Common payor - provider contract language allowing Silent PPOs to thrive Common Contract LanguageContract less vulnerable to Silent PPO “Provider shall provide services to Members enrolled under a Benefit Plan….” “Benefit Plan: a plan for health care coverage that is sponsored, issued or administered by a Payor and contains the terms and conditions of a Member’s coverage.” “Benefit Plan: a plan for health care coverage that is sponsored, issued or administered by an Approved Payor and contains the terms and conditions of a Member’s coverage. Benefit Plans must satisfy the criteria set forth in §X.”* “Payor: An entity or person authorized by the Network Sponsor to access one or more networks of Participating Providers and that has the financial responsibility for payment for Covered Services under a Benefit Plan.” “Approved Payor: An entity authorized by the Provider to have access to the Provider’s Covered Services under this Agreement. Approved Payors must satisfy the criteria set forth in §Y and be listed on Exhibit Z.”*

Controlling Which Plans Access the Agreement Common Contract LanguageContract less vulnerable to Unintended Product Participation Provider Participation in Benefit Plans. Provider agrees to participate in and provide services to Members in all Benefit Plans or products that may be offered or administered by Payor from time to time. Provider Participation in Benefit Plans. Provider agrees to participate in and provide Covered Services to Members in Benefit Plans accepted by Provider as meeting the criteria in this Agreement and Attachments (“Provider’s Criteria”), including products that may be offered by the Payor after the Effective Date if the Provider determines such future products meet Provider’s Criteria. “Benefit Plan: a plan for health care coverage that is sponsored, issued or administered by a Payor and contains the terms and conditions of a Member’s coverage.” “Benefit Plan: a plan for health care coverage that is sponsored, issued or administered by an Approved Payor and that is determined by the Provider to satisfy the Provider’s Criteria.”

Sample Provider’s Criteria for Approved Benefit Plans Provider’s Criteria for Approved Benefit Plans I. Approved Benefit Plans: Provider will participate in the network established by Payor for the Benefit Plan types described below: Benefit Plans in which Members are offered a network and must select a Primary Care Physician. Such Benefit Plans may or may not include an out-of-network benefit. Self Insured Benefit Plans for which the Payor guarantees payment for Covered Services. … III. Excluded Plans: Provider will not participate in the network of physicians and other health care professionals and providers established by Payor for the Health Plan types described below: Discount Benefit Plans which do not provide an insured benefit or obligate a Payor to provide benefits from a self insured fund. Benefit Plans in which Members’ Covered Services are subject to lifetime caps of less than $1,000,000 …