Participating Provider Roles and Responsibilities

Participating providers are those who have successfully completed the 1199SEIU Benefit Funds’ credentialing process and have signed an agreement with the Benefit Funds to comply with our policies and procedures. Additionally, participating providers agree to help ensure members can easily access quality covered services within the network.

Participating Provider Requirements

Participating providers are required to:

  • Provide timely access to appointments:
    • First appointment and routine physicals: within 12 weeks
    • Urgent care: within 24 hours
    • Non-urgent sick visits: within three days
    • Routine, preventive care: within four weeks
    • First prenatal visit: within three weeks during first trimester (every two weeks during the second and every week during the third)
    • First newborn visit: within 2 weeks of hospital discharge
    • First family-planning visit: within two weeks
    • Follow-up visit after a behavioral health or substance use ER or inpatient visit: five days
    • Non-urgent behavioral health or substance use visit: two weeks
  • Maintain and retain clinical records on all members
  • Acquire a member’s written consent prior to rendering non-covered services
  • Comply with the 1199SEIU Benefit Funds’ Utilization Management Program as outlined in Care Management Programs
  • Comply with HIPAA regulations to keep member information confidential
  • Verify member eligibility before services are rendered
  • Accept the Benefit Funds’ payment as payment in full and agree not to balance bill members as indicated in the physician contract
  • Submit claims within 90 days of the date of service or discharge
  • Submit facility and professional claims electronically in a UB-04 or CMS-1500 format
  • Notify the Benefit Funds of any demographic and billing changes as soon as possible
  • Notify the Provider Relations Department in writing immediately if any of the following occur:
    • Their ability to practice medicine is restricted or impaired in any way
    • Their license to practice their respective profession is revoked, suspended, restricted, requires a practice monitor or is limited in any way
    • Any adverse action is taken, including, but not limited to, being debarred or excluded by any state or federal agency
    • An investigation has been initiated by any authorized local, state or federal agency
    • They have been arrested, charged or indicted with any crime related to fraud or other healthcare-related offenses
    • There are new or pending malpractice actions
    • There is reduction, restriction or denial of clinical privileges at any affiliated hospital
  • Maintain standards for documentation of medical records as outlined in the Medical Record Guidelines section
  • Cooperate and participate in all Benefit Funds peer review functions, quality assurance reviews, utilization reviews, fraud and abuse investigations and audits, as well as administrative and appeals procedures as established by the Benefit Funds
  • Cooperate and participate in all onsite inspections and reviews conducted by the Benefit Funds or their agents
  • Adhere to the Benefit Funds’ telemedicine standards and guidelines, including the prescribing of medications, as described in Telemedicine Guidelines and Teladoc
  • Agree not to direct prescriptions to a specific pharmacy; members have the right to have prescriptions filled at the pharmacy of their choosing
  • Comply with the Benefit Funds’ re-credentialing procedure

Provider Changes

It is essential that the information in our database be accurate and up to date. We can only provide our members with correct information if providers inform us of changes in their credentials’ status, such as hospital affiliation, board certification and practice limitations. It is also important to notify us immediately if your telephone number, practice address or billing information changes. All participating providers are required to complete a W-9 form during the initial credentialing process and when changing billing information. Accurate information helps us pay claims quickly, send tax statements promptly and make accurate member referrals.

Providers must complete the Provider Demographic Information Change Request Form to communicate changes in status to the 1199SEIU Benefit Funds’ Provider Relations Department. Send the completed form, as well as a completed W-9 form, via email, [email protected], or fax, (646) 473-7229.