Provider Panels: The Credentialing Process

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PROVIDER PANELS: THE CREDENTIALING PROCESS Mary M. Kwei Chief, Life and Health Complaints

Agenda: The Credentialing Process 2

What is the Maryland Insurance Administration The Maryland Insurance Administration (MIA) is the state agency that regulates insurance in Maryland. The MIA: Licenses insurers and insurance producers (agents or brokers). Examines the business practices of licensees to ensure compliance. Monitors solvency of insurers. Reviews/approves insurance policy forms. Reviews insurance rates to ensure rates are not inadequate, excessive or unfairly discriminatory. Investigates consumer and provider complaints and allegations of fraud. Video: How the MIA can help

What is the Maryland Insurance Administration? If you feel that your insurer or insurance producer acted improperly, you have the right to file a complaint. Examples of improper actions include: Improperly denying or delaying payment of all or portions of a claim; Improperly terminating your insurance policy; Raising your insurance premiums without proper notice; Making false statements to you in connection with the sale of insurance or processing of insurance claims; and, Overcharging you for services, including premium finance charges.

Where to find the law Section 15-112 of the Insurance Article is the primary law on credentialing providers in Maryland. It applies to carriers. Carriers include insurers, health maintenance organizations, nonprofit health service plans, dental plan organizations, and an entity that arranges a provider panel for a carrier.

What types of providers are covered by the law? Section 15-112(a)(16) of the Insurance Article defines provider to mean a health care practitioner, or group of health care practitioners, who are licensed, certified, or otherwise authorized by law to provide health care services. Section 15-112(g) of the Insurance Article gives the requirements for the application process used by carriers to process an application by a provider to participate on the carrier’s provider panel.

What application form is required? Section 15-112.1 of the Insurance Article states that a carrier shall accept the uniform credentialing form as the sole application for a health care provider to become credentialed. The Maryland Insurance Administration issued Bulletin 09-25 to designate the Council for Affordable Quality Healthcare’s (CAQH) form as the uniform credentialing form for health plans. Dental plans have a separate credentialing form.

Time Frames The carrier should provide an application to a provider on request. If a carrier receives an incomplete application, the carrier must send notice to the provider within 10 days, indicating what additional information is needed. When a carrier receives a complete application, the carrier has 30 days to send the provider written notice of its intent to continue to process the application, or to reject the provider for participation. If the carrier proceeds with credentialing, it has 120 days from the date of the notice to accept or reject the provider for participation, and to send written notice of the decision.

Prohibited reasons for denials and terminations Carriers may not reject or terminate providers based on: Gender, race, age, religion, national origin, or a protected category under the Americans with Disabilities Act. Appeals based on medical necessity. Appeals or complaints through a process established by the carrier for that purpose. A carrier may not limit the number of behavioral health providers at a health care facility that may be credentialed.

Prohibited terminations and denials A carrier may deny or terminate participation due to: A full network. Any reason that is not prohibited, upon 90 days written notice to the provider. Fraud, patient abuse, incompetence, or loss of licensure status, without advance notice.

What if a group practice hires a provider who is not credentialed? Section 15-112(w) of the Insurance Article requires a carrier to reimburse a participating group practice at its participating rates for a practitioner who is not participating if: The practitioner is employed by, or a member of, the group practice; The practitioner has applied for credentialing and the carrier intends to continue to process the application; The practitioner has a valid license to practice in the state; and The practitioner is currently credentialed by an accredited hospital or has professional liability insurance.

What if a group practice hires a provider who is not credentialed? The carrier must reimburse the group practice at the participating rate from the date of written notice that the carrier will continue to process the provider’s application until the date of notice of acceptance or rejection of the practitioner’s application to participate on the provider panel. The carrier’s members may not be held liable for amounts other than the deductible, copayment, or coinsurance.

What if a group practice hires a provider who is not credentialed? The group practice must give notice to the patient that: The provider is not participating; The provider has applied to become participating; The carrier has not completed its assessment of the qualifications of the provider to participate; and Any covered services must be reimbursed at the participating provider rate.

What if a credentialed provider changes employers? Section 15-112(j) of the Insurance Article prohibits re-credentialing in some circumstances: If a provider changes a federal tax identification number; If the provider’s employer changes a federal tax identification number; or If the provider changes to a new employer and the new employer participates on the carrier’s provider panel or is the employer of providers that participate on the carrier’s provider panel.

What if a credentialed provider changes employers? If a participating provider changes employers or tax identification numbers, they need to send the carrier written notice at least 45 days before the effective date of the change. The provider contract will have the address to send notice to the carrier. The notice must include: A statement of intent to continue to provide services in the same field of specialization; The effective date of the change in tax identification numbers; A copy of the form W-9; The new employer’s name, the employer’s contact person, and the address, telephone number, fax number, and email address for the contact person. The carrier has 30 business days to acknowledge receipt.

Nonparticipating locations Sometimes a provider is credentialed by a carrier, and participates on the provider panel, but only for specific offices. If the provider participates through a group practice or health care facility, the carrier may not require the provider to be considered participating when: Providing services to member through an individual or group practice that does not have a contract with the carrier; and Billing for the services using a different federal tax identification number. The provider must notify the member that the provider is not participating and what the anticipated total charges are.

Provider Directory Updates Carriers are required to have accurate and up-to-date directories. You should respond to any requests for confirmation of your provider listing information promptly. The No Surprises Act added requirements for provider directory updates that will take effect in 2022.

Provider Directory Updates Beginning January 1, 2022, health care providers and facilities are required to have processes to ensure timely provision of provider directory information to carriers. Providers are required to give carriers information when beginning a network agreement, terminating a network agreement, or when there are material changes to the content of provider directory information.

Facilities When credentialing a facility, a carrier is not subject to the requirements in §15-112 of the Insurance Article because a facility does not fall under the definition of a provider in the statute. Generally, a facility is credentialed to provide facility services. Practitioners are credentialed and bill separately. For example, a hospital may be participating for emergency room facility services, but the physicians in the emergency room may or may not participate, and will bill separately.

MIA Contact Information You can call the Life and Health Complaints unit to ask questions at 410-468-2244 or 1-800-492-6116. The MIA’s website is www.insurance.maryland.gov. 20

Questions?

accept the uniform credentialing form as the sole application for a health care provider to become credentialed. The Maryland Insurance Administration issued Bulletin 09-25 to designate the Council for Affordable Quality Healthcare's (CAQH) form as the uniform credentialing form for health plans. Dental plans have a separate credentialing .

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