North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 20 - MANAGED CARE HEALTH BENEFIT PLANS › Section .0400 - NETWORK PROVIDER CREDENTIALS › Section 20 .0405 - VERIFICATION OF CREDENTIALS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Each
				carrier's process for verifying credentials shall take into account and make
				allowance for the time required to request and obtain primary source
				verifications and other information that must be obtained from third parties in
				order to authenticate the applicant's credentials, and shall make allowance for
				the scheduling of a final decision by a credentialing committee, if the
				carrier's credentialing program requires such review.
(b) Within 60 days after receipt of a
				completed application and all supporting documents, the carrier shall assess
				and verify the applicant's qualifications and notify the applicant of its
				decision. If, by the 60th day after receipt of the
				application, the carrier has not received all of the information or
				verifications it requires from third parties, or date-sensitive information has
				expired, the carrier shall issue a written notification to the applicant either
				closing the application and detailing the carrier's attempts to obtain the
				information or verification, or pending the application and detailing the
				carrier's attempts to obtain the information or verifications. If the
				application is held, the carrier shall inform the applicant of the length of
				time the application will be pending. The notification shall include the name,
				address and phone number of a credentialing staff person who will serve as a
				contact person for the applicant.
(c) Within 15 days after receipt of an
				incomplete application, the carrier shall notify the applicant in writing of
				all missing or incomplete information or supporting documents, in accordance
				with the following procedures:
(1) The notice
				to the applicant shall include a complete and detailed description of all of
				the missing or incomplete information or documents that must be submitted in
				order for review of the application to continue. The notification shall include
				the name, address, and telephone number of a credentialing staff person who
				will serve as a contact person for the applicant.
(2) Within 60 days after receipt of all of
				the missing or incomplete information or documents, the carrier shall assess
				and verify the applicant's qualifications and notify the applicant of its
				decision, in accordance with paragraph (b) of this rule.
(3) If the missing information or documents
				have not been received within 60 days after initial receipt of the application
				or if date-sensitive information has expired, the carrier shall close the
				application or delay final review, pending receipt of the necessary
				information. The carrier shall provide written notification to the applicant of
				the closed or pending status of the application and where applicable, the
				length of time the application will be pending. The notification shall include
				the name, address, and telephone number of a credentialing staff person who
				will serve as a contact person to the applicant.