PURPOSE: This rule sets forth the standard
form which shall be used by all health carriers when soliciting the credentials
of a health care professional in a managed care plan. This rule is promulgated
pursuant to section 354.485, RSMo, and implements
section 354.442.1(15), RSMo.
PUBLISHER'S NOTE: The secretary of state has
determined that the publication of the entire text of the material which is
incorporated by reference as a portion of this rule would be unduly cumbersome
or expensive. This material as incorporated by reference in this rule shall be
maintained by the agency at its headquarters and shall be made available to the
public for inspection and copying at no more than the actual cost of
reproduction. This note applies only to the reference material. The entire text
of the rule is printed here.
(1) Definitions.
(A) Health care professional means a
physician or other appropriately licensed health care practitioner.
(B) Health carrier means a health maintenance
organization as organized pursuant to sections
354.400 through
354.636, RSMo.
(C) Managed care plan means a health benefit
plan that either requires an enrollee to use, or creates incentives, including
financial incentives, for an enrollee to use health care providers managed,
owned, under contract with or employed by the health
carrier.
(2) The
Universal Credentialing DataSource form (Form UCDS), incorporated by reference
and published on October 31, 2006, by the Council for Affordable Quality
Healthcare, 601 Pennsylvania Avenue NW, South Building, Suite 500, Washington,
DC 20004, has been adopted and shall be used by all health carriers and their
agents when credentialing or recredentialing health care professionals in a
managed care plan. The director on request will supply in printed format the
form specified in this rule. The form referenced herein is available at
http://www.insur-ance.mo.gov.
This rule does not incorporate any subsequent amendments or additions. Use of
another standardized credentialing form is permissible so long as the director
determines prior to its use that it is substantially similar to Form UCDS.
Carriers shall accept any form approved by the director for credentialing
purposes, and shall not require a Missouri health care professional to use any
particular approved form to the exclusion of any other approved form, so long
as the form submitted by the Missouri health care professional is Form UCDS or
any other form approved pursuant to this rule. Requests for the director's
approval of the use of another standardized credentialing form should be
submitted to the following address: Missouri Department of Commerce and
Insurance, Managed Care Section, PO Box 690, Jefferson City, MO 65102-0690. A
request must include a complete copy of the form to be approved and the name,
address, and telephone number of the person requesting approval. The director
will provide written notice to all Missouri licensed health maintenance
organizations of the approval of the use of another standardized credentialing
form. The director also will provide on the department's Internet home page a
copy of Form UCDS with a list of other standardized credentialing forms that
have been approved.
(3) Health
carriers may request additional information to explain or provide details
regarding responses obtained on the standard form. Health carriers and their
agents are prohibited from routinely requiring additional information, or
information that duplicates information on Form UCDS, from health care
professionals. This prohibition shall not apply to gathering information on
standard claim forms for purposes of routine claims submission and payment
processes.
(4) An on-site
examination by the health carrier or their agent of the health care
professional's place of business shall not, in itself, be considered a routine
request for additional information.
(5) Accurate reproduction of the form may be
utilized in lieu of the printed form. This includes, but is not limited to,
accurate reproduction in paper, electronic, or Internet based formats. Health
carriers and their agents shall accept an accurate reproduction, and shall not
require a health care professional to use any particular accurate reproduction
to the exclusion of any other accurate reproduction, except that a health
carrier or agent may require a paper format if a health care professional
submits an electronic or Internet based format that the health carrier or agent
is not prepared to accept.
Notes
20 CSR 400-7.180
AUTHORITY:
section 354.442.1(15), RSMo 2000 and section
354.485, RSMo Supp. 2007.
Original rule filed Nov. 3, 1997, effective June 30, 1998. Amended: Filed June
6, 2000, effective Feb. 28, 2001. Amended: Filed May 14, 2008, effective Jan.
30, 2009. Non-substantive change filed Sept. 11, 2019, published Oct. 31,
2019.
AUTHORITY: section
354.442.1(15), RSMo 2000 and section
354.485, RSMo Supp. 2007.
Original rule filed Nov. 3, 1997, effective June 30, 1998. Amended: Filed June
6, 2000, effective Feb. 28, 2001. Amended: Filed May 14, 2008, effective Jan.
30, 2009. Non-substantive change filed Sept. 11, 2019, published Oct. 31,
2019.
