Provider Credentialing Clause Samples

Provider Credentialing. The Contractor shall have written credentialing and re-credentialing policies and procedures for ensuring quality of care is maintained or improved and assuring that all contracted providers hold current state licensure and enrollment in the IHCP. The Contractor’s credentialing and re-credentialing process for all contracted providers shall meet the National Committee for Quality Assurance (NCQA) guidelines. The same provider credentialing standards must apply across all Indiana Medicaid programs. The Contractor shall use OMPP’s standard provider credentialing form during the credentialing process. The Contractor must ensure that providers agree to meet all of FSSA’s and the Contractor’s standards for credentialing PMPs and specialists, and maintain IHCP manual standards, including:  Compliance with state record keeping requirements;  FSSA’s access and availability standards; and  Other quality improvement program standards. As provided in 42 CFR 438.214(c), which prevents discrimination in provider selection, the Contractor’s provider credentialing and selection policies shall not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. The Contractor shall not employ or contract with providers that have been excluded from participating in federal health care programs under Section 1128 or Section 1128A of the Social Security Act. The Contractor shall notify OMPP, in the manner prescribed by the State, of any credentialing applications that are denied due to program integrity related reasons. The Contractor shall process all credentialing applications within thirty (30) calendar days of receipt of a complete application. If the Contractor delegates credentialing functions to a delegated credentialing agency, the Contractor shall ensure all credentialed providers are loaded into the Contractor’s provider files and claims system within fifteen (15) calendar days of receipt from the delegated entity. The contractors credentialing and recredentialing process, policies and procedures must be demonstrated in readiness review. The State intends to implement a centralized model for provider enrollment and credentialing. Upon implementation the Contractor shall accept the FSSA enrollment and credentialing determinations as final. The Contractor shall not require providers to submit supplemental information for purposes of conducting an additional credentialing process. Contractor may n...

Provider Credentialing. The PIHP shall have written credentialing policies and procedures for ensuring that all providers rendering services to individuals are appropriately credentialed within the state and are qualified to perform their services. Credentialing shall take place every two years. The PIHP must ensure that network providers residing and providing services in bordering states meet all applicable licensing and certification requirements within their state. The PIHP also must have written policies and procedures for monitoring its providers and for sanctioning providers who are out of compliance with the PIHP's standards.

Provider Credentialing. Beyond requires that each Beyond PPO ----------------------- Network Provider meet specific participation and credentialing criteria in order to participate in the Beyond PPO Network.

Provider Credentialing. The Contractor shall have written credentialing and re-credentialing policies and procedures for ensuring quality of care is maintained or improved and assuring that all contracted providers hold current state licensure and enrollment in the IHCP. The Contractor’s credentialing and re- credentialing process for all contracted providers shall meet the National Committee for Quality Assurance (NCQA) guidelines. The same provider credentialing standards must apply across all Indiana Medicaid programs.

Provider Credentialing. Contractor shall perform, or may delegate activities related to, credentialing and re-credentialing Participating Providers in accordance with a process reviewed and approved by State Regulators.

Provider Credentialing. ‌ Insurer shall establish and follow policies and procedures for credentialing and recredentialing Providers. Such policies and procedures shall, at a minimum, comply with the uniform credentialing and recredentialing policy adopted by FHKC. Insurer may adopt credentialing and recredentialing policies and procedures that are more robust than FHKC’s uniform credentialing and recredentialing policy requires. In the event Insurer terminates a contract or declines to contract with a Provider or Provider group, Insurer shall provide FHKC and affected Providers with written notice of the reason for Insurer’s decision.

Provider Credentialing. Provider agrees that he/she/it meets all applicable Anthem credentialing standards and any other applicable standards of participation for Networks in which Provider participates. A description of the credentialing program or applicable standards of participation, including any applicable accreditation requirements, is set forth in the provider manual(s).

Provider Credentialing. Before any provider may become part of the contractor's network, that provider shall be credentialed by the contractor. The contractor must comply with Standard IX of NJ modified QARI/QISMC (Section B.4.14 of the Appendices). Additionally, the contractor's credentialing procedures shall include verification that providers and subcontractors have not been suspended, debarred, disqualified, terminated or otherwise excluded from Medicaid, Medicare, or any other federal or state health care program. The contractor shall obtain federal and State lists of suspended/debarred providers from the appropriate agencies.

Provider Credentialing a. Provider will submit to and abide by the CMO’s Credentialing programs with respect to Provider’s application for and continued participation in the CMO provider network. To the extent Provider operates a facility that provides services subject to review and accreditation by a recognized accrediting body under the CMO’s then-current credentialing requirements, Provider shall obtain and maintain such accreditation at all times during the term of this addendum. b. Provider shall notify the CMO within ten (10) business days following Provider’s receipt of any notice regarding an adverse action related to any restrictions upon, or any suspension, loss or surrender of, any professional license, certification or registration; privileges; Drug Enforcement Administration provider number; or any other action that impacts Provider’s ability to render Covered Services. In the case of a Provider who operates a facility, this requirement shall apply to any adverse action related to any restrictions upon, or any suspension or loss of, the provider’s accreditation as required under the CMO’s then-current credentialing requirements. c. Subject to applicable law, State Contract, and the Care Select Program requirements, this addendum shall immediately terminate upon any such expiration, surrender, revocation, restriction, or suspension as described in this section.