Florida Healthy Kids Uniform Credentialing and Recredentialing Policy

Transcription

1 Each Managed Care Organizatin (MCO) must be accredited by a natinally recgnized accrediting bdy, such as the Natinal Cmmittee fr Quality Assurance, r have initiated the accreditatin prcess within ne year and received accreditatin within eighteen mnths after executing the cntract with FHKC. The MCOs must maintain written plicies and prcedures fr credentialing and recredentialing prviders. At a minimum, the MCOs credentialing and recredentialing plicies and prcedures must include the fllwing activities: Verify prvider licenses, including licenses issued in states ther than Flrida. Verificatin must include the fllwing: Cnfirmatin that the license is nt expired Cnfirmatin that there are n current limitatins n the prvider s license Establish categrical risk levels fr prviders and prvider categries wh pse an increased financial risk f fraud, waste and abuse. Criminal backgrund checks, including fingerprints, must be cnducted fr prviders, and any persn with at least 5 percent direct r indirect wnership interest in the prvider, when such persn meets the criteria fr a high risk. Risk levels must be adjusted frm limited r mderate t high when any f the fllwing ccurs: A prvider has a payment suspensin impsed based n a credible allegatin f fraud, waste r abuse The prvider has an existing Medicaid r CHIP verpayment The prvider has been excluded by HHS r a state Medicaid r CHIP prgram within the previus 10 years A temprary mratrium has been lifted in the previus 6 mnths fr a particular prvider type r prvider. Cnduct pre- and pst-enrllment site visits t verify the accuracy f infrmatin submitted by prviders wh are designated as mderate r high categrical risks t the Flrida Healthy Kids prgram and t determine cmpliance with state and federal enrllment requirements. The MCO must require prviders t allw the Centers fr Medicare and Medicaid Services (CMS), FHKC, their agents, and their designated cntractrs t cnduct unannunced n-site inspectins f any and all prvider lcatins. Prviders must be denied enrllment in the netwrk r terminated frm the netwrk if the prvider fails t permit access t prvider lcatins fr any site visits, unless FHKC determines that denial r terminatin f the prvider is nt in the best interests f the prgram and dcuments such determinatins in writing. Cnfirm the identify and determine the exclusin status f prviders and any persn with an wnership r cntrl interest r wh is an agent r managing emplyee f the prvider thrugh checks f the fllwing federal databases upn enrllment and recredentialing: The Scial Security Agency s death master file The Natinal Plan and Prvider Enumeratin System (NPPES) The List f Excluded Individuals/Entities (LEIE) The Excluded Parties List System (EPLS) Cnfirm the exclusin status f prviders and any persn with an wnership r cntrl interest r wh is an agent r managing emplyee f the prvider thrugh checks f the LEIE and EPLS databases n a mnthly basis. 1

2 Mnitr prviders fr cmpliance with the prvider cntract, including: Appintment timeliness standards Maintenance f accurate directry infrmatin, including: Office hurs Street address Phne number Acceptance f new patients Develp a prcess t identify quality deficiencies, including: Mnitring and evaluating claims and encunter data fr patterns f care by individual prviders Cnducting nging reviews f prviders Take apprpriate crrective actin with prviders. Impse apprpriate sanctins, suspensin, restrictin and terminatin f prviders, including terminating r denying enrllment because f inability t verify the identity f the prvider applicant r upn determinatin that the prvider has falsified any infrmatin prvided n the applicatin. Ensure primary care prviders withut bard certificatin are remved frm the netwrk r receive an exemptin timely. Recredential prviders at least every three years. Criminal backgrund checks must be repeated at least every five years. Recredential prviders, including screening activities, prir t allwing prviders wh were remved frm the netwrk t re-enrll in the netwrk. The MCO may rely upn any credentialing r recredentialing activities cnducted by Flrida Medicaid fr a particular prvider. The MCO remains respnsible fr cnducting any activities required in this plicy that were nt cnducted by Flrida Medicaid. T be eligible t participate in the MCO s Flrida Healthy Kids netwrk, prviders must: Have a current state license (medical, ccupatinal r facility) r authrity t d business in the state in which they practice. Have n revcatin, mratrium r suspensin f their license impsed in Flrida r any ther state. Have n sanctins impsed by Medicare r Medicaid unless there is prf f reinstatement r ther dcumentatin shwing that all bligatins under the sanctin have been met. Prvide evidence f prfessinal liability claims histry. Prvide disclsures related t wnership and management, business transactins and cnvictin f crimes t the MCO. Ownership and management disclsures includes the infrmatin required by 42 CFR (b). Prviders must prvide this infrmatin upn submissin f an applicatin, executin f a prvider agreement, upn FHKC s request, during recredentialing, and within 35 days after any change in wnership. 2

3 MCOs must deny prviders enrllment in the netwrk r terminate them frm the netwrk when any persn with a 5 percent r greater direct r indirect wnership interest in the prvider, r wh is an agent r managing emplyee f the prvider, des nt submit timely and accurate infrmatin, unless FHKC determines that denial r terminatin f the prvider is nt in the best interests f the prgram and dcuments such determinatins in writing. MCOs must deny prviders enrllment in the netwrk r terminate them frm the netwrk when any persn with a 5 percent r greater direct r indirect wnership interest in the prvider, r wh is an agent r managing emplyee f the prvider, fails t cperate with any required screening methds, including failing t submit sets f fingerprints in the frm and manner required within 30 days f request, unless FHKC determines that denial r terminatin f the prvider is nt in the best interests f the prgram and dcuments such determinatins in writing. MCOs must deny prviders enrllment in the netwrk r terminate them frm the netwrk when any persn with a 5 percent r greater direct r indirect wnership interest in the prvider has been cnvicted f a criminal ffense related t that persn s invlvement with the Medicare, Medicaid, r Title XXI prgram in the last 10 years, unless FHKC determines that denial r terminatin f the prvider is nt in the best interests f the prgram and dcuments such determinatins in writing. Business transactin disclsures include infrmatin abut the wnership f any subcntractr with whm the prvider has had business transactins ttaling mre than $25,000 during the 12-mnth perid and any significant business transactins between the prvider and any whlly wned supplier, r between the prvider and any subcntractr during the previus five-year perid. The prvider must prvide such disclsures within 35 days f the date f request by CMS, the Agency fr Health Care Administratin (AHCA), r FHKC. MCOs must include a prvisin t prvide this infrmatin within the required timeframe the prvider agreement. Disclsures related t the cnvictin f crimes include the identity f any persn wh has wnership r cntrl interest, as defined in 42 CFR and 42 CFR , in the prvider, r is an agent r managing emplyee f the prvider, and has been cnvicted f a criminal ffense related t the persn s invlvement in any prgram under Medicare, Medicaid, r the Title XX services prgram since the inceptin f thse prgrams. Prviders must prvide this infrmatin upn entering int a new prvider agreement, renewing an existing prvider agreement, r upn request by FHKC. Nt be n the state r federal exclusins lists Nt have had Medicaid prescribing rights suspended by the AHCA Nt had enrllment terminated under Title XVIII f the Act r under the Medicaid prgram r CHIP f any ther state. This prvisin applies nly t prviders terminated n r after January 1, 2011 frm such prgrams. Cnsent t criminal backgrund checks, including fingerprinting. Prviders and any persn with a 5 percent r mre direct r indirect wnership interest in the prvider are required t submit a set f fingerprints in the requested frm and manner within 30 days upn request. Meet the fllwing requirements when the prvider is a physician: 3

4 Gd standing f privileges at the hspital designated at the primary admitting facility by the physician r if the physician des nt have admitting privileges, gd standing f privileges at the hspital by anther prvider with whm the physician has entered int an arrangement fr hspital cverage. Valid Drug Enfrcement Administratin (DEA) certificates, when applicable. Attestatin that the ttal active patient lad fr all ppulatins, including Medicaid FFS, Children s Medical Services Netwrk, Medicaid Managed Care Plans, Medicare, Flrida KidCare and cmmercial patients, is n mre than three thusand patients per prvider. An active patient is a patient wh is seen by the prvider at least three times per year. Facilities that meet the MCO s standards, including that adequate space, supplies, prper sanitatin, smke-free facilities, and prper fire and safety prcedures are in place, evidence that the prvider s ffice meets criteria fr access fr persns with disabilities, and acceptable medical recrd keeping practices. Prvide a statement regarding any physical r behaviral health prblems that may affect the prvider s ability t prvide health care, any histry f chemical dependency/substance use disrder, any histry f lss f license and/r felny r misdemeanr cnvictins, and eligibility t becme a Medicaid r CHIP prvider. Primary Care Prviders (PCPs) are limited t the fllwing: Bard-certified pediatricians Bard-certified family practitiners Physician extenders wrking under the direct supervisin f a bard-certified pediatrician r family practitiner Prviders wh have recently cmpleted a Natinal Bard fr Certificatin f Training Administratrs f Graduate Medical Educatin Prgrams apprved residency prgram in pediatrics r family practice and are eligible fr bard certificatin but have nt yet achieved bard certificatin. Such prviders must becme bard-certified within three years f jining the netwrk t remain eligible t act as a PCP fr the Flrida Healthy Kids ppulatin. Prviders wh have been granted a waiver t the bard-certificatin requirement in accrdance with FHKC s plicies and prcedures. Facilities must meet applicable accreditatin and licensure requirements and meet facility regulatins specified by the Agency fr Health Care Administratin. Behaviral health services must be prvided by individuals r entities wh meet the minimal licensure and credentialing standards set frth in statutes and rules f the Department f Children and Families, the Department f Health and the Divisin f Health Quality Assurance f the Agency fr Health Care Administratin pertinent t the treatment and preventin f mental health and substance abuse disrders in children and adlescents. The MCOs netwrks shall als include: Bard-certified child psychiatrists; r Practitiners licensed t practice medicine, stepathic medicine, psychlgy, clinical scial wrk, mental health cunseling, r marriage and family therapy with a minimum f tw years full-time, pst-graduate, paid 4

5 experience prviding mental health and/r substance abuse services in a setting that specializes in prviding mental health and/r substance abuse services t children and/r adlescents; and/r A certified addictin prfessinal certified in accrdance with Chapter 397, Flrida Statutes, prviding substance abuse services in a setting that specializes in prviding substance abuse services t children and/r adlescents. The MCOs must als have a system fr the verificatin and examinatin f each prvider s credentials. This system must maintain dcumentatin (including cpies f prvider licenses) f all prvider requirements listed abve, as well as each prvider s: Educatin Experience Prir training Onging service training Natinal Prvider Identifier (NPI) and taxnmy 5