KRS 205.532: Definitions for KRS 205.532 to 205.536 -- Contracts for Medicaid services

by managed care organizations -- Credentialing alliance -- Procedures --

Enrollment of and contracts with providers -- Failure to agree on terms and

conditions -- Application date -- Credentialing verification by university

hospitals -- Electronic verification of licensure information.

(1) As used in KRS 205.532 to 205.536:

(a) "Clean application" means:

1. For credentialing purposes, a credentialing application submitte d by a

provider to a credentialing verification organization that:

a. Is complete and correct;

b. Does not lack any required substantiating documentation; and

c. Is consistent with the requirements for the National Committee for

Quality Assurance requirements; or

2. For enrollment purposes, an enrollment application submitted by a

provider to the department that:

a. Is complete and correct;

b. Does not lack any required substantiating documentation;

c. Complies with all provider screening requirements pursuant to 42

C.F.R. pt. 455; and

d. Is on behalf of a provider who does not have accounts receivable

with the department;

(b) "Credentialing alliance" means a contractual agreement entered into by

Medicaid managed care organizations under which the managed care

organizations agree to utilize a single credentialing verification organization

and an identical credentialing process for the purpose of ensuring the timely

and efficient credentialing of providers;

(c) "Credentialing application date" means the date that a credentialing

verification organization receives a clean application from a provider;

(d) "Credentialing verification organization" means an organization that gathers

data and verifies the creden tials of providers in a manner consistent with

federal and state laws and the requirements of the National Committee for

Quality Assurance;

(e) "Department" means the Department for Medicaid Services;

(f) "Medicaid managed care organization" or "managed care organization" means

an entity with which the department has contracted to serve as a managed care

organization as defined in 42 C.F.R. sec. 438.2;

(g) "Provider" has the same meaning as in KRS 304.17A-700; and

(h) "Request for proposals" has the same meaning as in KRS 45A.070.

(2) Every contract entered into or renewed on or after June 29, 2023, for the delivery of

Medicaid services by a managed care organization shall:

(a) Be in compliance with KRS 205.522 and 205.532 to 205.536; and

(b) Require participation in a credentialing alliance recognized by the department

pursuant to subsection (4) of this section if such an alliance has been

established or utilization of the credentialing organization designated by the

department pursuant to subsection (5) of this section.

(3) The department shall enroll a provider within sixty (60) calendar days of receipt of

a clean provider enrollment application. The date of enrollment shall be the date

that the provider's clean application was initially received by the dep artment. The

time limits established in this section shall be tolled or paused for any delay caused

by an external entity. Tolling events include but are not limited to the screening

requirements contained in 42 C.F.R. pt. 455 and searches of federal datab ases

maintained by entities such as the United States Centers for Medicare and Medicaid

Services.

(4) (a) The department shall formally recognize a credentialing alliance formed by

managed care organizations if:

1. One hundred percent (100%) of the total n umber of managed care

organizations have entered into a contractual agreement to form the

credentialing alliance prior to December 1, 2023;

2. The credentialing verification organization contracted as part of the

credentialing alliance is accredited by the National Committee for

Quality Assurance; and

3. The credentialing verification organization contracted as part of the

credentialing organization is owned by or affiliated with a statewide

healthcare trade association.

(b) A credentialing alliance established pursuant to this section shall:

1. Implement a single credentialing application via a web -based portal

available to all providers seeking to be credentialed for any Medicaid

managed care organization that participates in the credentialing alliance;

2. Perform primary source verification and credentialing committee review

of each credentialing application that results in a recommendation on the

provider's credentialing within thirty (30) days of receipt of a clean

application;

3. Notify providers within five (5) business days of receipt of a

credentialing application if the application is incomplete;

4. Provide provider outreach and help desk services during common

business hours to facilitate provider applications and credentialing

information;

5. Expeditiously communicate the credentialing recommendation and

supporting credentialing information electronically to the department

and to each participating Medicaid managed care organization with

which the provider is seeking credentialing; and

6. Conduct re evaluation of provider documentation when required

pursuant to state or federal law or when necessary for the provider to

maintain participation status with a Medicaid managed care

organization.

(5) (a) If a credentialing alliance has not been established and recognized by the

department pursuant to subsection (4) of this section by December 31, 2023,

the department shall, through a request for proposals and in accordance with

KRS Chapter 45A, designate a single credentialing verification organization

to verify the credentials of providers on behalf of all managed care

organizations.

(b) If the department designates a single credentialing verification organization

pursuant to this subsection:

1. The contract between the department and the credentialing verification

organization shall be submitted to the Government Contract Review

Committee of the Legislative Research Commission for comment and

review;

2. The credentialing verification organization shall be reimbursed on a per

provider credentialing basis by the department with the reimbursement

being offset or deducted equally from each managed care organizations

capitation payment;

3. The credentialing verification organization shall comply with paragraph

(b) of subsection (4) of this section; and

4. The department may promulgate administrative regulations in

accordance with KRS Chapter 13A to ensure the timely and efficient

credentialing of providers.

(6) If a Medicaid managed care organization assumes resp onsibility and costs for their

own provider credentialing by entering into a credentialing alliance pursuant to this

section, the timely credentialing of providers shall be given significant weight as a

factor in the scoring process when the department eva luates the Medicaid managed

care organization's response to requests for proposals for all contract awards.

(7) A Medicaid managed care organization shall:

(a) Determine whether it will contract with the provider within thirty (30)

calendar days of receipt of the verified credentialing information from a

credentialing verification organization either designated by the department or

contracted by managed care organizations as part of a credentialing alliance;

and

(b) 1. Within ten (10) days of an executed co ntract, ensure that any internal

processing systems of the managed care organization have been updated

to include:

a. The accepted provider contract; and

b. The provider as a participating provider.

2. In the event that the loading and configuration of a c ontract with a

provider will take longer than ten (10) days, the managed care

organization may take an additional fifteen (15) days if it has notified

the provider of the need for additional time.

(8) (a) Nothing in this section requires a Medicaid managed care organization to

contract with a provider if the managed care organization and the provider do

not agree on the terms and conditions for participation.

(b) Nothing in this section shall prohibit a provider and a managed care

organization from negotiat ing the terms of a contract prior to the completion

of the department's enrollment and screening process.

(9) (a) For the purpose of reimbursement of claims, once a provider has met the

terms and conditions for credentialing and enrollment, the provider's

credentialing application date shall be the date from which the provider's

claims become eligible for payment.

(b) A Medicaid managed care organization shall not require a provider to appeal

or resubmit any clean claim submitted during the time period betw een the

provider's credentialing application date and the completion of the

credentialing process.

(c) Nothing in this section shall limit the department's authority to establish

criteria that allow a provider's claims to become eligible for payment in the

event of lifesaving or life -preserving medical treatment, such as, for an

illustrative but not exclusive example, an organ transplant.

(10) Nothing in this section shall prohibit a university hospital, as defined in KRS

205.639, from performing the activi ties of a credentialing verification organization

for its employed physicians, residents, and mid -level practitioners where such

activities are delineated in the hospital's contract with a Medicaid managed care

organization. The provisions of subsections (3), (4), (8), and (9) of this section with

regard to payment and timely action on a credentialing application shall apply to a

credentialing application that has been verified through a university hospital

pursuant to this subsection.

(11) To promote seaml ess integration of licensure information, the relevant provider

licensing boards in Kentucky are encouraged to forward and provide licensure

information electronically to the department and any credentialing verification

organization.