Current through Register Vol. 35, No. 18, September 24, 2024
The MCO shall verify that each contracted or subcontracted
provider participating in, or employed by the MCO meets applicable federal and
state requirements for licensing, certification, accreditation and
re-credentialing for the type of care or services within the scope of practice
as defined by federal medicaid statues and state law. The MCO shall verify that
billing providers, rendering providers, ordering providers, attending
providers, and prescribing providers are enrolled with MAD, unless the services
or providers are otherwise exempted by MAD. The MCO shall document the
mechanism for credentialing and re-credentialing of a provider with whom it
contracts or employs to treat its members outside the inpatient setting and who
fall under its scope of authority. The documentation shall include, but not be
limited to, defining the provider's scope of practice, the criteria and the
primary source verification of information used to meet the criteria, the
process used to make decisions, and the extent of delegated credentialing or
re-credentialing arrangements. The credentialing process shall be completed
within 45 calendar days from receipt of completed application with all required
documentation unless there are extenuating circumstances. The MCO shall use the
HSD approved primary source verification entity or one entity for the
collection and storage of provider credentialing application information unless
there are more cost effective alternatives approved by HSD. The MCO must load
provider contracts and claims systems must be able to recognize the provider as
a network provider no later than 45 calendar days after a provider is
credentialed, when required.
A.
Practitioner participation: The MCO shall have a process for receiving input
from participating providers regarding credentialing and re-credentialing of
its providers.
B. Primary source
verification: The MCO shall verify the following information from primary
sources during its credentialing process:
(1)
a current valid license to practice;
(2) the status of clinical privileges at the
institution designated by the practitioner as the primary admitting facility,
if applicable;
(3) valid drug
enforcement agency (DEA) or controlled substance registration (CSR)
certificate, if applicable;
(4)
education and training of practitioner including graduation from an accredited
professional program and the highest training program applicable to the
academic or professional degree, discipline and licensure of the
practitioner;
(5) board
certification if the practitioner states on the application that he or she is
board certified in a specialty;
(6)
current, adequate malpractice insurance, according to the MCOs policy and
history of professional liability claims that resulted in settlement or
judgment paid by or on behalf of the practitioner; and
(7) primary source verification shall not be
required for work history.
C. Credentialing application: The MCO shall
use the HSD approved credentialing form. The provider shall complete a
credentialing application that includes a statement by him or her regarding:
(1) ability to perform the essential
functions of the positions, with or without accommodation;
(2) lack of present illegal drug
use;
(3) history of loss of license
and felony convictions;
(4) history
of loss or limitation of privileges or disciplinary activity;
(5) sanctions, suspensions or terminations
imposed by medicare or medicaid; and
(6) applicant attests to the correctness and
completeness of the application.
D. External source verification: Before a
practitioner is credentialed, the MCO shall receive information on the
practitioner from the following organizations and shall include the information
in the credentialing files:
(1) national
practitioner data bank, if applicable to the practitioner type;
(2) information about sanctions or
limitations on licensure from the following agencies, as applicable:
(a) state board of medical examiners, state
osteopathic examining board, federation of state medical boards or the
department of professional regulations;
(b) state board of chiropractic examiners or
the federation of chiropractic licensing boards;
(c) state board of dental
examiners;
(d) state board of
podiatric examiners;
(e) state
board of nursing;
(f) the
appropriate state licensing board for other practitioner types, including
behavioral health; and
(g) other
recognized monitoring organizations appropriate to the practitioner's
discipline;
(3) a health
and human services (HHS) office of inspector general (OIG) exclusion from
participation on medicare, medicaid, the children's health insurance plan
(CHIP), and all federal health care programs (as defined in Section 1128B(f) of
the Social Security Act), and sanctions by medicare, medicaid, CHIP or any
federal health care program.
E. Evaluation of practitioner site and
medical records: The MCO shall perform an initial visit to the offices of a
potential PCP, obstetrician, and gynecologist, and shall perform an initial
visit to the offices of a potential high volume behavioral health care
practitioner prior to acceptance and inclusion as a contracted provider. The
MCO shall determine its method for identifying high volume behavioral health
practitioners.
(1) The MCO shall document a
structured review to evaluate the site against the MCO's organizational
standards and those specified by the HSD managed care contract.
(2) The MCO shall document an evaluation of
the medical record keeping practices at each site for conformity with the MCO's
organizational standards.
F. Re-credentialing: The MCO shall have
formalized re-credentialing procedures.
(1)
The MCO shall re-credential its providers at least every three years. The MCO
shall verify the following information from primary sources during
re-credentialing:
(a) a current valid license
to practice;
(b) the status of
clinical privileges at the hospital designated by the practitioner as the
primary admitting facility;
(c)
valid DEA or CSR certificate, if applicable;
(d) board certification, if the practitioner
was due to be recertified or became board certified since last credentialed or
re-credentialed;
(e) history of
professional liability claims that resulted in settlement or judgment paid by
or on behalf of the practitioner; and
(f) a current signed attestation statement by
the applicant regarding:
(i) ability to
perform the essential functions of the position, with or without
accommodation;
(ii) lack of current
illegal drug use;
(iii) history of
loss or limitation of privileges or disciplinary action; and
(iv) current professional malpractice
insurance coverage.
(2) There shall be evidence that, before
making a re-credentialing decision, the MCO has received information about
sanctions or limitations on licensure from the following agencies, if
applicable:
(a) the national practitioner data
bank;
(b) medicare and
medicaid;
(c) state board of
medical examiners, state osteopathic examining board, federation of state
medical boards or the department of professional regulations;
(d) state board of chiropractic examiners or
the federation of chiropractic licensing boards;
(e) state board of dental
examiners;
(f) state board of
podiatric examiners;
(g) state
board of nursing;
(h) the
appropriate state licensing board for other provider types;
(i) other recognized monitoring organizations
appropriate to the provider's discipline; and
(j) HHS/OIG exclusion from participation in
medicare, medicaid, CHIP and all federal health care programs.
(3) The MCO shall incorporate data
from the following sources in its re-credentialing decision making process for
its providers:
(a) member grievances and
appeals;
(b) information from
quality management and improvement activities; and
(c) medical record reviews conducted under
Subsection E this Section.
G. Imposition of remedies: The MCO shall have
policies and procedures for altering the conditions of the provider's
participation with the MCO based on issues of quality of care and service.
These policies and procedures shall define the range of actions that the MCO
may take to improve the provider's performance prior to termination:
(1) The MCO shall have procedures for
reporting to appropriate authorities, including HSD, serious quality
deficiencies that could result in a practitioner's suspension or
termination.
(2) The MCO shall have
an appeal process by which the MCO may change the conditions of a
practitioner's participation based on issues of quality of care and service.
The MCO shall inform providers of the appeal process in writing.
H. Assessment of organizational
providers: The MCO shall have written policies and procedures for the initial
and ongoing assessment of organizational providers with whom it intends to
contract or which it is contracted. At least every three years, the MCO shall:
(1) confirm that the provider has been
certified by the appropriate state certification agency, when applicable;
behavioral health organizational providers and services are certified by the
following;
(a) the department of health (DOH)
is the certification agency for organizational services and providers that
require certification, except for child and adolescent behavioral health
services; and
(b) the children,
youth and families department (CYFD) is the certification agency for child and
adolescent behavioral health organizational services and providers that require
certification; and
(2)
confirm that the provider has been accredited by the appropriate accrediting
body or has a detailed written plan expected to lead to accreditation within a
reasonable period of time; behavioral health organizational providers and
services are accredited by the following:
(a)
adult behavioral health organizational services or providers are accredited by
the council on accreditation of rehabilitation facilities (CARF);
(b) child and adolescent accredited
residential treatment centers are accredited by the joint commission (JC);
other child behavioral health organizational services or providers are
accredited by the council on accreditation (COA); and
(c) organizational services or providers who
serve adults, children and adolescents are accredited by either CARF or
COA.
