General Provider Credentialing Clause Samples

General Provider Credentialing. 2.9.3.1.1. The Contractor shall implement written policies and procedures that comply with the requirements of 42 C.F.R. §§ 422.504(i)(4)(iv) and 438.214(b) regarding the selection, retention and exclusion of providers and meet, at a minimum, the requirements below. 2.9.3.1.2. The Contractor shall submit such policies and procedures annually to DMAS, if amended, and shall demonstrate to DMAS, by reporting annually that all providers within the Contractor’s Provider Network are credentialed according to such policies and procedures. 2.9.3.1.3. The Contractor shall: 2.9.3.1.3.1. Designate and describe the department(s) and person(s) at the Contractor’s organization who will be responsible for provider credentialing and re-credentialing; 2.9.3.1.3.2. Maintain appropriate, documented processes for the credentialing and re-credentialing of licensed physician providers and all other licensed or certified providers who participate in the Contractor’s Provider Network to perform the services agreed to under this contract. At a minimum, the scope and structure of the processes shall be consistent with recognized managed care industry standards such as those provided by the NCQA and relevant state regulations, including regulations at 12 VAC ▇-▇▇▇-▇▇▇; 2.9.3.1.3.3. Ensure that all providers are credentialed prior to becoming network providers and that a site visit is conducted as appropriate for initial credentialing; 2.9.3.1.3.4. Maintain a documented re-credentialing process which shall occur at least every three years (thirty six months) and shall take into consideration various forms of data including, but not limited to, grievances, results of quality reviews utilization management information, and Enrollee satisfaction surveys; 2.9.3.1.3.5. The Contractor’s standards for licensure and certification shall be included in its participating Provider Network contracts with its network providers which must be secured by current subcontracts or employment contracts. 2.9.3.1.3.6. Upon notice from DMAS or CMS, not authorize any providers terminated or suspended from participation in the Virginia Medicaid Program, Medicare or from another state’s Medicaid program, to treat Enrollees and shall deny payment to such providers for services provided. In addition: 2.9.3.1.3.6.1. The Contractor shall comply with requirements detailed at 42 C.F.R. § 455.436, requiring the Contractor to, at a minimum, check the Department of Health Professions website at least twice per month fo...