Provider Credentialing and Recredentialing Clause Samples
Provider Credentialing and Recredentialing. The Contractor shall conduct Credentialing and Recredentialing in compliance with National Committee for Quality Assurance standards (NCQA), KRS 205.560(12), 907 KAR 1:672 or other applicable state regulations and federal law. The Contractor shall document the procedure, which shall comply with the Department’s current policies and procedures, for credentialing and recredentialing of providers with whom it contracts or employs to treat Members. Detailed documentation and scope of the Credentialing and Recredentialing process is contained in Appendix J. “Credentialing Process.” The Contractor shall complete the Credentialing or Recredentialing of a Provider within ninety (90) calendar days of receipt of all relative information from the Provider, or within forty-five (45) days if the Provider is providing substance use disorder services. The status of pending requests for credentialing or recredentialing shall be submitted as required in Appendix J. “Credentialing Process.” Unless prohibited by NCQA standards, if the Contractor allows the Provider to provide covered services to its Members before the credentialing or recredentialing process is completed and the Provider is credentialed, the Contractor shall allow the Provider to be paid for the period from the date of its application for credentials to completion of the credentialing or recredentialing process. If the Contractor accepts the Medicaid enrollment application on behalf of the provider, the Contractor will use the format provided in Appendix J. “Credentialing Process” to transmit the listed provider enrollment data elements to the Department. A Provider Enrollment Coversheet will be generated per provider. The Provider Enrollment Coversheet will be submitted electronically to the Department. The Contractor shall establish ongoing monitoring of provider sanctions, complaints and quality issues between recredentialing cycles, and take appropriate action. The Contractor shall provide a credentialing process whereby the Provider is only required to go through one credentialing process that applies to the Contractor and any or all of its Subcontractors, if one credentialing process meets NCQA requirements.
Provider Credentialing and Recredentialing. The Contractor shall conduct Credentialing and Recredentialing in compliance with National Committee for Quality Assurance standards (NCQA), KRS 205.560(12), 907 KAR 1:672 or other applicable state regulations and federal law. The Contractor shall document the procedure, which shall comply with the Department’s current policies and procedures, for credentialing and recredentialing of providers with whom it contracts or employs to treat Members. Detailed documentation and scope of the Credentialing and Recredentialing process is contained in Appendix J. “
Provider Credentialing and Recredentialing. Provider shall comply with Plan’s credentialing and recredentialing policies and requirements. Provider shall be licensed by the State and must be qualified to perform their services throughout the term of this Medicaid Attachment. Provider will be sanctioned for being out of compliance with Plan’s medical management standards.
Provider Credentialing and Recredentialing. 1. The SE shall have and implement policies and procedures that comply with NMAC 8.305.8.14, Standards for Credentialing and Recredentialing, as well as any other applicable credentialing/recredentialing requirements from member agencies.
2. The SE shall ensure that all network providers meet the credentialing and recredentialing requirements of all applicable Collaborative standards and policies. Requirements and procedures shall apply to both existing as well as new providers.
3. The SE shall use a Collaborative-approved application for network participation. Any changes to the application must be prior approved by the Collaborative.
4. The SE shall designate a credentialing committee or other peer review body to make recommendations regarding credentialing/recredentialing decisions.
5. The SE shall complete the credentialing process within sixty (60) days from receipt of a completed application with all required documentation unless there are extenuating circumstances.
6. The SE shall ensure that credentialing/recredentialing requirements and processes are streamlined and enable providers to move across agencies and settings without unnecessary restrictions, once credentialing has been granted. The SE’s credentialing/credentialing requirements shall recognize and promote approaches to services such as consumer- and family-run programs, Native American healing practices and programs, traditional curanderismo, and other legally acceptable programs.
7. The SE shall have a process for receiving input from providers regarding the credentialing and recredentialing process.
8. For independent practitioners, the SE shall:
a. Identify the types of practitioners who shall be credentialed/recredentialed. This shall include, at a minimum, all psychiatrists and other licensed independent practitioners.
b. Use a Collaborative-approved application form, which includes at a minimum, the items specified in NMAC 8.305.8.14 as well as a history of consumer complaints and their resolution.
c. As part of the initial credentialing process, verify, at minimum the items listed in NMAC 8.305.