Current through Register Vol. XLI, No. 38, September 20, 2024
7.1. A
prepaid limited health service organization shall ensure that its network has
sufficient numbers and types of providers. The PLHSO shall have a written access
plan outlining its strategy for maintaining an adequate network and shall implement
mechanisms designed to assure the availability of coordinating providers.
7.2. A prepaid limited health service organization
shall have written policies and procedures for the credentialing of all providers
that include the original credentialing, recredentialing, recertification and
reappointment of providers 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, coordinating
providers and physicians, as voting members.
7.3. In terms of initial credentialing, a PLHSO
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 institution designated by the provider 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 PLHSO's policy;
g. Complete professional liability claims history;
and
h. Any other information deemed
necessary by the PLHSO in determining whether to contract with a prospective
provider.
7.4. 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 present
illegal drug use and alcohol abuse;
c.
History of loss of license or felony convictions;
d. History of loss or limitation of privileges or
disciplinary activity;
e. Any other
information deemed necessary by a PLHSO in determining whether to contract with a
prospective provider; and
f. An
attestation to the correctness and completeness of the application.
7.5. A prepaid limited health service
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, the Board of
Social Work Examiners, the Board of Examiners of Psychologists, the Board of
Examiners in Counseling; and any Medicare/Medicaid sanctioning.
7.6. Representatives from the credentialing
committee or members of their staff shall make an initial visit to the office of
each coordinating provider. This process shall include documentation of a structured
review of the site and of treatment record keeping practices to ensure conformance
with the PLHSO's standards.
7.7. A
prepaid limited health service 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 PLHSO shall confirm that the
health delivery organization has been reviewed and approved by a recognized
accrediting body, if appropriate, 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 PLHSO must develop and implement standards of
participation. Health delivery organizations shall include, but are not limited to,
facilities providing mental health or substance abuse services in an inpatient,
residential or ambulatory setting.
a. At least
every three years, the prepaid limited health service 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.
7.8. In
terms of recredentialing, a prepaid limited health service organization shall
develop a process for the periodic verification of credentials which shall be
implemented at least every two 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
institution designated by the provider 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 a PLHSO 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. A PLHSO shall request
recredentialing information from the National Practitioner Data Bank; the
appropriate State licensing boards such as the Board of Medicine, the
Board of Social Work Examiners, the Board of Examiners of Psychologists, the Board
of Examiners in Counseling; and any Medicare/Medicaid sanctioning.
d. The recredentialing process shall also include
a review of data from member complaints andgrievances, results of quality reviews,
utilization management, member satisfaction surveys, treatment record reviews and
site visits.
e. The recredentialing
process shall include an on-site visit to all high-volume coordinating providers and
shall involve documentation of a structured review of the site and treatment record
keeping practices to ensure conformance with PLHSO standards.
f. A prepaid limited health service organization
shall have polices and procedures in place for reducing, suspending or terminating
provider 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.
