420-J:4 Credentialing Verification Procedures. –
I. A health carrier shall:
(a) Establish written policies and procedures for credentialing verification of all health care professionals with whom the health carrier contracts and apply these standards consistently.
(b) Verify the credentials of a health care professional. Prior to completion of credentialing verification the health carrier shall:
(1) Allow a health care provider who, at the time of submission of a clean and complete application, has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate, to deliver health care services to covered persons when covering on-call for another health care provider who is credentialed by the carrier.
(2) Allow a health care provider to deliver health care services to covered persons when that health care provider has a valid license from the respective state licensing board and has been credentialed by the hospital, if appropriate, and who at the time of submission of a clean and complete application is credentialed by the health carrier in another state or is in the health carrier's New Hampshire network based on employment with a particular health care entity. When a health care provider relocates or opens an additional office and the carrier requires a site visit, documentation of the new site evaluation shall be required as part of the credentialing process. The medical director of the health carrier or other designated health care professional shall have responsibility for, and shall participate in, health care professional credentialing verification.
(c) Establish a credentialing verification committee consisting of licensed physicians and other health care professionals to review credentialing verification information and supporting documents and make decisions regarding credentialing verification.
(d) Make available for review by the applying health care professional upon written request all application and credentialing verification policies and procedures.
(e) Retain records and documents relating to a health care professional's credentialing verification process for 7 years.
(f) Keep confidential all information obtained in the credentialing verification process, except as otherwise provided by law.
(g) Notify a health care provider that a submitted credentialing application is incomplete, not later than 15 business days after receiving the credentialing application.
(h) Act upon and finalize the credentialing process within 30 calendar days for primary care physicians and 45 days for specialists of receipt of a clean and complete application. In this section, "clean and complete" means an application signed and appropriately dated by the health care provider, that includes all of the applicable information required in paragraph II and any affirmative responses on questions related to quality and clinical competence shall contain explanations satisfactory to the carrier.
(i) An applicant's rights under this section and under RSA 420-J:8-c shall terminate upon denial of the credentialing application by the health carrier or if the applicant decides not to contract with the health carrier.
II. A health carrier shall obtain verification of at least the following information about the applicant:
(a) Graduation from health care professional school.
(b) Completion of post graduate training (if applicable).
(c) The health care professional's license history in this and all other states.
(d) The health care professional's malpractice history.
(e) The health care professional's practice history.
(f) Current license, certificate of authority, or registration to practice a health care profession in New Hampshire.
(g) Current level of professional liability coverage (if applicable).
(h) Status of hospital privileges (if applicable).
(i) Specialty board certification status (if applicable).
(j) Current Drug Enforcement Agency (DEA) registration certificate (if applicable).
III. A health carrier shall thereafter obtain, at least every 3 years, verification of a participating provider's:
(a) Current license, certificate of authority or registration to practice a health care profession in New Hampshire.
(b) Current level of professional liability coverage (if applicable).
(c) Status of hospital privileges (if applicable).
(d) Current DEA registration certificate (if applicable).
(e) Specialty board certification status (if applicable).
IV. A health carrier shall require all participating providers to notify the health carrier of changes in the status of any items listed in this section at any time, and shall identify for participating providers the individual or department to whom they should report such changes. The carrier shall act upon the change in status request within 30 days of receipt of the request or shall notify the provider of the reason for delay or inability to act.
V. Whenever a health carrier contracts to have another entity perform the credential verification functions required by this section or applicable rules, the commissioner shall hold the health carrier responsible for monitoring the activities of the entity with which it contracts and for ensuring that the requirements of this section and applicable rules are met.
VI. Nothing in this section shall be construed to require a health carrier to select a health care professional as a participating provider solely because the health care professional meets the health carrier's credentialing verification standards, or to prevent a health carrier from utilizing separate or additional criteria in selecting the health care professionals with whom it contracts.
VII. The commissioner shall accept and record complaints for health care providers regarding a health carrier's alleged non-compliance with the provisions of this section and may take such regulatory action as deemed necessary in response to complaints received.
Source. 1997, 345:1. 2002, 207:41. 2007, 98:1, eff. Aug. 10, 2007. 2023, 98:1, 2, eff. Aug. 19, 2023.