General provider credentialing
See bold sections below:
The provisions of this section apply equally to initial credentialing applications and applications for re-credentialing.
A. Credential verification program.
(1) In order to ensure accessibility and availability of services, each health carrier shall establish a program in accordance with this regulation that verifies that its participating providers are credentialed before the health carrier accepts a provider into its network and lists a provider in the health carrier’s provider directory, handbooks, or other marketing or member materials.
(2) The credential verification program established by each health carrier shall provide for an identifiable person(s) to be responsible for all credential verification activities, which person(s) shall be capable of carrying out that responsibility.
(3) A health carrier is not obligated to approve all applications for credentialing and may deny any application based on existing network adequacy, issues with an application, failure by provider to provide a complete credentialing application, or another reason.
(4) No contract between a health carrier and a participating provider shall include a clause that has the effect of relieving either party of liability for its actions or inactions.
B. Delegation of credential verification activities.
(1) Whenever a health carrier delegates credential verification activities to a contracting entity, whether a credentialing intermediary or subcontractor, the health carrier shall review and approve the contracting entity’s credential verification program before contracting and shall require that the entity comply with all applicable requirements of this regulation.
(2) The health carrier shall monitor the contracting entity’s credential certification activities.
(3) The health carrier shall implement oversight mechanisms, including:
(a) reviewing the contracting entity’s credential verification plans, policies, procedures, forms, and adherence to verification procedures; and
(b) conducting an evaluation of the contracting entity’s credential verification program at least every two years.
(4) The health carrier’s monitoring activities should at least meet the verification procedures and standards as defined by the national committee for quality assistance (NCQA).
C. Written credential verification plan.
(1) Each health carrier shall develop and adopt a written credentialing plan that contains policies and procedures to support the credentialing verification program.
(2) Each health carrier’s written credential verification plan shall:
(a) include the purpose, goals, and objectives of the credential verification program;
(b) include written criteria and procedures for initial enrollment, renewal, restrictions, and termination of providers;
(c) be provided to the superintendent upon request;
(d) provide an organized system to manage and protect confidentiality of credentialing files and records; and
(e) require that records and documents relating to provider credentialing be retained for at least six years.
(3) Each health carrier’s credentialing verification plan shall include a process to assess and verify the qualifications of providers applying to become participating providers within 45 calendar days of receipt of a provider’s request for credentialing or a provider’s completed uniform credentialing form, whichever is earlier. The plan shall allow for the following to take place within this 45 calendar days:
(a) time required to obtain the completed uniform credentialing form in electronic format, if necessary;
(b) time to request and obtain primary source verifications and other information that must be obtained from third parties in order to authenticate the applicant’s credentials;
(c) a final decision by a credentialing committee if the health carrier’s plan requires such review; and
(d) time to notify the provider of the health carrier’s decision.
D. Reporting requirements. Each health carrier shall submit a report to the superintendent regarding its credentialing process for the prior two-year period beginning December 31, 2018, and on December 31 for all even numbered years thereafter, or as otherwise directed by the superintendent. The report shall include the following:
(1) the number of applications made to the plan for each type of provider;
(2) the number of applications approved by the plan for each type of provider;
(3) the number of applications rejected by the plan for each type of provider;
(4) the number of providers terminated for reasons of quality; and
(5) the amount of time taken to review and reach a determination on an application.
E. Use of uniform credentialing forms required:
(1) Beginning January 1, 2017, a health carrier shall not use any provider credentialing application form other than uniform credentialing forms, as that term is defined in 188.8.131.52 NMAC.
(2) Should the superintendent determine that these forms no longer represent industry standards; the superintendent will issue a bulletin advising of alternative credentialing forms to be used to satisfy this requirement.
(3) A health carrier or its credentialing or re-credentialing intermediary shall make uniform credentialing application forms available to any health care provider that seeks to be credentialed or re-credentialed by that health carrier or its credentialing intermediary and also accept uniform credentialing applications electronically or through electronic transfer upon the request of any provider.
(4) An exception to Paragraph (1) of Subsection E of 184.108.40.206 NMAC is made for providers who:
(a) are licensed and also practice outside of New Mexico; and
(b) prefer to use the credentialing forms required by their respective states. In such circumstances, the health carrier and its delegated entity, if any, may accept those forms.
F. Required information. A health carrier shall not require an applicant to submit information not required by the uniform credentialing or re-credentialing forms other than information or documentation that is reasonably related to information on the application.
G. Accreditation by nationally recognized accrediting entity.
(1) Nothing in this section shall require a health carrier to violate or fail to meet a standard or requirement of a nationally recognized accrediting entity.
(2) A health carrier may seek a waiver of these requirements from the superintendent by submitting accreditation by a nationally recognized entity as evidence of compliance with the requirements of this section.
(3) In those instances where a health carrier seeks to meet the requirements of this section through accreditation by a private accrediting entity, the health carrier shall submit to the superintendent the following information:
(a) current standards of the private accrediting entity in order to demonstrate that the entity’s standards meet or exceed the requirements of this rule;
(b) documentation from the private accrediting entity showing that the health carrier has been accredited by the entity; and
(c) a summary of the data and information that was presented to the private accrediting entity by the health carrier and upon which accreditation of the health carrier was based.
(4) A health carrier accredited by the private accrediting entity that has submitted all of the requisite information to the superintendent may then be determined by the superintendent to have met the requirements of the relevant provisions of this section where comparable standards exist, provided that the private accrediting entity from which the health carrier obtained accreditation is recognized and approved by the superintendent.