Contracts and Contract Negotiations / 36-Point Checklist for Managed Care Contracting

Why This Topic Matters

Managed care contracts can materially affect reimbursement, billing workflow, liability exposure, and the ability to terminate or amend agreements. This checklist helps readers understand the major categories of terms that may warrant review during payer negotiations.

Article Sections

1. Payment and payer responsibilities

   Covers billing form requirements, payment timing, overpayment handling, rate adjustments, coordination of benefits, claims submission timing, credentialing, eligibility verification, and emergency-related payment issues.

2. Utilization review and quality assurance

   Addresses medical necessity review, appeals and grievance procedures, and the handling of quality assurance oversight by plans or third parties.

3. Insurance and indemnification

   Discusses indemnification, liability allocation, patient coverage denials, cancellation notification, and insurance coverage expectations.

4. Termination

   Focuses on contract termination triggers, insolvency concerns, and material breach provisions.

5. General administrative provisions

   Reviews broader contract administration topics such as hospital-based negotiations, product participation, rule changes, exclusivity, governing provisions, medical record ownership, promotional use, and renewal terms.