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SUBCHAPTER X. CREDENTIALING OF PHYSICIANS 28 TAC §21.3201

The Commissioner of Insurance adopts new Subchapter X, §21.3201, concerning a standardized credentialing application form for physicians. New §21.3201 is adopted with changes to the proposed text as published in the April 26, 2002 issue of the Texas Register (27 TexReg 3448).

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 20A.39 provides that the credentialing form must comply with the standards promulgated by the National Committee for Quality Assurance (NCQA), to the extent that the NCQA standards do not conflict with other laws of this state. The NCQA is an independent nonprofit organization that uses performance measures to assess and accredit managed care organizations, including HMOs. 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. The Department is adopting 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 adopts and incorporates 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 adopted form is designed for use not only for physicians but for other health care professionals who require credentialing. Therefore, while the adopted 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 adopted form is referenced in adopted §11.1902, concerning Quality of Care Improvement Program, which is published elsewhere in this issue 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 history, and ability to perform the job; Section III consists of an Authorization, Acknowledgement, Attestation, and Release Form.

Subsection (a) specifies the purpose and applicability of the new section. Subsection (b) specifies definitions. Subsection (c) adopts and incorporates by reference the standardized credentialing application form and specifies the types of information and disclosure requested in the form. Subsection (d) specifies the adopted effective date, which was changed from the proposed date of July 1 to August 1, 2002. Subsection (e) indicates where the form may be obtained, and subsection (f) permits the form to be submitted electronically if the credentialing entity accepts electronic submissions.

§21.3201(a): A commenter requests verification that the Texas Standardized Credentialing Application (TSCA) will apply to the reappointment process.

Response: The TSCA is required for both credentialing and recredentialing.

Comment: Several commenters request verification that the TSCA applies to all physicians and allied health professionals. The commenters also have concerns that if the form is used only for physicians and not other practitioners, it will defeat the purpose of a "common" application and not achieve consistency and continuity.

Response: The Department disagrees that using the form only for physicians and not for other practitioners will defeat the purpose of a "common" application, as its use is mandatory when credentialing all physicians. While the use of the form for credentialing other health care professionals is voluntary, the Department anticipates that credentialing entities will use the form for other types of providers.

Comment: Several commenters consider the use of the credentialing form for recredentialing to be too cumbersome, as many questions are appropriate for an initial applicant, but not necessary for recredentialing. Suggestions were made to delete this requirement, to use a shorter form for recredentialing, or to make this requirement optional.

Response: The Department disagrees, as the physician or provider may keep an electronic version of their form and update the specific fields that are appropriate and submit the updated form at the time of recredentialing. Alternatively, when recredentialing, a credentialing entity may provide the physician or provider with the previously completed form for the physician or provider to update the applicable items and submit the updated form for recredentialing.

§21.3201(c)(1): A commenter requests that the word "provider" be added after physician.

Response: The Department disagrees, as Article 21.58D requires the adoption of the standardized form for credentialing or recredentialing physicians. However, credentialing entities can utilize the form for other types of providers if they choose to do so.

Comment: A commenter requests clarification on how the use of the form will apply to physician groups.

Response: Physician groups must utilize the form to credential each individual physician.

§21.3201(d) Effective date: Some commenters are concerned that entities in the process of credentialing or recredentialing a physician on July 1, 2002 will be in violation of the rule if the TSCA form is not used. The commenters recommend implementing a grace period of 180-days to allow the credentialing and recredentialing entity to incorporate the new form into their process, extending the effective date of credentialing applications processed after September 1, 2002 to allow health plans to implement processes, or applying the effective date to all applications for credentialing or recredentialing distributed on or after July 1, 2002.

Response:The Department acknowledges this concern and has changed the rule to require the use of the new form for initial credentialing and recredentialing processes that begin on or after August 1, 2002.

Texas Standardized Credentialing Application

Comments: A commenter recommends replacing the TSCA form with one that includes information needed by licensing boards. In the alternative, the commenter recommends delaying the adoption of the TSCA until a "centralized credentialing solution" is considered by the Legislature in the upcoming session.

Response:The Department disagrees with both suggestions. The TSCA was developed from input from multiple credentialing entities and complies with the standards promulgated by the NCQA. The statute requires the adoption of a standardized form, and delaying adoption of the form until the next session of the Legislature is not appropriate.

Comment:A commenter requests that the following NCQA required statement be added to the last page of the form: "You will be notified prior to committee peer review of any information obtained during the credentialing process that varies substantially from the information provided on the application. You will be given an opportunity to correct any erroneous information."

Response: The Department disagrees. The Department anticipates that this statement will be found in the credentialing entity´s policies and procedures and that physicians will have the opportunity to review and rebut any erroneous information collected during their credentialing process. The credentialing entity can provide this information to the applicant in a cover letter.

Comment:A commenter suggests expanding the field lengths for the following fields to allow adequate space for responses: the Tax ID Number field in the Practice Location Information section; the Institution and Address fields in the Education section; the Primary Hospital Where You Have Admitting Privileges, Other Hospital Where You Have Privileges, and Hospital Name fields in the Hospital Affiliation section; the Practice/Employer Name field in the Work History section, and the Check Payable To field in the Practice Information section. Another commenter suggests consolidating the Practice Location Information and the Other Practice Information onto one page per practice site, to simplify the form. A commenter suggests that language is needed to inform the physician that the form continues to the following pages.

Response: The Department agrees with expanding the field lengths and has made the appropriate changes to the form. The Department has also changed the form to indicate the office practice location number. The Department disagrees with the last suggestion as the continuation of the form is self-explanatory.

Section I

Personal Information: A commenter requests that the ethnicity of the provider be requested on the form, as it is necessary for their Historically Underutilized Business report.

Response: The Department disagrees; this information is not necessary for the credentialing process. If an entity requires the ethnicity of an applicant for their HUB report, that information may be requested on an addendum.

Practice Location Information: A commenter notes that "doctor" is missing under this subsection.

Response: The Department disagrees with adding the word "doctor" to this subsection as unnecessary since the term "Physician" is already listed.

License and Other Identification Numbers: A commenter states that Medicaid numbers are provider and site specific and suggests that the Medicaid provider number be moved to the "Practice Location Information" section.

Response: The Department agrees and has made the changes to the form by including a field for "Medicaid Provider Number" under "Licenses and Certificates" and adding a new field for "Site Specific Medicaid Provider Number" under "Practice Location Information."

Comment: A commenter requests that the Prescriptive Authority Identification Number for Advanced Practice Nurses be added to the form.

Response: The Department disagrees as the credentialing form is required for physicians only. The Department anticipates that hospitals and providers will use the form for other medical staff at their discretion. If an entity requires this identification number, that information may be requested on an addendum.

Education: A commenter notes that "Podiatry" is missing from the "School Issuing Professional Degree."

Response: The Department disagrees with adding podiatry to the subtitle, as the list is not intended to be all-inclusive.

Professional/Specialty Information: A commenter states that hospitals need information regarding the limitations of the practice and suggests adding a field for "Practice Limited To" to that subsection.

Response: The Department disagrees, as the section Practice Location Information includes this inquiry on page 6 of the form.

Comment: A commenter suggests adding a field entitled "I have taken Part I and am eligible for Part II of the board exam."

Response: The Department agrees that the addition of this subsection would clarify the board certification status of the applicant. The Department has added the field to the form.

Other Practice Information: A commenter states that because this section applies primarily to managed care organizations, physicians applying for privileges within a hospital would not be required to provide this information. The commenter suggests that the pages containing this section be marked "Optional for Hospitals."

Response: The Department recognizes that individual HMOs, PPOs or hospitals who receive the completed form may find some sections more useful for their purposes than others. However, the goal is to provide a standardized form that physicians will need to complete only one time and that he/she can submit to any entity that will be credentialing the physician in the future, with only minor updates.

Comment: A commenter suggests deleting the Expiration Date requirement for office staff certifications for BLS, ATLS, CPR, ACLS, PALS, and NALS, as it may be confusing if multiple staff members held multiple certifications which had multiple expiration dates.

Response: The Department agrees and has made the appropriate changes to the form. The Department also notes that only current certifications are of importance and that the information required by the form regarding certifications should ask for only those certifications.

Hospital Affiliations: A commenter requests that a field be added for "Department Chairman´s Name."

Response: The Department agrees and has added the "Current Program Director."

Comment: A commenter requests that "MM/YY" be added to the "Start Date" and "Dates of Affiliation" fields.

Response: The Department agrees and has changed the form.

Comment: A commenter suggests deleting the requirement that providers disclose percentages of hospital admissions at each facility because the primary hospital is previously named in the form. The commenter also suggests limiting the required disclosure of previous hospital affiliations to the past 5 years.

Response: The Department recognizes that individual HMOs, PPOs or hospitals who receive the completed form may find some sections more useful for their purposes than others. However, the goal is to provide a standardized form that physicians will need to complete only one time and that he/she can submit to any entity that will be credentialing the physician in the future, with only minor updates.

Comment: To limit the number of attachments an applicant submits, a commenter requests that an additional space be added for one more current hospital affiliation.

Response: The Department disagrees. The form currently has 7 attachments; the Department believes that the provision of an additional page is not an onerous requirement.

Work History: A commenter requests the deletion of the phrase "may submit Curriculum Vitae" because it should not be submitted in lieu of completing the application.

Response: The Department agrees that the Curriculum Vitae is intended to supplement the form regarding chronological work history, and has made the appropriate changes.

Comment: A commenter suggests that there should be an explanation of any gaps greater than 3 months, rather than 6 months, because that is the standard used by many hospitals. A commenter states that gaps in education, training and work history need to be added to this section.

Response: The Department disagrees, as the NCQA guidelines require explanation of gaps of 6 months or longer for work history. Gaps in education or training are not necessary for the credentialing process and are not required by NCQA. If hospitals require a shorter period, the additional information may be requested on an addendum.

Comment: A commenter suggests that the date field include "___/___ to ___/___" which will provide the actual length of the gap.

Response: The Department agrees and has made the appropriate change to the form.

References: A commenter requests that a field be added for a phone number.

Response: The Department agrees and has made the appropriate changes to the form.

Comment: A commenter suggests that a field for degree or provider type be added.

Response: The Department agrees that the identification of the reference´s title to properly address him/her is needed. The Department has added the word "Title" to the Name field.

Required Attachments Or Supplemental Information: A commenter suggests that this section be moved to the beginning or end of the form for easy check-off by the provider.

Response: The Department agrees and has moved the attachments.

Comment: A commenter requests that the following documents be added to this section: current photograph, Curriculum Vitae, copy(ies) of license(s), and copy(ies) of continuing medical education certification.

Response: The Department disagrees. If credentialing entities require additional information from applicants, that information may be requested on an addendum.

Comment: A commenter notes that of the requested documents, a copy of the Texas license permit and the Educational Council for Foreign Medical Graduates (ECFMG) were missing.

Response: The Department disagrees with adding these requirements. A copy of the license is not necessary because the licensure of a physician is primary source verified by the credentialing organization. Further, the Department disagrees that a copy of the ECFMG is necessary because the physician must pass the ECFMG prior to taking his/her medical boards.

Section II

Disclosure Questions: Some commenters suggest that the terms "voluntary" or "involuntary" be included in the questions that pertain to licensure, hospital privileges and other affiliations, education, training and board certification, DEA or DPS, other sanctions or investigations and professional liability insurance information and claims history.

Response: The Department disagrees because the questions within those sections that pertain to acts that may be taken by the physician include the word voluntary. Questions that pertain to negative actions that may be taken against the physician by another are inherently involuntary.

Hospital Privileges and Other Affiliations: A commenter requests that the term "Medical Staff Membership" be added to "clinical privileges," as the two are distinct terms.

Response: The Department agrees and has made the appropriate changes to the form.

Other Sanctions or Investigations: A commenter suggests changing the wording of the sexual harassment question from "accusation" to "a final finding." The commenter suggests the deletion of the phrase "named as a defendant" because only final actions or final findings should be reported by providers.

Response: The Department agrees and has deleted the question regarding sexual harassment as well as the phrase "named as defendant" from other questions on the form.

Malpractice Claims History: A commenter requests several additions to this section including the word "each" before "Malpractice" in the header, name of the patient involved, outcome of the patient, closure date, and amount paid on behalf of the applicant.

Response: The Department disagrees, as the form clearly states that all malpractice claims are to be listed.

Comment: A commenter requests limiting the malpractice claims history to the last 10 years.

Response: The Department disagrees, as NCQA standards require 5 years.

Criminal/Civil History: Some commenters question the necessity of the asterisked statement as a criminal record would not necessarily be a bar to acceptance is applicable to all of the Disclosure Questions and recommend the deletion of that statement.

Response: The Department agrees with the commenters´ assertion and the form has been changed to delete the asterisked statement.

Malpractice Actions Indicated for Disclosure - Questions addressing Malpractice Claims

Comment: A commenter requests expanding the fields for "Description of Allegation" and "Description of Alleged Injury to the Patient" to a full page which will allow applicants to use at a later date.

Response: The Department agrees that the sections should be expanded but not increased to a full page. The Department has added additional spacing to both sections.

Additional Information for Disclosure questions: A commenter requests the deletion of this section because most affirmative responses will require more space to answer than provided, therefore an attached sheet of paper can be used. In the alternative the commenter suggests moving the section to the bottom of page 10 where there is blank space.

Response: The Department disagrees with deleting the entire section but agrees that the section should be moved to adequately utilize the space. The Department has made the appropriate changes to the form.

For with changes: American Association of Preferred Providers; Bexar Credentials Verification, Inc.; Christus St. Joseph´s Health System; Federation of State Medical Boards of the United States, Inc.; Healthcare Partners of East Texas, Inc.; Hendrick Health Systems; Mainland Medical Center; Methodist Hospitals of Dallas; Mid Jefferson Hospital; Parkland Health & Hospital System; St. David´s Medical Center; Texas Association of Health Plans; Texas Association of Preferred Provider Organizations;

Texas Tech Medical Center ­ El Paso; and Wadley Regional Medical Center.

Against: None.

The new section is adopted 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.

§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 August 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 Section, HMO Division, Mail Code 103-6A, P. O. Box 149104, Austin, Texas, 78714-9104; or by calling 1-800-599-SHOP (1476); in Austin, 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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Last updated: 09/06/2014

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