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SUBCHAPTER X. CREDENTIALING OF PHYSICIANS 28 TAC §21.3201

The Texas Department of Insurance proposes new §21.3201 concerning a standardized credentialing application for physicians. The new section is necessary to implement Senate Bill 544 (Acts 2001, 77 th Leg., ch. 1369, §3, eff. Sept. 1, 2001). Senate Bill 544 enacted Insurance Code Article 21.58D, which requires the Commissioner by rule to adopt a standardized form for the verification of the credentials of a physician and to require that a public or private hospital, a health maintenance organization (HMO) operating under the Insurance Code Chapter 20A, and a preferred provider organization operating under the Insurance Code Article 3.70-3C use the form for verification of credentials. Article 21.58D(b) provides that, in adopting the form, the Commissioner shall consider any credentialing application form that is widely used in this state. After such consideration, the Department is proposing a credentialing application form that was originally developed by the Coalition for Affordable Quality Healthcare (CAQH) as part of its single source credentialing system and that has been modified by the Department for use in Texas. The CAQH, a nonprofit trade association, is a coalition of 26 of the largest health plans and insurers in the United States and three health plan associations whose stated purpose is to work together to help improve the health care experience for consumers and physicians.

The new section proposes to adopt and incorporate by reference the Texas Standardized Credentialing Application for required use by public and private hospitals, HMOs, preferred provider benefit plan insurers, and preferred provider organizations for credentialing and recredentialing of physicians. The proposed form is designed for use not only for physicians but for other health care professionals who require credentialing. Therefore, while the proposed rule requires the form to be used for credentialing and recredentialing of physicians, the form may also be used for credentialing other health care professionals at the option of the credentialing entity. This proposed form is referenced in proposed §11.1902 which is published elsewhere in this edition of the Texas Register. The credentialing application consists of three sections: Section I requests personal, professional, and educational information; Section II consists of disclosure questions on sanctions, professional liability insurance, malpractice claims history, criminal/civil history, and ability to perform job; Section III consists of an Authorization, Acknowledgement, Attestation, and Release form.

Proposed new subsection (a) specifies the purpose and applicability of the new section. Proposed new subsection (b) specifies definitions. Proposed new subsection (c) adopts and incorporates by reference the standardized credentialing application and specifies the types of information and disclosure requested in the form. Proposed new subsection (d) specifies the proposed effective date. Proposed new subsection (e) indicates where the form may be obtained, and proposed new subsection (f) permits the form to be submitted electronically if the credentialing entity accepts electronic submissions.

The proposed effective date is for initial credentialing or recredentialing that occurs on or after July 1, 2002.

Kimberly Stokes, Senior Associate Commissioner, Life/Health/Licensing, has determined that during the first five years the proposed section will be in effect, there will be no fiscal impact on state or local government as a result of enforcing or administering the section. There will be no measurable effect on local employment or the local economy as a result of administering or enforcing the section.

Ms. Stokes has also determined that for each year of the first five years the section is in effect, the public benefits anticipated as a result of the section will be a uniform credentialing application form for physicians that will allow physicians to complete a single application that may be submitted in paper copy or electronically to all public or private hospitals, HMOs, preferred provider benefit insurers and preferred provider organizations with whom the physician contracts to provide health care services or seeks to obtain hospital privileges. Many physicians currently contract with numerous entities that require credentialing, and the standardized form will result in reduced time and paperwork for physicians. The anticipated benefit to public and private hospitals, HMOs, preferred provider benefit plan insurers, and preferred provider organizations that credential and recredential physicians is that these entities will no longer have to expend financial and staff resources in design and format updates of the physician credentialing application form. The economic costs to any public or private hospital, HMO, preferred provider benefit plan insurer, preferred provider organization, or physician required to comply with the proposed section are the direct result of the enactment of Senate Bill 544, and not a result of the administration or enforcement of the proposed section.

Ms. Stokes has determined that there is no adverse economic impact on any public or private hospital, HMO, preferred provider benefit plan insurer, preferred provider organization, or physician that qualifies as a small business or micro-business under the Government Code §2006.001 as a result of the proposed new section. The economic costs to any small business or micro-business public required to comply with the proposed section are the direct result of the legislative enactment of Senate Bill 544. The determining factor in the costs incurred by a public or private hospital, HMO, preferred provider benefit plan insurer, or preferred provider organization is not based on the size of the entity but rather is based on the number of physicians that require credentialing by the entity. Regardless of the size of the physician´s business, the proposed section will allow physicians to complete a single credentialing application for submission to all public or private hospitals, HMOs, preferred provider benefit insurers and preferred provider organizations with whom the physician contracts to provide health care services or seeks to obtain hospital privileges. The size of the business, therefore, has no bearing upon the applicability of the proposed section. Because of the intent of Senate Bill 544 to standardize the physician credentialing application used by public or private hospitals, HMOs, preferred provider benefit plan insurers, and preferred provider organizations, it is neither legal nor feasible to exempt small businesses or micro-businesses from the requirements of the proposed section.

To be considered, written comments on the proposal must be submitted no later than 5:00 p.m. on May 28, 2002 to Lynda H. Nesenholtz, General Counsel and Chief Clerk, Mail Code 113-1C, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to to Margaret Lazaretti, Director of Project Development, Life/Health/Licensing, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. A request for a public hearing must be submitted separately to the Office of Chief Clerk.

The new section is proposed pursuant to the Insurance Code Article 21.58D and §36.001. Article 21.58D requires the Commissioner by rule to adopt a standardized form for the verification of the credentials of a physician and to require public and private hospitals, HMOs operating under the Insurance Code Chapter 20A, and preferred provider organizations operating under Insurance Code Article 3.70-3C to use the form for verification of credentials. Section 36.001 provides that the Commissioner of Insurance may adopt rules to execute the duties and functions of the Texas Department of Insurance only as authorized by statute.

The following articles are affected by the proposal: Insurance Code Article 21.58D

§21.3201. Texas Standardized Credentialing Application for Physicians.

(a) Purpose and Applicability. The purpose of this section is to adopt a standardized credentialing application form as required by the Insurance Code Article 21.58D. Hospitals, health maintenance organizations, preferred provider benefit plans, and preferred provider organizations are required to use this form for credentialing and recredentialing of physicians.

(b) Definitions. The following words and terms when used in this section shall have the following meanings:

(1) Credentialing--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.

(2) Department--Texas Department of Insurance.

(3) Health maintenance organization--A health maintenance organization as that term is defined by the Insurance Code Article 20A.02(n).

(4) Hospital--A licensed public or private institution as defined by Chapter 241, Health and Safety Code, and any hospital owned or operated by state government.

(5) Physician--An individual licensed to practice medicine in this state.

(6) Preferred provider benefit plan--A plan issued by an insurer under the Insurance Code Article 3.70-3C.

(7) Preferred provider organization--An organization contracting with an insurer issuing a preferred provider benefit plan under the Insurance Code Article 3.70-3C, for the purpose of providing a network of preferred providers.

(8) Recredentialing--The periodic process by which:

(A)qualifications of physicians are reassessed;

(B) performance indicators including utilization and quality indicators are evaluated; and

(C) continued eligibility to provide services is determined.

(c)Texas Standardized Credentialing Application.

(1) The Department adopts and incorporates by reference the Texas Standardized Credentialing Application for required use by hospitals, health maintenance organizations, preferred provider benefit plan insurers, and preferred provider organizations for credentialing and recredentialing of physicians.

(2) The application consists of three sections. Section I requests personal, professional, and educational information. Section II consists of disclosure questions on sanctions, professional liability insurance, malpractice claims history, criminal/civil history, and ability to perform job. Section III consists of an Authorization, Acknowledgment, Attestation, and Release form.

(d) Effective date. The application form is required for initial credentialing or recredentialing that occurs on or after July 1, 2002.

(e) Availability. This form may be obtained on the Department´s Web site at www.tdi.state.tx.us or from the Texas Department of Insurance, Quality Assurance Division, Mail Code 103-6A, P. O. Box 149104, Austin, Texas, 78714-9104; or by calling 1-800-599-SHOP (1476); in Austin, (512)305-7211. Reproduction of this form without any changes is allowed.

(f) Electronic submission. The form may be submitted electronically to the credentialing entity in the same format as the hard copy form if the credentialing entity accepts such electronic submissions.



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