N.J. Admin. Code § 11:24B-3.6

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:24B-3.6 - ODS: credentialing

(a) If an ODS performs credentialing and recredentialing activities, whether with respect only to the ODS' contracted providers or other providers that may be contracted with the carrier directly or through another ODS, the ODS shall demonstrate that it meets the following requirements:

1. Credentialing and recredentialing shall be under the supervision of a medical director who is a physician licensed to practice medicine in New Jersey, whether under contract with the ODS, or the carrier with which the ODS has contracted;

2. Establishment of clearly written and detailed qualifications for credentialing participating providers for each network of providers being credentialed;

3. Establishment of clearly written and detailed time frames for performing credentialing and recredentialing activities, except that in no instance shall routine recredentialing be performed less frequently than once every 36 months;

4. Establishment of a mechanism for ensuring review of provider credentials by a multidisciplinary team;

5. Establishment of a system for verification of provider credentials, recertifications, performance reviews and obtaining information about any disciplinary action against the provider available from the New Jersey Board of Medical Examiners or any other State licensing board applicable to the type of provider, and the Federal Clearinghouse established pursuant to the Health Care Quality Improvement Act, Pub.L. 99-660 ( 42 U.S.C. §§ 1101 et seq.), and any amendments thereto; and

6. Establishment of a system assuring that the ODS' functions are linked and coordinated with the carrier's (or the carrier's contractor's) continuous quality improvement and complaint systems.

N.J. Admin. Code § 11:24B-3.6

Amended by R.2009 d.243, effective 8/3/2009.
See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a).
Rewrote the introductory paragraph of (a).