Sec. 533.0064. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN PROVIDERS. (a) In this section, "applicant provider" means a physician or other health care provider applying for expedited credentialing under this section.
(b) Notwithstanding any other law and subject to Subsection (c), a managed care organization that contracts with the commission to provide health services to recipients shall, in accordance with this section, establish and implement an expedited credentialing process that would allow applicant providers to provide services to recipients on a provisional basis.
(c) The commission shall identify the types of providers for which an expedited credentialing process must be established and implemented under this section.
(d) To qualify for expedited credentialing under this section and payment under Subsection (e), an applicant provider must:
(1) be a member of an established health care provider group that has a current contract in force with a managed care organization described by Subsection (b);
(2) be a Medicaid-enrolled provider;
(3) agree to comply with the terms of the contract described by Subdivision (1); and
(4) submit all documentation and other information required by the managed care organization as necessary to enable the organization to begin the credentialing process required by the organization to include a provider in the organization's provider network.
(e) On submission by the applicant provider of the information required by the managed care organization under Subsection (d), and for Medicaid reimbursement purposes only, the organization shall treat the provider as if the provider were in the organization's provider network when the provider provides services to recipients, subject to Subsections (f) and (g).
(f) Except as provided by Subsection (g), if, on completion of the credentialing process, a managed care organization determines that the applicant provider does not meet the organization's credentialing requirements, the organization may recover from the provider the difference between payments for in-network benefits and out-of-network benefits.
(g) If a managed care organization determines on completion of the credentialing process that the applicant provider does not meet the organization's credentialing requirements and that the provider made fraudulent claims in the provider's application for credentialing, the organization may recover from the provider the entire amount of any payment paid to the provider.
Added by Acts 2015, 84th Leg., R.S., Ch. 1272 (S.B. 760), Sec. 5, eff. September 1, 2015.
Section: Previous 533.0053 533.0055 533.006 533.0061 533.0062 533.0063 533.0064 533.0066 533.007 533.0071 533.0072 533.0073 533.0075 533.0076 NextLast modified: September 28, 2016