Subject to the provisions of Subsections A., B., C., and D.
of this Section, a managed care entity shall provide a health care professional
with the sources from which credentialing information is received, notification
of any information that varies substantially from the information the health
care professional provided, and the opportunity to correct information received
from a third party that is incorrect or misleading.
A. Each health care professional who is
subject to the credentialing verification process shall have the right to
request information regarding the sources utilized by the managed care entity
to verify credentialing information, including a summary of information
obtained by the managed care entity to satisfy the requirements of this
Regulation.
B. A managed care
entity shall notify a health care professional of any information obtained
during the managed care entity's credentialing verification process that does
not meet the managed care entity's credentialing verification standards or that
varies substantially from the information provided to the managed care entity
by the health care professional, except, that the managed care entity shall not
be required to allow the health care professional to (1) review the contents of
a verification, (2) identify the source of information, or (3) provide a
summary of differing information, if the information is not obtained to meet
the requirements of this Regulation or if disclosure is prohibited by law.
Responses provided by personal or professional references shall not be
available to the health care professional.
C. A health care professional shall have the
right to correct any erroneous information submitted by a third party when the
health care professional feels that the managed care entity's credentialing
verification committee has received information that is incorrect or
misleading. The managed care entity shall have a formal process by which the
health care professional may submit supplemental or corrected information to
the managed care entity's credentialing verification committee. Supplemental
information shall be subject to confirmation by the managed care
entity.
D. Nothing in this Section
8 shall prohibit a managed care entity from denying an application or
reapplication or terminating privileges, employment or a provider participation
agreement where a health care professional intentionally withholds material
information, intentionally omits material information, or intentionally submits
material false or misleading information in a credentialing or re-credentialing
application which is submitted to a managed care entity.
