Credentialing Standards   /   December 2019

State-by-State Series, Part I: The Outliers – Illinois & New Mexico

State-by-State Series, Part I: The Outliers – Illinois & New Mexico

As an industry-leading  NCQA CVO, CredSimple follows not only NCQA CVO standards, but also follows state-specific guidelines to help keep our customers in compliance with all regulations.  Credentialing guidelines are multi-faceted and states have their own requirements in addition to NCQA, CMS, and other Accrediting organizations. 

Over the next few weeks, we’re going to be reviewing different states’ requirements – not individually, of course, because that would take forever! We’re going to be grouping states with others that have similar requirements, so this will be a multi-part series. Today’s post focuses on Illinois and New Mexico. What do they have in common? Pretty much nothing! However, they both are unique and have very specific requirements – so what they have in common is that they are both so unique that they have nothing in common with any other state. Make sense? Awesome, let’s get to it!

Illinois  

The state of Illinois requires all health care entities, including health plans and hospitals to utilize the IL Uniform Application for provider enrollment or when applying for privileges.  This confidential application allows for the providers to have one standard format to complete when applying to a health care entity. The entity is required to complete the Credentialing and Re-Credentialing event within sixty days after receipt of a complete application.  Unless a provider’s credentialing data changes significantly, a health care entity obtains Re-Credentialing data based on a Single Credentialing Cycle. This three year Single Credentialing Cycle is based on the last digit of the provider’s social security number. The healthcare entity has a two month collection period to obtain the necessary re-credentialing documentation.   The Single Credentialing Cycle reflects a six-month open period coinciding with the IL Department of Professional Regulation licensing schedule in which data cannot be collected – unless the data is related to a Quality of Care issue

 

New Mexico

The state of New Mexico utilizes the CAQH application for all provider credentialing and re-credentialing.  The health plan is required to notify a provider within ten business days, in writing, via Certified Mail that the application has been received.  If the application is incomplete, the health plan will request the missing data. The letter should include a contact name, address, phone number should the provider have additional questions.  Also, notify the provider that the forty-five day time period to complete an application review for acceptance or denial will begin with the receipt of the requested information. If the provider does not return the requested information within sixty days of the request, the application and any supporting documentation will be returned to the provider along with a letter of rejection.

A health plan may not request any additional information than what is required in the CAQH application.  A health plan is not required to accept a provider into their network, however, the credentialing process must be completed prior to a provider being listed in the directory or being accepted into the network.  The health plan notifies the providers of the decision to accept or deny the application within forty-five days of receipt of a completed application via US mail or email if the provider provided. Re-Credentialing cannot be more often than every three years unless investigating a quality of care matter.

A written credentialing plan is required and will be provided to the Department of Insurance if requested.  The plan includes a dispute process for the providers during the credentialing process. The health plan will also submit a report to the Department of Insurance every two years outlining its credentialing process.  The report would include the length of time to review and make a determination of applications, the number of applications received, approved, denied and the number of providers terminated due to qualifications.

 

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