N.J. Admin. Code § 11:24C-1.3

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24C-1.3 - Credentialing standards

(a) For providers using the Council for Affordable Quality Healthcare (CAQH) Universal Provider Datasource, carriers shall complete provider credentialing within 90 days of receipt of a complete credentialing application in accordance with this subchapter.

1. Within 45 days of a carrier's receipt of notice from CAQH of an applicant's credentialing application, a carrier shall notify the applicant whether the application is complete or incomplete. If the application contained an e-mail address, the carrier may provide the notice electronically. If the application did not contain an e-mail address, the carrier shall provide the notice in writing. If an application is incomplete, the notice shall identify all deficiencies and specify all additional information required to be submitted by third parties and, if applicable, by the applicant in order for the application to be considered complete. The notice shall also specify the due date for receipt of any additional information required from the applicant.

2. The notice referenced in (a)1 above shall include the phone number and e-mail address of the carrier's department responsible for accepting the information required to complete the application and for providing assistance regarding the carrier's credentialing process and the status of a credentialing application. Carriers shall respond to all credentialing inquiries within five business days.

(b) For providers not using the CAQH Universal Credentialing Datasource, carrier credentialing timing requirements shall be as stated in N.J.A.C. 11:24-3.9 and 11:24A-4.7.

(c) Carriers that offer managed care plans shall accept the New Jersey Universal Physician Application, as set forth in Exhibit 1 of the Appendix to this subchapter and incorporated herein by reference, for the purpose of credentialing physicians who seek to participate in the carrier's network(s).

(d) Carriers that offer managed care plans may continue to use another physician credentialing application form but shall inform physicians that a downloadable version of the New Jersey Universal Physician Application is available through the Department's website www.state.nj.us/dobi or indicate where physicians may obtain a hard copy of the New Jersey Universal Physician Application.

1. When a physician makes an oral inquiry concerning a credentialing application, then a carrier's response concerning the availability of the New Jersey Universal Physician Application may be oral; however, any mailing of the carrier's credentialing application form as a follow-up to the oral request shall include a written notice referencing the availability of the New Jersey Universal Physician Application, and information on how to access the application.

2. When a physician inquires in writing concerning a credentialing application, then the carrier shall include with its credentialing application form a written notice referencing the availability of the New Jersey Universal Physician Application and information on how to access the application.

3. Carriers shall not require providers to use the carrier's credentialing form in lieu of the New Jersey Universal Physician Application in order to participate in the carrier's network(s).

(e) As an alternative to the requirements set forth in (c) or (d) above, carriers may access information about a physician from a recognized, national credentialing database, data bank or repository of health care providers subject to the following conditions:

1. Carriers shall not require providers to use a national database in lieu of one of the forms set forth in (c) or (d) above in order to participate in the carrier's network(s).

2. The database shall include credentialing data commonly requested by carriers, hospitals and other health care entities and credentials verification organizations for purposes of credentialing and shall minimize the need for the collection of additional credentials data.

3. The database shall be accessible to physicians at no cost.

4. The database shall be accessible to physicians through multiple methods including electronic and paper formats.

5. The database shall incorporate adequate security features to ensure that credentials data submitted by physicians and provided for review shall remain confidential, as provided by law, and shall not be released without the written consent of the physician.

i. An electronic signature or other similar alternative that acknowledges the physician's consent to the release of credentials data shall satisfy the written consent requirement.

6. The database shall, at a minimum, collect the following physician credentialing information:

i. Education and degrees;

ii. Specialty, if applicable;

iii. Board certification status;

iv. Hospital affiliations;

v. Office hours;

vi. Whether accepting new patients;

vii. Liability insurance coverage;

viii. Languages spoken;

ix. Professional references; and

x. State and Federal license and/or registration number.

7. The database shall require physicians to provide all information concerning any license actions, sanctions or restrictions; professional sanctions from any source; felony conviction(s) and malpractice claim history from settled or closed case(s).

8. The database shall require the physician to attest to the completeness and accuracy of the information provided.

9. The database shall require primary and secondary source verification for all licenses, board certifications, registrations and insurance.

10. Nothing set forth in this subsection shall preclude a carrier from consulting a national database to verify data submitted in accordance with (c) or (d) above.

N.J. Admin. Code § 11:24C-1.3

Amended by R.2013 d.048, effective 3/18/2013 (operative January 1, 2014).
See: 44 N.J.R. 376(a), 45 N.J.R. 651(a).
Rewrote the section.