Chapter 26 Uniform Credentialing Form

Chapter 26 Uniform Credentialing Form | Library of Maryland Regulations

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Code of Maryland Regulations

Title 31 MARYLAND INSURANCE ADMINISTRATION

Subtitle 10 HEALTH INSURANCE — GENERAL

Chapter 26 Uniform Credentialing Form

Code of Maryland Regulations

Chapter 26 Uniform Credentialing Form

Administrative History Effective date: December 25, 2000 (27:25 Md. R. 2285) Chapter revised effective December 6, 2007 (34:24 Md. R. 2159) Regulation .03B amended effective January 20, 2014 (41:1 Md. R. 13) Regulation .03F adopted effective January 20, 2014 (41:1 Md. R. 13) Authority Insurance Article, §§ 2-109 and 15-112 .1, Annotated Code of Maryland

.01 Scope. This chapter applies to all: A. Carriers as defined in Regulation .02B(1) of this chapter ; and B. Credentialing intermediaries as defined in Regulation .02B(2) of this chapter .

.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) Carrier. (a) "Carrier" means: (i) An insurer; (ii) A nonprofit health service plan; (iii) A health maintenance organization; (iv) A dental plan organization; or (v) Any other person that provides health benefit plans subject to regulation by the State. (b) "Carrier" includes an entity that arranges a provider panel for a carrier. (2) "Credentialing intermediary" means a person to whom a carrier has delegated credentialing or recredentialing authority and responsibility. (3) "Health benefit plan" means: (a) A hospital or medical policy, contract, or certificate, including those issued under multiple employer trusts or associations; (b) A hospital or medical policy, contract, or certificate issued by a nonprofit health service plan; (c) A health maintenance organization contract; or (d) A dental plan organization contract. (4) "Health care provider" means an individual who is licensed, certified, or otherwise authorized under the Health Occupations Article, Annotated Code of Maryland , to provide health care services. (5) "Provider panel" means the health care providers that contract with a carrier to provide health care services to the enrollees under a health benefit plan of the carrier. (6) "Uniform credentialing form" means the form designated by the Insurance Commissioner for use by a carrier or its credentialing intermediary for credentialing and recredentialing a health care provider for participation on a provider panel.

.03 Uniform Credentialing Form — Carrier and Credentialing Intermediary Requirements. A. A carrier or its credentialing intermediary shall: (1) Accept the uniform credentialing form as the sole application for a health care provider to become credentialed or recredentialed for a provider panel of the carrier; and (2) Make the uniform credentialing form available to any health care provider that is to be credentialed or recredentialed by the carrier or credentialing intermediary. B. A carrier may not, for purposes of credentialing or recredentialing, require a health care provider to: (1) Modify the uniform credentialing form; (2) Submit additional credentialing forms; (3) Use any other credentialing form not designated by the Commissioner; or (4) Submit any additional information not specified by the uniform credentialing form, except as stated in §F of this regulation . C. A carrier may preprint the designated carrier information on the uniform credentialing form. D. A carrier may not deny a uniform credentialing form because the form does not include the designated carrier information of the carrier. E. A carrier may require a health care provider to submit a new Authorization to Release Information and Affirmation page, with an original signature and date, for the purpose of credentialing or recredentialing. F. A carrier that is a managed care organization may require a provider to make the disclosure required by 42 CFR §1002.3.

.04 Electronic Filing. A. The uniform credentialing form may be obtained in an electronic format. B. The uniform credentialing form may be transmitted by facsimile. C. A transmission by facsimile is not considered an electronic transfer for the purposes of this chapter. D. Capability of Electronic Filing. (1) The uniform credentialing form developed under this chapter shall be capable of electronic filing. (2) The uniform credentialing form may be filed electronically in any format that contains the data required to be contained in the uniform credentialing form.

.05 Effective Date. The regulations in this chapter are applicable for all credentialing and recredentialing forms used on or after January 1, 2008.

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