Common use of Provider Credentialing and Recredentialing Clause in Contracts

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 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 This documentation and shall include, but not be limited to, defining the scope of providers covered, the Credentialing criteria and Recredentialing the primary source verification of information used to meet the criteria, the process is contained in Appendix J. “Credentialing Process.” used to make decisions and the extent of delegated credentialing and recredentialing arrangements. The Contractor shall complete have a process for receiving input from participating providers regarding credentialing and recredentialing of providers. Those providers accountable to a formal governing body for review of credentials shall include physicians, dentists, advanced registered nurse practitioners, audiologist, CRNA, optometrist, podiatrist, chiropractor, physician assistant and other licensed or certified practitioners. Providers required to be recredentialed by the Credentialing or Recredentialing of a Provider within ninety (90) calendar days of receipt of all relative information from the ProviderContractor per Department policy are physicians, or within forty-five (45) days if the Provider is providing substance use disorder servicesaudiologists, certified registered nurse anesthetists, advanced registered nurse practitioners, podiatrists, chiropractors and physician assistants. The status of pending requests for credentialing or recredentialing shall be submitted as required in Appendix J. “Credentialing Process.” Unless prohibited by NCQA standardsHowever, if the Contractor allows the Provider to provide covered services to its Members before the any of these providers are hospital-based, 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 performed by the Department. The Contractor shall establish be responsible for the ongoing monitoring review of provider sanctions, complaints performance and quality issues between recredentialing cyclescredentialing as specified below: A. The Contractor shall verify that its enrolled network Providers to whom Members may be referred are properly licensed in accordance with all applicable Commonwealth law and regulations and have in effect such current policies of malpractice insurance as may be required by the Contractor. B. The process for verification of Provider credentials and insurance, and take appropriate actionany additional facts for further verification and periodic review of Provider performance, shall be embodied in written policies and procedures, approved in writing by the Department. C. The Contractor shall maintain a file for each Provider containing a copy of the Provider’s current license issued by the Commonwealth and such additional information as may be specified by the Department. D. The process for verification of Provider credentials and insurance shall be in conformance with the Department’s policies and procedures. The Contractor shall provide meet requirements under KRS 205.560(12) related to credentialing. The Contractor’s enrolled providers shall complete a credentialing application in accordance with the Department’s policies and procedures. The process whereby for verification of Provider credentials and insurance shall include the Provider is only required to go through one following: A. Written policies and procedures that include the Contractor’s initial process for credentialing as well as its re-credentialing process that applies must occur, at a minimum, every three (3) years; B. A governing body, or the groups or individuals to whom the governing body has formally delegated the credentialing function; C. A review of the credentialing policies and procedures by the formal body; D. A credentialing committee which makes recommendations regarding credentialing; E. Written procedures, if the Contractor delegates the credentialing function, as well as evidence that the effectiveness is monitored; F. Written procedures for the termination or suspension of Providers; and G. Written procedures for, and implementation of, reporting to the Contractor appropriate authorities serious quality deficiencies resulting in suspension or termination of a provider. The contractor shall meet requirements under KRS 205.560(12) related to credentialing. Verification of Provider’s credentials shall include the following: A. A current valid license or certificate to practice in the Commonwealth of Kentucky; B. A Drug Enforcement Administration (DEA) certificate and any or all of its Subcontractorsnumber, if applicable; C. Primary source of graduation from medical school and completion of an appropriate residency, or accredited nursing, dental, physician assistant or vision program as applicable; if provider is not board certified. D. Board certification if the practitioner states on the application that the practitioner is board certified in a specialty; E. Professional board certification, eligibility for certification, or graduation from a training program to serve children with special health care needs under twenty-one credentialing process meets NCQA requirements.(21) years of age; F. Previous five (5) years’ work history; G. Professional liability claims history; H. Clinical privileges and performance in good standing at the hospital designated by the Provider as the primary admitting facility, for all providers whose practice requires access to a hospital, as verified through attestation; I. Current, adequate malpractice insurance, as verified through attestation; J. Documentation of revocation, suspension or probation of a state license or DEA/BNDD number; K. Documentation of curtailment or suspension of medical staff privileges; L. Documentation of sanctions or penalties imposed by Medicare or Medicaid;