PURPOSE: This rule sets forth the standard form which shall be used by all health carriers when soliciting the credentials of a health care professional in a managed care plan. This rule is promulgated pursuant to section 354.485, RSMo, and implements section 354.442.1(15), RSMo.

1. (1) Definitions.

   1. (A) Health care professional means a physician or other health care practitioner licensed, accredited or certified by the state of Missouri to perform specified health services consistent with state law.
   2. (B) Health carrier means a health maintenance organization as organized pursuant to sections 354.400 through 354.636, RSMo.
   3. (C) Managed care plan means a health benefit plan that either requires an enrollee to use, or creates incentives, including financial incentives, for an enrollee to use health care providers managed, owned, under contract with or employed by the health carrier.
2. (2) The form provided in Exhibit A shall be used by all health carriers and their agents when credentialing or recredentialing health care professionals in a managed care plan. Use of another state’s standardized credentialing form is permissible so long as the director determines prior to its use that it is substantially similar to the form in Exhibit A. Carriers shall accept any form approved by the director for credentialing purposes, and shall not require a Missouri health care professional to use any particular approved form to the exclusion of any other approved form, so long as the form submitted by the Missouri health care professional is Missouri’s Standardized Credentialing Form or any other form approved pursuant to this rule. Requests for the director’s approval of the use of another state’s standardized credentialing form should be submitted to the following address: Missouri Department of Insurance, Managed Care Section, P.O. Box 690, Jefferson City, MO 65102-0690. A request must include a complete copy of the form to be approved and the name, address and telephone number of the person requesting approval. The director will provide written notice to all Missouri licensed health maintenance organizations of the approval of the use of another state’s standardized credentialing form. The director also will provide on the department’s Internet home page a copy of Missouri’s Standardized Credentialing Form with a list of other state standardized credentialing forms that have been approved.
3. (3) Health carriers may request additional information to explain or provide details regarding responses obtained on the standard form. Health carriers are prohibited from routinely requiring additional information from health care professionals.
4. (4) An on-site examination by the health carrier or their agent of the health care professional’s place of business shall not, in itself, be considered a routine request for additional information.
5. (5) A health carrier may require a health care professional to sign an affirmation and release of the health carrier’s own design.

AUTHORITY: sections 354.442.1(15), RSMo Supp. 1999 and 354.485, RSMo 1994. Original rule filed Nov. 3, 1997, effective June 30, 1998. Amended: Filed June 6, 2000, effective Feb. 28, 2001.

*Original authority: 354.442, RSMo 1997 and 354.485, RSMo 1983.