Subchapter L. CREDENTIALING
Sec.
9.761. Provider credentialing.
9.762. Credentialing standards.
9.763. Nonphysician providers at facilty, agency or organizations.
Authority The provisions of this Subchapter L issued under Article XXI of The Insurance Company Law of 1921 (40 P. S. § § 991.2101—991.2193), unless otherwise noted.
Source The provisions of this Subchapter L adopted June 8, 2001, effective June 9, 2001, 31 Pa.B. 3043, unless otherwise noted.
Cross References This subchapter cited in 28 Pa. Code § 9.601 (relating to applicability).
§ 9.761. Provider credentialing.
(a) A plan shall establish, maintain and adhere to a health care provider credentialing system to evaluate and enroll qualified health care providers for the purpose of creating an adequate health care provider network. The credentialing system shall include policies and procedures for the following:
(1) Initial credentialing.
(2) Recredentialing at least every 3 years.
(3) Including in the initial credentialing and recredentialing process, a plan assessment of the participating health care providers’ ability to provide urgent care and routine care, and their ability to enroll additional patients in the practice in accordance with standards adopted by the plan.
(4) Inclusion of enrollee satisfaction and quality assurance data in the recredentialing review.
(5) Restrictions or limitations.
(6) Termination of a health care provider’s participation.
(7) In cases of denial or nonrenewals, notification to health care providers that includes a clear rationale for the decision.
(8) Evaluating credentials of health care providers who may be directly accessed for obstetrical and gynecological care.
(9) Evaluating credentials for specialists who are being requested to serve as primary care providers, including standing referral situations, to ensure that access to primary health care services remain available throughout the arrangement.
(10) Enrollee access to only those participating providers who have been properly credentialed.
(b) The plan shall submit its credentialing plan to the Department for approval. Changes to the credentialing plan shall also be submitted to the Department for approval before implementation.
(c) A plan may meet the requirements of this section by establishing a credentialing system that meets or exceeds standards of a Nationally recognized accrediting body acceptable to the Department. The Department will publish a list of these bodies annually in the Pennsylvania Bulletin.
(d) A plan may not require full credentialing of nonparticipating health care providers providing health care services to new enrollees under the continuity of care provision. A plan may require verification of basic credentials such as licensure, malpractice insurance, hospital privileges and malpractice history as basic terms and conditions.
(e) Upon written request, a plan shall disclose relevant credentialing criteria and procedures to health care providers that apply to become participating providers or who are already participating.
(f) A plan shall submit a report to the Department regarding its credentialing process every 2 years. The report shall include the following:
(1) The number of applications made to the plan.
(2) The number of applications approved by the plan.
(3) The number of applications rejected by the plan.
(4) The number of providers terminated for reasons of quality.
(g) A plan shall comply with all requirements of section 2121 of the act (40 P. S. § 991.2121).
§ 9.762. Credentialing standards.
(a) At a minimum, for PCPs and specialists, a plan shall verify the following credentialing elements:
(1) Current licensure.
(2) Education and training.
(3) Board certification status.
(4) Drug enforcement administration certification status.
(5) Current and adequate malpractice coverage.
(6) Malpractice claims history.
(7) Work history.
(8) Hospital privileges if the provider provides services at hospitals.
(9) Any other information the Department may require.
(b) A plan shall verify, at a minimum, for non-PCPs and nonspecialists, current licensure and malpractice coverage, to the extent licensure and coverage is required by State or Federal law.
Cross References This section cited in 28 Pa. Code § 9.763 (relating to nonphysician providers at facility, agency or organizations).
§ 9.763. Nonphysician providers at facility, agency or organizations.
A plan is not required to credential a nonphysician provider who practices as an employee or independent contractor of a plan-contracted facility, agency or organization if the plan verifies that the facility, agency or organization conducts credentialing that meets the standards of § 9.762 (relating to credentialing standards).
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