1 Tex. Admin. Code § 353.423 - Expedited Credentialing
(a) HHSC
identifies applicant provider types for which an expedited credentialing
process must be established and implemented.
(b) An MCO must comply with the requirements
of Texas Insurance Code Chapter 1452, Subchapters C, D, and E, regarding
expedited credentialing and payment of physicians, podiatrists, and therapeutic
optometrists. Additionally, each MCO must establish and implement an expedited
credentialing process that allows applicant providers to provide services to
members for the following provider types:
(1)
dentists;
(2) dental specialists
(endodontist, oral/maxillofacial surgeon, orthodontist, pediatric dentist,
periodontist, prosthodontist, and physicians providing dental specialty
care);
(3) licensed clinical social
workers;
(4) licensed professional
counselors;
(5) licensed marriage
and family therapists; and
(6)
psychologists.
(c) To
qualify for expedited credentialing under this section and payment under
subsection (e) of this section, an applicant provider must:
(1) be a member of an established health care
provider group that has a current contract with an MCO;
(2) be a Medicaid-enrolled
provider;
(3) agree to comply with
the terms of the contract described in paragraph (1) of this subsection;
and
(4) submit all documentation
and information required by the MCO as necessary for the MCO to begin the
credentialing process.
(d) An MCO must establish and implement an
expedited credentialing process for a nursing facility that successfully
undergoes a change of ownership (CHOW). The requirements for applicant
providers to qualify for expedited credentialing listed in subsection (c) of
this section apply to CHOWs, with the exception of subsection (c)(1) of this
section.
(e) On submission by the
applicant provider of the information required by the MCO under subsection (c)
of this section, for Medicaid reimbursement purposes, the MCO must treat the
provider as if the provider were in the MCO's provider network when the
provider provides services to recipients, subject to subsections (f) and (g) of
this section.
(f) Except as
provided by subsection (g) of this section, if, on completion of the
credentialing process, an MCO determines that the applicant provider does not
meet the MCO's credentialing requirements, the MCO may recover from the
provider or provider group the difference between payments for in-network
benefits and out-of-network benefits.
(g) If an MCO determines on completion of the
credentialing process that the applicant provider does not meet the MCO's
credentialing requirements and that the provider or provider group made
fraudulent claims in the provider's application for credentialing, the MCO may
recover from the provider or provider group the entire amount of any payment
paid to the provider or provider group.
Notes
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