Section 500.3528 - Health maintenance organization; duties.
THE INSURANCE CODE OF 1956 (EXCERPT)
Act 218 of 1956
500.3528 Health maintenance organization; duties.
Sec. 3528.
(1) A health maintenance organization shall do all of the following:
(a) Establish written policies and procedures for credentialing verification of all health professionals with whom the health maintenance organization contracts and shall apply these standards consistently.
(b) Verify the credentials of a health professional before entering into a contract with that health professional. The health maintenance organization's medical director or other designated health professional shall have responsibility for, and shall participate in, health professional credentialing verification.
(c) Establish a credentialing verification committee consisting of licensed physicians and other health professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification.
(d) Make available for review by the applying health professional upon written request all application and credentialing verification policies and procedures.
(e) Retain all records and documents relating to a health professional's credentialing verification process for at least 2 years.
(f) Keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.
(2) A health maintenance organization shall obtain primary verification of at least all of the following information about an applicant to become a health professional with the health maintenance organization:
(a) Current license to practice in this state and history of licensure.
(b) Current level of professional liability coverage, if applicable.
(c) Status of hospital privileges, if applicable.
(3) A health maintenance organization shall obtain, subject to either primary or secondary verification at the health maintenance organization's discretion, all of the following information about an applicant to become an affiliated provider with the health maintenance organization:
(a) The health professional's license history in this and all other states.
(b) The health professional's malpractice history.
(c) The health professional's practice history.
(d) Specialty board certification status, if applicable.
(e) Current drug enforcement agency (DEA) registration certificate, if applicable.
(f) Graduation from medical or other appropriate school.
(g) Completion of postgraduate training, if applicable.
(4) A health maintenance organization shall obtain at least every 3 years primary verification of all of the following for a participating health professional:
(a) Current license to practice in this state.
(b) Current level of professional liability coverage, if applicable.
(c) Status of hospital privileges, if applicable.
(5) A health maintenance organization shall require all participating providers to notify the health maintenance organization of changes in the status of any of the items listed in this section at any time and identify for providers the individual at the health maintenance organization to whom they should report changes in the status of an item listed in this section.
(6) A health maintenance organization shall provide a health professional with the opportunity to review and correct information submitted in support of that health professional's credentialing verification application as follows:
(a) Each health professional who is subject to the credentialing verification process has the right to review all information, including the source of that information, obtained by the health maintenance organization to satisfy the requirements of this section during the health maintenance organization's credentialing process.
(b) A health maintenance organization shall notify a health professional of any information obtained during the health maintenance organization's credentialing verification process that does not meet the health maintenance organization's credentialing verification standards or that varies substantially from the information provided to the health maintenance organization by the health professional, except that the health maintenance organization is not required to reveal the source of information if the information is not obtained to meet the requirements of this section or if disclosure is prohibited by law.
(c) A health professional has the right to correct any erroneous information. A health maintenance organization shall have a formal process by which a health professional may submit supplemental or corrected information to the health maintenance organization's credentialing verification committee and request a reconsideration of the health professional's credentialing verification application if the health professional feels that the health carrier's credentialing verification committee has received information that is incorrect or misleading. Supplemental information is subject to confirmation by the health maintenance organization.
(7) If a health maintenance organization contracts to have another entity perform the credentialing functions required by this section, the commissioner shall hold the health maintenance organization responsible for monitoring the activities of the entity with which it contracts and for ensuring that the requirements of this section are met.
(8) Nothing in this act shall be construed to require a health maintenance organization to select a provider as a participating provider solely because the provider meets the health maintenance organization's credentialing verification standards, or to prevent a health maintenance organization from utilizing separate or additional criteria in selecting the health professionals with whom it contracts.
History: Add. 2000, Act 252, Imd. Eff. June 29, 2000 ;-- Am. 2002, Act 621, Imd. Eff. Dec. 23, 2002
Popular Name: Act 218
Popular Name: HMO