Zenith -- Provider Appeal for Network Exclusion Policy
a given geographic area; (3) Provider being convicted of a felony; (4) Provider being declared mentally incompetent by a court of law; or (5) failure to maintain unrestricted required licensure.
“Provider” means physicians and surgeons holding an M.D. or D. O. degree, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners, medical groups, medical clinics, hospitals, surgical centers, durable medical equipment entities, physical therapists or any other entity or individual that either participates in a Zenith Network or is seeking to participate in a Zenith Network in order to provide medically necessary services an injured worker is entitled to receive under the applicable state workers’ compensation system within the scope of practice as defined by the appropriate licensing board.
“Qualitative Considerations” means that Zenith based its Exclusion of the Provider upon one or more factors that does not qualify as an Objective Consideration, including but not limited to (1) performance or quality of care issues including failure to follow applicable treatment guidelines, failing to meet expected performance for return to work or total disability; (2) violation of the terms and conditions of the Provider’s network contract; (3) failure to pass credentialing; or (4) other subjective determinations of a provider’s worthiness to be in the network such as responsiveness to Zenith, timeliness in reporting, accessibility to injured workers or other performance related considerations.
“Zenith Network” means the network of providers and facilities that Zenith has access to through either a direct or indirect contractual relationship. It does not include subsets of providers within a Zenith Network or other providers who may participate in medical management, quality or other programs implemented by Zenith that are permitted under the Workers’ Compensation laws, rules and regulations, including but not limited to programs developed pursuant to Zenith’s
Provider Evaluation Policy.
A Provider may be Excluded based upon either Objective Considerations or Qualitative Considerations. Exclusions based on Objective Considerations may be made by the Zenith Provider Relations team or a Zenith Medical Director (with concurrence of the National Medical Director). Exclusions based on Qualitative Considerations must be made by a Zenith Medical Director (with concurrence of the National Medical Director) or by a contracted network based on the contracted network’s policies. The reasons for Exclusion based on either Objective or Qualitative Considerations shall be applied in a substantively rational and procedurally fair manner.
After a decision is made to Exclude a Provider, the Provider Relations department shall notify the Provider in writing that he or she has been Excluded from the network. This letter will state the reason for the Exclusion, and set forth appeal rights.
When the Objective Exclusion is based on volume and/or network saturation, the Provider will be given the opportunity to request that he or she be placed on a network waiting list for future consideration. Any Provider Excluded based on Qualitative Considerations will not be eligible for placement on the network waiting list.
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