Maryland carriers must speed provider applications and update directories

Carriers must send written application updates, offer online submissions of the uniform credentialing form, and answer questions through dedicated phone and email contacts. These rules apply to carriers processing applications from providers who seek to join a carrier’s provider panel. Carriers must send notices by email, or by mail if the application has no email address. A carrier that misses a required notice may owe a $500 daily penalty payable to the provider, plus other penalties. Carriers must send the first notice within 15 days after receiving a completed application. If they continue processing it, they generally have 60 days after that notice to decide; for specified community-based providers, they have 30 days after receiving the completed application.

Carriers must use the online credentialing system as the main source for creating and updating provider directories, under rules set by the Insurance Commissioner. This applies to carriers’ online directories of participating providers and health care facilities. The common directory system must let providers update their information every 120 days or at a frequency set by the Commissioner. The online directory must also be updated at least every 15 days. Carriers must review a reasonable sample of directory entries or contact providers who have not filed a claim in six months. The Commissioner’s rules will set how carriers use the credentialing system, including how often it updates directory information. The two-working-day deadline follows a participating provider’s notice of a change. Mailed notice is presumed received three working days after mailing if the provider keeps a stamped certificate of mailing; courier notice counts on the recorded delivery date.

Carriers must pay an eligible group practice the participating-provider rate for covered care while a provider’s application is under review. This applies to a provider who is not yet on the carrier’s panel but works for or belongs to an eligible group practice that is on the panel. The provider must work for or belong to a group practice already on the carrier’s panel, hold a valid Maryland license, and be credentialed by an accredited hospital, have professional liability insurance, or have immunity under federal or Maryland tort claims law. The group practice must tell the patient in writing that the provider is not yet participating and the review is unfinished. The patient may owe the usual deductible, copayment, or coinsurance, but not other costs for covered care during this period. The payment rule starts when the carrier says it will continue processing the application and ends when it sends an acceptance or rejection notice.

Carriers may not limit how many providers from specified community health settings can join their panels. The protected settings include health care facilities, federally qualified health centers, local health departments, school-based health centers, and other essential community providers.