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Timely credentialing of physicians by carriers
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Colorado law establishing requirements for carriers' credentialing and recredentialing of physicians, including receipt and completeness notices, timelines for credentialing, directory updates, claim denial prohibitions, public posting of credentialing information, enforcement and penalties; applies to physicians applying to be participating providers in Colorado carrier networks.
No material clinical or coverage changes in this revision.
Key Terms
Provider Notices, Timelines, and Directory Obligations
Timely receipt, completeness notices, credentialing timelines, and directory-update obligations
Within seven calendar days after receiving an application, the carrier must provide the applicant a receipt in written or electronic form. If the carrier determines the application is incomplete, it must notify the applicant in writing or by electronic means within ten calendar days after receipt and the notice must describe the items required to complete the application. The carrier must conclude credentialing within sixty calendar days after receiving a completed application and provide written or electronic notice of the outcome within ten calendar days after conclusion. The carrier must correct discrepancies in its provider or network directory within thirty calendar days after receiving a report of the discrepancy; participating physicians must notify the carrier of changes in name, address, telephone number, business structure, or tax identification number within fifteen business days after making the change. The carrier must also post on its website its credentialing policies and procedures, a list of information required in an application, a checklist of materials to submit, and designated contact information (point of contact, email, and telephone) for credentialing inquiries.
- Provide applicant a written or electronic receipt within 7 calendar days of receiving the application.
- If application is incomplete, notify applicant in writing or electronically within 10 calendar days and describe missing items.
- If receipt not provided within 7 days, applicant is considered a participating physician no later than 53 calendar days after carrier's receipt.
- Conclude credentialing within 60 calendar days after receiving a completed application; notify applicant of outcome in writing or electronically within 10 calendar days after conclusion.
- Correct provider/network directory discrepancies within 30 calendar days after receiving a report.
- Participating physicians must notify carrier of changes (name, address, phone, business structure, TIN) within 15 business days of the change.
- Post on website: credentialing policies/procedures; list of required application information; checklist of materials; designated contact info (point of contact, email, telephone).
Credentialing Status and Claim Denial Rules
Credentialing and claim-denial rules
Claims and network participation rules tied to credentialing status. Covered services meeting the conditions below may not be denied on the basis of credentialing status.
ALL of the following
- Service is a covered benefit under the covered person's health coverage plan.
- Service is provided by a participating physician who is in the carrier's provider network for the carrier's health coverage plan and has concluded the carrier's credentialing process.
ALL of the following
- A carrier shall allow a participating physician to remain credentialed and included in the carrier's health coverage plan provider network unless the carrier discovers information indicating the physician no longer satisfies the carrier's guidelines for participation; in that event the carrier must satisfy the requirements of section 10-16-705(5) before terminating participation.
ANY of the following
- Recredentialing is permitted if required by federal or state law or by the carrier's accreditation standards.
- Recredentialing is permitted if permitted by the carrier's contract with the participating physician.
- A carrier shall not require a participating physician to submit an application or participate in a contracting process in order to be recredentialed.
ALL of the following
- A carrier shall make the following nonproprietary information available to all applicants and post it on its website: the carrier's credentialing policies and procedures; a list of information required to be included in an application; a checklist of materials that must be submitted in the credentialing process; designated contact information including a point of contact, email address, and telephone number for credentialing inquiries; and the requirements described in subsection (2) and the authority of the commissioner to enforce the requirements and impose penalties.
- A carrier shall correct discrepancies in its provider or network directory within thirty calendar days after receiving a report of the discrepancy from a participating physician; a participating physician shall notify the carrier of changes in name, address, telephone number, business structure, or tax identification number within fifteen business days after making the change.
ALL of the following
- The commissioner has authority to enforce the requirements and impose penalties as described in subsection (10).
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