Common use of Provider Credentialing and Qualifications Clause in Contracts

Provider Credentialing and Qualifications. ‌ The Contractor must prepare, submit to the Division for approval, and follow a documented process for credentialing and recredentialing of Providers who have signed contracts or participation agreements with the Contractor, in accordance with 42 C.F.R. § 438.214 and Mississippi Department of Insurance Regulation 98-1. The Contractor shall maintain a Credentialing Committee and the Contractor’s Medical Director shall have overall responsibility for the committee’s activities. The Contractor’s credentialing and recredentialing policies and procedures must meet the requirements within 42 C.F.R.§438.12 and must not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. The Contractor may not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. The Contractor shall use credentialing and recredentialing standards set forth by the National Committee for Quality Assurance (NCQA) and EQRO recommendations. The Contractor must follow the most current version of the credentialing organization’s credentialing requirements from year to year. The Contractor shall verify and certify to the Division that all Network Providers and any Out-of-network Providers to whom Members may be referred are properly licensed in accordance with all applicable State law and regulations, are eligible to participate in the Medicaid program, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and the Division. The Contractor must ensure that all Network Providers are enrolled with the State as Medicaid providers consistent with the provider disclosure, screening and enrollment requirements of 42 C.F.R. part 455, subparts B and E. This provision does not require the Network Provider to render services to fee for service beneficiaries. All Contractor Network Providers must also be enrolled in the Mississippi Medicaid program using the same National Provider Identifier (NPI) numbers. Contracted nurse practitioners acting at PCPs shall be held to the same requirements and standards as physicians acting at PCPs. The Contractor may execute Network Provider agreements pending the outcome of the process in §438.602 (b)(1) of up to one hundred and twenty (120) days, but must terminate a Network Provider immediately upon notification from the State that the Network Provider cannot be enrolled, or the expiration of one (1) one hundred and twenty (120) day period without enrollment of the provider, and notify affected enrollees. In contracting with Providers, the Contractor will be responsible for obtaining all disclosure information from all Network Providers and Out-of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. §455.104 and §455.106. during the credentialing and recredentialing process. The Contractor shall maintain a file for each Provider containing complete Provider application including a signed attestation statement, a copy of the Provider's current license issued by the State, a valid DEA or Controlled Dangerous Substances certificate; proof cover page of malpractice insurance (copy of certificates or cover pages), and such additional information as may be specified by the Division. In contracting with laboratory Providers and or any Provider who bills for laboratory services, the Contractor must ensure that all laboratory testing sites providing services under the Contract have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. Provider attestation of CLIA certificate is not acceptable. The Contractor shall maintain copies of the CLIA certificate or waiver of the certificate of registration in the Provider’s credentialing and recredentialing files. The process for verification of Provider credentials and insurance and periodic review of Provider performance shall be embodied in written policies and procedures, approved in writing by the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and Division requirements and shall include:

Provider Credentialing and Qualifications. ‌ The Contractor must prepare, submit to the Division for approval, and follow a documented process for credentialing and recredentialing of Providers providers who have signed contracts or participation agreements with the Contractor, in accordance with 42 C.F.R. § 438.214 and Mississippi Department of Insurance Regulation 98-1. The Contractor shall maintain a Credentialing Committee and the Contractor’s Medical Director shall have overall responsibility for the committee’s activities. The Contractor’s credentialing and recredentialing policies and procedures must meet the requirements within 42 C.F.R.§438.12 and must not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. The Contractor may not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. The Contractor shall use credentialing and recredentialing standards set forth by the National Committee for NCQA and External Quality Assurance Review Organization (NCQAEQRO) and EQRO recommendations. The Contractor must follow the most current version of the credentialing organization’s credentialing requirements from year to year. The Contractor shall verify and certify to the Division DOM that all Network Providers contracted providers and any Out-of-network Non- Contracted Providers to whom Members may be referred are properly licensed in accordance with all applicable State law and regulations, are eligible to participate in the Medicaid programCHIP, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and the Division. The Contractor must ensure that all Network Providers are enrolled with the State as Medicaid providers consistent with the provider disclosure, screening and enrollment requirements of 42 C.F.R. part 455, subparts B and E. This provision does not require the Network Provider to render services to fee for service beneficiaries. All Contractor Network Providers must also be enrolled in the Mississippi Medicaid program using the same National Provider Identifier (NPI) numbersDOM. Contracted nurse practitioners acting at PCPs shall be held to the same requirements and standards as physicians acting at PCPs. The Contractor may execute Network Provider agreements pending the outcome of the process in §438.602 (b)(1) of up to one hundred and twenty (120) days, but must terminate a Network Provider immediately upon notification from the State that the Network Provider cannot be enrolled, or the expiration of one (1) one hundred and twenty (120) day period without enrollment of the provider, and notify affected enrollees. In contracting with Providersproviders, the Contractor will be responsible for obtaining all disclosure information from all Network Providers contracted providers and OutNon-of-network Contracted Providers and abide by all applicable Federal regulations, including 42 C.F.R. §455.104 and §455.106. during the credentialing and recredentialing process. The § Part 455, Subpart B. Contractor shall maintain a file for each Provider provider containing complete Provider application including a signed attestation statement, a copy of the Providerprovider's current license issued by the State, a valid DEA or Controlled Dangerous Substances certificate; proof cover page of malpractice insurance (copy of certificates or cover pages)insurance, and such additional information as may be specified by the DivisionDOM. In contracting with laboratory Providers providers and or any Provider provider who bills for laboratory services, the Contractor must ensure that all laboratory testing sites providing services under the Contract contract have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. Provider attestation of CLIA certificate is not acceptable. The Contractor shall maintain copies of the CLIA certificate or waiver of the certificate of registration in the Providerprovider’s credentialing and recredentialing files. The process for verification of Provider provider credentials and insurance and periodic review of Provider provider performance shall be embodied in written policies and procedures, approved in writing by the Division DOM as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and Division DOM requirements and shall include:

Provider Credentialing and Qualifications. ‌ The Contractor must prepare, submit to the Division for approval, and follow a documented process for credentialing and recredentialing of Providers who have signed contracts or participation agreements with the Contractor, in accordance with 42 C.F.R. § 438.214 and Mississippi Department of Insurance Regulation 98-1. The Contractor shall maintain a Credentialing Committee and the Contractor’s Medical Director shall have overall responsibility for the committee’s activities. The Contractor’s credentialing and recredentialing policies and procedures must meet the requirements within 42 C.F.R.§438.12 and must not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. The Contractor may not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. The Contractor shall use credentialing and recredentialing standards set forth by the National Committee for Quality Assurance (NCQA) and EQRO recommendations. The Contractor must follow the most current version of the credentialing organization’s credentialing requirements from year to year. The Contractor shall verify and certify to the Division that all Network contracted Providers and any OutNon-of-network Contracted Providers to whom Members may be referred are properly licensed in accordance with all applicable State law and regulations, are eligible to participate in the Medicaid program, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and the Division. The Contractor must ensure that all Network Providers are enrolled with the State as Medicaid providers consistent with the provider disclosure, screening and enrollment requirements of 42 C.F.R. part 455, subparts B and E. This provision does not require the Network Provider to render services to fee for service beneficiaries. All Contractor Network contracted Providers must also be enrolled in the Mississippi Medicaid program using the same National Provider Identifier (NPI) numbers. Contracted nurse practitioners acting at PCPs shall be held to the same requirements and standards as physicians acting at PCPs. The Contractor may execute Network Provider agreements pending the outcome of the process in §438.602 (b)(1) of up to one hundred and twenty (120) days, but must terminate a Network Provider immediately upon notification from the State that the Network Provider cannot be enrolled, or the expiration of one (1) one hundred and twenty (120) day period without enrollment of the provider, and notify affected enrollees. In contracting with Providers, the Contractor will be responsible for obtaining all disclosure information from all Network contracted Providers and OutNon-of-network Contracted Providers and abide by all applicable Federal regulations, including 42 C.F.R. §§ 455.104 and §§ 455.106. during the credentialing and recredentialing process. The Contractor shall maintain a file for each Provider containing complete Provider application including a signed attestation statement, a copy of the Provider's current license issued by the State, a valid DEA or Controlled Dangerous Substances certificate; proof cover page of malpractice insurance (copy of certificates or cover pages)insurance, and such additional information as may be specified by the Division. In contracting with laboratory Providers and or any Provider who bills for laboratory services, the Contractor must ensure that all laboratory testing sites providing services under the Contract contract have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. Provider attestation of CLIA certificate is not acceptable. The Contractor shall maintain copies of the CLIA certificate or waiver of the certificate of registration in the Provider’s credentialing and recredentialing files. The process for verification of Provider credentials and insurance and periodic review of Provider performance shall be embodied in written policies and procedures, approved in writing by the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and Division requirements and shall include:

Provider Credentialing and Qualifications. ‌ The Contractor must prepare, submit to the Division for approval, and follow a documented process for credentialing and recredentialing of Providers who have signed contracts or participation agreements with the Contractor, in accordance with 42 C.F.R. § §438.214 and Mississippi Insurance Department of Insurance Regulation 98-1. The Contractor shall maintain a Credentialing Committee and the Contractor’s Medical Director shall have overall responsibility for the committee’s activities. The Contractor’s credentialing and recredentialing policies and procedures must meet the requirements within 42 C.F.R.§438.12 and must not discriminate against particular providers Providers that serve high-risk populations or specialize in conditions that require costly treatment. The Contractor may not employ or contract with providers Providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. The Contractor shall use credentialing and recredentialing standards set forth by the National Committee for NCQA and External Quality Assurance Review Organization (NCQAEQRO) and EQRO recommendations. The Contractor must follow the most current version of the credentialing organization’s credentialing requirements from year to year. The Contractor shall verify and certify to the Division that all Network Providers and any Out-of-network Providers to whom Members may be referred are properly licensed in accordance with all applicable State law and regulations, are eligible to participate in the Medicaid programCHIP, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and the Division. The Contractor must ensure that all Network Providers are enrolled with the State as Medicaid providers consistent with the provider submit disclosure, and meet screening and enrollment requirements of 42 C.F.R. part 455, subparts B and E. This provision does not require the Network Provider to render services to fee for fee-for-service beneficiariesMembers. All Contractor Network Providers must also be enrolled in submit the Mississippi Medicaid program using the same appropriate National Provider Identifier (NPI) numbers. Contracted nurse practitioners acting at PCPs shall be held to the same requirements and standards as physicians acting at as PCPs. The Contractor may execute Network Provider agreements pending the outcome of the process in §438.602 (b)(1) of up to one hundred and twenty (120) days, but must terminate a Network Provider immediately upon notification from the State that the Network Provider cannot be enrolled, or the expiration of one (1) one hundred and twenty (120) day period without enrollment of the providerProvider, and notify affected enrollees. In contracting with Providers, the Contractor will be responsible for obtaining all disclosure information from all Network Providers and Out-of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455.104, and Subparts B and E §455.104 and §455.106. 455.106 during the credentialing and recredentialing process. The Contractor shall maintain a file for each Provider containing complete Provider application including a signed attestation statement, a copy of the Provider's current license issued by the State, a valid DEA or Controlled Dangerous Substances certificate; proof cover page of malpractice insurance (copy of certificates or cover pages), and such additional information as may be specified by the Division. In contracting with laboratory Providers and or any Provider who bills for laboratory services, the Contractor must ensure that all laboratory testing sites providing services under the Contract have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. Provider attestation of CLIA certificate is not acceptable. The Contractor shall maintain copies of the CLIA certificate or waiver of the certificate of registration in the Provider’s credentialing and recredentialing files. The process for verification of Provider credentials and insurance and periodic review of Provider performance shall be embodied in written policies and procedures, approved in writing by the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and the Division requirements and shall include:

Provider Credentialing and Qualifications. ‌ The Contractor must prepare, submit to the Division for approval, and follow a documented process for credentialing and recredentialing of Providers who have signed contracts or participation agreements with the Contractor, in accordance with 42 C.F.R. § §438.214 and Mississippi Insurance Department of Insurance Regulation 98-1. The Contractor shall maintain a Credentialing Committee and the Contractor’s Medical Director shall have overall responsibility for the committee’s activities. The Contractor’s credentialing and recredentialing policies and procedures must meet the requirements within 42 C.F.R.§438.12 and must not discriminate against particular providers Providers that serve high-risk populations or specialize in conditions that require costly treatment. The Contractor may not employ or contract with providers Providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. The Contractor shall use credentialing and recredentialing standards set forth by the National Committee for NCQA and External Quality Assurance Review Organization (NCQAEQRO) and EQRO recommendations. The Contractor must follow the most current version of the credentialing organization’s credentialing requirements from year to year. The Contractor shall verify and certify to the Division that all Network Providers and any Out-of-network Providers to whom Members may be referred are properly licensed in accordance with all applicable State law and regulations, are eligible to participate in the Medicaid programCHIP, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and the Division. The Contractor must ensure that all Network Providers are enrolled with the State as Medicaid providers consistent with the provider submit disclosure, and meet screening and enrollment requirements of 42 C.F.R. part 455, subparts B and E. This provision does not require the Network Provider to render services to fee for fee-for-service beneficiariesMembers. All Contractor Network Providers must also be enrolled in submit the Mississippi Medicaid program using the same appropriate National Provider Identifier (NPI) numbers. Contracted nurse practitioners acting at PCPs shall be held to the same requirements and standards as physicians acting at as PCPs. The Contractor may execute Network Provider agreements pending the outcome of the process in §438.602 (b)(1) of up to one hundred and twenty (120) days, but must terminate a Network Provider immediately upon notification from the State that the Network Provider cannot be enrolled, or the expiration of one (1) one hundred and twenty (120) day period without enrollment of the providerProvider, and notify affected enrollees. In contracting with Providers, the Contractor will be responsible for obtaining all disclosure information from all Network Providers and Out-of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455.104, and Subparts B and E §455.104 and §455.106. 455.106 during the credentialing and recredentialing process. The Contractor shall maintain a file for each Provider containing complete Provider application including a signed attestation statement, a copy of the Provider's current license issued by the State, a valid DEA or Controlled Dangerous Substances certificate; proof cover page of malpractice insurance (copy of certificates or cover pages), and such additional information as may be specified by the Division. In contracting with laboratory Providers and or any Provider who bills for laboratory services, the Contractor must ensure that all laboratory testing sites providing services under the Contract have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. Provider attestation of CLIA certificate is not acceptable. The Contractor shall maintain copies of the CLIA certificate or waiver of the certificate of registration in the Provider’s credentialing and recredentialing files. The process for verification of Provider credentials and insurance and periodic review of Provider performance shall be embodied in written policies and procedures, approved in writing by the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and the Division requirements and shall include:

Provider Credentialing and Qualifications. ‌ The Contractor must prepare, submit to the Division for approval, and follow a documented process for credentialing and recredentialing of Providers who have signed contracts or participation agreements with the Contractor, in accordance with 42 C.F.R. § 438.214 and Mississippi Department of Insurance Regulation 98-1. The Contractor shall maintain a Credentialing Committee and the Contractor’s Medical Director shall have overall responsibility for the committee’s activities. The Contractor’s credentialing and recredentialing policies and procedures must meet the requirements within 42 C.F.R.§438.12 and must not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment. The Contractor may not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Act. The Contractor shall use credentialing and recredentialing standards set forth by the National Committee for Quality Assurance (NCQA) and EQRO recommendations. The Contractor must follow the most current version of the credentialing organization’s credentialing requirements from year to year. The Contractor shall verify and certify to the Division that all Network contracted Providers and any OutNon-of-network Contracted Providers to whom Members may be referred are properly licensed in accordance with all applicable State law and regulations, are eligible to participate in the Medicaid program, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and the Division. The Contractor must ensure that all Network Providers are enrolled with the State as Medicaid providers consistent with the provider disclosure, screening and enrollment requirements of 42 C.F.R. part 455, subparts B and E. This provision does not require the Network Provider to render services to fee for service beneficiaries. All Contractor Network contracted Providers must also be enrolled in the Mississippi Medicaid program using the same National Provider Identifier (NPI) numbers. Contracted nurse practitioners acting at PCPs shall be held to the same requirements and standards as physicians acting at PCPs. The Contractor may execute Network Provider agreements pending the outcome of the process in §438.602 (b)(1) of up to one hundred and twenty (120) days, but must terminate a Network Provider immediately upon notification from the State that the Network Provider cannot be enrolled, or the expiration of one (1) one hundred and twenty (120) day period without enrollment of the provider, and notify affected enrollees. In contracting with Providers, the Contractor will be responsible for obtaining all disclosure information from all Network contracted Providers and OutNon-of-network Contracted Providers and abide by all applicable Federal regulations, including 42 C.F.R. §§ 455.104 and §§ 455.106. during the credentialing and recredentialing process. The Contractor shall maintain a file for each Provider containing complete Provider application including a signed attestation statement, a copy of the Provider's current license issued by the State, a valid DEA or Controlled Dangerous Substances certificate; proof cover page of malpractice insurance (copy of certificates or cover pages)insurance, and such additional information as may be specified by the Division. In contracting with laboratory Providers and or any Provider who bills for laboratory services, the Contractor must ensure that all laboratory testing sites providing services under the Contract contract have either a Clinical Laboratory Improvement Amendments (CLIA) certificate or waiver of a certificate of registration along with a CLIA identification number. Provider attestation of CLIA certificate is not acceptable. The Contractor shall maintain copies of the CLIA certificate or waiver of the certificate of registration in the Provider’s credentialing and recredentialing files. The process for verification of Provider credentials and insurance and periodic review of Provider performance shall be embodied in written policies and procedures, approved in writing by the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and Division requirements and shall include: