205.532 Definitions for KRS 205.532 to 205.536 -- Contracts for Medicaid services
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/ky/205-532A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
by managed care organizations -- Credentialing alliance -- Procedures --
Enrollment of and contracts with providers -- Failure to agree on terms and
conditions -- Application date -- Credentialing verification by university
hospitals -- Electronic verification of licensure information.
(1)As used in KRS 205.532 to 205.536:
(a)"Clean application" means:
1. For credentialing purposes, a credentialing application submitted by a
provider to a credentialing verification organization that:
a. Is complete and correct;
b. Does not lack any required substantiating documentation; and
c. Is consistent with the requirements for the National Committee for
Quality Assurance requirements; or
2. For enrollment purposes, an enrollment application submitted by a
provider to the department that:
a. Is complete and correct;
b. Does not lack any required substantiating documentation;
c. Complies with all provider screening requirements pursuant to 42
C.F.R. pt. 455; and
d. Is on behalf of a provider who does not have accounts receivable
with the department;
(b)"Credentialing alliance" means a contractual agreement entered into by
Medicaid managed care organizations under which the managed care
organizations agree to utilize a single credentialing verification organization
and an identical credentialing process for the purpose of ensuring the timely
and efficient credentialing of providers;
(c)"Credentialing application date" means the date that a credentialing
verification organization receives a clean application from a provider;
(d)"Credentialing verification organization" means an organization that gathers
data and verifies the credentials of providers in a manner consistent with
federal and state laws and the requirements of the National Committee for
Quality Assurance;
(e)"Department" means the Department for Medicaid Services;
(f)"Medicaid managed care organization" or "managed care organization" means
an entity with which the department has contracted to serve as a managed care
organization as defined in 42 C.F.R. sec. 438.2;
(g)"Provider" has the same meaning as in KRS 304.17A-700; and
(h)"Request for proposals" has the same meaning as in KRS 45A.070.
(2)Every contract entered into or renewed on or after June 29, 2023, for the delivery of
Medicaid services by a managed care organization shall:
(a)Be in compliance with KRS 205.522 and 205.532 to 205.536; and
(b)Require participation in a credentialing alliance recognized by the department
pursuant to subsection
(4)of this section if such an alliance has been
established or utilization of the credentialing organization designated by the
department pursuant to subsection
(5)of this section.
(3)The department shall enroll a provider within sixty
(60)calendar days of receipt of
a clean provider enrollment application. The date of enrollment shall be the date
that the provider's clean application was initially received by the department. The
time limits established in this section shall be tolled or paused for any delay caused
by an external entity. Tolling events include but are not limited to the screening
requirements contained in 42 C.F.R. pt. 455 and searches of federal databases
maintained by entities such as the United States Centers for Medicare and Medicaid
Services.
(a)The department shall formally recognize a credentialing alliance formed by
managed care organizations if:
1. One hundred percent (100%) of the total number of managed care
organizations have entered into a contractual agreement to form the
credentialing alliance prior to December 1, 2023;
2. The credentialing verification organization contracted as part of the
credentialing alliance is accredited by the National Committee for
Quality Assurance; and
3. The credentialing verification organization contracted as part of the
credentialing organization is owned by or affiliated with a statewide
healthcare trade association.
(b)A credentialing alliance established pursuant to this section shall:
1. Implement a single credentialing application via a web-based portal
available to all providers seeking to be credentialed for any Medicaid
managed care organization that participates in the credentialing alliance;
2. Perform primary source verification and credentialing committee review
of each credentialing application that results in a recommendation on the
provider's credentialing within thirty
(30)days of receipt of a clean
application;
3. Notify providers within five
(5)business days of receipt of a
credentialing application if the application is incomplete;
4. Provide provider outreach and help desk services during common
business hours to facilitate provider applications and credentialing
information;
5. Expeditiously communicate the credentialing recommendation and
supporting credentialing information electronically to the department
and to each participating Medicaid managed care organization with
which the provider is seeking credentialing; and
6. Conduct reevaluation of provider documentation when required
pursuant to state or federal law or when necessary for the provider to
maintain participation status with a Medicaid managed care
organization.
(a)If a credentialing alliance has not been established and recognized by the
department pursuant to subsection
(4)of this section by December 31, 2023,
the department shall, through a request for proposals and in accordance with
KRS Chapter 45A, designate a single credentialing verification organization
to verify the credentials of providers on behalf of all managed care
organizations.
(b)If the department designates a single credentialing verification organization
pursuant to this subsection:
1. The contract between the department and the credentialing verification
organization shall be submitted to the Government Contract Review
Committee of the Legislative Research Commission for comment and
review;
2. The credentialing verification organization shall be reimbursed on a per
provider credentialing basis by the department with the reimbursement
being offset or deducted equally from each managed care organizations
capitation payment;
3. The credentialing verification organization shall comply with paragraph
(b)of subsection
(4)of this section; and
4. The department may promulgate administrative regulations in
accordance with KRS Chapter 13A to ensure the timely and efficient
credentialing of providers.
(6)If a Medicaid managed care organization assumes responsibility and costs for their
own provider credentialing by entering into a credentialing alliance pursuant to this
section, the timely credentialing of providers shall be given significant weight as a
factor in the scoring process when the department evaluates the Medicaid managed
care organization's response to requests for proposals for all contract awards.
(7)A Medicaid managed care organization shall:
(a)Determine whether it will contract with the provider within thirty
calendar days of receipt of the verified credentialing information from a
credentialing verification organization either designated by the department or
contracted by managed care organizations as part of a credentialing alliance;
and
(b)1. Within ten
(10)days of an executed contract, ensure that any internal
processing systems of the managed care organization have been updated
to include:
a. The accepted provider contract; and
b. The provider as a participating provider.
2. In the event that the loading and configuration of a contract with a
provider will take longer than ten
(10)days, the managed care
organization may take an additional fifteen
(15)days if it has notified
the provider of the need for additional time.
(a)Nothing in this section requires a Medicaid managed care organization to
contract with a provider if the managed care organization and the provider do
not agree on the terms and conditions for participation.
(b)Nothing in this section shall prohibit a provider and a managed care
organization from negotiating the terms of a contract prior to the completion
of the department's enrollment and screening process.
(a)For the purpose of reimbursement of claims, once a provider has met the
terms and conditions for credentialing and enrollment, the provider's
credentialing application date shall be the date from which the provider's
claims become eligible for payment.
(b)A Medicaid managed care organization shall not require a provider to appeal
or resubmit any clean claim submitted during the time period between the
provider's credentialing application date and the completion of the
credentialing process.
(c)Nothing in this section shall limit the department's authority to establish
criteria that allow a provider's claims to become eligible for payment in the
event of lifesaving or life-preserving medical treatment, such as, for an
illustrative but not exclusive example, an organ transplant.
(10)Nothing in this section shall prohibit a university hospital, as defined in KRS
205.639, from performing the activities of a credentialing verification organization
for its employed physicians, residents, and mid-level practitioners where such
activities are delineated in the hospital's contract with a Medicaid managed care
organization. The provisions of subsections (3), (4), (8), and
(9)of this section with
regard to payment and timely action on a credentialing application shall apply to a
credentialing application that has been verified through a university hospital
pursuant to this subsection.
(11)To promote seamless integration of licensure information, the relevant provider
licensing boards in Kentucky are encouraged to forward and provide licensure
information electronically to the department and any credentialing verification
organization.