saturation of providers within
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