Credentialing and Recredentialing Criteria. The credentialing process must comply with West Virginia C.S.R. §114-53-6 and 42 CFR 455, Subpart B and at a minimum include a statement by the applicant regarding: • Any physical or mental health problems that may affect current ability to provide health care; • Any history of chemical dependency/SUD; • History of loss of license; • Felony convictions as required by West Virginia C.S.R. §114-53-6.3 and other criminal convictions as required by 42 CFR 455.106 ; • History of loss or limitation of privileges or disciplinary activity; • History of debarment, suspension or exclusion from any Federal or State healthcare programs; and • An attestation to correctness/completeness of the application. During the initial credentialing process, the MCO must verify: • The identity and the exclusion status of provider and any person with an ownership or control interest or who is an agent or managing employee of the provider through checks of Federal databases as described in 42 CFR 455.436; • The provider holds a current valid license to practice; • Valid Drug Enforcement Administration (DEA) or Controlled Dangerous Substance (CDS) certificate, as applicable; • Graduation from medical school and completion of a residency, or other post-graduate training, as applicable; • Board certification or eligibility, or specialized training as appropriate; • Work history; • Professional liability claims history; • Good standing of clinical privileges at the hospital designated by the provider as the primary admitting facility (this requirement may be waived for practices which do not have or do not need access to hospitals); • The provider holds current, adequate malpractice insurance with minimum coverage requirements of $1 million per individual episode and $1 million in the aggregate; • Any revocation or suspension of a state license or DEA/ Bureau of Narcotics and Dangerous Drugs (BNDD) number; • Any curtailment or suspension of medical staff privileges (other than for incomplete records); • Any censure by the State or County Medical Association; and • Any enrollee complaints. In addition, the MCO must request information on the provider from the National Practitioner Data Bank and appropriate state licensing boards such as the Board of Medicine, Chiropractic Board, Osteopathic Board and/or Dental Board. During the recredentialing process, the MCO must re-verify and update all of the above information, and consider performance indicators such as those collected through the q...
