Code of Massachusetts Regulations
211 CMR - DIVISION OF INSURANCE
Title 211 CMR 52.00 - Managed Care Consumer Protections And Accreditation Of Carriers
Section 52.09 - Credentialing

Universal Citation: 211 MA Code of Regs 211.52

Current through Register 1531, September 27, 2024

(1) A Carrier will credential all Health Care Providers according to the NCQA Standards for credentialing and recredentialing, and the Bureau of Managed Care will review a Carrier's credentialing and recredentialing processes that are set forth in the Carrier's application for Accreditation for compliance with the applicable NCQA Standards for credentialing and recredentialing if the Carrier does not have Deemed Accreditation with respect to credentialing and recredentialing.

(2) Credentialing of Health Care Professionals.

(a) A Carrier shall accept, in both electronic and paper form, a Health Care Professional credentialing application that is submitted in an application format specified by the Commissioner. For purposes of 211 CMR 52.09(2), acceptance in electronic form shall mean that a Carrier, at minimum, shall accept a Health Care Professional credentialing application by means of facsimile and electronic mail and may implement an online process for the purpose of processing credentialing applications. For purposes of 211 CMR 52.09(2),Carriers may charge Health Care Professionals a reasonable administrative charge associated with the costs of processing submissions in electronic or paper form that differs from the form used by the majority of Health Care Professionals

(b) Unless there are otherwise binding arrangements between a Carrier and specific Providers holding Carriers to a shorter time standard, a Carrier shall notify a Health Care Professional that a submitted credentialing application is incomplete no later than 20 business days after the Carrier receives the credentialing application.

(c) All Carriers shall complete credentialing of 95% of Health Care Professionals' initial Clean and Complete Credentialing Applications within 60 Days of receipt of the Health Care Professional's Clean and Complete Credentialing Application, and all Carriers shall complete credentialing of 95% of Health Care Professionals' Clean and Complete re-Credentialing Applications within 120 Days of receipt of the Health Care Professional's Clean and Complete re-Credentialing Application, and Carriers shall inform a Health Care Professional within 75 Days of receipt of an initial Clean and Complete Credentialing Application of the status of the application, including, if applicable, the reasons for any delay in the completion of credentialing and a timeline of the expected resolution of the application and, if a Health Care Professional is not credentialed, the reasons that the Health Care Professional is not credentialed.

(3) Nothing in this 211 CMR 52.09 shall be construed to prevent a Carrier from utilizing additional credentialing information in selecting the Providers with which it contracts.

(4) Nothing in this 211 CMR 52.09 shall be construed to require a Carrier to select a Provider as a Participating Provider, even if the Provider meets the Carrier's credentialing criteria.

(5) Carriers shall maintain documentation regarding all submissions.

(6) A Carrier shall not be required to meet the requirements of 211 CMR 52.09 if the Carrier does not provide Benefits through a Network or does not have contracts with Participating Providers.

(7) A Carrier that provides specified services through a workers' compensation preferred Provider arrangement shall be deemed to have met the requirements of 211 CMR 52.09 if it has met the requirements of 211 CMR 51.00: Preferred Provider Health Plans and Workers' Compensation Preferred Provider Arrangements and 452 CMR 6.00: Utilization Review and Quality Assessment.

(8) Nothing in 211 CMR 52.09 shall be construed to prevent a Carrier from implementing time lines that are more stringent than otherwise provided in 211 CMR 52.09.

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