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Managed Care Contract

Draft Managed Care Contracts in Minutes, Not Days

12 minutes with CaseMark

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Workflow

Managed Care Contract

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Workflow

Managed Care Contract

Overview

Healthcare attorneys spend 6-8 hours drafting managed care contracts, manually researching regulatory requirements, HIPAA provisions, and reimbursement standards across multiple sources. Ensuring compliance with state and federal regulations while customizing terms for each provider relationship is time-consuming and error-prone, often requiring extensive review cycles.

Managed care contracts require extensive regulatory knowledge spanning HIPAA, Medicare Advantage, Medicaid, anti-kickback laws, and state-specific requirements. Attorneys spend 12-20 hours drafting comprehensive provider agreements that balance payment terms, quality metrics, utilization management, and compliance obligations. Manual drafting risks missing critical regulatory provisions or creating inconsistencies between payment methodologies and operational requirements.

CaseMark generates complete managed care contracts with all required regulatory provisions, payment structures, and compliance frameworks in minutes. The AI analyzes your uploaded provider credentials, fee schedules, and existing agreements to create customized contracts that incorporate your organization's standards while ensuring HIPAA compliance, CMS guideline adherence, and state regulatory conformity. Every contract includes comprehensive definitions, utilization management procedures, quality reporting requirements, and dispute resolution mechanisms.

How it works

  1. 1. Upload your documents

  2. 2. AI analyzes and extracts key information

  3. 3. Review and customize the generated content

  4. 4. Export in your preferred format (DOCX, PDF)

What you get

  • Parties

  • Recitals and Purpose

  • Definitions

  • Services and Network Participation

  • Compensation and Reimbursement

  • Quality Assurance and Utilization Management

  • Term and Termination

  • Confidentiality and HIPAA Compliance

  • Indemnification and Insurance

  • Dispute Resolution and Governing Law

  • General Provisions

  • Signatures

What it handles

  • Parties

  • Recitals and Purpose

  • Definitions

  • Services and Network Participation

  • Compensation and Reimbursement

  • Quality Assurance and Utilization Management

  • Term and Termination

  • Confidentiality and HIPAA Compliance

  • Indemnification and Insurance

  • Dispute Resolution and Governing Law

  • General Provisions

  • Signatures

Required documents

  • Provider Information

    Provider credentials, licenses, NPI numbers, specialty certifications, and practice information

    .pdf, .docx, .txt

  • Managed Care Organization Details

    MCO legal name, insurance license, accreditation status, and service area information

    .pdf, .docx

Supporting documents

  • Existing Provider Agreements

    Prior managed care contracts to extract standard provisions and payment structures

    .pdf, .docx

  • Fee Schedules

    Payment rates for CPT/HCPCS codes and capitation rate tables

    .pdf, .xlsx, .csv

  • Medical Policies and Clinical Guidelines

    Utilization management criteria, prior authorization requirements, and quality metrics

    .pdf, .docx

  • State Regulatory Requirements

    State-specific managed care statutes, prompt payment laws, and network adequacy standards

    .pdf, .docx

  • Provider Manual

    Administrative procedures, billing requirements, and operational standards

    .pdf, .docx

  • Credentialing Materials

    Credentialing applications, recredentialing requirements, and verification procedures

    .pdf, .docx

Why teams use it

Generate complete managed care contracts in 12 minutes vs. 6+ hours manually

Automatic HIPAA compliance provisions and federal regulatory requirements

AI-powered research of state-specific managed care statutes and CMS guidelines

Consistent quality across all provider agreements with standardized terms

Built-in verification against AMA, Medicare, and state regulatory databases

Questions

How does CaseMark ensure the managed care contract complies with state-specific regulations?

CaseMark's AI is trained on managed care regulations across all 50 states, including prompt payment laws, network adequacy standards, and utilization review requirements. When you upload state regulatory guidance or specify your jurisdiction, the system incorporates applicable state-specific provisions including required notice periods, payment timelines, and external review procedures. The contract includes provisions that satisfy both federal requirements for Medicare Advantage and Medicaid managed care programs and state insurance laws governing commercial managed care.

Can the contract accommodate different payment methodologies like capitation and fee-for-service?

Yes, CaseMark generates contracts supporting any payment structure including fee-for-service with detailed fee schedules, capitation with per-member-per-month rates and risk adjustment, shared savings arrangements, bundled payments, and hybrid models. When you upload your fee schedules or payment rate tables, the AI incorporates them into comprehensive payment provisions that address rate updates, claims processing, payment reconciliation, and dispute resolution. The contract includes all necessary definitions and calculation methodologies for your chosen payment approach.

Does the contract include all required HIPAA business associate and privacy provisions?

Absolutely. Every managed care contract includes comprehensive HIPAA compliance provisions covering permitted uses and disclosures of protected health information for treatment, payment, and healthcare operations. The contract establishes business associate requirements for subcontractors, breach notification obligations, security safeguard requirements, and data retention standards. CaseMark ensures the privacy and security provisions align with the HIPAA Omnibus Rule and HITECH Act breach notification requirements while addressing state health information privacy laws that may provide greater protections.

How does the contract handle utilization management and prior authorization requirements?

The contract includes detailed utilization management provisions specifying which services require prior authorization, the process for submitting authorization requests, decision timeframes for urgent and non-urgent requests, and appeal procedures for adverse determinations. CaseMark incorporates your organization's medical policies and clinical criteria, establishes that qualified healthcare professionals make medical necessity decisions, and includes all procedural protections required by state utilization review laws and federal regulations for Medicare Advantage and Medicaid managed care programs.

Can I customize the quality metrics and HEDIS reporting requirements in the contract?

Yes, CaseMark allows complete customization of quality assurance provisions including HEDIS measures, patient satisfaction surveys, clinical outcome tracking, and accreditation standards. When you upload your quality program materials or specify required metrics, the AI incorporates them into comprehensive quality assurance provisions that establish provider participation obligations, data submission requirements, and performance improvement expectations. The contract balances quality accountability with provider autonomy and includes provisions for using quality data in network management decisions.

What termination and dispute resolution provisions are included in the contract?

The contract includes comprehensive termination provisions covering termination without cause with 90-180 day notice, termination for cause with immediate or 30-day notice for serious breaches, and automatic termination for triggering events like license loss or bankruptcy. Dispute resolution provisions establish a multi-tiered process starting with good faith negotiation, escalating to mediation, and culminating in binding arbitration for unresolved disputes. The contract specifies transitional care obligations, claims submission deadlines after termination, and survival of indemnification and confidentiality obligations beyond contract termination.

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