Current through Register Vol. XLI, No. 38, September 20, 2024
6.1. A
health maintenance organization shall ensure that its network has sufficient numbers
and types of providers. The HMO shall have a written access plan outlining its
strategy for maintaining an adequate network and shall implement mechanisms designed
to assure the availability of primary care and specialty practitioners.
6.2. A health maintenance organization shall have
written policies and procedures for the credentialing of all providers that include
the original credentialing, recredentialing, recertification and or reappointment of
physicians and other licensed independent practitioners who fall under its scope of
authority and action.
a. The governing body, or
the group or individual to whom the governing body has formally delegated the
credentialing function, shall review and approve credentialing policies and
procedures.
b. A credentialing committee
or other peer review body shall be established to make recommendations regarding
credentialing decisions. The committee shall include providers, including but not
limited to physicians, as voting members.
6.3. In terms of initial credentialing, an HMO
shall obtain and review verification of the following from primary sources:
a. A current valid license to practice;
b. When applicable, clinical privileges in good
standing at the hospital designated by the practitioner as the primary admitting
facility;
c. A valid Drug Enforcement
Administration (DEA) certificate, as applicable;
d. Graduation from medical school or appropriate
graduate school and completion of a residency, specialty training and board
certification, as applicable;
e.
Complete work history;
f. Current
adequate malpractice insurance according to the HMO's policy;
g. Complete professional liability claims history;
and
h. Any other information deemed
necessary by the HMO in determining whether to contract with a prospective
provider.
6.4. A prospective
provider shall complete an application for membership which includes a statement by
the applicant regarding:
a. Reasons for any
inability to perform the essential functions of the position, with or without
accommodation;
b. Lack of substance
abuse or chemical dependency;
c. History
of loss of license and/or felony convictions;
d. History of loss or limitation of privileges or
disciplinary activity;
e. Any other
information deemed necessary by an HMO in determining whether to contract with a
prospective provider; and
f. An
attestation to the correctness/completeness of the application.
6.5. A health maintenance organization shall
request information on the prospective provider from recognized monitoring
organizations including: the National Practitioner Data Bank; the appropriate state
licensing boards such as the Board of Medicine, Chiropractic Board, Osteopathic
Board and/or Dental Board; and any Medicare/Medicaid sanctioning.
6.6. Representatives from the credentialing
committee or members of their staff shall make an initial visit to each potential
primary care practitioner's office and to the offices of obstetricians/gynecologists
and other high-volume specialists. This process shall include documentation of a
structured review of the site and of medical record keeping practices to ensure
conformance with the HMO's standards.
6.7. A health maintenance organization shall have
written policies and procedures for the initial and ongoing quality assessment of
health delivery organizations with which it intends to contract. The HMO shall
confirm that the health delivery organization has been reviewed and approved by a
recognized accrediting body and is in good standing with state and federal
regulatory bodies. If the health delivery organization has not been approved by a
recognized accrediting body, the HMO must develop and implement standards of
participation. Health delivery organizations shall include but are not limited to
hospitals, home health agencies, behavioral health agencies, nursing
homes, skilled nursing facilities and free-standing surgical centers.
a. At least every three years, the health
maintenance organization shall confirm that the health delivery organization
continues to be in good standing with the state and federal regulatory bodies and,
if applicable, is reviewed and approved by an accrediting body.
6.8. In terms of recredentialing, a health
maintenance organization shall develop a process for the periodic verification of
credentials which shall be implemented at least every three years.
a. At a minimum, recredentialing shall include
verification from primary sources of:
1. A valid
state license to practice;
2. Clinical
privileges in good standing at the hospital designated by the practitioner as the
primary admitting facility;
3. A valid
Drug Enforcement Administration (DEA) certificate, as applicable;
4. Board certification, as applicable;
5. Current, adequate malpractice
insurance;
6. Professional liability
claims history; and
7. Any other
information deemed necessary by an HMO in determining whether to re-contract with a
provider.
b. The
recredentialing process shall include a current statement by the applicant regarding
reasons for any inability to perform the essential functions of the position, with
or without accommodation and lack of present illegal drug use and alcohol
abuse.
c. An HMO shall request
recredentialing information from the National Practitioner Data Bank; the
appropriate state licensing boards such as the Board of Medicine, Chiropractic
Board, Osteopathic Board and/or Dental Board; and any Medicare/Medicaid
sanctioning.
d. The recredentialing
process shall also include a review of data from member complaints and grievances,
results of quality reviews, utilization management, member satisfaction surveys,
medical record reviews and site visits.
e. The recredentialing process shall include an
on-site visit to all primary care providers, obstetricians/ gynecologists and
high-volume specialists and shall involve documentation of a structured review of
the site and medical record keeping practices to ensure conformance with HMO
standards.
f. A health maintenance
organization shall have polices and procedures in place for reducing, suspending or
terminating practitioner privileges which shall include but is not limited to:
1. A mechanism for reporting to the appropriate
authorities serious quality deficiencies resulting in suspension or termination;
and
2. An appeal process for and notice
thereof to the provider.
