| (a) HHSC identifies applicant provider types for which
an expedited credentialing process must be established and implemented.
(b) An MCO must comply with the requirements of Texas
Insurance Code Chapter 1452, Subchapters C, D, and E, regarding expedited
credentialing and payment of physicians, podiatrists, and therapeutic
optometrists. Additionally, each MCO must establish and implement
an expedited credentialing process that allows applicant providers
to provide services to members for the following provider types:
(1) dentists;
(2) dental specialists (endodontist, oral/maxillofacial
surgeon, orthodontist, pediatric dentist, periodontist, prosthodontist,
and physicians providing dental specialty care);
(3) licensed clinical social workers;
(4) licensed professional counselors;
(5) licensed marriage and family therapists; and
(6) psychologists.
(c) To qualify for expedited credentialing under this
section and payment under subsection (e) of this section, an applicant
provider must:
(1) be a member of an established health care provider
group that has a current contract with an MCO;
(2) be a Medicaid-enrolled provider;
(3) agree to comply with the terms of the contract
described in paragraph (1) of this subsection; and
(4) submit all documentation and information required
by the MCO as necessary for the MCO to begin the credentialing process.
(d) An MCO must establish and implement an expedited
credentialing process for a nursing facility that successfully undergoes
a change of ownership (CHOW). The requirements for applicant providers
to qualify for expedited credentialing listed in subsection (c) of
this section apply to CHOWs, with the exception of subsection (c)(1)
of this section.
(e) On submission by the applicant provider of the
information required by the MCO under subsection (c) of this section,
for Medicaid reimbursement purposes, the MCO must treat the provider
as if the provider were in the MCO's provider network when the provider
provides services to recipients, subject to subsections (f) and (g)
of this section.
(f) Except as provided by subsection (g) of this section,
if, on completion of the credentialing process, an MCO determines
that the applicant provider does not meet the MCO's credentialing
requirements, the MCO may recover from the provider or provider group
the difference between payments for in-network benefits and out-of-network
benefits.
(g) If an MCO determines on completion of the credentialing
process that the applicant provider does not meet the MCO's credentialing
requirements and that the provider or provider group made fraudulent
claims in the provider's application for credentialing, the MCO may
recover from the provider or provider group the entire amount of any
payment paid to the provider or provider group.
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