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.
This workflow is applicable across multiple practice areas and use cases
During healthcare M&A transactions, managed care contracts are critical assets that must be reviewed, assigned, or renegotiated as part of the deal structure and due diligence process.
Healthcare M&A attorneys regularly need to draft, review, and modify managed care contracts when hospitals, medical groups, or health plans are acquired, as provider network agreements directly impact valuation and operational continuity.
Healthcare organizations require managed care contracts as part of their corporate governance framework to establish formal relationships with payers and ensure compliance with board-approved contracting policies.
In-house counsel and corporate governance teams at healthcare entities need standardized managed care contract templates to maintain consistent contracting practices and meet fiduciary duties in payer negotiations.
New healthcare entities, medical groups, and health plans need managed care contracts immediately upon formation to establish provider networks and begin operations with payer relationships in place.
Attorneys forming new healthcare businesses must draft initial managed care contracts as foundational documents to enable the entity to participate in insurance networks and generate revenue from day one.
Managed care contracts contain extensive HIPAA compliance and data privacy provisions that govern how protected health information is shared between providers and payers, requiring specialized privacy law expertise.
Privacy attorneys need to ensure managed care contracts include proper Business Associate Agreements, data breach notification procedures, and cybersecurity requirements that comply with HIPAA and state privacy laws.
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.
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.
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.
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.
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.
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.