A network is a grouping of providers within ND MMIS that is used to link providers to the services that they are authorized to deliver. These groupings or networks are generally based on the fact that the providers are authorized to perform some common set of services. A network is one of the codes, or rules, that must be set up before ND MMIS can process claims.
Although provider networks are traditionally viewed as a component of commercial-style healthcare plans, an example of how networks are used in the Medicaid context is to set up a network for out-of-state providers or a network for disproportionate share hospitals. Each network would have specific services associated with it that providers in that network are eligible to perform.
For example, a network identified as General Medicaid might include all doctors, hospitals, and pharmacies that can bill for Medicaid services. A more complex example of a network might be a Disproportionate Share network. These providers might be hospitals in an inner city that see more Medicaid patients than other hospitals. Assigning them to this network would allow them to be paid more money per claim to cover the extra work load.
A group of doctors who have formed a practice (no matter how large) is not a network.
Providers are assigned during the enrollment process to an ND MMIS network. These assignments can be changed within the Provider Maintenance function on the Provider Maintenance - Identifiers/Enrollment page.
Networks make it much faster to determine which providers can supply what services under a particular benefit plan. Instead of adding each individual provider to a plan, you can add an entire network of providers. Networks give you more flexibility in paying claims. Claims are already paid based on provider type and location, but creating a network for a special grouping would allow you to change the payment structure just for this network.
Normally, you add networks using the Network function of Rules Management when ND MMIS is set up for the first time. Periodically, you may need to add a new network. When you add a network, you must identify the type of network this is, for example, a general Medicaid or a managed care network.
You connect networks to an MMIS benefit plan when the plan is added or edited, using the Provider Network Association panel of the Benefit Plan Navigator main page. Networks can be connected to several plans and may be given a different in-network, out-of-network, or out-of-area status for different plans. You can also see a list of all the benefit plans associated with a network on the Network page.
Networks are connected to lines of business through the benefit plans with which they are associated. Lines of business may have multiple networks connected to it.
Provider Inquiry/Maintenance - Identifiers/Enrollment Page
Version as of 5/16/14.
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