6/3/2016 3:12 pm
Date / Time filed with the Register of Regulations
VA.R. Document Number: R____-______
Virginia Register Publication Information

Transmittal Sheet: Response to Petition for Rulemaking
Initial Agency Notice
X
Agency Decision
Promulgating Board: State Board of Health
Regulatory Coordinator: Joe Hilbert

(804)864-7006

joe.hilbert@vdh.virginia.gov
Agency Contact: Erik Bodin

Director, Office of Licensure and Certification

(804)367-2102

erik.bodin@vdh.virginia.gov
Contact Address: Department of Health

Virginia Department of Health

9960 Mayland Drive, Ste. 401

Richmond, VA 23233
Chapter Affected:
12 vac 5 - 408: Regulation for the Certificate of Quality Assurance of Managed Care Health Insurance Plan (MCHIP) Licensees
Statutory Authority: State: Section 32.1-137.1 et seq.

Federal: N/A
Date Petition Received 01/19/2016
Petitioner Medical Society of Virginia
 Petitioner's Request
January 11, 2016 Ms. Marissa Levine, MD, MPH State Health Commissioner Virginia Department of Health 109 Governor Street Richmond, Virginia 23219 RE: Public Petition for Rulemaking Dear Dr. Levine: The Medical Society of Virginia respectfully submits a petition for rulemaking, per Section 2.2-4007 of the Code of Virginia, on behalf of our nearly 11,000 members. The Medical Society of Virginia (MSV) represents physician, medical student and physician assistant members and aims to make Virginia the best place to practice and receive medical care. Specifically, MSV proposes amending 12VAC5-408-170: Provider credentialing and recredentialing. The purpose of these suggested changes is to update and streamline the credentialing and recredentialing process. Many physicians have expressed concern over the current process, as it takes significant time and resources away from delivering care to patients. MSV has engaged with key stakeholders including several health plans on this topic and have mutually agreed upon the proposed changes. As such, we hope the agency will consider these proposed changes eligible for the fast track regulatory process. MSV appreciates the department's consideration of this request and looks forward to our continued work together to make Virginia the healthiest state in the nation. With best regards, Michael Jurgensen Senior Vice President, Health Policy & Planning CC:      Erik Bodin, Director Office of Licensure and Certification, VDH             Melina Davis-Martin, Executive Vice President, MSV             Lauren Bates-Rowe, Senior Director of Health Policy, MSV             Ralston King, Senior Director of Government Affairs, MSV             W. Scott Johnson, Esq., General Counsel, MSV Public Petition for Rulemaking: MSV Proposed Changes to Provider Credentialing and Recredentialing  1      12VAC5-408-170. Provider Credentialing and Recredentialing. 2      A. The MCHIP licensee shall establish and maintain a comprehensive credentialing verification 3      program to ensure its providers meet the minimum standards of professional licensure or 4      certification. Written supporting documentation for providers who have completed their 5      residency or fellowship requirements for their specialty area more than 12 months prior to the 6      credentialing decision shall include: 7      1. Current valid license and history of licensure or certification; 8      2. Status of hospital privileges, if applicable; 9      3. Valid DEA certificate, if applicable; 10      4. Information from the National Practitioner Data Bank, as available; 11      5. Education and training, including post graduate training, if applicable; 12      6. Specialty board certification status, if applicable; 13      7. Practice or work history covering at least the past five years; and 14      8. Current, adequate malpractice insurance and malpractice history of at least the past five years. 15      B. The MCHIP licensee may grant provisional credentialing for providers who have completed 16      their residency or fellowship requirements for their specialty area within 12 months prior to the 17      credentialing decision. Written supporting documentation necessary to provisionally credential a 18      practitioner shall include: 19      1. Primary source verification of a current, valid license to practice prior to granting the 20      provisional status; 21      2. Written confirmation of the past five years of malpractice claims or settlements, or both, from 22      the malpractice carrier or the results of the National Practitioner Data Bank query prior to 23      granting provisional status; and 24      3. A completed application and signed attestation. 25      C. Providers provisionally credentialed may remain so for 60 calendar days. 26      D. Policies for credentialing and recredentialing shall include: 27      1. Criteria used to credential and recredential; 28      2. Process used to make credentialing and recredentialing decisions; 29        3. Type of providers, including network providers, covered under the credentialing and 30      recredentialing policies; 31      4. Process for notifying providers of information obtained that varies substantially from the 32      information provided by the provider; 33      5. Process for receiving input from participating providers to make recommendations regarding 34      the credentialing and recredentialing process; and 35      6. Process and timeframes for communicating credentialing application receipt, progress and 36      decisions to the primary credentialing contact at the address, either electronic or physical, listed 37      on the credentialing application; and 38      67. A requirement that the MCHIP licensee notify the applicant or his designee if permission is 39      granted by the applicant within 60 calendar days of receipt of an application if information is 40      missing or if there are other deficiencies in the application. The MCHIP licensee shall complete 41      the credentialing process within 90 calendar days of the receipt of a complete and accurate  42      application all such information requested by the MCHIP licensee or, if information is not 43      requested from the applicant, within 120 calendar days of receipt of an application. The 44      department may impose administrative sanctions upon an MCHIP licensee for failure to 45      complete the credentialing process as provided herein if it finds that such failure occurs with 46      such frequency as to constitute a general business practice. 47      The current policies shall be made available to participating providers and applicants upon 48      written request via publication on the MCHIP licensee's website or within the licensee's 49      provider manual. 50      E. A provider fully credentialed by an MCHIP licensee, who changes his place of employment or 51      his nonMCHIP licensee employer, shall, if within 60 calendar days of such change and if 52      practicing within the same specialty, continue to be credentialed by that MCHIP licensee upon 53      receipt by the MCHIP licensee of the following: 54      1. The effective date of the change; 55      2. The new tax ID number and copy of W-9, as applicable; 56      3. The name of the new practice, contact person, address, telephone and fax numbers; and 57      4. Other such information as may materially differ from the most recently completed 58      credentialing application submitted by the provider to the MCHIP licensee. 59      This provision shall not apply if the provider's prior place of employment or employer had been 60      delegated credentialing responsibility by the MCHIP licensee. 61      Nothing in this section shall be construed to require an MCHIP licensee to contract or recontract 62      with a provider. 63        F. The appropriate credentialing process applicant shall be considered to be participating with the 64      MCHIP licensee on the effective date which, for the purposes of this section, is the date of 65      credentialing committee approval or the date the applicant executes a contract with the MCHIP 66      licensee as an individual or is subject to be governed by an existing contract with the MCHIP 67      licensee, whichever occurs later. If credentialing provides information about the malpractice 68      insurance and if that insurance is not effective until after these dates, the effective date will be 69      the effective date of the malpractice insurance. Beginning on the effective date the provider shall 70      be obligated to the terms and conditions of the contract and shall be entitled to be paid as a 71      participating provider pursuant to the terms of the contract. The MCHIP licensee shall notify the 72      applicant and the primary credentialing contact of the effective date in a reasonable timeframe; in 73      the event of a negative decision, the communication will include instructions for appeal, if any. 74      completed before the provider: 75      1. Begins seeing covered persons; 76      2. Enters into the employment or contractual relationship with the MCHIP licensee; and 77      3. Is included in the listing of health care providers as a participating provider in any marketing 78      and covered person materials. 79      G. The providers shall be recredentialed at least every three years. Recredentialing 80      documentation shall include: 81      1. Current valid license or certification; 82      2. Status of hospital privileges, if applicable; 83      3. Current valid DEA registration, if applicable; 84      4. Specialty board eligibility or certification status, if applicable; 85      5. Data from covered person complaints and the results of quality reviews, utilization 86      management reviews and covered persons satisfaction surveys, as applicable; and 87      6. Current, adequate malpractice insurance and history of malpractice claims and professional 88      liability claims resulting in settlements or judgments. 89      H. All information obtained in the credentialing process shall be subject to review and correction 90      of any erroneous information by the health care provider whose credentials are being reviewed. 91      Nothing in the previous sentence shall require an MCHIP or MCHIP licensee to disclose to a 92      provider, or any other person or party, information or documents: (i) that the MCHIP or the 93      MCHIP licensee, itself, develops or causes to be developed as part of the MCHIP's credentialing 94      process or (ii) that are privileged under applicable law. The department may require the MCHIP 95      licensee to provide a copy of its credentialing policies. 96      I. Providers shall be required by the MCHIP licensee to notify the MCHIP of any changes in the 97      status of any credentialing criteria. 98      J. The MCHIP licensee shall not refuse to initially credential or refuse to reverify the credentials 99      of a health care provider solely because the provider treats a substantial number of patients who 100      require expensive or uncompensated care. 101     K. The MCHIP licensee shall have policies and procedures for altering the conditions of the 102     provider's participation with the MCHIP licensee. The policies shall include actions to be taken 103     to improve performance prior to termination and an appeals process for instances when the 104     MCHIP licensee chooses to alter the condition of provider participation based on issues of 105     quality of care or service, except in circumstances where an covered person's health has been 106     jeopardized. Providers shall have complete and timely access to all data and information used by 107     the licensee to identify or determine the need for altering the conditions of participation. 108     L. The MCHIP licensee shall retain the right to approve new providers and sites based on quality 109     issues, and to terminate or suspend individual providers. Termination or suspension of individual 110     providers for quality of care considerations shall be supported by documented records of 111     noncompliance with specific MCHIP expectations and requirements for providers. The provider 112     shall have a prescribed system of appeal of this decision available to them as prescribed in the 113     contract between the MCHIP or its delegated service entity and the provider. 114     M. Providers shall be informed of the appeals process. Profession specific providers actively 115     participating in the MCHIP plan shall be included in reviewing appeals and making 116     recommendations for action. 117     N. The MCHIP licensee shall notify appropriate authorities when a provider's application or 118     contract is suspended or terminated because of quality deficiencies by the health care provider 119     whose credentials are being reviewed. 120     O. There shall be an organized system to manage and protect the confidentiality of personnel 121     files and records. Records and documents relating to a provider's credentialing application shall 122     be retained for at least seven years.
 Agency Plan
In accordance with Virginia law, the petition has been filed with the Registrar of Regulations and will be published on February 8, 2016 and posted to the Virginia Regulatory Town Hall at www.townhall.virginia.gov. Comment on the petition will be accepted until March 9, 2016 and may be posted on the Town Hall or sent to the Board. Following receipt of all comment on the petition, and within 90 days of March 9, 2016, the matter will be considered by the State Health Commissioner, acting on behalf of the Board, in order to decide whether to grant the petition.
Publication Date 02/08/2016  (comment period will also begin on this date)
Comment End Date 03/09/2016
 Agency Decision
Initiate a regulatory change
Agency Response Date 06/03/2016
 Agency Decision Text
The Virginia Department of Health will prepare and submit a Notice of Intended Regulatory Action