Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 30 - Health Insurance › Part 9 - Network Plans › Section 230-RICR-20-30-9.8 - Professional Provider Credentialing and Re-credentialing

Current through June 14, 2024
A. Each health care entity's professional
				  provider credentialing and re-credentialing requirements, policies and
				  processes must be submitted to the Office and must adhere, at a minimum, to the
				  following.
1. Each professional provider
				  credentialing application shall be reviewed by the health care entity's
				  credentialing body; however, the credentialing body may delegate to one or more
				  of its members decision making authority.
2. Professional provider credentialing and
				  re-credentialing criteria shall include:
a.
				  Input from providers credentialed in the entity's network plans and the
				  criteria developed shall be available to applicants;
b. That any economic considerations taken
				  into account by the health care entity factor in and/or adjust for applicant's
				  specialty, applicant's utilization and practice patterns, comparison of the
				  applicant to peers in same specialty, applicant's case mix, severity of illness
				  and/or age of the applicant's patients, and any features of an applicant's
				  practice that may account for higher or lower than expected costs; and
c. That any economic profiling used
				  as part of credentialing or re-credentialing be made available to those
				  provider's profiled.
3.
				  Each health care entity shall evidence to the Office compliance with R.I. Gen.
				  Laws §§
											27-18-83,
				  27-19-74,
				  27-20-70, and
				  27-41-87 that include the
				  following:
a. Communication to the applicant
				  of its credentialing and re-credentialing decision as soon as practical, but no
				  later than forty-five (45) calendar days after the date of receipt of a
				  completed application.
b. For minor
				  changes to the demographic information of a professional provider who is
				  already credentialed with a health care entity, evidence that the health care
				  entity shall complete such change within seven (7) business days of receipt of
				  the health care provider's request. Minor changes shall include, but not be
				  limited to, changes of address and changes to a health care provider's tax
				  identification number.
c. Each
				  health care entity or network plan shall establish a written standard
				  acceptable to the Commissioner defining what elements constitute a complete
				  credentialing and re-credentialing application and shall distribute this
				  standard with the written version of the credentialing application and make
				  such standard available on its website.
4. During the re-credentialing process, if
				  applicable, network plans must have an established mechanism to assure
				  effective communications with in-network professional providers, including
				  without limitation:
a. A two-way
				  communication to assure that the health care entity has directly informed the
				  provider of the need for re-credentialing;
b. Adequate due diligence by the health care
				  entity in obtaining the current and correct mailing address or other
				  provider-preferred mode of communication to directly communicate with the
				  network provider;
c. A mechanism to
				  adequately follow up with network providers who have not responded to the
				  initial re-credentialing communications with a diligent effort to validate the
				  provider's current physical and/or electronic address used as the mode of
				  communication and confirm receipt of the initial re-credentialing
				  communication; and d. Health care entities and/or network plans shall not
				  de-credential a network provider if the health care entity has failed to
				  properly adhere to these re-credentialing requirements.
5. Each health care entity or network plan
				  shall promptly respond to inquiries by the applicant regarding the status of a
				  credentialing or re-credentialing application as well as provide the applicant
				  with an automated application status update at least once every fifteen (15)
				  calendar days to inform the applicant of any missing application materials
				  until the application is deemed complete; and
6. Within five (5) business days of deeming
				  an application complete each health care entity or network plan shall inform
				  the applicant that the credentialing or re-credentialing application is
				  complete.
7. The effective date for
				  billing privileges shall be the next business day following the date of
				  approval of a credentialing application.