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Credentialing for Group Practices
In this year’s session, the General Assembly passed HB 594/SB 595 Health Insurance – Carrier Credentialing – Reimbursement of Providers of Health Care Services, which relates to participating groups hiring practitioners who are not currently credentialed by a health plan. Essentially, the bill requires that the new practitioners’ services be reimbursed at the in-network rate if a complete application has been submitted. The provisions of this new law (see http://mlis.state.md.us/2008rs/bills/sb/sb0595e.pdf for complete details), signed by the governor and recorded in Chapter 598, took effect on October 1, 2008.
At its TriState Care Management Center Professional Leadership Advisory Group meeting on October 13, Magellan provided the following information regarding its implementation of the new law:
Upon submission of a completed credentialing packet, evidence of license and evidence of malpractice insurance, Magellan will issue a Letter of Intent to pursue that practitioner for credentialing. This letter should come within 10 days if the license and insurance issues are clear. From the time of receipt of the Letter of Intent, the group practice can begin scheduling patients for the applying practitioner. The practitioner and/or group can also seek authorizations for a member at this time. These patients will be reimbursed by CareFirst at the in-network rate during process of credentialing. Magellan asks that the practice hold off submitting claims for 60 days to allow Magellan and CareFirst to verify all credentialing information and process a Provider Number. Without the CareFirst Provider Number, authorizations are unable to download to the CareFirst claims systems, and if the authorization is not there, claims will not be paid. This process only applies to group practitioners applying to be part of the Magellan network and seeing CareFirst members.
The practice can count on reimbursement for services provided by the applying practitioner under the above circumstance. It should be noted that during the full credentialing process, if Magellan feels that they cannot credential that practitioner, they will send a letter to inform that practitioner of this determination. From the date of that letter, that practitioner will no longer be able to be reimbursed at the in-network rate.
According to the law, it is the responsibility of the group to disclose in writing to the member:
- That the practitioner is a non-participating practitioner,
- The practitioner has applied to become a participating practitioner,
- Magellan has not completed its assessment of the qualifications of that practitioner to provide services as a participating practitioner; and
- Any covered services rendered must be covered by Magellan/CareFirst at the participating practitioner rate.
An additional piece of information that is not part of the law, but helpful in ensuring that new practitioners are credentialed with Magellan, concerns the submission of incomplete applications. If Magellan receives an incomplete application they will notify the practitioner what is missing. The practitioner will have 14 days from that notification to send the needed materials. If the information is not received in 14 days, the application will be inactivated and credentialing will not proceed. Magellan will contact the practitioner two additional times during the 14 days to attempt to get the information. Since the application would not be complete, this practitioner would not fall under the new law as only completed applications meet the criteria of HB594/SB595.
Philip B. Dvoskin, M.D., Member
Payer Relations Committee