In-network provider: Which document does the auditor review to determine the provider's obligations?

In-network provider: Which document does the auditor review to determine the provider's obligations?

• A. The contract between payer and provider
• B. The provider's license
• C. The payer's marketing materials
• D. The patient's medical record

Answer: (A)

In-network provider obligations come from the contract between the payer and the provider. The auditor reviews this contract to confirm what the provider is required to do, what services are covered, the negotiated payment terms, billing rules, preauthorization and documentation requirements, credentialing standards, and other network duties. The provider’s license shows they’re legally allowed to practice but doesn’t define network obligations. Marketing materials aren’t binding for claims or payment terms, and the patient’s medical records document clinical care, not contractual duties with the payer. So the contract between payer and provider is the document that sets the provider’s obligations within the network.

In-network provider obligations come from the contract between the payer and the provider. The auditor reviews this contract to confirm what the provider is required to do, what services are covered, the negotiated payment terms, billing rules, preauthorization and documentation requirements, credentialing standards, and other network duties. The provider’s license shows they’re legally allowed to practice but doesn’t define network obligations. Marketing materials aren’t binding for claims or payment terms, and the patient’s medical records document clinical care, not contractual duties with the payer. So the contract between payer and provider is the document that sets the provider’s obligations within the network.