Common use of Provider Credentialing and Qualifications Clause in Contracts

Provider Credentialing and Qualifications. ‌ Contractor must follow a documented process for credentialing and recredentialing of providers who have signed contracts with Contractor, in accordance with 42 C.F.R. § 438.214 and Mississippi Department of Insurance Regulation 98-1. Contractor shall maintain a Credentialing Committee and Contractor’s Medical Director shall have overall responsibility for the committee’s activities. Contractor shall use credentialing and recredentialing standards set forth by NCQA and External Quality Review Organization (EQRO) recommendations. Contractor must follow the most current version of the credentialing organization’s credentialing requirements from year to year. Contractor shall verify and certify to DOM that all contracted providers and any 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 CHIP, and have in effect appropriate policies of malpractice insurance as may be required by Contractor and DOM. Contracted nurse practitioners acting at PCPs shall be held to the same requirements and standards as physicians acting at PCPs. In contracting with providers, Contractor will be responsible for obtaining all disclosure information from all contracted providers and Non-Contracted Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455, Subpart B. Contractor shall maintain a file for each provider containing a copy of the provider's current license issued by the State, cover page of malpractice insurance, and such additional information as may be specified by DOM. In contracting with laboratory providers and or any provider who bills for laboratory services, 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. 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 DOM as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider from a primary source, site assessment; 2. A methodology and process for recredentialing providers;

Provider Credentialing and Qualifications. ‌ The Contractor must 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 shall use credentialing and recredentialing standards set forth by NCQA the National Committee for Quality Assurance (NCQA) and External Quality Review Organization (EQRO) 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 DOM the Division that all contracted providers Providers and any Non- 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 CHIPthe Medicaid program, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and DOMthe Division. All Contractor 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. In contracting with providersProviders, the Contractor will be responsible for obtaining all disclosure information from all contracted providers Providers and Non-Contracted Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455, Subpart B. 455.104 and § 455.106. The Contractor shall maintain a file for each provider Provider containing a copy of the providerProvider's current license issued by the State, cover page of malpractice insurance, and such additional information as may be specified by DOMthe Division. 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 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 DOM the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM Division requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider Provider from a primary source, site assessment; 2. A methodology and process for recredentialing providersProviders;

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 NCQA the National Committee for Quality Assurance (NCQA) and External Quality Review Organization (EQRO) 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 DOM the Division that all contracted providers Network Providers and any Non- Contracted 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 CHIPthe Medicaid program, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and DOMthe 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 providersProviders, the Contractor will be responsible for obtaining all disclosure information from all contracted providers Network Providers and NonOut-Contracted of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455, Subpart B. §455.104 and §455.106. during the credentialing and recredentialing process. The 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 insuranceinsurance (copy of certificates or cover pages), and such additional information as may be specified by DOMthe Division. 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 DOM the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM Division requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider admitting Provider from a primary source, site assessment;; hospital admitting privileges or admitting plan. Proof of this verification must be maintained within each provider file. 2. A methodology and process for recredentialing Providers every 3 years; 3. A description of site assessment including: a. The initial site assessment, prior to the completion of the initial credentialing process, of private practitioner offices and other patient care settings conducted in-person during the Provider office visit; b. A site reassessment if the provider location has changed since the previous credentialing activity; c. A site reassessment of private practitioner offices and other patient care settings, conducted in-person, when a complaint has been lodged against the specific provider. This reassessment must be completed within 60 calendar days of the complaint. 4. Procedures for disciplinary action, such as reducing, suspending, or terminating Provider privileges; 5. Procedures for practitioners to correct erroneous information; 6. Process for making available to practitioners the Contractor’s confidentiality requirements to ensure that all information obtained in the credentialing process is confidential except as otherwise provided by law; 7. Procedures for verifying that contracted nurse practitioners acting as PCPs have a formal, written collaborative/consultative relationship with a licensed physician with admitting privileges at a contracted inpatient hospital facility; and 8. Procedures for verifying the inclusion of Providers including but not limited to the following databases: HHS-OIG’s List of Excluded Individuals and Entities (LEIE), System of Award Management (XXX), CMS’ Medicare Exclusion Databank (MED), State Board of Examiners, National Practitioner Data Bank (NPDB), Health Integrity and Protection Databank (HIPDB), and any State listings of excluded Providers. Copies or prints of all queries shall be included in Provider credentialing files. Receipt of all elements contained within the credentialing file prior to the credentialing and recredentialing decision with no element older than 180 days. The Contractor maintains a Credentialing Committee: a. That meets at regular intervals; b. Is chaired by the Contractor’s Medical Director; c. Membership includes a variety of participating practitioners; d. Reviews credentialing files for practitioner who do not meet the established criteria; e. Credentialing files that meet criteria are reviewed and approved by the Medial Director or designated physician; f. Ensure the date of the Credentialing Committee decisions is included in each credentialing file. 9. Specific provisions that address acute, primary, behavioral, substance use disorders, and LTSS providers;, as appropriate.

Provider Credentialing and Qualifications. ‌ The Contractor must follow a documented process for credentialing and recredentialing of providers Providers who have signed contracts 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 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 NCQA and External Quality Review Organization (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 DOM the Division that all contracted providers Network Providers and any Non- Contracted 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 CHIP, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and DOMthe Division. The Contractor must ensure that all Network Providers 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-service Members. All Contractor Network Providers must submit the 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 Provider, and notify affected enrollees. In contracting with providersProviders, the Contractor will be responsible for obtaining all disclosure information from all contracted providers Network Providers and NonOut-Contracted of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455455.104, Subpart B. and Subparts B and E §455.106 during the credentialing and recredentialing process. The 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 insuranceinsurance (copy of certificates or cover pages), and such additional information as may be specified by DOMthe Division. 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 DOM the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM the Division requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider admitting Provider from a primary source, site assessment;; hospital admitting privileges or admitting plan. Proof of this verification must be maintained within each Provider file. 2. A methodology and process for recredentialing providersProviders every three (3) years; 3. A description of site assessment including: a. The initial site assessment, prior to the completion of the initial credentialing process, of private practitioner offices and other patient care settings conducted in-person during the Provider office visit; b. A site reassessment if the Provider location has changed since the previous credentialing activity; c. A site reassessment of private practitioner offices and other patient care settings, conducted in-person, when a complaint has been lodged against the specific Provider. This reassessment must be completed within 60 calendar days of the complaint.

Provider Credentialing and Qualifications. ‌ The Contractor must follow a documented process for credentialing and recredentialing of providers Providers who have signed contracts 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 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 NCQA and External Quality Review Organization (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 DOM the Division that all contracted providers Network Providers and any Non- Contracted 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 CHIP, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and DOMthe Division. The Contractor must ensure that all Network Providers 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-service Members. All Contractor Network Providers must submit the 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 Provider, and notify affected enrollees. In contracting with providersProviders, the Contractor will be responsible for obtaining all disclosure information from all contracted providers Network Providers and NonOut-Contracted of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455455.104, Subpart B. and Subparts B and E §455.106 during the credentialing and recredentialing process. The 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 insuranceinsurance (copy of certificates or cover pages), and such additional information as may be specified by DOMthe Division. 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 DOM the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM the Division requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider admitting Provider from a primary source, site assessment;; hospital admitting privileges or admitting plan. Proof of this verification must be maintained within each Provider file. 2. A methodology and process for recredentialing providersProviders every three (3) years; 3. A description of site assessment including: a. The initial site assessment, prior to the completion of the initial credentialing process, of private practitioner offices and other patient care settings conducted in- person during the Provider office visit; b. A site reassessment if the Provider location has changed since the previous credentialing activity; c. A site reassessment of private practitioner offices and other patient care settings, conducted in-person, when a complaint has been lodged against the specific Provider. This reassessment must be completed within 60 calendar days of the complaint.

Provider Credentialing and Qualifications. ‌ The Contractor must follow a documented process for credentialing and recredentialing of providers Providers who have signed contracts 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 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 NCQA and External Quality Review Organization (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 DOM the Division that all contracted providers Network Providers and any Non- Contracted 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 CHIP, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and DOMthe Division. The Contractor must ensure that all Network Providers 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-service Members. All Contractor Network Providers must submit the 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 Provider, and notify affected enrollees. In contracting with providersProviders, the Contractor will be responsible for obtaining all disclosure information from all contracted providers Network Providers and NonOut-Contracted of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455455.104, Subpart B. and Subparts B and E §455.106 during the credentialing and recredentialing process. The 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 insuranceinsurance (copy of certificates or cover pages), and such additional information as may be specified by DOMthe Division. 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 DOM the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM the Division requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider admitting Provider from a primary source, site assessment;; hospital admitting privileges or admitting plan. Proof of this verification must be maintained within each Provider file. 2. A methodology and process for recredentialing providersProviders every three (3) years; 3. A description of site assessment including: a. The initial site assessment, prior to the completion of the initial credentialing process, of private practitioner offices and other patient care settings conducted in-person during the Provider office visit; b. A site reassessment if the Provider location has changed since the previous credentialing activity; c. A site reassessment of private practitioner offices and other patient care settings, conducted in-person, when a complaint has been lodged against the specific Provider. This reassessment must be completed within 60 calendar days of the complaint.

Provider Credentialing and Qualifications. ‌ The Contractor must follow a documented process for credentialing and recredentialing of providers Providers who have signed contracts 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 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 NCQA and External Quality Review Organization (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 DOM the Division that all contracted providers Network Providers and any Non- Contracted 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 CHIP, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and DOMthe Division. The Contractor must ensure that all Network Providers 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-service Members. All Contractor Network Providers must submit the 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 Provider, and notify affected enrollees. In contracting with providersProviders, the Contractor will be responsible for obtaining all disclosure information from all contracted providers Network Providers and NonOut-Contracted of-network Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455455.104, Subpart B. and Subparts B and E §455.106 during the credentialing and recredentialing process. The 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 insuranceinsurance (copy of certificates or cover pages), and such additional information as may be specified by DOMthe Division. 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 DOM the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM the Division requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider admitting Provider from a primary source, site assessment;; hospital admitting privileges or admitting plan. Proof of this verification must be maintained within each Provider file. 2. A methodology and process for recredentialing providersProviders every three (3) years; 3. A description of site assessment including: a. The initial site assessment, prior to the completion of the initial credentialing process, of private practitioner offices and other patient care settings conducted in- person during the Provider office visit; b. A site reassessment if the Provider location has changed since the previous credentialing activity; c. A site reassessment of private practitioner offices and other patient care settings, conducted in-person, when a complaint has been lodged against the specific Provider. This reassessment must be completed within 60 calendar days of the complaint.

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 shall use credentialing and recredentialing standards set forth by NCQA the National Committee for Quality Assurance (NCQA) and External Quality Review Organization (EQRO) 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 DOM the Division that all contracted providers Providers and any Non- 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 CHIPthe Medicaid program, and have in effect appropriate policies of malpractice insurance as may be required by the Contractor and DOMthe Division. All Contractor 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. In contracting with providersProviders, the Contractor will be responsible for obtaining all disclosure information from all contracted providers Providers and Non-Contracted Providers and abide by all applicable Federal regulations, including 42 C.F.R. § Part 455, Subpart B. 455.104 and § 455.106. The Contractor shall maintain a file for each provider Provider containing a copy of the providerProvider's current license issued by the State, cover page of malpractice insurance, and such additional information as may be specified by DOMthe Division. 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 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 DOM the Division as part of the readiness review prior to implementation. Credentialing policies and procedures must meet Federal, State, and DOM Division requirements and shall include: 1. The verification of the existence and maintenance of credentials, licenses, malpractice claims history, certificates, and insurance coverage of each provider Provider from a primary source, site assessment; 2. A methodology and process for recredentialing providersProviders;