Standards for Credentialing and Recredentialing. HCA intends to implement centralized credentialing and recredentialing applicable to all MCOs during the term of this Agreement. The CONTRACTOR shall assist HCA with the transition and implementation of centralized credentialing and recredentialing and comply with all HCA requirements related thereto. Pending the implementation of centralized credentialing and recredentialing by HCA, the CONTRACTOR shall establish and implement a documented process for credentialing and recredentialing its Contract Providers, or Providers it employs, to treat Members. The CONTRACTOR’s credentialing and recredentialing process shall adhere to NMAC 13.10.28.10 and NCQA credentialing and recredentialing standards and include, but not be limited to, (i) defining the scope of Providers covered; (ii) the criteria and the primary source verification of information used to meet the criteria; (iii) use of a single, centralized, NCQA approved CVV to process applications and perform primary source verifications; (iv) the process and time frames for making credentialing and recredentialing decisions; (v) the time frame for loading approved providers to the CONTRACTOR’s claims payment system; and (vi) the extent of delegating credentialing and recredentialing arrangements. The CONTRACTOR’s credentialing and recredentialing process shall not discriminate against providers, including those that serve high-risk populations or specialize in conditions that require costly treatment. The CONTRACTOR shall work with all other MCOs to contract with a single, centralized and NCQA approved CVV to process credentialing applications and perform primary source verifications. The CVV’s responsibilities shall include the following: Receiving and processing completed applications, attestations, and primary source verification documents for current and prospective Contract Providers; Offering a portal that allows providers to submit applications and upload all required documentation for the credentialing and recredentialing process online; Performing credentialing verification processes on behalf of the CONTRACTOR for initial credentialing, and for recredentialing every three (3) years; and Reporting credentialing and recredentialing metrics on a monthly basis to the CONTRACTOR, to include the volume of credentialing applications and recredentialing activities; time frame for processing applications; credentialing and recredentialing outcomes; and any other metrics required by HCA. Prior to executing a contract with a CVV, the CONTRACTOR shall obtain HCA’s prior written approval of the CVV and contract, and the CONTRACTOR’s written policies and procedures for its credentialing and recredentialing processes. The CONTRACTOR shall comply with the following credentialing and recredentialing requirements: Develop and implement written policies and procedures for the credentialing and recredentialing process; Meet NCQA standards and State and federal regulations for credentialing and recredentialing, including NMAC 13.10.28.10, 42 C.F.R. § 455.104, § 455.105, § 455.106, § 455.107 and § 1002.3(b); Collaborate with the other MCOs to define and use the same NCQA approved primary source verification sources; Participate and collaborate with any statewide initiatives to streamline and standardize the credentialing/recredentialing process; Use a single, standardized credentialing form developed by the Provider Workgroup and collaborate with the other MCOs to develop other standard forms used for credentialing and recredentialing; Ensure credentialing/recredentialing forms require ownership and control disclosures, disclosure of business transactions, and criminal conviction information; Screen and confirm, upon initial credentialing and recredentialing, the identity and the exclusion status of Providers, and any person with an ownership or control interest, or who is an agent or managing employee of a Provider against federal databases as defined in 42 C.F.R. § 455.436 to ensure Providers are not employing or contracting with excluded individuals and do not employ or contract with Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Designate a credentialing and recredentialing committee or other peer review body to make recommendations and decisions regarding credentialing/recredentialing issues; Complete the credentialing and recredentialing process within forty-five (45) Calendar Days from the receipt of a completed application with all required primary source documentation, for all Provider types; Notify Providers of credentialing decisions (approved or denied) within ten (10) Calendar Days of the credentialing committee or peer review body decision; Recredential providers at least every three (3) years; Ensure and verify that Providers have appropriate licenses and certifications to perform services outlined in their respective Turquoise Care provider agreements; Maintain records that verify its credentialing and recredentialing activities, including primary source verification and compliance with credentialing/recredentialing requirements; and Ensure and verify hospital privileges for Providers who indicate they have privileges. The CONTRACTOR shall enter provider specific contract information into its system(s) such that its Claims system(s) is able to recognize the provider as a Contract Provider with accuracy sufficient to pay claims no later than fifteen (15) Calendar Days after a Provider is credentialed. Credentialed providers shall be entered/loaded into the CONTRACTOR’s claims payment system with an effective date no later than the date the provider was approved by the credentialing committee/peer review body or the Provider agreement effective date, whichever is later. The CONTRACTOR shall update the rosters of agencies approved for Supervisory Certification and for provider additions related to behavioral health specialized services as required in NMAC 8.321.2. Within fifteen (15) Calendar Days of receipt of a clean roster provided to the CONTRACTOR, the CONTRACTOR shall complete the rostering updates so the CONTRACTOR’s claims payment system can recognize and pay claims. The CONTRACTOR shall add rostered providers to their Provider directories. The CONTRACTOR shall perform the following functions: Credential any provider who contracts with the CONTRACTOR and maintain complete credentialing information for these Providers; Identify potential and actual Contract Providers who are enrolled with HCA as Medicaid Providers; Require any Contract Provider, including Contract Providers of a Subcontractor, to be enrolled through a Provider Participation Agreement with the State Medicaid Agency as a managed care provider; and Refer any Provider who notifies the CONTRACTOR of a change in their location, licensure or certification, or status to New Mexico Medicaid’s Provider web portal for updating their enrollment information/status with the New Mexico Medicaid program. The CONTRACTOR’s credentialing and recredentialing process for HCBS Providers shall include assessment of each provider setting to ensure that all applicable HCB settings requirements are met. For applicable Community Benefit Providers, EPSDT Providers, and Home Health Providers the CONTRACTOR shall ensure that its credentialing and recredentialing process includes verification of the use of EVV. For a period of at least twelve (12) months following implementation of EVV for home health providers, the CONTRACTOR shall conduct monthly education and training for affected providers regarding the use of the EVV system. Such period may be extended as determined necessary by HCA. The CONTRACTOR shall coordinate with the public health offices operated by the New Mexico Department of Health regarding the following services: Sexually transmitted disease services, including screening, diagnosis, treatment, follow-up and contact investigations; HIV prevention counseling, testing and early intervention; Tuberculosis screening, diagnosis and treatment; Disease outbreak prevention and management, including reporting according to State law and regulatory requirements, responding to epidemiology requests for information and coordination with epidemiology investigations and studies; Referral and coordination to ensure maximum participation in the Supplemental Food Program for Women, Infants and Children (WIC); Health Education services for individuals and families with a particular focus on injury prevention, including car seat use, safe sleep, domestic violence, and lifestyle issues, including tobacco use, vaping, exercise, nutrition and substance use; Home visiting programs for families of newborns and other at-risk families, including the MHV program; and Participation and support for local health councils to create healthier and safer communities with a focus on coordination of efforts, such as driving while intoxicated (DWI) councils, maternal and child health councils, tobacco coalitions, safety councils, safe kids and others. The CONTRACTOR shall participate in the New Mexico Department of Health’s (DOH) New Mexico State Immunization Information System to ensure the secure, electronic exchange of immunization records to support the elimination of vaccine preventable diseases. The CONTRACTOR shall contract with the ECECD for services covered for families, and children age zero-to-five (0-5). In providing services under this Agreement, the CONTRACTOR shall: Expand, promote, and employ broad-based utilization of statewide access to HIPAA-compliant Telemedicine service systems, including the following modalities: Live audio/video – real-time, two-way audiovisual connection between a Member and Provider (synchronous); Store and forward – transmission of recorded health history to a Provider (asynchronous); Remote Member monitoring – use of electronic tools to monitor and record a Member’s physiological status which then transmit the data to a Provider in a setting other than where the Member is physically located; Other telehealth visits – any other services delivered via telehealth; and Telephone visits - used for limited professional services delivered by telephone without video, as permitted by HCA. Follow State guidelines for Telemedicine equipment or connectivity; Follow accepted HIPAA and 42 C.F.R. part 2 regulations that affect Telemedicine transmission, including but not limited to, staff and Contract Provider training, room setup, security of transmission lines, etc. The CONTRACTOR shall have and implement policies and procedures that follow all State and federal security and procedure guidelines; Identify, develop and implement training for accepted Telemedicine practices; Participate in the needs assessment of the organizational, developmental and programmatic requirements of Telemedicine programs; Report to HCA on the Telemedicine outcomes of Telemedicine projects and submit a Telemedicine Report as directed by HCA; Ensure that Telemedicine services meet the following shared values, which are ensuring: (i) competent care with regard to culture and language needs; (ii) work sites are distributed across the State, including Native American sites, for both clinical and educational purposes; and (iii) coordination of Telemedicine and technical functions at either end of network connection. The CONTRACTOR shall participate in Project ECHO, in accordance with State prescribed requirements and standards, including but not limited to, paying its fair share of administrative costs as negotiated between the CONTRACTOR and Project ECHO and approved by HCA to support Project ECHO, and shall: Work collaboratively with the University of New Mexico, HCA and Providers on Project ECHO; Identify high needs, high cost, or high-risk pregnancy Members who may benefit from their Providers participating in applicable Project ECHO educational sessions; Identify PCPs and OB/GYNs who serve high needs, high cost, or high-risk pregnancy Members to participate in Project ECHO; Work with Project ECHO and the UNM Section of Geriatrics (Department of Internal Medicine) to: Create a statewide program for quality improvement in Nursing Facilities to measurably improve quality ratings over the term of the contract; and Create a program for reduction of readmissions from Nursing Facilities to hospitals, and measurably lower readmission rates over the course of the contract; Work with Project ECHO, the New Mexico Perinatal Collaborative, and the Alliance for Innovation on Maternal Health to: Develop Care Coordination models designed to improve maternal and child health outcomes for prenatal and Postpartum Members. Create a training program for care coordinators along with a training program for Providers on appropriate Care Coordination for pregnant women who may be experiencing a high risk pregnancy or during their Postpartum period. Reimburse Primary Care clinics and any other providers caring for pregnant or Postpartum Members, including Behavioral Health Providers when presenting their patients in the Project ECHO model; Provide Claims data to support evaluation of Project ECHO; Appoint a centralized liaison to obtain prior authorizations approvals related to Project ECHO; and Track quality of care and outcome measures related to Project ECHO. The CONTRACTOR shall collaborate with Project ECHO to develop a quarterly report template to report number and types of Providers trained, location of Providers by county, number of cases presented for consultation, what coordination and development activities occurred, and overall Project ECHO expenditures.
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Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Standards for Credentialing and Recredentialing. HCA HSD intends to implement centralized credentialing and recredentialing applicable to all MCOs during the term of this AgreementAgreement as part of the implementation of the State’s new Medicaid Management Information System Replacement (MMIS-R) system. The CONTRACTOR shall assist HCA HSD with the transition and implementation of its centralized credentialing and recredentialing module and comply with all HCA HSD requirements related thereto. Pending the implementation of Until HSD implements centralized credentialing and recredentialing by HCAthrough MMIS-R, the CONTRACTOR shall establish and implement a documented process for credentialing and recredentialing its Contract Providers, or Providers it employs, to treat Members. The CONTRACTOR’s credentialing and recredentialing process shall adhere to NMAC 13.10.28.10 and NCQA credentialing and recredentialing standards and include, but not be limited to, (i) defining the scope of Providers covered; (ii) the criteria and the primary source verification of information used to meet the criteria; (iii) use of a single, centralized, NCQA approved CVV to process applications and perform primary source verifications; (iv) the process and time frames for making credentialing and recredentialing decisions; (v) the time frame for loading approved providers to the CONTRACTOR’s claims payment system; and (vi) the extent of delegating credentialing and recredentialing arrangements. The CONTRACTOR’s credentialing and recredentialing process shall not discriminate against providers, including those that serve high-risk populations or specialize in conditions that require costly treatment. The CONTRACTOR shall work with all other MCOs to contract with a single, centralized and NCQA approved CVV to process credentialing applications and perform primary source verifications. The CVV’s responsibilities shall include the following: Receiving and processing completed applications, attestations, and primary source verification documents for current and prospective Contract Providers; Offering a portal that allows providers to submit applications and upload all required documentation for the credentialing and recredentialing process online; Performing credentialing verification processes on behalf of the CONTRACTOR for initial credentialing, and for recredentialing every three (3) years; and Reporting credentialing and recredentialing metrics on a monthly basis to the CONTRACTOR, to include the volume of credentialing applications and recredentialing activities; time frame for processing applications; credentialing and recredentialing outcomes; and any other metrics required by HCAHSD. Prior to executing a contract with a CVV, the CONTRACTOR shall obtain HCAHSD’s prior written approval of the CVV and contract, and the CONTRACTOR’s written policies and procedures for its credentialing and recredentialing processes. The CONTRACTOR shall comply with the following credentialing and recredentialing requirements: Develop and implement written policies and procedures for the credentialing and recredentialing process; Meet NCQA standards and State and federal regulations for credentialing and recredentialing, including NMAC 13.10.28.10, 42 C.F.R. § 455.104, § 455.105, § 455.106, § 455.107 and § 1002.3(b); Collaborate with the other MCOs to define and use the same NCQA approved primary source verification sources; Participate and collaborate with any statewide initiatives to streamline and standardize the credentialing/recredentialing process; Use a single, standardized credentialing form developed by the Provider Workgroup and collaborate with the other MCOs to develop other standard forms used for credentialing and recredentialing; Ensure credentialing/recredentialing forms require ownership and control disclosures, disclosure of business transactions, and criminal conviction information; Screen and confirm, upon initial credentialing and recredentialing, the identity and the exclusion status of Providers, and any person with an ownership or control interest, or who is an agent or managing employee of a Provider against federal databases as defined in 42 C.F.R. § 455.436 to ensure Providers are not employing or contracting with excluded individuals and do not employ or contract with Providers excluded from participation in federal health care programs under either Section 1128 or Section 1128A of the Social Security Act, unless otherwise granted by federal authority; Designate a credentialing and recredentialing committee or other peer review body to make recommendations and decisions regarding credentialing/recredentialing issues; Complete the credentialing and recredentialing process within forty-five thirty (4530) Calendar Days from the receipt of a completed application with all required primary source documentation, for all Provider types; Notify Providers of credentialing decisions (approved or denied) within ten (10) Calendar Days of the credentialing committee or peer review body decision; Recredential providers at least every three (3) years; Ensure and verify that Providers have appropriate licenses and certifications to perform services outlined in their respective Turquoise Care provider agreements; and Maintain records that verify its credentialing and recredentialing activities, including primary source verification and compliance with credentialing/recredentialing requirements; and Ensure and verify hospital privileges for Providers who indicate they have privileges. The CONTRACTOR shall enter provider specific contract information into its system(s) such that its Claims system(s) is able to recognize the provider as a Contract Provider with accuracy sufficient to pay claims no later than fifteen (15) Calendar Days after a Provider is credentialed. Credentialed providers shall be entered/loaded into the CONTRACTORContractor’s claims payment system with an effective date no later than the date the provider was approved by the credentialing committee/peer review body or the Provider agreement effective date, whichever is later. The CONTRACTOR shall update the rosters of agencies approved for Supervisory Certification and for provider additions related to behavioral health specialized services as required in NMAC 8.321.2. Within fifteen (15) Calendar Days of receipt of a clean roster provided to the CONTRACTOR, the CONTRACTOR shall complete the rostering updates so the CONTRACTOR’s claims payment system can recognize and pay claims. The CONTRACTOR shall add rostered providers to their Provider directories. The CONTRACTOR shall perform the following functions: Credential any provider who contracts with the CONTRACTOR and maintain complete credentialing information for these Providers; Identify potential and actual Contract Providers who are enrolled with HCA HSD as Medicaid Providers; Require any Contract Provider, including Contract Providers of a Subcontractor, to be enrolled through a Provider Participation Agreement with the State Medicaid Agency as a managed care provider; and Refer any Provider who notifies the CONTRACTOR of a change in their location, licensure or certification, or status to New Mexico Medicaid’s Provider web portal for updating their enrollment information/status with the New Mexico Medicaid program. The CONTRACTOR’s credentialing and recredentialing process for HCBS Providers shall include assessment of each provider setting to ensure that all applicable HCB settings requirements are met. For applicable Community Benefit Providers, EPSDT Providers, and Home Health Providers the CONTRACTOR shall ensure that its credentialing and recredentialing process includes verification of the use of EVV. For a period of at least twelve (12) months following implementation of EVV for home health providers, the CONTRACTOR shall conduct monthly education and training for affected providers regarding the use of the EVV system. Such period may be extended as determined necessary by HCA. The CONTRACTOR shall coordinate with the public health offices operated by the New Mexico Department of Health regarding the following services: Sexually transmitted disease services, including screening, diagnosis, treatment, follow-up and contact investigations; HIV prevention counseling, testing and early intervention; Tuberculosis screening, diagnosis and treatment; Disease outbreak prevention and management, including reporting according to State law and regulatory requirements, responding to epidemiology requests for information and coordination with epidemiology investigations and studies; Referral and coordination to ensure maximum participation in the Supplemental Food Program for Women, Infants and Children (WIC); Health Education services for individuals and families with a particular focus on injury prevention, including car seat use, safe sleep, domestic violence, and lifestyle issues, including tobacco use, vaping, exercise, nutrition and substance use; Home visiting programs for families of newborns and other at-risk families, including the MHV program; and Participation and support for local health councils to create healthier and safer communities with a focus on coordination of efforts, such as driving while intoxicated (DWI) councils, maternal and child health councils, tobacco coalitions, safety councils, safe kids and others. The CONTRACTOR shall participate in the New Mexico Department of Health’s (DOH) New Mexico State Immunization Information System to ensure the secure, electronic exchange of immunization records to support the elimination of vaccine preventable diseases. The CONTRACTOR shall contract with the ECECD for services covered for families, and children age zero-to-five (0-5). In providing services under this Agreement, the CONTRACTOR shall: Expand, promote, and employ broad-based utilization of statewide access to HIPAA-compliant Telemedicine service systems, including the following modalities: Live audio/video – real-time, two-way audiovisual connection between a Member and Provider (synchronous); Store and forward – transmission of recorded health history to a Provider (asynchronous); Remote Member monitoring – use of electronic tools to monitor and record a Member’s physiological status which then transmit the data to a Provider in a setting other than where the Member is physically located; Other telehealth visits – any other services delivered via telehealth; and Telephone visits - used for limited professional services delivered by telephone without video, as permitted by HCA. Follow State guidelines for Telemedicine equipment or connectivity; Follow accepted HIPAA and 42 C.F.R. part 2 regulations that affect Telemedicine transmission, including but not limited to, staff and Contract Provider training, room setup, security of transmission lines, etc. The CONTRACTOR shall have and implement policies and procedures that follow all State and federal security and procedure guidelines; Identify, develop and implement training for accepted Telemedicine practices; Participate in the needs assessment of the organizational, developmental and programmatic requirements of Telemedicine programs; Report to HCA on the Telemedicine outcomes of Telemedicine projects and submit a Telemedicine Report as directed by HCA; Ensure that Telemedicine services meet the following shared values, which are ensuring: (i) competent care with regard to culture and language needs; (ii) work sites are distributed across the State, including Native American sites, for both clinical and educational purposes; and (iii) coordination of Telemedicine and technical functions at either end of network connection. The CONTRACTOR shall participate in Project ECHO, in accordance with State prescribed requirements and standards, including but not limited to, paying its fair share of administrative costs as negotiated between the CONTRACTOR and Project ECHO and approved by HCA to support Project ECHO, and shall: Work collaboratively with the University of New Mexico, HCA and Providers on Project ECHO; Identify high needs, high cost, or high-risk pregnancy Members who may benefit from their Providers participating in applicable Project ECHO educational sessions; Identify PCPs and OB/GYNs who serve high needs, high cost, or high-risk pregnancy Members to participate in Project ECHO; Work with Project ECHO and the UNM Section of Geriatrics (Department of Internal Medicine) to: Create a statewide program for quality improvement in Nursing Facilities to measurably improve quality ratings over the term of the contract; and Create a program for reduction of readmissions from Nursing Facilities to hospitals, and measurably lower readmission rates over the course of the contract; Work with Project ECHO, the New Mexico Perinatal Collaborative, and the Alliance for Innovation on Maternal Health to: Develop Care Coordination models designed to improve maternal and child health outcomes for prenatal and Postpartum Members. Create a training program for care coordinators along with a training program for Providers on appropriate Care Coordination for pregnant women who may be experiencing a high risk pregnancy or during their Postpartum period. Reimburse Primary Care clinics and any other providers caring for pregnant or Postpartum Members, including Behavioral Health Providers when presenting their patients in the Project ECHO model; Provide Claims data to support evaluation of Project ECHO; Appoint a centralized liaison to obtain prior authorizations approvals related to Project ECHO; and Track quality of care and outcome measures related to Project ECHO. The CONTRACTOR shall collaborate with Project ECHO to develop a quarterly report template to report number and types of Providers trained, location of Providers by county, number of cases presented for consultation, what coordination and development activities occurred, and overall Project ECHO expenditures.
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