Current through all regulations passed and filed through September 16, 2024
In accordance with the federal
credentialing standards found in
42 CFR
422.204, "provider selection and
credentialing" (as in effect on October 1, 2021), this rule details the
credentialing and recredentialing process for medicaid providers.
(A)
For purposes of
this rule, the following definitions apply.
(1)
"Council for
affordable quality healthcare (CAQH)" is a non-profit organization which
created a process allowing ODM to use a single, uniform application for
credentialing. This end-to-end process simplifies data collection, primary
source verification, and sanctions monitoring, to support ODM's credentialing
needs.
(2)
"Credentialing" means an evaluation of the
qualifications of health care providers that seek contracts or participation
agreements with ODM.
(3)
"Credentialing committee" means the group of
individuals appointed by ODM for provider and facility review, as well as
reconsidering providers and facilities initially denied by credentialing as
described in paragraph (K) of this rule.
(4)
"Delegate" means
a hospital group or physician hospital organization formed by a hospital and
group of physicians granted the authority by ODM to credential its health care
providers who require credentialing.
(5)
"Delegation"
means the act of ODM granting another health care entity the authority to
credential its health care providers who require credentialing.
(6)
"Designee" means
a third party with whom ODM has contracted to complete certain credentialing
related administrative tasks and information gathering tasks required to
fulfill credentialing and re-credentialing for those providers whose
credentialing is not completed through the process of delegation;
and
(7)
"Eligible provider" has the same meaning as a person or
entity who is an eligible provider as defined in rule
5160-1-17 of the Administrative
Code who is enrolled with ODM.
(B)
Credentialing by
ODM is mandatory for the following practitioners:
(1)
Physicians as
defined in Chapter 4731. of the Revised Code;
(2)
Psychologists as
defined in Chapter 4732. of the Revised Code;
(3)
Physician
assistant as defined in Chapter 4730. of the Revised Code;
(4)
Dentists as
defined in Chapter 4715. of the Revised Code;
(5)
Optometrists as
defined in Chapter 4725. of the Revised Code;
(6)
Pharmacists as
defined in Chapter 4729. of the Revised Code;
(7)
Chiropractors as
defined in Chapter 4734. of the Revised Code;
(8)
Acupuncturists as
defined in Chapter 4762. of the Revised Code;
(9)
Clinical nurse
specialist, certified nurse-midwife, or certified nurse practitioner as defined
in Chapter 4723. of the Revised Code;
(10)
Licensed
independent social worker, licensed independent marriage and family therapist,
or licensed professional clinical counselor as defined in Chapter 4757. of the
Revised Code;
(11)
Licensed independent chemical dependency counselor as
defined in Chapter 4758. of the Revised Code;
(12)
Certified Ohio
behavior analysts as defined in Chapter 4783. of the Revised
Code;
(13)
Audiologists as defined in Chapter 4753. of the Revised
Code;
(14)
Occupational therapist as defined in Chapter 4755. of
the Revised Code;
(15)
Physical therapist as defined in Chapter 4755. of the
Revised Code;
(16)
Speech-language pathologist as defined in Chapter 4753.
of the Revised Code; and
(17)
Dietitians as defined in Chapter 4759. of the Revised
Code.
(C)
Credentialing by ODM is mandatory for the following
facilities:
(1)
Nursing facilities as defined in Chapter 5165. of the
Revised Code;
(2)
Hospitals as defined in Chapter 3727. of the Revised
Code;
(3)
Hospice as defined in Chapter 3721. of the Revised
Code;
(4)
Home health agencies as defined in rule
3701-60-01 of the Administrative
Code;
(5)
Ambulatory surgical facilities as defined in section
3702.30 of the Revised
Code;
(6)
Community mental health services providers as defined
in Chapter 5119. of the Revised Code;
(7)
Community
addiction services providers as defined in Chapter 5119. of the Revised
Code;
(8)
End stage renal disease (ESRD) treatment centers as
described in rule
3701-83-23.1 of the
Administrative Code;
(9)
Radiology centers as described in rule
3701-83-51 of the Administrative
Code; and
(10)
Residential facility as defined in Chapter 5119. of the
Revised Code.
(D)
Credentialing by ODM is not mandatory for the following
practitioners:
(1)
Health care professionals who are permitted to provide
services only under the direct supervision of an independently enrolled
practitioner as defined in rule
5160-4-02 of the Administrative
Code;
(2)
Hospital-based health care professionals who provide
services "incidental-to" a hospital service and are not independently
enrolled;
(3)
Health care professionals who are designated as current
residents, interns, or fellows as defined in Chapter 5160-4 of the
Administrative Code; and
(4)
Moonlighting residents as defined in
42 CFR
415.208 (as in effect on October 1,
2021).
(E)
Those providers listed in paragraph (B) of this rule
will provide ODM or ODM's credentialing designee the following information for
initial credentialing verification:
(1)
Access to the standard provider credentialing
application form used by the council for affordable quality healthcare (CAQH)
in accordance with section
3963.05 of the Revised Code
within one-hundred-eighty days prior to credentialing date;
(2)
Active provider
licensing information;
(3)
Board certification, if applicable;
(4)
Education;
(5)
Clinical
privileges, if applicable;
(6)
Medical
malpractice insurance;
(7)
Drug enforcement administration (DEA) certification, if
applicable;
(8)
National practitioner data bank information regarding
malpractice and clinical privilege actions;
(9)
Sanctions or
limitations on licensure;
(10)
Eligibility for
participation in medicare and medicaid, if applicable; and
(11)
Minimum
five-year work history. The five-year timeframe begins with date of initial
licensure. If the provider has been licensed for less than five years,
available work history should be provided.
(F)
The facilities
listed in paragraph (C) of this rule will provide ODM or ODM's credentialing
designee access to the following information for initial credentialing
verification:
(1)
The Ohio department of insurance (ODI) form INS5036,
revision date February of 2021, found at
https://insurance.ohio.gov/static/Forms/Documents/INS5036.pdf;
(2)
Active provider licensing information;
(3)
Certification
through an accrediting body or a site visit completed by a state designated
agency;
(4)
Eligibility for participation in medicare and medicaid,
if applicable;
(5)
Verification of good standing with applicable state and
federal bodies; and
(6)
Active malpractice insurance.
(G)
Prerequisites for becoming a delegate as defined in
paragraph (A)(4) of this rule are the following:
(1)
Maintain an
active, valid delegation contract approved by the credentialing
committee;
(2)
The delegate has to complete a pre-delegation audit
prior to their becoming an active delegate;
(3)
The delegate has
to adhere to the standards set forth in the delegated contract, including the
time frames and content for reporting, duties assigned, necessary processes and
procedures, and collaborating of a yearly audit;
(4)
The delegate has
to have their own credentialing committee, with decision making capabilities,
and delegation contract monitoring;
(5)
The delegate has
to report any additions, changes, and terminations in a timely manner including
both credentialed and non-credentialed practitioners and
facilities;
(6)
Delegates will be audited by ODM every twelve months;
and
(7)
Practitioners with a delegated group understand they
are still expected to update their information in the provider data system, and
to revalidate according to their ODM determined schedule.
(H)
Every
thirty-six months, those providers listed in paragraph (B) of this rule will
provide ODM or ODM's credentialing designee information listed in paragraphs
(E)(1) to (E) (10) of this rule for recredentialing.
(I)
Every thirty-six
months, facilities listed in paragraph (C) of this rule will provide ODM or
ODM's credentialing designee the information listed in paragraphs (F)(1) to
(F)(6) of this rule for recredentialing verification.
(J)
The following
information may be requested by the state or its designee from providers or
facilities as listed in paragraph (B) or (C) of this rule at any time during
the credentialing or recredentialing process:
(1)
Demographic
information;
(2)
Information missing in CAQH;
(3)
Verification of
certifying board names;
(4)
Explanation for work history gaps;
(5)
Updates regarding
expired information;
(6)
Verification of specialty information;
(7)
Information
regarding previous sanctions or affirmative responses to CAQH disclosure
questions; and
(8)
Continuing education (CE) prerequisites as required by
the provider's state licensing board.
(K)
ODM will
establish and utilize a credentialing committee for provider and facility
review and appeals when the credentialing prerequisites specified in paragraph
(K) (1) of this rule are under review. The credentialing committee will follow
the process described in this paragraph when a provider or facility is found to
be non-compliant with the credentialing prerequisites.
(1)
Providers or
facilities that fail to meet the following prerequisites, have a discrepancy,
or negative findings with the information provided in paragraph (E) or (F) of
this rule, are subject to review by the state established credentialing
committee. Prerequisites are the following:
(a)
Previous
licensing board sanctions;
(b)
Previous clinical
actions taken by a medical group or hospital;
(c)
Affirmative
responses to CAQH disclosure questions, with the exception of the following
CAQH questions:
(i)
To your knowledge, has information pertaining to you
ever been reported to the national practitioner data bank (NPDB) or healthcare
integrity and protection data bank (HIPDB)?
(ii)
Have you had any
professional liability actions (pending, settled, arbitrated, mediated or
litigated) within the past ten years? And if yes, provide information for each
case.
(d)
Excessive malpractice claims within the past ten years,
as defined by the credentialing committee;
(e)
Inappropriate
training or education for disclosed provider specialty;
(f)
Previous medicare
or medicaid disbarments or actions;
(g)
Site visit
non-compliance;
(h)
Previous DEA actions;
(i)
Material
misrepresentation or omission concerning professional credentials;
and
(j)
Prior criminal history in accordance with rule
5160-1-17.8 of the
Administrative Code.
(2)
The following
individuals will participate in the ODM credentialing committee as determined
by ODM. Voting members are expected to attend no less than seventy-five per
cent of all meetings held to maintain voting rights, and sign
non-discrimination and conflict of interest forms.
(a)
Committee
chair;
(b)
Community-based peers of providers requiring
credentialing as defined in paragraph (B) of this rule;
(c)
Managed care
organization representatives;
(d)
Medical
directors; and
(e)
Staff from ODM and ODM's designee.
(3)
The
credentialing committee members will carry out the following
responsibilities:
(a)
Review the credentials of
practitioners;
(b)
Review and approve sanctions
monitoring;
(c)
Review and approve delegated audits, contracts, and
agreements; and
(d)
Review and approve credentialing reports from ODM and
ODM's designee.
(4)
When a provider
or facility is denied by the credentialing committee, the following process
will occur.
(a)
The provider or facility is sent a denial letter by ODM
outlining the unmet credentialing prerequisites or negative findings under
review, and their appeal rights and instructions for
proceeding;
(b)
The provider or facility will have no more than thirty
calendar days to appeal to the credentialing committee;
(c)
The appellant
provides the credentialing committee with supplemental information which
supports its appeal of the decision;
(d)
Appeal decision
is rendered by the credentialing committee; and
(e)
Credentialing
committee decisions on appeals are final, and those providers and facilities
denied by the credentialing committee are not subject to reconsideration as
found in paragraph (D) of rule
5160-70-02 of the Administrative
Code. The practitioners denied by the credentialing committee are denied ODM
enrollment.
(L)
Providers and
facilities who do not have any negative findings regarding the information
needed for initial credentialing verification or recredentialing listed in
paragraph (E) or (F) of this rule and meet the prerequisites listed in
paragraph (K)(1) of this rule are considered to have a clean file and have met
the requirements for credentialing with ODM. Providers and facilities with
clean files and no negative findings will not meet with the credentialing
committee unless otherwise determined by ODM and ODM's designee. Clean files
for initial credentialing and recredentialing will have a final review by ODM's
medical director.
