W. Va. Code R. § 114-53-6

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-53-6 - Credentialing & Recredentialing

6.1. A health maintenance organization shall ensure that its network has sufficient numbers and types of providers. The HMO shall have a written access plan outlining its strategy for maintaining an adequate network and shall implement mechanisms designed to assure the availability of primary care and specialty practitioners.

6.2. A health maintenance organization shall have written policies and procedures for the credentialing of all providers that include the original credentialing, recredentialing, recertification and or reappointment of physicians and other licensed independent practitioners who fall under its scope of authority and action.

a. The governing body, or the group or individual to whom the governing body has formally delegated the credentialing function, shall review and approve credentialing policies and procedures.

b. A credentialing committee or other peer review body shall be established to make recommendations regarding credentialing decisions. The committee shall include providers, including but not limited to physicians, as voting members.

6.3. In terms of initial credentialing, an HMO shall obtain and review verification of the following from primary sources:

a. A current valid license to practice;

b. When applicable, clinical privileges in good standing at the hospital designated by the practitioner as the primary admitting facility;

c. A valid Drug Enforcement Administration (DEA) certificate, as applicable;

d. Graduation from medical school or appropriate graduate school and completion of a residency, specialty training and board certification, as applicable;

e. Complete work history;

f. Current adequate malpractice insurance according to the HMO's policy;

g. Complete professional liability claims history; and

h. Any other information deemed necessary by the HMO in determining whether to contract with a prospective provider.

6.4. A prospective provider shall complete an application for membership which includes a statement by the applicant regarding:

a. Reasons for any inability to perform the essential functions of the position, with or without accommodation;

b. Lack of substance abuse or chemical dependency;

c. History of loss of license and/or felony convictions;

d. History of loss or limitation of privileges or disciplinary activity;

e. Any other information deemed necessary by an HMO in determining whether to contract with a prospective provider; and

f. An attestation to the correctness/completeness of the application.

6.5. A health maintenance organization shall request information on the prospective provider from recognized monitoring organizations including: the National Practitioner Data Bank; the appropriate state licensing boards such as the Board of Medicine, Chiropractic Board, Osteopathic Board and/or Dental Board; and any Medicare/Medicaid sanctioning.

6.6. Representatives from the credentialing committee or members of their staff shall make an initial visit to each potential primary care practitioner's office and to the offices of obstetricians/gynecologists and other high-volume specialists. This process shall include documentation of a structured review of the site and of medical record keeping practices to ensure conformance with the HMO's standards.

6.7. A health maintenance organization shall have written policies and procedures for the initial and ongoing quality assessment of health delivery organizations with which it intends to contract. The HMO shall confirm that the health delivery organization has been reviewed and approved by a recognized accrediting body and is in good standing with state and federal regulatory bodies. If the health delivery organization has not been approved by a recognized accrediting body, the HMO must develop and implement standards of participation. Health delivery organizations shall include but are not limited to hospitals, home health agencies, behavioral health agencies, nursing homes, skilled nursing facilities and free-standing surgical centers.

a. At least every three years, the health maintenance organization shall confirm that the health delivery organization continues to be in good standing with the state and federal regulatory bodies and, if applicable, is reviewed and approved by an accrediting body.

6.8. In terms of recredentialing, a health maintenance organization shall develop a process for the periodic verification of credentials which shall be implemented at least every three years.

a. At a minimum, recredentialing shall include verification from primary sources of:

1. A valid state license to practice;

2. Clinical privileges in good standing at the hospital designated by the practitioner as the primary admitting facility;

3. A valid Drug Enforcement Administration (DEA) certificate, as applicable;

4. Board certification, as applicable;

5. Current, adequate malpractice insurance;

6. Professional liability claims history; and

7. Any other information deemed necessary by an HMO in determining whether to re-contract with a provider.

b. The recredentialing process shall include a current statement by the applicant regarding reasons for any inability to perform the essential functions of the position, with or without accommodation and lack of present illegal drug use and alcohol abuse.

c. An HMO shall request recredentialing information from the National Practitioner Data Bank; the appropriate state licensing boards such as the Board of Medicine, Chiropractic Board, Osteopathic Board and/or Dental Board; and any Medicare/Medicaid sanctioning.

d. The recredentialing process shall also include a review of data from member complaints and grievances, results of quality reviews, utilization management, member satisfaction surveys, medical record reviews and site visits.

e. The recredentialing process shall include an on-site visit to all primary care providers, obstetricians/ gynecologists and high-volume specialists and shall involve documentation of a structured review of the site and medical record keeping practices to ensure conformance with HMO standards.

f. A health maintenance organization shall have polices and procedures in place for reducing, suspending or terminating practitioner privileges which shall include but is not limited to:

1. A mechanism for reporting to the appropriate authorities serious quality deficiencies resulting in suspension or termination; and

2. An appeal process for and notice thereof to the provider.

W. Va. Code R. § 114-53-6