South Atlantic Medical Group’s Provider Network Operations (PNO) department serves as a liaison between contracted providers and HMOs. Services include advising providers of new policies and procedures, recommending best practices, answering questions, and assisting with issue resolution. Another key function revolves around provider activation and directory reconciliation which includes facilitating new provider training. PNO also supports provider contracting to ensure network specialty access is maintained.

Our PNO team has the collective healthcare industry and other related knowledge to build new networks and expand existing networks. They assist with contract management and analysis to establish and maintain comprehensive network and tertiary level specialty panels while supporting Primary Care Physicians (PCPs).

Application Process

All applicants will be considered for participation with South Atlantic Medical Group (SAMG) when a formal request is submitted. All criteria and verification requirements must meet compliance standards, including copies of pertinent documentation, properly signed applications, attestations, and attachments. Any missing information or failure to meet minimal requirements will result in requests for further information and may lead to denial or termination.

South Atlantic Medical Group will identify and investigate any non-compliance with credentialing requirements. Every attempt will be made to accommodate the applicant by meeting South Atlantic Medical Group’s credentialing requirements. If delegated to process behavioral health providers, South Atlantic Medical Group will comply with AB2581 to notify applicants within seven (7) business days to acknowledge receipt and inform the applicant whether the application is complete.

Geographic Standards – Availability & Adequacy

It is South Atlantic Medical Group, IPA (SAMG) goal to review and monitor the Specialty Provider Networks in order to ensure adequate access to qualified specialty care and in-patient services are geographically available to all SAMG members.

Participating Provider availability and accessibility standards are as follows:

1. To offer an adequate number and type of contracted or participating providers to meet the health needs of SAMGs enrollees.
2. To offer a network of participating providers that is geographically accessible to SAMGs enrollees.
3. The standards are found at 42 CFR 422.112(a)(10) and require a new or expanding Medicare Advantage coordinated care plan to show that it meets “prevailing community pattern of health care delivery” within its proposed service area.  CMS will make this determination using the following factors:
   1. The total number and location of providers eligible and available to contract with the plan in the plan’s proposed service area.
   2. The prevailing market conditions in the plan’s service area (how many available providers contract with other commercial and Medicare plans in the plan’s service area?)
   3. Whether the service area is rural, urban or some combination of the two. 
   4. Whether the MA plan’s proposed network meets Medicare time and distance standards; and
   5. Other factors that CMS determines are relevant for an acceptable health care delivery network in a particular service area

Non contracted providers/OON

1. South Atlantic Medical Group may use nonphysician medical practitioners to meet network expectations.
2. In cases where South Atlantic Medical Group is unable to meet time or distance standards to a core specialist, South Atlantic Medical Group will assist any requesting member in obtaining an appointment with an appropriate OON primary and core specialty provider, in accordance with APL 21-006, in person or via telehealth, when contracted for those services.
3. When assisting the member, South Atlantic Medical Group must make their best effort to establish a member‑specific case agreement with an OON core specialist at the Medi-Cal Managed Care fee-for-service or a mutually agreed upon rate, unless South Atlantic Medical Group has already attempted to establish a member‑specific case agreement with the OON core specialist in the magreement.t fiscal year, and the core specialist has refused to enter into an agreement:
   1. South Atlantic Medical Group’s UM and Claims departments will initiate an MOU (Memorandum of Understanding) to providers of health care service who are non-contracted or out network with South Atlantic Medical Group (SAMG) for the rendering of care when a member in need of a referral to a non-contracted provider that is geographically accessible to the member. (see PNO 10_Agreements with Non-Contracted Providers for process).
   2. If this cannot be arranged, South Atlantic Medical Group must arrange for an appointment with an in‑network provider that is geographically accessible to the member.
4. The OON primary and core specialty provider must be able to provide services to a member within the applicable time or distance and timely access standards and, in cases where the OON primary and core specialty provider are not able to provide services to a member under these standards, South Atlantic Medical Group must arrange for nonemergency medical transportation or nonmedical transportation.
5. South Atlantic Medical Group is responsible for authorizing OON access to medically necessary providers within timely access standards and applicable time or distance standards, regardless of associated transportation or provider cost.