Common use of General Provider Credentialing Clause in Contracts

General Provider Credentialing. 2.9.3.1.1. The Contractor shall implement written policies and procedures that comply with the requirements of 42 C.F.R. §§ 422.504(i)(4)(iv) and 438.214(b) regarding the selection, retention and exclusion of providers and meet, at a minimum, the requirements below. 2.9.3.1.2. The Contractor shall submit such policies and procedures annually to DMAS, if amended, and shall demonstrate to DMAS, by reporting annually that all providers within the Contractor’s Provider Network are credentialed according to such policies and procedures. 2.9.3.1.3. The Contractor shall: 2.9.3.1.3.1. Designate and describe the department(s) and person(s) at the Contractor’s organization who will be responsible for provider credentialing and re-credentialing; 2.9.3.1.3.2. Maintain appropriate, documented processes for the credentialing and re-credentialing of licensed physician providers and all other licensed or certified providers who participate in the Contractor’s Provider Network to perform the services agreed to under this contract. At a minimum, the scope and structure of the processes shall be consistent with recognized managed care industry standards such as those provided by the NCQA and relevant state regulations, including regulations at 12 VAC ▇-▇▇▇-▇▇▇; 2.9.3.1.3.3. Ensure that all providers are credentialed prior to becoming network providers and that a site visit is conducted as appropriate for initial credentialing; 2.9.3.1.3.4. Maintain a documented re-credentialing process which shall occur at least every three years (thirty six months) and shall take into consideration various forms of data including, but not limited to, grievances, results of quality reviews utilization management information, and Enrollee satisfaction surveys; 2.9.3.1.3.5. The Contractor’s standards for licensure and certification shall be included in its participating Provider Network contracts with its network providers which must be secured by current subcontracts or employment contracts. 2.9.3.1.3.6. Upon notice from DMAS or CMS, not authorize any providers terminated or suspended from participation in the Virginia Medicaid Program, Medicare or from another state’s Medicaid program, to treat Enrollees and shall deny payment to such providers for services provided. In addition: 2.9.3.1.3.6.1. The Contractor shall comply with requirements detailed at 42 C.F.R. § 455.436, requiring the Contractor to, at a minimum, check the Department of Health Professions website at least twice per month for its Providers, OIG List of Excluded Individuals Entities (LEIE), Medicare Exclusion Database (MED), and the System for Awards Management (▇▇▇) (the successor to the Excluded Parties List System (EPLS)) for its providers at least monthly, before contracting with the provider, and at the time of a provider’s credentialing and recredentialing; 2.9.3.1.3.6.2. If a provider is terminated or suspended from the Virginia Medicaid Program, Medicare, or another state’s Medicaid program or is the subject of a state or federal licensing action, the Contractor shall terminate, suspend, or decline a provider from its network as appropriate. 2.9.3.1.3.6.3. The Contractor shall notify CMS and DMAS within seven (7) calendar days, via the CMT, when it terminates, suspends, or declines a provider from its network because of fraud, integrity, or quality; 2.9.3.1.3.7. Not contract with, or otherwise pay for any items or services furnished, directed or prescribed by, a provider that has been excluded from participation in federal health care programs by the Office of the Inspector General of the U.S. Department of Health and Human Services under either Section 1128 or Section 1128A of the Social Security Act, or that has been terminated from participation under Medicare or another state’s Medicaid program, except as permitted under 42 C.F.R. §1001.1801 and §1001.1901; 2.9.3.1.3.8. Not establish provider selection policies and procedures that discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment; 2.9.3.1.3.9. Ensure that no credentialed provider engages in any practice with respect to any Enrollee that constitutes unlawful discrimination under any other state or federal law or regulation, including, but not limited to, practices that violate the provisions of 45 C.F.R. Part 80, 45 C.F.R. Part 84, and 45 C.F.R. Part 90; 2.9.3.1.3.10. Search and do not contract with the names of parties disclosed during the credentialing and recredentialing process in the DHP, OIG LEIE, MED, and ▇▇▇ exclusion or debarment databases, and parties that have been terminated from participation under Medicare or another state’s Medicaid program; 2.9.3.1.3.11. Obtain disclosures from all network providers and applicants and consistent with 42 C.F.R. 455 Subpart B [42 CFR 455.104, 455.105, 455.106], and as required by 42 C.F.R.§ 1002.3, including but not limited to obtaining such information through provider enrollment forms and credentialing and recredentialing packages, and maintain such disclosed information in a manner which can be periodically searched by the Contractor for exclusions and provided to DMAS in accordance with this Contract, including this Section, and relevant state and federal laws and regulations; and 2.9.3.1.3.12. Notify CMS and DMAS at least on a quarterly basis when a provider fails credentialing or re-credentialing because of a program integrity or adverse action reason, and shall provide related and relevant information to CMS and DMAS as required by CMS, DMAS or state or federal laws, rules, or regulations. 2.9.3.1.3.13. Include the consideration of performance indicators obtained through the Quality Improvement Plan (QIP), utilization management program, grievance and appeals system, and Enrollee satisfaction surveys in the Contractor’s recredentialing process.

General Provider Credentialing. 2.9.3.1.1. The Contractor shall implement shall: 2.8.3.1.1. Implement written policies and procedures that comply with the requirements of 42 C.F.R. §§ 422.504(i)(4)(iv) and 438.214(b) regarding the selection, retention and exclusion of providers and meet, at a minimum, the requirements below. 2.9.3.1.2. The Contractor shall submit such policies and procedures annually to DMASEOHHS, if amended, and shall demonstrate to DMASEOHHS, by reporting annually that all providers within the Contractor’s Provider Network are credentialed according to such policies and procedures. 2.9.3.1.3. The Contractor shall: 2.9.3.1.3.12.8.3.1.1.1. Designate and describe the department(sdepartments(s) and person(s) at the Contractor’s organization who will be responsible for provider credentialing and re-credentialing; 2.9.3.1.3.22.8.3.1.1.2. Maintain appropriate, documented processes for the credentialing and re-credentialing of licensed physician providers and all other licensed or certified providers who participate in the Contractor’s Provider Network to perform the services agreed to under this contractNetwork. At a minimum, the scope and structure of the processes shall be consistent with recognized managed care industry standards such as those provided by the NCQA National Committee for Quality Assurance (NCQA) and relevant state State regulations, including regulations issued by the Board of Registration in Medicine (BORIM) at 12 VAC ▇243 CMR 3.13. Such processes must also be consistent with any uniform credentialing policies specified by EOHHS addressing acute, primary and Behavioral Health Providers, including but not limited to substance use disorder providers, and any other EOHHS-▇▇▇-▇▇▇;specified providers. 2.9.3.1.3.32.8.3.1.1.3. Ensure that all providers are credentialed prior to becoming network providers Network Providers and that a site visit is conducted with recognized managed care industry standards such as appropriate those provided by the National Committee for initial credentialingQuality Assurance (NCQA) and relevant State regulations; 2.9.3.1.3.42.8.3.1.1.4. Maintain a documented re-credentialing process which shall occur at least every three years (thirty thirty-six months) and shall take into consideration various forms of data including, but not limited to, grievancesGrievances, results of quality reviews utilization management information, and Enrollee satisfaction surveys; 2.9.3.1.3.52.8.3.1.1.5. The Contractor’s Maintain a documented re-credentialing process that requires that physician providers and other licensed and certified professional providers, including Behavioral Health Providers, maintain current knowledge, ability, and expertise in their practice area(s) by requiring them, at a minimum, to conform with recognized managed care industry standards for licensure such as those provided by NCQA and certification shall relevant State regulations, when obtaining Continuing Medical Education (CME) credits or continuing Education Units (CEUs) and participating in other training opportunities, as appropriate. Such processes must also be included in its participating Provider Network contracts consistent with its network providers which must be secured any uniform re-credentialing policies specified by current subcontracts or employment contracts.CMS and EOHHS addressing acute, primary and Behavioral Health Providers, including but not limited to substance use disorder providers, and any other EOHHS-specified providers; 2.9.3.1.3.62.8.3.1.1.6. Upon notice from DMAS or CMSEOHHS, not authorize any providers terminated or suspended from participation in the Virginia Medicaid ProgramMassHealth, Medicare or from another state’s Medicaid program, to treat Enrollees and shall deny payment to such providers for services provided. In addition: 2.9.3.1.3.6.12.8.3.1.1.6.1. The Contractor shall comply with requirements detailed monitor providers and prospective providers by monitoring all of the databases described in Appendix O, at 42 C.F.R. § 455.436the frequency described in Appendix O as follows: 2.8.3.1.1.6.1.1. The Contractor shall search the databases in Appendix O for individual providers, requiring provider entities, and owners, agents, and managing employees of providers at the time of enrollment and re-enrollment, credentialing and recredentialing, and revalidation. 2.8.3.1.1.6.1.2. The Contractor toshall evaluate the ability of existing providers, provider entities, and owners, agents, and managing employees of providers to participate by searching newly identified excluded and sanctioned individuals and entities reported as described in Appendix O. 2.8.3.1.1.6.1.3. The Contractor shall identify the appropriate individuals to search and evaluate pursuant to this section by using, at a minimum, check the Department federally required disclosures form provided by EOHHS. 2.8.3.1.1.6.1.4. The Contractor shall submit a monthly Excluded provider Monitoring Report to EOHHS, as described in Appendix N, which demonstrates the Contractor’s compliance with this section. At the request of Health Professions website at least twice per month for its ProvidersEOHHS, OIG List of Excluded Individuals Entities (LEIE), Medicare Exclusion Database (MED), and the System for Awards Management (▇▇▇) (Contractor shall provide additional information demonstrating to EOHHS’ satisfaction that the successor to the Excluded Parties List System (EPLS)) for its providers at least monthly, before contracting Contractor complied with the providerrequirements of this section, which may include, but shall not be limited to computer screen shots from the databases set forth in Appendix O. 2.8.3.1.1.6.1.5. The Contractor shall develop and at maintain policies and procedures to implement the time of a provider’s credentialing requirements as set forth in this section and recredentialing;to comply with 42 C.F.R. § 438.608(a)(1). 2.9.3.1.3.6.22.8.3.1.1.6.2. If a provider is terminated or suspended from the Virginia Medicaid ProgramMassHealth, Medicare, or another state’s Medicaid program or is the subject of a state State or federal licensing action, the Contractor shall terminate, suspend, or decline a provider from its network Provider Network as appropriate. 2.9.3.1.3.6.32.8.3.1.1.6.3. The Contractor shall notify CMS and DMAS within seven (7) calendar daysEOHHS, via the CMTContract Management Team, when it terminates, suspends, or declines a provider from its network Provider Network because of fraud, integrity, or quality; 2.9.3.1.3.7. Not contract with, or otherwise pay for any items or services furnished, directed or prescribed by, a provider that has been excluded from participation in federal health care programs by the Office of the Inspector General of the U.S. Department of Health and Human Services under either Section 1128 or Section 1128A of the Social Security Act, or that has been terminated from participation under Medicare or another state’s Medicaid program, except as permitted under 42 C.F.R. §1001.1801 and §1001.1901; 2.9.3.1.3.8. Not establish provider selection policies and procedures that discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment; 2.9.3.1.3.9. Ensure that no credentialed provider engages in any practice with respect to any Enrollee that constitutes unlawful discrimination under any other state or federal law or regulation, including, but not limited to, practices that violate the provisions of 45 C.F.R. Part 80, 45 C.F.R. Part 84, and 45 C.F.R. Part 90; 2.9.3.1.3.10. Search and do not contract with the names of parties disclosed during the credentialing and recredentialing process in the DHP, OIG LEIE, MED, and ▇▇▇ exclusion or debarment databases, and parties that have been terminated from participation under Medicare or another state’s Medicaid program; 2.9.3.1.3.11. Obtain disclosures from all network providers and applicants and consistent with 42 C.F.R. 455 Subpart B [42 CFR 455.104, 455.105, 455.106], and as required by 42 C.F.R.§ 1002.3, including but not limited to obtaining such information through provider enrollment forms and credentialing and recredentialing packages, and maintain such disclosed information in a manner which can be periodically searched by the Contractor for exclusions and provided to DMAS in accordance with this Contract, including this Section, and relevant state and federal laws and regulations; and 2.9.3.1.3.12. Notify CMS and DMAS at least on a quarterly basis when a provider fails credentialing or re-credentialing because of a program integrity or adverse action reason, and shall provide related and relevant information to CMS and DMAS as required by CMS, DMAS or state or federal laws, rules, or regulations. 2.9.3.1.3.13. Include the consideration of performance indicators obtained through the Quality Improvement Plan (QIP), utilization management program, grievance and appeals system, and Enrollee satisfaction surveys in the Contractor’s recredentialing process.

General Provider Credentialing. 2.9.3.1.1. The Contractor shall implement written policies and procedures that comply with the requirements of 42 C.F.R. §§ 422.504(i)(4)(iv) and 438.214(b) regarding the selection, retention and exclusion of providers and meet, at a minimum, the requirements below. 2.9.3.1.2. The Contractor shall submit such policies and procedures annually to DMAS, if amended, and shall demonstrate to DMAS, by reporting annually that all providers within the Contractor’s Provider Network are credentialed according to such policies and procedures. 2.9.3.1.3. The Contractor shall: 2.9.3.1.3.1. Designate and describe the department(s) and person(s) at the Contractor’s organization who will be responsible for provider credentialing and re-credentialing; 2.9.3.1.3.2. Maintain appropriate, documented processes for the credentialing and re-credentialing of licensed physician providers and all other licensed or certified providers who participate in the Contractor’s Provider Network to perform the services agreed to under this contract. At a minimum, the scope and structure of the processes shall be consistent with recognized managed care industry standards such as those provided by the NCQA and relevant state regulations, including regulations at 12 VAC ▇-▇▇▇-▇▇▇; 2.9.3.1.3.3. Ensure that all providers are credentialed prior to becoming network providers and that a site visit is conducted as appropriate for initial credentialing; 2.9.3.1.3.4. Maintain a documented re-credentialing process which shall occur at least every three years (thirty six months) and shall take into consideration various forms of data including, but not limited to, grievances, results of quality reviews utilization management information, and Enrollee satisfaction surveys; 2.9.3.1.3.5. The Contractor’s standards for licensure and certification shall be included in its participating Provider Network contracts with its network providers which must be secured by current subcontracts or employment contracts. 2.9.3.1.3.6. Upon notice from DMAS or CMS, not authorize any providers terminated or suspended from participation in the Virginia Medicaid Program, Medicare or from another state’s Medicaid program, to treat Enrollees and shall deny payment to such providers for services provided. In addition: 2.9.3.1.3.6.1. The Contractor shall comply with requirements detailed at 42 C.F.R. § 455.436, requiring the Contractor to, at a minimum, check the Department of Health Professions website at least twice per month for its Providers, OIG List of Excluded Individuals Entities (LEIE), Medicare Exclusion Database (MED), and the System for Awards Management (▇▇▇) (the successor to the Excluded Parties List System (EPLS)) for its providers at least monthly, before contracting with the provider, and at the time of a provider’s credentialing and recredentialing; 2.9.3.1.3.6.2. If a provider is terminated or suspended from the Virginia Medicaid Program, Medicare, or another state’s Medicaid program or is the subject of a state or federal licensing action, the Contractor shall terminate, suspend, or decline a provider from its network as appropriate. 2.9.3.1.3.6.3. The Contractor shall notify CMS and DMAS within seven (7) calendar days, via the CMT, when it terminates, suspends, or declines a provider from its network because of fraud, integrity, or quality; 2.9.3.1.3.7. Not contract with, or otherwise pay for any items or services furnished, directed or prescribed by, a provider that has been excluded from participation in federal health care programs by the Office of the Inspector General of the U.S. Department of Health and Human Services under either Section 1128 or Section 1128A of the Social Security Act, or that has been terminated from participation under Medicare or another state’s Medicaid program, except as permitted under 42 C.F.R. §1001.1801 and §1001.1901; 2.9.3.1.3.8. Not establish provider selection policies and procedures that discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment; 2.9.3.1.3.9. Ensure that no credentialed provider engages in any practice with respect to any Enrollee that constitutes unlawful discrimination under any other state or federal law or regulation, including, but not limited to, practices that violate the provisions of 45 C.F.R. Part 80, 45 C.F.R. Part 84, and 45 C.F.R. Part 90; 2.9.3.1.3.10. Search and do not contract with the names of parties disclosed during the credentialing and recredentialing process in the DHP, OIG LEIE, MED, and ▇▇▇ exclusion or debarment databases, and parties that have been terminated from participation under Medicare or another state’s Medicaid program; 2.9.3.1.3.11. Obtain disclosures from all network providers and applicants and consistent with 42 C.F.R. 455 Subpart B [42 CFR 455.104, 455.105, 455.106], and as required by 42 C.F.R.§ 1002.3, including but not limited to obtaining such information through provider enrollment forms and credentialing and recredentialing packages, and maintain such disclosed information in a manner which can be periodically searched by the Contractor for exclusions and provided to DMAS in accordance with this Contract, including this Section, and relevant state and federal laws and regulations; and 2.9.3.1.3.12. Notify CMS and DMAS at least on a quarterly basis when a provider fails credentialing or re-re- credentialing because of a program integrity or adverse action reason, and shall provide related and relevant information to CMS and DMAS as required by CMS, DMAS or state or federal laws, rules, or regulations. 2.9.3.1.3.13. Include the consideration of performance indicators obtained through the Quality Improvement Plan (QIP), utilization management program, grievance and appeals system, and Enrollee satisfaction surveys in the Contractor’s recredentialing process.