Virginia Regulatory Town Hall
Health and Human Resources
Virginia Department of Health
State Board of Health
Petition 236
Petition Information
Petition Title Recommended Amendments Concerning Provider Credentialing and Recredentialing
Date Filed 1/19/2016    [Transmittal Sheet]
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's 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 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.

Comment Period Began 2/8/2016    Ended 3/9/2016
Virginia Register Announcement Submitted on 1/19/2016
The Virginia Register of Regulations
Published on: 2/8/2016     Volume: 32  Issue: 12
Agency Decision Initiate a regulatory change [Transmittal Sheet]    
Response Date 6/3/2016
Decision Publication Date Published on: 6/27/2016     Volume: 32  Issue: 22
Agency Decision Summary

The Virginia Department of Health will prepare and submit a Notice of Intended Regulatory Action

Associated regulatory action Amend regulations to conform to Ch.703 of the 2018 Acts of Assembly and changes related to Provider Credentialing
Latest Stage: Fast-Track

Contact Information
Name / Title: Erik Bodin  / Director, Office of Licensure and Certification
Address: Virginia Department of Health
9960 Mayland Drive, Ste. 401
Richmond, 23233
Email Address:
Telephone: (804)367-2102    FAX: (804)527-4502    TDD: ()-