MCO Claims Payment Requirements on CHOWs
THCA has been asked to remind NFs that there is a MCO claims payment requirement when a facility undergoes a successful change of ownership. The Uniform Managed Care Contract states that:
The MCO must also establish and implement an expedited credentialing process for nursing facilities that successfully underwent a change of ownership (CHOW). The requirements for applicant providers to qualify for expedited credentialing listed above apply to CHOWs with the exception of (1).
Additionally, if a provider qualifies for expedited credentialing, the MCO’s claims system must be able to process claims from the provider as if the Provider 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.
Below is the requirement found in the Uniform Managed Care Contract (UMCC):
8.1.4.4.1 Expedited Credentialing Process
The MCO must comply with the requirements of Texas Insurance Code Chapter 1452, Subchapters C, D, and E, regarding expedited credentialing and payment of physicians, podiatrists, and therapeutic optometrists who have joined established medical groups or professional practices that are already contracted with the MCO.
The MCO must also establish and implement an expedited credentialing process, as required by Texas Government Code § 533.0064, that allows applicant providers to provide services to Members on a provisional basis for the following provider types: 1) dentists, 2) dental specialists (including dentists and physicians providing dental specialty care), 3) licensed clinical social workers, 4) Licensed Professional Counselors, 5) Licensed Marriage and Family Therapists, and 6) Psychologists. To qualify for expedited credentialing the provider must: (1) be a member of an established health care provider group that has a current contract in place with an MCO, (2) be a Medicaid enrolled provider, (3) agree to comply with the terms of the contract between the MCO and the health care provider group, and (4) timely submit all documentation and information required by the MCO as necessary for the MCO to begin the credentialing process.
The MCO must also establish and implement an expedited credentialing process for nursing facilities that successfully underwent a change of ownership (CHOW). The requirements for applicant providers to qualify for expedited credentialing listed above apply to CHOWs with the exception of (1).
Additionally, if a provider qualifies for expedited credentialing, the MCO’s claims system must be able to process claims from the provider as if the Provider 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.