Checklists for Managed Care - Operations, Networks and Provider Agreements

PPO Operations Filings Checklist

In North Carolina, the Department of Insurance regulates a licensed insurer offering a Preferred Provider Organization (PPO). N.C.G.S. § 58-50-56 defines a Preferred Provider Organization. A licensed insurer that wants to market a Preferred Provider Organization (PPO) product in North Carolina must first file a PPO Operations with the Life and Health Division for approval. The Life and Health Division reviews the proposed PPO product application. The review may include the provider and intermediary contracts, provider credentialing, provider availability and accessibility, utilization review, and grievance procedures. The insurer must demonstrate the infrastructure to provide adequate services to insureds covered under its PPO product.

 

Initial PPO Operations Filing PPO Modifications Filings

PPO Modifications Filings

PPO Modifications Filing Instructions

Data Grid for PPO Operations Initial and Modifications Filings

Data Grid for PPO Operations Initial and Modifications Filings

Initial PPO Operations Network Filings

Addition to PPO Operations Network

Provider/IntermediaryAgreements Checklist

Provider/IntermediaryAgreements Checklist

Provider/Intermediary Contract Compliance Checklist

Company Certifications Delivery System Docs Filing Requirements

Delivery System Docs Filing Requirements

When a tiered network/narrow network is a SUBSET of an existing global approved network covering, a Delivery System Docs filing is required with the Life and Health Division.

 

Credentialing Application Credentialing Questions and Answers

Credentialing Questions and Answers

Uniform Credentialing Questions and Answers

North Carolina Department of Insurance Response to Questions Regarding N.C.G.S. § 58-3-230 - Uniform Provider Credentialing

1. Recredentialing “Short Form”

Do we understand correctly that it is permissible for health plans to use a shorter form than the Uniform Application for recredentialing purposes? We understand that this form could not ask questions or raise any issues that were not part of the Uniform Application, but a form that is essentially a subset of the full application would be much less burdensome for all concerned than requiring providers to note “not applicable” next to almost every line on the application. What is important for recredentialing is identifying what has changed since the initial credentialing of the Often, little or nothing has changed and a shorter form for seems appropriate in these cases. Please also confirm that this “short form” does not have to look like the Uniform Application (i.e., plans can recreate a  form using the information from the Uniform Application).

Response: Health plans may create a shortened version of the Uniform Application for purposes by eliminating unnecessary questions and/or requesting responses only to those questions pertaining to information that has changed. 

2. Procedure for credentialing of health care facilities

Does NCDOI agree that health plans are not required to use the Uniform Application for credentialing and recredentialing of health care facilities? The Application would not appear to be geared for such a purpose. It would seem to be more appropriate to follow the rules laid out in Title 11 NCAC 20.0404(2), namely requiring health plans to:… obtain and retain on file the following information regarding facility provider credentials, when applicable: (a) Joint Commission on Accreditation of Healthcare Organization's certification or certification from other accrediting agencies. (b) State licensure. (c) Medicare and Medicaid certification. (d) Evidence of current malpractice insurance. Since this section of the credentialing rule was not amended, we assume this approach is what NCDOI had in mind.

Response: The Uniform Application is not intended for use in the credentialing of facilities and the law does not apply to the credentialing of facilities. All policies and procedures regarding credentialing of facilities shall include the minimum requirements of Title 11 NCAC 20.0404(2).

3. Acceptability of scanned and faxed forms

NCQA allows health plans the option of accepting credentialing forms that are scanned, faxed, or otherwise submitted electronically (including the signature block on the attestation page). Will NCDOI allow health plans to follow the same option? This would seem to be consistent with N.C.G.S. § 66-317 that governs electronic signatures.

Response: It is permissible, though not required, for health plans to accept credentialing forms that are scanned, faxed or otherwise submitted electronically. The date of receipt of the electronic document will be the date the information is submitted and the date must be clearly documented. For purposes of examination pursuant to Title 11 NCAC 19.0107, subsections (c) and (d), the Department will consider all electronic submissions regarding Uniform Applications to be “duplicate” records in which case the health plans must be able to meet the requirements of subsection (d).

4. Possible problems accommodating non-physicians/special types of providers

Requiring a single credentialing form for all health care providers makes it difficult to accommodate the diverse needs of subspecialty MDs and the wide variety of non-MD providers, including psychologists, physician assistants, etc. This was the main reason NCAHP developed an application specifically designed for physician assistants in 2000. NCAHP members will report any problems encountered in credentialing non-MD providers to the Association and we will provide feedback to NCDOI that may be helpful in revising the Uniform Application or creating multiple, provider-specific applications.

No response required at this time.

5. Credentialing contact person.

The draft, red-line version of the Uniform Application included places to identify both a general administrative contact and a contact specific to the credentialing process. The final version of the Application asks only for an administrative contact. In the event the application is lacking some key document or information, having a specific contact for credentialing can help to speed the correspondence with the applicant. Why was the credentialing contact line deleted? Would NCDOI consider amending future versions of the Application to include it? Alternately, will NCDOI allow plans to inform applicants (say, in a cover letter) that the administrative contact question should be answered with the name of the credentialing contact? My members say that the administrative contact and the individual responsible for credentialing are quite often not the same individual, especially in situations where credentialing is delegated to some entity outside the provider’s office. 

Response: The Department is in favor of amending the Uniform Application to include the name of the “credentialing contact.” In the meantime, health plans may inform applicants how to answer the question regarding “administrative contact” in their cover letters.

6. Specifics on 60-day requirement.

It is clear that health plans must respond to all credentialing applications within 60 days of receipt. However, in the event that the response cannot be definitive (missing information, additional details required), what information must be included in the notice to the provider? Is it sufficient to note what additional information is required to complete consideration of the application? Would the plan have the option of declining to credential the provider and asking for resubmission of a complete application?

Response: As you have stated above, all providers submitting applications must receive a response from the health plans within 60 days. It is unlikely that the health plans will be unable to provide a definitive response to providers if they are compliant with the requirements of Title 11 NCAC 20.0405(a) and (b).  In the event that the provider fails to submit the necessary information or if previously submitted information has expired, health plans are permitted to close the application pursuant to Title 11 NCAC 20.0405(c) and request resubmission of the completed application.

 

 

Top of Form

Utilization Review Organizations (URO's)

Utilization Review Organizations (URO's)

 

Independent utilization review organizations (“UROs”), as defined in N.C.G.S § 58-50-61(a)(18), providing services to insurers, Service Corporations, Multiple Employer Welfare Arrangements (“MEWAs”) and health maintenance organizations (“HMOs”) in North Carolina are not required to register with or to be licensed with the North Carolina Department of Insurance but may be required to register as a business entity with the North Carolina Secretary of State office.  Although these entities are not required to register with or to be licensed by the North Carolina Department of Insurance, the insurers, Service Corporations, MEWAs and HMOs are subject to the general statutes that apply to utilization review activities under N.C.G.S. § 58-50-61(a)(10) and must demonstrate compliance through the monitoring the delegated activities.

Utilization review requirements applicable to insurers, Service Corporations, MEWAs and HMOs can be found in N.C.G.S. §§ 58-50-61 and 58-50-62, which are subject to the regulatory authority of the North Carolina Department of Insurance.  Specifically, N.C.G.S. § 58-50-61(a)(7) defines the health benefit plans subject to utilization review requirements.

An insurer, Service Corporation, MEWA or HMO is responsible for its own compliance, the compliance of any contracted entity acting on its behalf and for ongoing monitoring and oversight of the contracted entity’s performance.  A contracting entity’s compliance does not remove a carrier’s responsibility to monitor and oversee that entity’s performance.  The act of monitoring a contracted entity’s performance does not relieve a carrier from its responsibility to demand corrective action, end a contract, or rescind delegation, if applicable and necessary.

 

 

External Review Model Evidence of Coverage Language and Written Notice

External Review Model Evidence of Coverage Language and Written Notice

North Carolina law provides for a review of a health plan's decision to deny coverage for payment of a service (non-certification decision).  N.C.G.S. § 58-50-75 gives covered persons the opportunity for an independent review of a non-certification decision by an external, Independent Review Organization (IRO). An external review either upholds the health plan's decision or overturns all or some of the decision. The health plan must accept the binding decision.

N.C.G.S. § 58-50-77 requires the insurer to provide a written notice to the covered person explaining the right to request an external review. This written notice must contain specific information.  N.C.G.S. § 58-50-93 also  requires insurers to describe the external review procedures in or attached to the evidence of coverage.  To assist insurers in complying with the general statutes the North Carolina Department has developed suggested model contract language and notice language.

Model Evidence of Coverage (EOC) Language

Member Notice Language

Need Help with Health Claim Denied