| (a) Networks must have a documented process for selection
and retention of preferred providers sufficient to ensure that preferred
providers are adequately credentialed. At a minimum, a network's credentialing
standards must meet the standards promulgated by the National Committee
for Quality Assurance (NCQA) or URAC to the extent that those standards
do not conflict with other laws of this state. Networks will be presumed
to be in compliance with statutory and regulatory requirements regarding
credentialing if they have received nonconditional accreditation or
certification by the NCQA, The Joint Commission, URAC, or the Accreditation
Association for Ambulatory Health Care; maintain evidence of that
accreditation or certification; and provide it to the department on
request.
(b) The requirements of §10.41 of this title (relating
to Network-Carrier Contracts) apply to delegation of credentialing.
(c) Delegation of credentialing.
(1) If the network delegates credentialing functions
to other entities, it must have:
(A) a process for developing delegation criteria and
for performing pre-delegation and annual audits;
(B) a delegation agreement;
(C) a monitoring plan; and
(D) a procedure for termination of the delegation agreement
for non-performance.
(2) If the network delegates credentialing functions
to an entity accredited by one of the national accreditation organizations
as described in §10.81(c) of this title (relating to Quality
Improvement Program), the annual audit of that entity is not required
for the function(s) listed in the accreditation; however, evidence
of this accreditation must be made available to the department for
review.
(3) The network must maintain and must make available
for the department to review:
(A) documentation of pre-delegation and annual audits;
(B) executed delegation agreements;
(C) semi-annual reports received from the delegated
entities;
(D) evidence of evaluation of the reports;
(E) current rosters or copies of signed contracts with
doctors and health care practitioners who are affected by the delegation
agreement; and
(F) documentation of ongoing monitoring.
(4) Credentialing files maintained by the other entities
to which the network has delegated credentialing functions must be
made available to the department for examination upon request.
(5) In all cases, the network must maintain the right
to approve credentialing, suspension, and termination of doctors and
health care practitioners.
(d) Compliance. Until January 1, 2023, entities subject
to this section will be deemed to be in compliance with the section
if they are in compliance with the section as adopted to be effective
December 5, 2005. Entities subject to this section must make a filing
attesting to compliance no later than January 1, 2023.
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