Health Care Professional’s Right to Review Credentialing Verification Information

Health Care Professional’s Right to Review Credentialing Verification Information Subject to the provisions of Subsections A., B., C., and D. of this Section, a managed care entity shall provide a health care professional with the sources from which credentialing information is received, notification of any information that varies substantially from the information the health care professional provided, and the opportunity to correct information received from a third party that is incorrect or misleading. A. Each health care professional who is subject to the credentialing verification process shall have the right to request information regarding the sources utilized by the managed care entity to verify credentialing information, including a summary of information obtained by the managed care entity to satisfy the requirements of this Regulation. B. A managed care entity shall notify a health care professional of any information obtained during the managed care entity’s credentialing verification process that does not meet the managed care entity’s credentialing verification standards or that varies substantially from the information provided to the managed care entity by the health care professional, except, that the managed care entity shall not be required to allow the health care professional to (1) review the contents of a verification, (2) identify the source of information, or (3) provide a summary of differing information, if the information is not obtained to meet the requirements of this Regulation or if disclosure is prohibited by law. Responses provided by personal or professional references shall not be available to the health care professional. C. A health care professional shall have the right to correct any erroneous information submitted by a third party when the health care professional feels that the managed care entity’s credentialing verification committee has received information that is incorrect or misleading. The managed care entity shall have a formal process by which the health care professional may submit supplemental or corrected information to the managed care entity’s credentialing verification committee. Supplemental information shall be subject to confirmation by the managed care entity. D. Nothing in this Section 8 shall prohibit a managed care entity from denying an application or reapplication or terminating privileges, employment or a provider participation agreement where a health care professional intentionally withholds material information, intentionally omits material information, or intentionally submits material false or misleading information in a credentialing or re-credentialing application which is submitted to a managed care entity.