230 R.I. Code R. 230-RICR-20-30-9.8

Current through December 3, 2024

Section 230-RICR-20-30-9.8 - Professional Provider Credentialing and Re-credentialing

A. Each health care entity's professional provider credentialing and re-credentialing requirements, policies and processes must be submitted to the Office and must adhere, at a minimum, to the following.

1. Each professional provider credentialing application shall be reviewed by the health care entity's credentialing body; however, the credentialing body may delegate to one or more of its members decision making authority.

2. Professional provider credentialing and re-credentialing criteria shall include:

a. Input from providers credentialed in the entity's network plans and the criteria developed shall be available to applicants;

b. That any economic considerations taken into account by the health care entity factor in and/or adjust for applicant's specialty, applicant's utilization and practice patterns, comparison of the applicant to peers in same specialty, applicant's case mix, severity of illness and/or age of the applicant's patients, and any features of an applicant's practice that may account for higher or lower than expected costs; and

c. That any economic profiling used as part of credentialing or re-credentialing be made available to those provider's profiled.

3. Each health care entity shall evidence to the Office compliance with R.I. Gen. Laws §§ 27-18-83, 27-19-74, 27-20-70, and 27-41-87 that include the following:

a. Communication to the applicant of its credentialing and re-credentialing decision as soon as practical, but no later than forty-five (45) calendar days after the date of receipt of a completed application.

b. For minor changes to the demographic information of a professional provider who is already credentialed with a health care entity, evidence that the health care entity shall complete such change within seven (7) business days of receipt of the health care provider's request. Minor changes shall include, but not be limited to, changes of address and changes to a health care provider's tax identification number.

c. Each health care entity or network plan shall establish a written standard acceptable to the Commissioner defining what elements constitute a complete credentialing and re-credentialing application and shall distribute this standard with the written version of the credentialing application and make such standard available on its website.

4. During the re-credentialing process, if applicable, network plans must have an established mechanism to assure effective communications with in-network professional providers, including without limitation:

a. A two-way communication to assure that the health care entity has directly informed the provider of the need for re-credentialing;

b. Adequate due diligence by the health care entity in obtaining the current and correct mailing address or other provider-preferred mode of communication to directly communicate with the network provider;

c. A mechanism to adequately follow up with network providers who have not responded to the initial re-credentialing communications with a diligent effort to validate the provider's current physical and/or electronic address used as the mode of communication and confirm receipt of the initial re-credentialing communication; and d. Health care entities and/or network plans shall not de-credential a network provider if the health care entity has failed to properly adhere to these re-credentialing requirements.

5. Each health care entity or network plan shall promptly respond to inquiries by the applicant regarding the status of a credentialing or re-credentialing application as well as provide the applicant with an automated application status update at least once every fifteen (15) calendar days to inform the applicant of any missing application materials until the application is deemed complete; and

6. Within five (5) business days of deeming an application complete each health care entity or network plan shall inform the applicant that the credentialing or re-credentialing application is complete.

7. The effective date for billing privileges shall be the next business day following the date of approval of a credentialing application.

B. Evidence to the Office that if the health care entity denies a credentialing or re-credentialing application, the health care entity or network plan shall notify the health care provider in writing and shall provide the health care provider with any and all reasons for denying the application.

C. A health care entity shall establish a transitional or conditional credentialing approval processes in any provider category where there is an established "need" (geographic "need" or "need" by specialty type such as resident graduates, primary care providers, behavioral health providers or certain specialist providers), and shall include:

1. "Need" shall be assessed by the Commissioner considering continuity of care for beneficiaries, insufficient network by provider type and/or the inability of the entity to provide timely access to covered services to its beneficiaries.

2. To be considered for a transitional or conditional credentialing approval, the provider must have:

a. Submitted an otherwise completed credentialing application and met all other credentialing criteria;

b. Successfully graduated from the training program; and

c. Includes a mechanism to ensure that providers with transitional, conditional or temporary credentialing approval receive an effective date for billing privileges of the first business day after the transitional, conditional and/or temporary credentialing approval.

D. A credentialing application and a re-credentialing application, if applicable shall be considered complete when all the following requested material has been submitted and the health care entity or network plan may not require the submission of additional material for an application to be considered complete unless any such additional requirement is approved by the Commissioner:

1. Provider demographics to include name, current mailing address;

2. Current valid license, registration or certificate required in order for professional provider to practice in Rhode Island or other state as applicable;

3. History of any revocation, suspension, probationary status or other disciplinary action regarding provider's license, registration or certificate noted in § 9.8(D)(2) of this Part above;

4. Clinical privileges at a hospital, as applicable;

5. Valid Drug Enforcement Agency and Controlled Substance certificate/registration and/or other state or federal verification to prescribe controlled substances (if applicable);

6. Evidence of board certifications if the professional provider states that he/she is board certified;

7. Evidence of malpractice/professional liability insurance; and

8. History of professional liability claims and description of any settlements or judgements paid to a claimant in connection with a professional liability claim.

E. A health care entity may utilize an alternative credentialing program approved by the Commissioner.

230 R.I. Code R. 230-RICR-20-30-9.8

Adopted effective 12/16/2018