New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 308 - MANAGED CARE PROGRAM › Part 2 - PROVIDER NETWORK › Section 8.308.2.16 - STANDARDS FOR CREDENTIALING AND RE-CREDENTIALING

Current through Register Vol. 35, No. 13, July 16, 2024
The MCO shall verify that each contracted or subcontracted
				  provider participating in, or employed by the MCO meets applicable federal and
				  state requirements for licensing, certification, accreditation and
				  re-credentialing for the type of care or services within the scope of practice
				  as defined by federal medicaid statues and state law. The MCO shall verify that
				  billing providers, rendering providers, ordering providers, attending
				  providers, and prescribing providers are enrolled with MAD, unless the services
				  or providers are otherwise exempted by MAD. The MCO shall document the
				  mechanism for credentialing and re-credentialing of a provider with whom it
				  contracts or employs to treat its members outside the inpatient setting and who
				  fall under its scope of authority. The documentation shall include, but not be
				  limited to, defining the provider's scope of practice, the criteria and the
				  primary source verification of information used to meet the criteria, the
				  process used to make decisions, and the extent of delegated credentialing or
				  re-credentialing arrangements. The credentialing process shall be completed
				  within 45 calendar days from receipt of completed application with all required
				  documentation unless there are extenuating circumstances. The MCO shall use the
				  HSD approved primary source verification entity or one entity for the
				  collection and storage of provider credentialing application information unless
				  there are more cost effective alternatives approved by HSD. The MCO must load
				  provider contracts and claims systems must be able to recognize the provider as
				  a network provider no later than 45 calendar days after a provider is
				  credentialed, when required.
A.
				Practitioner participation: The MCO shall have a process for receiving input
				from participating providers regarding credentialing and re-credentialing of
				its providers.
B. Primary source
				verification: The MCO shall verify the following information from primary
				sources during its credentialing process:
(1)
				a current valid license to practice;
(2) the status of clinical privileges at the
				institution designated by the practitioner as the primary admitting facility,
				if applicable;
(3) valid drug
				enforcement agency (DEA) or controlled substance registration (CSR)
				certificate, if applicable;
(4)
				education and training of practitioner including graduation from an accredited
				professional program and the highest training program applicable to the
				academic or professional degree, discipline and licensure of the
				practitioner;
(5) board
				certification if the practitioner states on the application that he or she is
				board certified in a specialty;
(6)
				current, adequate malpractice insurance, according to the MCOs policy and
				history of professional liability claims that resulted in settlement or
				judgment paid by or on behalf of the practitioner; and
(7) primary source verification shall not be
				required for work history.