Provider Qualification and Selection. The MCO must implement written policies and procedures for selection and retention of affiliated providers. If such functions are delegated, credentialing and recredentialing policies and procedures must meet the requirements of this section. In contracting with its providers, the MCO must abide by all applicable federal regulations including but not limited to W. Va. C.S.R. §114-53-6 and 42 CFR 438.610 and 42 CFR 455, Subpart B. For physicians and other licensed health care professionals, including members of physician groups, the process includes: • Procedures for initial credentialing; • Procedures for recredentialing at least every three (3) years, recertifying, and/or reappointment of providers; • A process for receiving advice from contracting health care professionals with respect to criteria for credentialing and recredentialing of individual health care professionals; and • Written policies and procedures for denying, suspending, or terminating affiliation with a contracting health care professional, including an appeals process, and for reporting serious quality deficiencies to appropriate authorities. For each institutional provider or supplier, the MCO must determine, and redetermine at specified intervals, that the provider or supplier is licensed to operate in the state, is in compliance with any other applicable state or federal requirements, and is reviewed and approved by an appropriate accrediting body or is determined by the MCO to meet standards established by the MCO itself. The MCO must submit a report to the Department monthly with the names, National Provider Identifiers (NPIs), and Employer Identification Number (EIN) or Medicaid ID of any health care professional, institutional provider, or supplier that has been the subject of program integrity actions. Actions may include denied credentialing, suspension, termination, CAPs, fines, or sanctions because of concerns about provider fraud, integrity, or quality deficiencies during the prior calendar month. The report must also state the action taken by the MCO (e.g., denied credentialing, education). This information must be reported using the appropriate template created by the Department. Suspensions, terminations, providers denied credentialing, and providers not renewed are reported on the Suspension and Adverse Enrollment Action Report template. Other program integrity actions are reported on the Fraud, Waste, and Abuse (FWA) Monthly Report template. Additional information can b...
Provider Qualification and Selection. The MCO must implement written policies and procedures for selection and retention of affiliated providers. If such functions are delegated, credentialing and recredentialing policies and procedures must meet the requirements of this section. In contracting with its providers, the MCO must abide by all applicable federal regulations including but not limited to W. Va.
Provider Qualification and Selection. The MCO must implement written policies and procedures for selection and retention of affiliated providers. If such functions are delegated, credentialing and recredentialing policies and procedures must meet the requirements of this section. In contracting with its providers, the MCO must abide by all applicable federal regulations including but not limited to W. Va. C.S.R. §114-53-6 and 42 CFR §438.610 and 42 CFR §455, Subpart B. For physicians and other licensed health care professionals, including members of physician groups, the process includes: Procedures for initial credentialing; Procedures for recredentialing at least every three (3) years, recertifying, and/or reappointment of providers; A process for receiving advice from contracting health care professionals with respect to criteria for credentialing and recredentialing of individual health care professionals; and Written policies and procedures for denying, suspending, or terminating affiliation with a contracting health care professional, including an appeals process, and for reporting serious quality deficiencies to appropriate authorities. Upon receipt of an individual provider’s initial credentialing or re-credentialing application, the MCO must make a determination on that application within ninety (90) calendar days for credentialing and sixty (60) calendar days for recredentialing. The MCO must make a determination on a provider’s clean application within this timeframe unless the MCO identifies a substantive quality or safety concern in the course of provider credentialing or recredentialing that requires further investigation. Upon notice to the individual provider, clinic, or facility, the MCO is allowed thirty (30) additional calendar days to investigate the quality or safety concern(s), after which, notice of the application determination must be made to the individual provider, clinic, or facility. For each institutional provider or supplier, the MCO must determine, and redetermine at specified intervals, that the provider or supplier is licensed to operate in the state, is in compliance with any other applicable state or federal requirements, and is reviewed and approved by an appropriate accrediting body or is determined by the MCO to meet standards established by the MCO itself. The MCO must submit a report to the Department monthly with the names, National Provider Identifiers (NPIs), and Employer Identification Number (EIN) or Medicaid ID of any health care professio...
Provider Qualification and Selection. Each MCO shall implement written policies and procedures for selection and retention of affiliated providers. If such functions are delegated, credentialing and recredentialing policies and procedures must meet the requirements of this section. In contracting with its providers, the MCO must abide by all applicable federal regulations including 42 CFR 455.106. For physicians and other licensed health care professionals, including members of physician groups, the process includes: • Procedures for initial credentialing; • Procedures for recredentialing at least every three years, recertifying, and/or reappointment of providers; • A process for receiving advice from contracting health care professionals with respect to criteria for credentialing and recredentialing of individual health care professionals; and • Written policies and procedures for suspending or terminating affiliation with a contracting health care professional, including an appeals process, and for reporting serious quality deficiencies to appropriate authorities. The application process must 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/substance abuse; • History of loss of license and/or felony convictions; • History of loss or limitation of privileges or disciplinary activity; and • An attestation to correctness/completeness of the application. During the initial credentialing process, the MCO must verify: • The practitioner holds a current valid license to practice; • Valid DEA or 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 practitioner as the primary admitting facility (this requirement may be waived for practices which do not have or do not need access to hospitals); • The practitioner 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/BNDD number; • Any curtailment or suspension of medical staff privileges (other than for incomplete records); • Any sanctions imposed by Medicare, Medicaid, or Tit...
