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RULE §10.82Credentialing

(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.

Source Note: The provisions of this §10.82 adopted to be effective December 5, 2005, 30 TexReg 8099; amended to be effective August 2, 2022, 47 TexReg 4534

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