Toolkit Managed Care Resource

2023 Managed Care Resource Kit

The Managed Care Legal Database is a resource identifying how state and federal statutes and regulations address many issues that may occur between private payers and physicians, such as prior authorization, credentialing, network adequacy, out-of-network payment, and contract termination. The Database also contains relevant AMA policy, issue briefs, advocacy resources, model legislation, and a State Laws Map.

Payment Issues

• Fee Schedules
• Fee Schedules-Med. Adv.
• Liability-insurer shifting to physician
• Liability-insurer shifting to physician-Med. Adv.
• Most Favored Nation
• Overpayments / Recoupments
• Payment Edits
• Payment Rules
• Prohibited financial incentives
• Prohibited financial incentives-Med. Adv.
• Risk—Physicians Taking
• Risk-Physicians Taking-Med. Adv.

Network Issues

• Continuity of Care Post-Contract
• Continuity of Care Post-Contract-Fed. Exchange Reg.
• Credentialing-Deadlines
• Credentialing-Due Process-Denial of Contract
• Credentialing-Patient Demographics
• Credentialing-Payment Issues
• Directories
• Directories-Med. Adv.
• Directories-Fed. Exchange Reg.
• Network Adequacy
• Network Adequacy-Fed. Exchange Reg.
• Network Adequacy-Med. Adv.
• OON-Payment Issues
• Participation in Products, Plans, or Networks
• Profiling
• Rental Networks

Contract Changes / Disputes

• Amendments
• Amendments-Med. Adv.
• Anti-gag clause
• Anti-gag clause-Med. Adv.
• Anti-retaliation
• Anti-retaliation-Med. Adv.
• Restrictive Covenants
• Termination
• Termination-Med. Adv.
• Termination-Due Process
• Termination-Due Process-Med. Adv.

Coverage / Utilization Review

• Medical Necessity-Definition
• State Medical Necessity Decisions-Deadlines
• State Medical Necessity Appeals-Deadlines
• ERISA-Med. Nec. Decisions-Deadlines
• ERISA-Med. Nec. Appeals-Deadlines
• Preemption-ERISA
• Med. Adv.-Med. Nec. Decisions-Deadlines
• Med. Adv.-Med. Nec. Appeals-Deadlines
• Preemption-Medicare Advantage
• Retroactive Denial
• Step Therapy Override
• U.R. Criteria

Claims Processing

• Claims Filing Deadlines
• Prompt Payment Deadlines
• Prompt Payment Deadlines-Med. Adv.