Common use of Provider Credentialing and Re-credentialing Clause in Contracts

Provider Credentialing and Re-credentialing. The MCO must review, approve and periodically recertify the credentials of all participating physician Providers and all other licensed Providers who participate in the MCO’s Network. The MCO may subcontract with another entity to which it delegates such credentialing activities if such delegated credentialing is maintained in accordance with the National Committee for Quality Assurance (NCQA) delegated credentialing requirements and any comparable requirements defined by HHSC. At a minimum, the scope and structure of a MCO’s credentialing and re-credentialing processes must be consistent with recognized MCO industry standards, such as those provided by NCQA, and relevant state and federal regulations including 28 T.A.C. §§11.1902, relating to provider credentialing and notice. Medicaid MCOs must also comply with 42 C.F.R. §438.12 and 42 C.F.R. §438.214(b). The initial credentialing process, including application and verification of information, must be completed before the effective date of the Provider’s initial Network Provider agreement. The re-credentialing process must occur at least every three (3) years. The MCO may not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. Additionally, if the MCO declines to include individual or groups of providers in its Network, it must give the affected providers written notice of the reasons for its decision. The re-credentialing process must take into consideration Provider performance data including, but not be limited to, Member Complaints and Appeals, quality of care, and utilization management. MCOs must comply with the requirements of Texas Insurance Code Chapter 1452, Subchapter C, regarding expedited credentialing and payment of physicians who have joined medical groups that are already contracted with the MCO.

Provider Credentialing and Re-credentialing. The MCO HMO must review, approve and periodically recertify the credentials of all participating physician Providers and all other licensed Providers who participate in the MCOHMO’s Provider Network. The MCO HMO may subcontract with another entity to which it delegates such credentialing activities if such delegated credentialing is maintained in accordance with the National Committee for Quality Assurance (NCQA) delegated credentialing requirements and any comparable requirements defined by HHSC. At a minimum, the scope and structure of a MCOHMO’s credentialing and re-credentialing processes must be consistent with recognized MCO HMO industry standards, standards such as those provided by NCQA, NCQA and relevant state and federal regulations including 28 T.A.C. §§11.1902, relating to provider credentialing and notice. Medicaid MCOs must also comply with 42 , and as an additional requirement for Xxxxxxxx XXXx, 00 C.F.R. §438.12 and 42 C.F.R. §438.214(b). The initial credentialing process, including application and verification of information, must be completed before the effective date of the initial contract with the physician or Provider’s initial Network Provider agreement. The re-credentialing process must occur at least every three (3) years. The MCO HMO may not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. Additionally, if the MCO HMO declines to include individual or groups of providers in its Network, it must give the affected providers written notice of the reasons for its decision. The re-credentialing process must take into consideration Provider performance data including, but not be limited to, Member Complaints and Appeals, quality of care, and utilization management. MCOs HMOs must comply with the requirements of Texas Insurance Code Chapter 1452, Subchapter C, regarding expedited credentialing and payment of physicians who have joined medical groups that are already contracted with the MCOHMO.

Provider Credentialing and Re-credentialing. The MCO must review, approve approve, and periodically recertify the credentials of all participating physician Providers and all other licensed Providers who participate in the MCO’s Network. The MCO may subcontract with another entity to which it delegates such credentialing activities if such the delegated credentialing is maintained in accordance with the National Committee for Quality Assurance (NCQA) delegated credentialing requirements and any comparable requirements defined by HHSC. At a minimum, the scope and structure of a an MCO’s credentialing and re-credentialing processes must be consistent with recognized MCO industry standards, such as those provided by NCQA, or URAC and relevant state and federal regulations including 28 T.A.C. Tex. Admin. Code §§11.1902§ 11.1902 and 11.1402(c), relating to provider credentialing and notice. Medicaid MCOs must also comply with 42 C.F.R. §§ 438.12 and 42 C.F.R. §§ 438.214(b). The initial credentialing process, including application and verification of information, must be completed before the effective date of the Provider’s initial Network Provider agreement. The re-credentialing process must occur at least every three (3) years. The MCOs must use state-identified credentialing criteria for Nursing Facilities and may only contract with a Nursing Facility with a valid certification, license, and contract with DADS. The MCO may not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. Additionally, if the MCO declines to include individual or groups of providers in its Network, it must give the affected providers written notice of the reasons for its decision. The re-credentialing process must take into consideration Provider performance data including, but not be limited to, including Member Complaints and Appeals, quality of care, and utilization management. MCOs must comply with the requirements of Texas Insurance Code Chapter 1452, Subchapter C, regarding expedited credentialing and payment of physicians who have joined medical groups that are already contracted with the MCO.

Provider Credentialing and Re-credentialing. The MCO must review, approve approve, and periodically recertify the credentials of all participating physician Providers and all other licensed Providers who participate in the MCO’s Network. The MCO may subcontract with another entity to which it delegates such credentialing activities if such the delegated credentialing is maintained in accordance with the National Committee for Quality Assurance (NCQA) delegated credentialing requirements and any comparable requirements defined by HHSC. At a minimum, the scope and structure of a an MCO’s credentialing and re-credentialing processes must be consistent with recognized MCO industry standards, such as those provided by NCQA, standards and relevant state and federal regulations including 28 T.A.C. Tex. Admin. Code §§11.1902§ 11.1902 and 11.1402(c), relating to provider credentialing and notice. Medicaid MCOs must also comply with 42 C.F.R. §§ 438.12 and 42 C.F.R. §§ 438.214(b-e). The initial credentialing process, including application and verification of information, must be completed before the effective date of the Provider’s initial Network Provider agreement. The re-credentialing process must occur at least every three (3) years. The MCOs must use state-identified credentialing criteria for Nursing Facilities and may only contract with a Nursing Facility with a valid certification, license, and contract with DADS. The MCO may not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of that license or certification. Additionally, if the MCO declines to include individual or groups of providers in its Network, it must give the affected providers written notice of the reasons for its decision. The re-credentialing process must take into consideration Provider performance data including, but not be limited to, including Member Complaints and Appeals, quality of care, and utilization management. MCOs must comply with the requirements of Texas Insurance Code Chapter 1452, Subchapter C, regarding expedited credentialing and payment of physicians who have joined medical groups that are already contracted with the MCO.