HCX Protocol
v0.8
v0.8
  • Summary
  • Context
  • Introduction to HCX
  • Approach
    • Design Principles
    • Key Specifications
    • Governance
  • Technical Specifications
    • Open Protocol
      • Registries
      • Claims Data Exchange (HCX) Protocol
        • Exchange Protocol
        • Message Structure
        • API Structure
        • Error Handling
      • Data Security and Privacy
        • Transport Security
        • Message Security and Integrity
        • API Security
      • Audit and Reporting
      • Notifications
        • Terminology
        • Categories
        • API specifications
        • List of key topics
        • Future considerations
      • Third party Information sharing
    • Digital Network Policies
  • Domain Specifications
    • Domain Data Models
      • Handling Attachments
      • Handling Processing Errors
    • Terminologies (Code sets or Metadata standards)
    • Domain Specific Languages (DSLs)
    • Implementation Guide
  • Business Policy Specifications
    • Access Control (Roles)
    • Guidelines for Participant Onboarding
    • Guidelines for Grievance Redressal
      • Scope of disputes
      • Involved participants
      • Guideline process for dispute resolution
      • Guidelines for leveraging FTA
      • Next steps
    • Guidelines for SLAs and ecosystem satisfaction
    • Guidelines for Operating charges
    • Guidelines for Beneficiary Authentication by Providers/Payors
    • Guidelines for Event audits
    • Reference Templates
      • HCX - Terms of use
      • Payer-Provider addendum
      • Payer-Policyholder addendum
    • Next steps
  • Contributing to the specifications
  • Future Roadmap
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  • Template - Addendum to Payer-Provider contract

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  1. Business Policy Specifications
  2. Reference Templates

Payer-Provider addendum

Guidelines On Enhancements in Payor/Provider Agreements

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Last updated 2 years ago

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Approach

The proposed template addendum aims to provide the needed clauses that payors and providers can use to make their contracts FTA friendly.

An FTA friendly contract is one where, to the extent possible, the potential disputes that may occur between parties are anticipated, the evidence required by parties to prove their case is pre-defined, and so are the compensation computation mechanisms.

The benefits of an FTA friendly contract are two-fold:

  1. Because there is less ambiguity, it reduces the likelihood of parties getting into disputes

  2. Even if a dispute does occur, having an FTA friendly agreement enables the adjudicator (arbitrator/tribunal/ombudsman/court) to quickly adjudicate the dispute, thereby reducing the time spent litigating.

In order to do so, it is essential to first identify potential disputes. Based on a reading of the multi-party dispute document and the sample agreement, the following disputes could arise between a payor and provider:

  1. Provider’s obligation to provide ‘reasonable care’ to the Members

  2. Delayed payment of invoices by payor/defective invoice submitted by provider

  3. Company’s right to levy penalty in the case of ‘proven error/omission’ by provider

  4. Charges for services which are not detailed in the tariff list given by the provider to the payor.

In addition, the temaplte addendum also contains suggestions for modification of certain other clauses in a payor-provider contract.

In addition to the guidelines metioned in this document (specially the guidance for grievance redressal) the template is based on the between a Payor and a Provider. The clauses referred to in the addendum have been taken from the sample agreement.

Template -

Payers may execute addendums in the case of existing contracts. For new contracts, Payers may simply incorporate the clauses mentioned in the addendum into their drafts.

following sample agreement
Addendum to Payer-Provider contract