1 Tex. Admin. Code § 353.423
Current through Register Vol. 49, No. 48, November 29, 2024
Section 353.423 - Expedited Credentialing(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:(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(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.1 Tex. Admin. Code § 353.423
Adopted by Texas Register, Volume 44, Number 16, April 19, 2019, TexReg 1983, eff. 4/24/2019