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Section 1: Getting Started

1.3 Provider Rights & Responsibilities

1. To join AHP subject to the AHP Credentialing plan and to maintain adequate medical records incorporating medical record standards.
2. To utilize AHP participating Specialty Providers, hospitals and facilities, unless otherwise approved by AHP.
3. To provide services to AHP Members in the same manner and quality as those services provided to patients who are not Members.
4. To receive notice of revisions to the AHP Policies at least thirty (30) days in advance of changes.
5. To close enrollment if applicable, to new Members with sixty (60) days notice to AHP.
6. To receive claims payment directly, based on the Provider’s contractual agreement with AHP.
7. To accept the AHP reimbursement as payment in full (minus any copays, deductibles, or coinsurance) for each covered service under the Member’s contract.  To recognize all payments are subject to the Coordination of Benefits (COB) provisions of AHP.
8. To receive information, education, and support from AHP Network Services Department on Plan policies and operations as well as for problem resolution.  Please contact your Network Services Representative by calling 605-322-4545 or toll-free at 1-888-322-2115.
9. To keep all Member medical record information complete and confidential.  To open medical and administrative records with notice from AHP, regarding the Member to a review by AHP staff during normal business hours for the purpose of AHP performing Medical Management, Quality Improvement, Credentialing, and/or Peer Review activities.
10. To cooperate with Health Services in activities such as precertification, case management, quality improvement and peer review as requested.
11. To comply with all the AHP policies and procedures as outlined in the contract.
12. To provide AHP with the necessary information and documentation regarding any appeal.
13. To authorize the publication of Provider information in the AHP Provider Directory.
14. To promptly notify AHP of any of the following occurrences:
    • A change in status of license, certification, specialty board status or DEA registration.
    • Any circumstance that is required to be reported to the National Practitioner Data Bank, The Health Protection and Integrity Data Bank or any other reporting agency.
    • If a Provider is no longer employed, contracted or otherwise affiliated with a clinic or facility.
    • Any change or loss of liability insurance coverage.
    • If the Provider is no longer compliant with AHP’S credentialing criteria.
    • Any circumstance in which a Provider is sanctioned (ie. to be suspended, debarred, or excluded from participation in or convicted of any criminal offense related to the delivery of health care).
    • Any situation where a Provider is charged with a felony or is under formal investigation for fraud or any felony.
15. To notify AHP of a change in address, ownership, Tax Identification Number or network participation. 
16. To notify AHP Members in a timely manner if Provider no longer participates with AHP Network.

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