Skip navigation

Practitioner and Provider Responsibilities

Responsibilities of All Providers

AmeriHealth Caritas health plans are regulated by state and Federal laws.  Providers who participate in AmeriHealth Caritas health plans have responsibilities, including but not limited to:

  • Treat AmeriHealth Caritas members in the same manner as other patients.
  • Communicate with various public agencies including, but not limited to, local public health agencies for the purpose of participating in immunization registries and programs, e.g., vaccines for children, communications regarding management of infectious or reportable diseases, cases involving children with lead poisoning, special education programs, early intervention programs, etc.
  • Comply with all applicable State disease notification laws.
  • Provide information to AmeriHealth Caritas and/or  State Medicaid agencies and/or the Centers for Medicare and Medicaid Service (CMS) as required.
  • Inform members about all treatment options, regardless of cost or whether such services are covered by the Plan or other State programs.
  • As appropriate, work cooperatively with specialists, consultative services and other facilitated care situations to accommodate special needs of our members, such as those who are deaf and hearing impaired, and those with experience-sensitive conditions such as HIV/AIDS, self-referred women’s health services, family planning services, etc.
  • Not refuse an assignment of or transfer a member or otherwise discriminate against a member solely on the basis of religion, gender, sexual orientation, race, color, age, national origin, creed, ancestry, political affiliation, personal appearance, health status, pre-existing condition, ethnicity, mental or physical disability, participation in any governmental program, source of payment, marital status, type of illness or condition or any other basis prohibited by law, except when that illness or condition may be better treated by another provider type.
  • Ensure that ADA requirements are met, including use of appropriate technologies in the daily operations of the physician’s office, e.g., TTY/TDD and language services, to accommodate the member’s special needs.
  • Abide by and cooperate with the policies, rules, procedures, programs, activities and guidelines contained in your Provider Agreement (to which this Provider Manual and any revisions or updates are incorporated by reference).
  • Accept AmeriHealth Caritas payment and any applicable third party resource as payment-in-full for covered services.
  • Comply fully with AmeriHealth Caritas Quality Improvement, Utilization Management, Integrated Care Management, Credentialing and Audit Programs.
  • Comply with all applicable training requirements as required by AmeriHealth Caritas, the State and/or CMS.
  • Promptly notify AmeriHealth Caritas of claims processing payment or encounter data reporting errors.
  • For the applicable period of time, maintaining all records required by law regarding services rendered and making such records and related information available to AmeriHealth Caritas or any appropriate government entity.
  • Treat and handle all individually identifiable health information as confidential in accordance with all laws and regulations, including HIPAA Privacy and Security requirements.
  • Immediately notify AmeriHealth Caritas of adverse actions against license or accreditation status.
  • Comply with all applicable Federal, State, and local laws and regulations.
  • Maintain liability insurance in the amount required by the terms of the Provider Agreement.
  • Notify AmeriHealth Caritas of the intent to terminate the Provider Agreement as a participating provider within the timeframe specified in the Provider Agreement and provide continuity of care in accordance with the terms of the Provider Agreement.
  • Verify member eligibility immediately prior to service.
  • Obtain all required signed consents prior to service.
  • Obtain prior authorization for applicable services.
  • Maintain hospital privileges when hospital privileges are required for the delivery of the covered service.
  • Provide prompt access to records for review, survey or study if needed.
  • Report known or suspected child, elder or domestic abuse to local law authorities and have established procedures for these cases.
  • Inform member(s) of the availability of AmeriHealth Caritas’s interpretive services and encourage the use of such services, as needed.
  • Notify AmeriHealth Caritas of any changes in business ownership, business location, legal or government action, or any other situation affecting or impairing the ability to carry out duties and obligations under the AmeriHealth Caritas Provider Agreement.
  • Maintain oversight of non-physician practitioners as mandated by State and Federal law.