211 CMR, § 52.09 - Credentialing
(1) A Carrier will credential all Health Care
Providers according to the NCQA Standards for credentialing and
recredentialing, and the Bureau of Managed Care will review a Carrier's
credentialing and recredentialing processes that are set forth in the Carrier's
application for Accreditation for compliance with the applicable NCQA Standards
for credentialing and recredentialing if the Carrier does not have Deemed
Accreditation with respect to credentialing and recredentialing.
(2)
Credentialing of Health Care
Professionals.
(a) A Carrier
shall accept, in both electronic and paper form, a Health Care Professional
credentialing application that is submitted in an application format specified
by the Commissioner. For purposes of
211
CMR 52.09(2), acceptance in
electronic form shall mean that a Carrier, at minimum, shall accept a Health
Care Professional credentialing application by means of facsimile and
electronic mail and may implement an online process for the purpose of
processing credentialing applications. For purposes of
211
CMR 52.09(2),Carriers may
charge Health Care Professionals a reasonable administrative charge associated
with the costs of processing submissions in electronic or paper form that
differs from the form used by the majority of Health Care
Professionals
(b) Unless there are
otherwise binding arrangements between a Carrier and specific Providers holding
Carriers to a shorter time standard, a Carrier shall notify a Health Care
Professional that a submitted credentialing application is incomplete no later
than 20 business days after the Carrier receives the credentialing
application.
(c) All Carriers shall
complete credentialing of 95% of Health Care Professionals' initial Clean and
Complete Credentialing Applications within 60 Days of receipt of the Health
Care Professional's Clean and Complete Credentialing Application, and all
Carriers shall complete credentialing of 95% of Health Care Professionals'
Clean and Complete re-Credentialing Applications within 120 Days of receipt of
the Health Care Professional's Clean and Complete re-Credentialing Application,
and Carriers shall inform a Health Care Professional within 75 Days of receipt
of an initial Clean and Complete Credentialing Application of the status of the
application, including, if applicable, the reasons for any delay in the
completion of credentialing and a timeline of the expected resolution of the
application and, if a Health Care Professional is not credentialed, the reasons
that the Health Care Professional is not credentialed.
(3) Nothing in this
211
CMR 52.09 shall be construed to prevent a
Carrier from utilizing additional credentialing information in selecting the
Providers with which it contracts.
(4) Nothing in this
211
CMR 52.09 shall be construed to require a
Carrier to select a Provider as a Participating Provider, even if the Provider
meets the Carrier's credentialing criteria.
(5) Carriers shall maintain documentation
regarding all submissions.
(6) A
Carrier shall not be required to meet the requirements of
211
CMR 52.09 if the Carrier does not provide
Benefits through a Network or does not have contracts with Participating
Providers.
(7) A Carrier that
provides specified services through a workers' compensation preferred Provider
arrangement shall be deemed to have met the requirements of
211
CMR 52.09 if it has met the requirements of
211 CMR
51.00: Preferred Provider Health Plans and
Workers' Compensation Preferred Provider Arrangements and
452 CMR
6.00: Utilization Review and Quality
Assessment.
Notes
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