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What are the HMO credentialing requirements?

The purpose of this web page is to provide you with information about HMO credentialing requirements. You will find statures and rules that govern the HMO credentialing process and you will find the Texas Standardized Credentialing Application which an HMO must use to verify the credentials of its contracted physicians/providers.

Credentialing, as defined by Texas Administrative Code (TAC) §11.2(b)(17), is the "process of collecting, assessing and validating qualifications and other relevant information pertaining to a physician or provider to determine eligibility to deliver health care services." The credentialing process is part of the required Quality Improvement Program described in 28 §TAC 11.1902 and 28 TAC §11.2207 and the quality assurance procedures that are required under Texas Insurance Code, §843.102. All certified HMOs are required to document, create policies and procedures, and develop written criteria for credentialing HMO physicians/providers.

The initial credentialing process may begin with a physician/provider submitting a completed Texas Standardized Credentialing Application to the HMO in which they wish to participate. The HMO's credentialing committee will verify items such as the applicants work history, current professional liability insurance, education, board certification (if applicable), history of loss, sanctions or other disciplinary activity. The process may also consist of an on-site visit to assess the applicant's location of practice or facility. The credentialing committee must complete initial credentialing within 180 calendar days prior to the applicant being deemed a credentialed provider. The applicant must be notified of the credentialing committee's decision no later than 60 days after the decision. The HMO is required to re-credential each participating credentialed provider every 3 years.

In accordance with Texas Insurance Code, §843.303, and HMO that denies a contract to a physician or provider who initially applies to contract with the HMO to provided covered health care services must provide to the applicant written notice of the reason(s) the physician's/provider's initial application was denied. this means that Texas is not an "any willing provider" state and the HMO is not required to contract with a physician/provider applicant if the HMO network includes a sufficient number of qualified physicians/providers. However, pursuant to 28 TAC §11.1402(c), an HMO must notify a physician/provider of acceptance or non-acceptance, in writing no later than 90 days from receipt of an application for participation by that physician or provider.

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Last updated: 03/25/2015

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