Uniform Managed Care Manual Changes HHSC amended . UMCM Chapter 8.6, replacing the current language in section 2.13.1 that requires MCO to deem nursing facilities. Start Date, Deadline, and Allowances for Deeming. UMCM Chapter 8.6 section 2.13.1 sets a start date of April 1, 2018 when MCOs must begin using
SNF Update Effective April 1, 2018, STAR+PLUS managed care organizations (MCOs) will begin using the STAR+PLUS nursing facility (NF) state-identified credentialing standards to credential NF providers seeking to participate in their STAR+PLUS provider networks. By December 31, 2018, STAR+PLUS MCOs must complete credentialing of all NF providers that were in its network from April 1, 2018 forward. HHSC amended the Medicaid managed care contracts and the Uniform Managed Care Manual (UMCM) to reflect these changes. This notice contains a description of those amendments, as well as information from the Texas Association of Health Plans about the credentialing process with the Credentialing Verification Organization. Background Texas Government Code (TGC) 533.00251(e) requires HHSC to develop credentialing and minimum performance standards for NF providers seeking to participate in STAR+PLUS. During 2017, HHSC convened a stakeholder workgroup comprised of NF providers, NF provider associations, MCO representatives, MCO associations, consumer advocates, and HHSC staff. The workgroup developed the credentialing standards. The minimum performance standards are currently under development and will be included in a future amendment. Please note the NF significant traditional provider provision expired in contract February 28, 2018. Medicaid Managed Care Contract Changes Below are the Medicaid managed care contract amendments concerning NF credentialing effective March 1, 2018. These changes are included in the Uniform Managed Care Contract (UMCC), STAR+PLUS Medicaid Rural Service Area (MRSA), and STAR+PLUS Expansion contracts posted on the HHSC website. HHSC amended the Medicaid managed care contracts to allow MCOs to only contract with a NF that has a valid certification, license, and contract with HHSC, and that meets the NF credentialingstandards outlined in the UMCM Chapter 8.6 (section 8.1.4.4 of the UMCC and STAR+PLUS contracts). According to section 8.1.4 of the UMCC and STAR+PLUS contracts, the STAR+PLUS MCO must enter into a provider contract with any willing NF provider that is Medicaid-certified, licensed and contracted with HHSC; that meets the NF credentialing standards and minimum performance standards in UMCM Chapter 8.6, and agrees to the MCO's contract rates and terms. MCOs must comply with the rate requirements set forth in UMCC 8.3.9.4. A STAR+PLUS MCO is prohibited from contracting with a NF if the NF does not meet credentialing standards. A STAR+PLUS MCO may refuse to contract with a NF if the NF does not meet the minimum performance standards in UMCM Chapter 8.6. Credentialing was also added to the UMCC section 8.3.9, STAR+PLUS Expansion section 8.1.47, and STAR+PLUS MRSA section 8.1.48. NF Providers must meet all of the state licensure, certification, and contracting requirements, as well as the NF credentialing standards in UMCM Chapter 8.6 for providing the services in Attachment B-2.2, "STAR+PLUS Covered Services." An MCO may refuse to contract with a NF if the NF does not meet the minimum performance standards in UMCM Chapter 8.6. MHTCredentialing_4191 Uniform Managed Care Manual Changes HHSC amended UMCM Chapter 8.6, replacing the current language in section 2.13.1 that requires MCO to deem nursing facilities. Start Date, Deadline, and Allowances for Deeming UMCM Chapter 8.6 section 2.13.1 sets a start date of April 1, 2018 when MCOs must begin using the credentialing standards listed in section 2.13.1 to credential NFs seeking to participate in STAR+PLUS. MCOs have until December 31, 2018 to complete credentialing of all NF providers that were in its network from April 1, 2018 forward. UMCM Chapter 8.6 sections 2.13.1 (a) and 2.13.1 (b) describe when an MCO is allowed to deem NFs. April 1, 2018 through December 31, 2018. The MCO may deem a NF to have met the MCO's credentialing standards if: o In the case of a skilled nursing facility (SNF), the SNF is already credentialed for its Medicare products and the Medicare SNF credentialing criteria includes all of the STAR+PLUS NF state-identified credentialing standards in section 2.13.1 (c); or o The NF is Medicaid-certified and licensed by and contracted with HHSC. December 31, 2018 - forward. The MCO may deem a NF to have met the MCO's credentialing standards if: o In the case of a SNF, the SNF is already credentialed for its Medicare products and the Medicare SNF credentialing criteria includes all of the STAR+PLUS NF stateidentified credentialing standards in section 2.13.1 (c). Credentialing Standards The MCO must ensure and maintain documentation showing that the NF meets the following STAR+PLUS NF credentialing standards listed in UMCM Chapter 8.6 section 2.13.1 (c): · The NF has completed the MCO credentialing application, which includes but is not limited to: o demographic forms, with supporting documentation, o requests for provider disclosure of all federal or state NF sanctions and penalties for the most recent three years, and o the most recent HHSC inspection/survey. · The NF has a valid Texas NF license, · The NF has a Medicare or Medicaid certification, · The NF has a Clinical Laboratory Improvement Amendment (CLIA) Certification or CLIA Certificate of Waiver, · The NF is not listed on the following websites as excluded from participation in any federal or state health care program o HHSC-OIG exclusions , and o HHSC-OIG Exclusion Search; and · The NF's enrollment has not been terminated or its Medicaid provider contract cancelled by the HHSC-OIG. Complete Application for Expedited Credentialing The UMCC 8.1.4.4.1 requires MCOs to consider a NF Change of Ownership (CHOW) as eligible for expedited credentialing, and to process claims from the provider as if it was a network provider no later than 30 calendar days after receipt of a complete application, even if the MCO has not yet completed the credentialing process. The intent of UMCC 8.1.4.4.1 is that the provider is paid at network rate by the MCO within 30 calendar days of submitting the proper paperwork for credentialing, regardless of whether the credentialing process is complete or the contract is executed. The provider is then at risk of recoupment for the difference between in-network and out-ofnetwork rates, should the contract not be fully executed. UMCM Chapter 8.6 section 2.13.1 (d) outlines the required items a NF undergoing a CHOW must submit to the MCO for an application of expedited credentialing to be considered complete. Section 2.13.1 (d) requires a NF provider's complete application for expedited credentialing to include all items listed as STAR+PLUS NF stateidentified credentialing standards in section 2.13.1 (c), except for the CLIA Certification or CLIA Certificate of waiver. HHSC made this exception, because the CLIA application can take several weeks to process, which would delay expedited credentialing. The MCO must ensure that the NF submits its CLIA Certification or CLIA Certificate of Waiver to the MCO within 84 calendar days from the submission date of the NF's complete application for expedited credentialing. Implementation of the Credentialing Verification Organization The Texas Association of Health Plans (TAHP) in collaboration with the Texas Medical Association (TMA) and Medicaid Managed Care Organizations released a notice about the implementation of the Credentialing Verification Organization (CVO), which can be found at the following link. Click here for more information about the CVO, including a link to a recording of a March 2018 TAHP webinar that provided an overview of the CVO process.Microsoft Word 2013