{"data":{"id":"us-ky/krs-205.532","jurisdiction":"us-ky","citation":"KRS 205.532","heading":"Definitions for KRS 205.532 to 205.536 -- Contracts for Medicaid services","body":"by managed care organizations -- Credentialing alliance -- Procedures --\nEnrollment of and contracts with providers -- Failure to agree on terms and\nconditions -- Application date -- Credentialing verification by university\nhospitals -- Electronic verification of licensure information.\n(1) As used in KRS 205.532 to 205.536:\n(a) \"Clean application\" means:\n1. For credentialing purposes, a credentialing application submitte d by a\nprovider to a credentialing verification organization that:\na. Is complete and correct;\nb. Does not lack any required substantiating documentation; and\nc. Is consistent with the requirements for the National Committee for\nQuality Assurance requirements; or\n2. For enrollment purposes, an enrollment application submitted by a\nprovider to the department that:\na. Is complete and correct;\nb. Does not lack any required substantiating documentation;\nc. Complies with all provider screening requirements pursuant to 42\nC.F.R. pt. 455; and\nd. Is on behalf of a provider who does not have accounts receivable\nwith the department;\n(b) \"Credentialing alliance\" means a contractual agreement entered into by\nMedicaid managed care organizations under which the managed care\norganizations agree to utilize a single credentialing verification organization\nand an identical credentialing process for the purpose of ensuring the timely\nand efficient credentialing of providers;\n(c) \"Credentialing application date\" means the date that a credentialing\nverification organization receives a clean application from a provider;\n(d) \"Credentialing verification organization\" means an organization that gathers\ndata and verifies the creden tials of providers in a manner consistent with\nfederal and state laws and the requirements of the National Committee for\nQuality Assurance;\n(e) \"Department\" means the Department for Medicaid Services;\n(f) \"Medicaid managed care organization\" or \"managed care organization\" means\nan entity with which the department has contracted to serve as a managed care\norganization as defined in 42 C.F.R. sec. 438.2;\n(g) \"Provider\" has the same meaning as in KRS 304.17A-700; and\n(h) \"Request for proposals\" has the same meaning as in KRS 45A.070.\n(2) Every contract entered into or renewed on or after June 29, 2023, for the delivery of\nMedicaid services by a managed care organization shall:\n(a) Be in compliance with KRS 205.522 and 205.532 to 205.536; and\n(b) Require participation in a credentialing alliance recognized by the department\npursuant to subsection (4) of this section if such an alliance has been\nestablished or utilization of the credentialing organization designated by the\ndepartment pursuant to subsection (5) of this section.\n(3) The department shall enroll a provider within sixty (60) calendar days of receipt of\na clean provider enrollment application. The date of enrollment shall be the date\nthat the provider's clean application was initially received by the dep artment. The\ntime limits established in this section shall be tolled or paused for any delay caused\nby an external entity. Tolling events include but are not limited to the screening\nrequirements contained in 42 C.F.R. pt. 455 and searches of federal datab ases\nmaintained by entities such as the United States Centers for Medicare and Medicaid\nServices.\n(4) (a) The department shall formally recognize a credentialing alliance formed by\nmanaged care organizations if:\n1. One hundred percent (100%) of the total n umber of managed care\norganizations have entered into a contractual agreement to form the\ncredentialing alliance prior to December 1, 2023;\n2. The credentialing verification organization contracted as part of the\ncredentialing alliance is accredited by the  National Committee for\nQuality Assurance; and\n3. The credentialing verification organization contracted as part of the\ncredentialing organization is owned by or affiliated with a statewide\nhealthcare trade association.\n(b) A credentialing alliance established pursuant to this section shall:\n1. Implement a single credentialing application via a web -based portal\navailable to all providers seeking to be credentialed for any Medicaid\nmanaged care organization that participates in the credentialing alliance;\n2. Perform primary source verification and credentialing committee review\nof each credentialing application that results in a recommendation on the\nprovider's credentialing within thirty (30) days of receipt of a clean\napplication;\n3. Notify providers within  five (5) business days of receipt of a\ncredentialing application if the application is incomplete;\n4. Provide provider outreach and help desk services during common\nbusiness hours to facilitate provider applications and credentialing\ninformation;\n5. Expeditiously communicate the credentialing recommendation and\nsupporting credentialing information electronically to the department\nand to each participating Medicaid managed care organization with\nwhich the provider is seeking credentialing; and\n6. Conduct re evaluation of provider documentation when required\npursuant to state or federal law or when necessary for the provider to\nmaintain participation status with a Medicaid managed care\norganization.\n(5) (a) If a credentialing alliance has not been established and recognized by the\ndepartment pursuant to subsection (4) of this section by December 31, 2023,\nthe department shall, through a request for proposals and in accordance with\nKRS Chapter 45A, designate a  single credentialing verification organization\nto verify the credentials of providers on behalf of all managed care\norganizations.\n(b) If the department designates a single credentialing verification organization\npursuant to this subsection:\n1. The contract between the department and the credentialing verification\norganization shall be submitted to the Government Contract Review\nCommittee of the Legislative Research Commission for comment and\nreview;\n2. The credentialing verification organization shall be reimbursed on a per\nprovider credentialing basis by the department with the reimbursement\nbeing offset or deducted equally from each managed care organizations\ncapitation payment;\n3. The credentialing verification organization shall comply with paragraph\n(b) of subsection (4) of this section; and\n4. The department may promulgate administrative regulations in\naccordance with KRS Chapter 13A to ensure the timely and efficient\ncredentialing of providers.\n(6) If a Medicaid managed care organization assumes resp onsibility and costs for their\nown provider credentialing by entering into a credentialing alliance pursuant to this\nsection, the timely credentialing of providers shall be given significant weight as a\nfactor in the scoring process when the department eva luates the Medicaid managed\ncare organization's response to requests for proposals for all contract awards.\n(7) A Medicaid managed care organization shall:\n(a) Determine whether it will contract with the provider within thirty (30)\ncalendar days of receipt  of the verified credentialing information from a\ncredentialing verification organization either designated by the department or\ncontracted by managed care organizations as part of a credentialing alliance;\nand\n(b) 1. Within ten (10) days of an executed co ntract, ensure that any internal\nprocessing systems of the managed care organization have been updated\nto include:\na. The accepted provider contract; and\nb. The provider as a participating provider.\n2. In the event that the loading and configuration of a c ontract with a\nprovider will take longer than ten (10) days, the managed care\norganization may take an additional fifteen (15) days if it has notified\nthe provider of the need for additional time.\n(8) (a) Nothing in this section requires a Medicaid managed  care organization to\ncontract with a provider if the managed care organization and the provider do\nnot agree on the terms and conditions for participation.\n(b) Nothing in this section shall prohibit a provider and a managed care\norganization from negotiat ing the terms of a contract prior to the completion\nof the department's enrollment and screening process.\n(9) (a) For the purpose of reimbursement of claims, once a provider has met the\nterms and conditions for credentialing and enrollment, the provider's\ncredentialing application date shall be the date from which the provider's\nclaims become eligible for payment.\n(b) A Medicaid managed care organization shall not require a provider to appeal\nor resubmit any clean claim submitted during the time period betw een the\nprovider's credentialing application date and the completion of the\ncredentialing process.\n(c) Nothing in this section shall limit the department's authority to establish\ncriteria that allow a provider's claims to become eligible for payment in the\nevent of lifesaving or life -preserving medical treatment, such as, for an\nillustrative but not exclusive example, an organ transplant.\n(10) Nothing in this section shall prohibit a university hospital, as defined in KRS\n205.639, from performing the activi ties of a credentialing verification organization\nfor its employed physicians, residents, and mid -level practitioners where such\nactivities are delineated in the hospital's contract with a Medicaid managed care\norganization. The provisions of subsections (3), (4), (8), and (9) of this section with\nregard to payment and timely action on a credentialing application shall apply to a\ncredentialing application that has been verified through a university hospital\npursuant to this subsection.\n(11) To promote seaml ess integration of licensure information, the relevant provider\nlicensing boards in Kentucky are encouraged to forward and provide licensure\ninformation electronically to the department and any credentialing verification\norganization.","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=54016","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:03Z","sha256":"0679d9997c9d01d3276476dcdf6f0eb25736e531f150fa77cfa2acbdb184a1bd","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.531","next":"us-ky/krs-205.5321"},"notice":"GroundRules: Original legal text. Not legal advice."}