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Managed Care Contracting Toolkit


Updated on December 7, 2016 (Originally Published on June 22, 2009)

Toolkit Overview

Originally created in June 2009 and updated in December 2016, the updated Managed Care Contracting Toolkit (Toolkit) follows the previous form but provides updated information in light of changes in law, including the implementation of the Affordable Care Act. The Toolkit is organized in the order of a typical managed care contract and outlines general principles that should be considered when negotiating contract provisions as a Provider or Managed Care Organization (MCO). Where applicable and unambiguous, sample contract language has been marked as either MCO- or provider-friendly, or neutral. Important principles have been listed at the beginning of each section to provide a roadmap and some general thoughts for contracting parties.

Toolkit Contents           

Complete Toolkit

Managed Care Contracting Toolkit

  • Includes all sections and appendices.

Sections and Appendices

  1. Definitions
  2. Scope of Agreement
  3. Provider Obligations
  4. MCO and Payer Obligations
  5. Reciprocal Rights and Obligations
  6. Claims and Payment
  7. Information, Records, Audits, and Recoupments
  8. Dispute Resolution
  9. Term and Termination
  10. Miscellaneous Terms

Appendix A

  • Includes case law addressing issues involving managed care contracting as well as provider-payer relationships generally. Topics addressed include Employee Retirement Income Security Act Preemption; in-network and out-of-network reimbursement issues; establishing Usual, Customary, and Reasonable charges; balance billing; Pharmacy Benefits Management litigation; and antitrust issues.

Appendix B

  • Includes post- Health Information Technology for Economic and Clinical Health Act and Omnibus Rule information regarding Business Associate Agreements.

Appendix C

  • Includes links to state law statutes governing managed care contracting and is updated and expanded to cover more states than addressed in the 2009 Toolkit.

Appendix D-1

  • Medicare Advantage and Part D Contract Provisions Checklist (Terminology)
    • Updated on February 28, 2019. Special thanks to Emily A. Moseley (Strategic Health Law, Chapel Hill, NC), Annie Hsu Shieh (Central Health Plan of California, Diamond Bar, CA), Jeff J. Wurzburg (Norton Rose Fulbright US LLP, San Antonio, TX), and Janice H. Ziegler (Dentons, Washington, DC) for updating this Appendix.

Appendix D-2

  • Medicare Advantage and Pard D Compliance Program Guidelines (Core Requirements)

Toolkit Editors and Contributors

The update to this Toolkit was directed and edited by David Dirr, Chair of the Managed Care Contracting Affinity Group of the Payers, Plans, and Managed Care Practice Group, and Tami Horton, Vice Chair of the Health Care Liability and Litigation Practice Group, with the assistance of Elizabeth Lemoine. David Dirr is an attorney with Dressman Benzinger LaVelle PSC in Crestview Hills, KY. Tami Horton is General Counsel, Chief Privacy Officer and Compliance Officer with the Illinois Bone and Joint Institute LLC in Des Plaines, IL. Elizabeth Lemoine is an attorney with Wick Phillips Gould & Martin LLP in Dallas, TX.

Special thanks to the following contributors to the December 2016 Toolkit Update:

  • Melissa Borrelli (Western Health Advantage, Sacramento, CA)
  • Daniel Brzozowski (University of Wisconsin Hospitals and Clinics Authority, Madison, WI)
  • Matthew Ehrlich (McLaren Health Care, Flint, MI)
  • Helaine Fingold (Epstein Becker & Green PC, Baltimore, MD)
  • Sarah Lechner (Barnabus Health, Lambertville, NJ)
  • Elizabeth Lippincott (Strategic Health Law, Chapel Hill, NC)
  • Timothy Maloney (UC Health, Cincinnati, OH)
  • Jen McDowell (Express Scripts, Saint Louis, MO)
  • Emily Moseley (Strategic Health Law, Chapel Hill, NC)
  • Sydney Nash (American Addiction Centers Inc., Brentwood, TN)
  • Terri O’Connell (Goodsill Anderson Quinn & Stifel, Honolulu, HI)
  • Edward Ohanian (Greenberg Traurig LLP, Albany, NY)
  • Whitney Phelps (Greenberg Traurig LLP, Albany, NY)
  • Layna C. Rush (Baker Donelson Bearman Caldwell & Berkowitz PC, Baton Rouge, LA)
  • Jackie Selby (Epstein Becker & Green PC, New York, NY)
  • Melissa Wong (Holland & Knight LLP, Boston, MA)
  • Janice Ziegler (Dentons LLP, Washington, DC)

Special thanks to the following individuals for their work on previous iterations of the Toolkit:

  • Roy M. Albert (Bon Secours Health System Inc., Columbia, MD)
  • Wilson M. Acevedo (OptumHealth, Eden Prairie, MN)
  • Douglas Aldeen (Community First Health Plans, San Antonio, TX)
  • Shakeba DuBose (The DuBose Law Firm, Columbus, OH)
  • Mandie C. Eichenlaub (UnitedHealthcare Community Plan of Texas, Houston, TX)
  • Robin J. Fisk (Fisk Law Office, Ashland, NH)
  • James G. Fouassier (Stony Brook University Hospital, East Setauket, NY)
  • Kathy S. Ghiladi (Feldsman Tucker Leifer Fidell LLP, Washington, DC)
  • Nancy P. Gillette (Ohio State Medical Association, Dublin, OH)
  • Lisa Ge Shang Han
  • Mark S. Kopson (Plunkett Cooney PC, Bloomfield Hills, MI)
  • Darryl T. Landahl (DaVita Inc., Denver, CO)
  • David A. Levenstein (David Levenstein Law PC, Amherst, MA)
  • Jennifer S. Lewin (King & Spalding LLP, Atlanta, GA)
  • Nupa Patel (MultiPlan Inc., Bedford, MA)
  • R. Brent Rawlings (Virginia Hospital and Healthcare Association, Glen Allen, VA)
  • Nancy J. Reed (GlobalHealth Inc., Oklahoma City, OK)
  • Blake A. Schofield (University of Missouri, Columbus, MO)
  • Annie Hsu Shieh (Central Health Plan of California, Diamond Bar, CA)
  • Leah B. Stewart (Beatty Bangle Strama PC, Austin, TX)
  • Suzanne B. Strothkamp (Express Scripts, St. Louis, MO)
  • Tara Swenson Dwyer (Mintz Levin Cohn Ferris Glovsky and Popeo PC, Washington, DC)
  • Kim Marie Uva (Quest Diagnostics Inc., Madison, NJ)
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