1. Provider Enrollment Regulatory Considerations
February 8, 2019

2. Statutes
Arizona Title 20, Chapter 26, Article 1, Section (Eff 12/31/18)
The health insurer shall conclude the process of credentialing and loading the applicant’s information into the health insurer’s billing system within 100 hundred days after the date the health insurer receives a complete application.
Kentucky KRS to (Eff 01/01/19)
Medicaid designate a single organization as a credentialing verification organization.
Medicaid shall enroll a provider within 30 calendar days of receipt of a verified credentialing packet for the provider from a credentialing verification organization. The date of the enrollment shall be the date that the provider’s clean application was initially received by a credentialing verification organization.
Rhode Island Gen L § (2017) (Eff 01/01/18)
A health care entity or health plan operating in the state shall be required to issue a decision regarding the credentialing of a health care provider as soon as practicable, but no later than forty-five (45) calendar days after the date of receipt of a complete credentialing application.
The effective date for billing privileges for health care providers under a particular health care entity or health plan shall be the next business day following the date of approval of the credentialing application.

3. Statutes Maine § 4303. Plan requirements (Eff 2015)
A carrier shall make credentialing decisions, including those granting or denying credentials, within 60 days of receipt of a completed credentialing application from a provider.
Payment to provider for services rendered during pendency of credentialing. A carrier offering or renewing a health plan in the State shall pay claims for services rendered to an enrollee by a provider prior to credentials being granted from the date a complete application for credentialing is submitted to the carrier as long as credentials are granted to that provider by the carrier.
New Mexico § (Eff 01/01/17)
Each health carrier’s credentialing verification plan shall include a process to assess and verify the qualifications of providers applying to become participating providers within 45 calendar days of receipt of a completed uniform credentialing form.
The date of service is more that 45 calendar days after the date on which the health carrier received a completed uniform credentialing application for that provider, including submission of any supporting documentation that the health carrier requested in writing.

4. Statutes New York § 4803 (Eff 2015)
If the completed application of a newly-licensed health care professional or a health care professional who has recently relocated to this state from another state and has not previously practiced in this state, who joins a group practice of health care professionals each of whom participates in the in-network portion of an insurer's network, is neither approved nor declined within 60 days of submission of a completed application, the health care professional shall be deemed “provisionally credentialed” and may participate in the in-network portion of an insurer's network;  provided, however, that a provisionally credentialed physician may not be designated as an insured's primary care physician until such time as the physician has been fully credentialed.  The network participation for a provisionally credentialed health care professional shall begin on the day following the 60th day of receipt of the completed application and shall last until the final credentialing determination is made by the insurer.
A carrier shall make credentialing decisions, including those granting or denying credentials, within 60 days of receipt of a completed credentialing application from a provider.

5. Challenges Credentialing to Contracting to Loading
Post credentialing decision, payors complete contracting activities and finally load providers in claims systems
Delegation does not resolve contracting and loading timeframe issues
Service Location Complexity
Each provider/group service location need to be enrolled
Separate paperwork required; entirely separate from Credentialing Application
Service location enrollment is a prerequisite to provider being loaded and tied to office address with payor
Data validation performed by payor prior to approval
Cannot add new service locations until after initial location enrollment is approved
“Just in case” approach may not be viable
Secret shopper programs can result in automatic disenrollment without notification to the group/provider (no visibility until provider roster audit or claims denial)

6. Challenges Provider Directory Accuracy
CMS changes addressed in 2016 call letter, including requirement for payors to update their provider directories in real-time
More stringent CMS requirements became effective January 2018 with fines of up to $25k per beneficiary can be assessed for errors in Medicare Advantage plan directories
Three-pronged approach for health plans to monitor compliance required, 1. direct monitoring, 2. audit protocol, 3. compliance and/or enforcement actions
Several states have legislative oversight in excess of CMS monthly provider directory update requirements (CA – weekly, NJ – every 10 days, MD/NY – every 15 days, etc.), while others have less onerous standards for commercial health plans (FL/VT – semi-annually, NC/TN/WI – annually)
Provider groups lack dedicated provider data management resources and don’t have effective processes to support reporting changes and responding to validation/attestations (Availity, CAQH, Change Healthcare, Optum, etc.)