New MCO Credentialing Requirements Effective April 1, 2018

Credentialing Standards

The MCO must ensure and maintain documentation showing that the NF meets the following STAR+PLUS NF credentialing standards listed in UMCM Chapter 8.6 section 2.13.1 (c):

  • The NF has completed the MCO credentialing application, which includes but is not limited to:
    • demographic forms, with supporting documentation,
    • requests for provider disclosure of all federal or state NF sanctions and penalties for the most recent three years, and
    • the most recent HHSC inspection/survey.
  • The NF has a valid Texas NF license,
  • The NF has a Medicare or Medicaid certification,
  • The NF has a Clinical Laboratory Improvement Amendment (CLIA) Certification or CLIA Certificate of Waiver,
  • The NF is not listed on the following websites as excluded from participation in any federal or state health care program
    • HHSC-OIG exclusions , and
    • HHSC-OIG Exclusion Search; and
  • The NF’s enrollment has not been terminated or its Medicaid provider contract cancelled by the HHSC-OIG.

Complete Application for Expedited Credentialing

The UMCC requires MCOs to consider a NF Change of Ownership (CHOW) as eligible for expedited credentialing, and to process claims from the provider as if it was a network provider no later than 30 calendar days after receipt of a complete application, even if the MCO has not yet completed the credentialing process. The intent of UMCC is that the provider is paid at network rate by the MCO within 30 calendar days of submitting the proper paperwork for credentialing, regardless of whether the credentialing process is complete or the contract is executed. The provider is then at risk of recoupment for the difference between in-network and out-of-network rates, should the contract not be fully executed.

NOTE: The first step in credentialing will be for the MCOs to determine NFs that can be deemed credentialed. After this, NFs not deemed will be contacted by Aperture to complete the credentialing application. THCA will publish a timeline for our members and launch a resource center on our website to consolidate information and keep NFs apprised of new information as it is made available.