Network Adequacy Standards

It is the NCPPO and HealthLink network program's goal that enrollees have access to qualified, diverse care that offers an appropriate amount of choice. Toward meeting this goal, NCPPO and HealthLink has established network standards regarding provider availability and accessibility.

Specifically, the purposes of participating provider availability and accessibility standards are as follows:

• To offer an adequate number and type of contracted or participating providers to meet the health needs of enrollees.
• To offer a network of participating providers that is geographically accessible to enrollees.
• To describe the participating provider availability and accessibility standards to state and/or federal regulators, accreditation agencies, benefit consultants, employers and other health care purchasers or prospective purchasers of NCPPO and HealthLink services.

Provider Network Adequacy Goals

The number of network providers of different types will vary from one service region/county to another. The NCPPO and HealthLink network program will recruit and contract with sufficient providers of all types necessary to provide a full range of covered services.

In general, the provider network will:

• Be adequate in numbers and types of providers to meet the full range of health care service needs of the enrolled population.
• Include at least one community hospital; where one is available.
• Include at least 50 percent of the primary care physicians (PCPs) with active staff privileges on the medical staff of the contracted community hospital, within each county or multi-county region.
• Include within each county or multi-county region, enough primary care and specialty care physicians to provide enrollees a choice of physicians.

Contracting Criteria - Health Care Facilities, Ancillary Care Providers, and Other Provider Specialty Networks

Hospitals, other health care facilities, programs and ancillary care providers who/that desire to contract with NCPPO and HealthLink are required to meet the following contracting criteria, as applicable:

• Provider must be located within the approved service area (developed or in development as indicated in the corporate market plan and approved by management).
• Provider must provide health care services covered by benefit plans and/or benefit plans administered by affiliated insurance carriers.
  

National Capital Preferred Provider Organization, Inc. ("NCPPO") is a Maryland corporation. HealthLink®, Inc., is an Illinois corporation. Both are organizers of independently contracted provider networks, which are made available by contract to a variety of payors of health benefits, including insurers, third party administrators or employers. Neither has control nor right of control over the professional, medical judgment of contracted providers, nor are they liable for any acts or failures to act, by contracted providers. Neither is an insurance company and neither has liability for benefits under benefit plans offered or administered by payors. HealthLink® is a registered trademark of HealthLink, Inc. Both companies are subsidiaries of WellPoint, Inc.