Standard Form To Establish Credentials

PURPOSE: This rule sets forth the standard form which shall be used by all health carriers when soliciting the credentials of a health care professional in a managed care plan. This rule is promulgated pursuant to section 354.485, RSMo, and implements section 354.442.1(15), RSMo. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Definitions. (A) Health care professional means a physician or other appropriately licensed health care practitioner. (B) Health carrier means a health maintenance organization as organized pursuant to sections 354.400 through 354.636, RSMo. (C) Managed care plan means a health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use health care providers managed, owned, under contract with or employed by the health carrier. (2) The Universal Credentialing DataSource form (Form UCDS), incorporated by reference and published on October 31, 2006, by the Council for Affordable Quality Healthcare, 601 Pennsylvania Avenue NW, South Building, Suite 500, Washington, DC 20004, has been adopted and shall be used by all health carriers and their agents when credentialing or recredentialing health care professionals in a managed care plan. The director on request will supply in printed format the form specified in this rule. The form referenced herein is available at http://www.insurance.mo.gov. This rule does not incorporate any subsequent amendments or additions. Use of another standardized credentialing form is permissible so long as the director determines prior to its use that it is substantially similar to Form UCDS. Carriers shall accept any form approved by the director for credentialing purposes, and shall not require a Missouri health care professional to use any particular approved form to the exclusion of any other approved form, so long as the form submitted by the Missouri health care professional is Form UCDS or any other form approved pursuant to this rule. Requests for the director’s approval of the use of another standardized credentialing form should be submitted to the following address: Missouri Department of Commerce and Insurance, Managed Care Section, PO Box 690, Jefferson City, MO 65102-0690. A request must include a complete copy of the form to be approved and the name, address, and telephone number of the person requesting approval. The director will provide written notice to all Missouri licensed health maintenance organizations of the approval of the use of another standardized credentialing form. The director also will provide on the department’s Internet home page a copy of Form UCDS with a list of other standardized credentialing forms that have been approved. (3) Health carriers may request additional information to explain or provide details regarding responses obtained on the standard form. Health carriers and their agents are prohibited from routinely requiring additional information, or information that duplicates information on Form UCDS, from health care professionals. This prohibition shall not apply to gathering information on standard claim forms for purposes of routine claims submission and payment processes. (4) An on-site examination by the health carrier or their agent of the health care professional’s place of business shall not, in itself, be considered a routine request for additional information. (5) Accurate reproduction of the form may be utilized in lieu of the printed form. This includes, but is not limited to, accurate reproduction in paper, electronic, or Internet based formats. Health carriers and their agents shall accept an accurate reproduction, and shall not require a health care professional to use any particular accurate reproduction to the exclusion of any other accurate reproduction, except that a health carrier or agent may require a paper format if a health care professional submits an electronic or Internet based format that the health carrier or agent is not prepared to accept. AUTHORITY: section 354.442.1(15), RSMo 2000 and section 354.485, RSMo Supp. 2007. Original rule filed Nov. 3, 1997, effective June 30, 1998. Amended: Filed June 6, 2000, effective Feb. 28, 2001. Amended: Filed May 14, 2008, effective Jan. 30, 2009. Non-substantive change filed Sept. 11, 2019, published Oct. 31, 2019. *Original authority: 354.442, RSMo 1997 and 354.485, RSMo 1983, amended 2007.