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Uniform Provider Credentialing

Bulletin
Tuesday, December 12, 2006
Health Care Bulletin #122

Bulletin HCA - 122

Uniform Provider Credentialing

Section 1. Definitions.

Terms used in this Bulletin shall have the meanings defined in 18 V.S.A. § 9408a.

Section 2. Authority.

(a) 18 V.S.A. § 9408a, enacted during the 2006 Session of the Vermont General Assembly, directs the Vermont Department of Banking, Insurance, Securities and Health Care Administration (hereinafter “Department”) to prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (hereinafter “CAQH”), or a similar, nationally recognized form prescribed by the Commissioner. The law further directs that the credentialing application form prescribed by the Commissioner must be used by health insurers and hospitals that perform credentialing of providers beginning January 1, 2007.

(b) This Bulletin is issued pursuant to the authority conferred on the Commissioner by 18 V.S.A. § 9408a, and by 8 V.S.A. § 15.

Section 3. CAQH Credentialing Form Prescribed.

(a) The Department has considered the requirements of the statute, and has explored alternatives to the CAQH credentialing form. Pursuant to the authority conferred upon the Commissioner by 8 V.S.A. § 9408a, the CAQH credentialing application form, as amended from time to time, is hereby prescribed for use by health insurers and hospitals for credentialing and re-credentialing purposes, beginning January 1, 2007.

(b) A health insurer or hospital shall use the CAQH credentialing application form whenever the health insurer or hospital makes a determination concerning whether the provider is eligible to provide health care services to an insured, or to a hospital patient, or whether the provider is eligible to receive reimbursement for health care services. Health insurers and hospitals shall use the CAQH credentialing application form for the initial application, and for applications for re-credentialing which are filed in due course as required by the re-credentialing process of the health insurer or hospital after January 1, 2007.

(c) The CAQH credentialing application form shall be used in electronic or paper format, as determined by the health insurer or hospital.

(d) A health insurer or hospital shall use the CAQH credentialing form to the exclusion of any other form, but a health insurer or hospital may use reasonable supplemental forms or materials in addition to the CAQH application credentialing form, as necessary for the legitimate purposes of the health insurer or hospital.

(e) The provisions of this Bulletin require the use of the CAQH credentialing form by health insurers and hospitals. The provisions of this Bulletin do not apply to the manner in which health insurers and hospitals use the CAQH credentialing form. For example, a health insurer or hospital may determine that in particular circumstances, the entire CAQH credentialing form does, or does not need to be completed by the provider, or that in particular circumstances the CAQH credentialing form does, or does not need to be completed in accordance with the instructions of the health insurer or hospital.

Section 4. Enforcement.

Failure by a health insurer or hospital to comply with the provisions of 18 V.S.A. § 9408a, and with the requirements of this Bulletin, may be enforced pursuant to 8 V.S.A. § 3661.

Section 5. Effective Date; applicability.

(a) This Bulletin shall take effect from the date of signing, and shall apply to health insurers and hospitals on and after January 1, 2007. The provisions of this Bulletin shall not apply to credentialing applications submitted to health insurers and hospitals before January 1, 2007.

(b) The Department does not intend to monitor the activities of health insurers and hospitals with respect to this Bulletin before July 1, 2007.

Dated this _12th__ day of ___December__, 2006.