| (a) Purpose and applicability. The purpose of this
section is to identify the standardized credentialing application
form required by Insurance Code §1452.052. Hospitals, health
maintenance organizations, preferred provider benefit plans, and preferred
provider organizations are required to use this form for credentialing
and recredentialing of physicians, advanced practice nurses, and physician
assistants.
(b) Definitions. The following words and terms when
used in this section have the following meanings.
(1) Advanced practice nurse--An advanced practice nurse
as that term is defined by Occupations Code §301.152.
(2) Credentialing--The process of collecting, assessing,
and validating qualifications and other relevant information pertaining
to a physician or provider to determine eligibility to deliver health
care services.
(3) Department--Texas Department of Insurance.
(4) Health maintenance organization--A health maintenance
organization as that term is defined by Insurance Code §843.002(14).
(5) Hospital--A licensed public or private institution
as defined by Health and Safety Code Chapter 241 and any hospital
owned or operated by state government.
(6) Physician--An individual licensed to practice medicine
in this state.
(7) Physician assistant--A person who holds a license
issued under Occupations Code Chapter 204.
(8) Preferred provider benefit plan--A plan issued
by an insurer under Insurance Code Chapter 1301.
(9) Preferred provider organization--An organization
contracting with an insurer issuing a preferred provider benefit plan
under Insurance Code Chapter 1301 for the purpose of providing a network
of preferred providers.
(10) Recredentialing--The periodic process by which:
(A) qualifications of physicians, advanced practice
nurses and physician assistants are reassessed;
(B) performance indicators including utilization and
quality indicators are evaluated; and
(C) continued eligibility to provide services is determined.
(c) Texas Standardized Credentialing Application. The
Texas Standardized Credentialing Application must be used by all hospitals,
health maintenance organizations, preferred provider benefit plan
insurers, and preferred provider organizations for credentialing and
recredentialing of physicians, advanced practice nurses, and physician
assistants.
(d) Effective date. The application form is required
for initial credentialing or recredentialing that occurs on or after
August 1, 2002 for physicians. The application form is required for
advanced practice nurses and physician assistants for initial credentialing
and recredentialing that occurs on or after May 20, 2003.
(e) Availability. This form may be obtained on the
department's website at www.tdi.texas.gov. Reproduction of this form
without any changes is allowed.
(f) Electronic submission. The form may be submitted
electronically to the credentialing entity in the same format as the
hard copy form if the credentialing entity accepts such electronic
submissions.
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| Source Note: The provisions of this §21.3201 adopted to be effective July 31, 2002, 27 TexReg 6709; amended to be effective May 15, 2005, 30 TexReg 2678; amended to be effective November 7, 2021, 46 TexReg 7408 |
