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,
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
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;
6. A requirement that the MCHIP licensee notify the applicant
39 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
all such information requested by the MCHIP licensee or, if information is not
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 policies shall be made available to participating providers and applicants
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 shall be
completed before the provider:
1. Begins seeing covered persons;
2. Enters into the employment or contractual relationship with the MCHIP licensee; and
3. Is included in the listing of health care providers as a participating provider in any marketing
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.