Medicaid plans must meet deadlines for provider credentialing

The Department of Human Services or its agent must decide whether to enroll a Medicaid provider within five business days after receiving a complete application. This rule covers Medicaid provider enrollment decisions made by the department or its agent. If required documents are missing, the applicant must receive an electronic notice within two business days explaining what is missing and providing a secure link to send it. The agent must be accredited by the National Committee for Quality Assurance and allow multiple people to log into its system. Missed deadlines must be reportable to the department and included in quarterly performance audits. The department or its agent must meet this deadline by July 1, 2026.

Medicaid managed care organizations must finish checking a provider's qualifications within 60 calendar days after receiving a clean, complete application. These rules apply when Medicaid managed care organizations check providers' qualifications. An organization may request one extension of up to 30 days by giving the department a written reason and notifying the applicant. For missed deadlines, the organization is subject to contract penalties, which may include a corrective action plan, a money penalty, or credentialing by default if the department chooses. Organizations must meet this deadline by July 1, 2026.

The Office of the Insurance Commissioner must prescribe an electronic standard form, and Medicaid managed care organizations must use it and cannot demand extra information. The form rules apply when Medicaid managed care organizations initially check or recheck providers for health care policies, contracts, and agreements. The form must be as simple and easy to use as possible, taking into account forms widely used by the state's Medicaid managed care organizations. The credentialing process may still limit which basic, specialty, or supplemental health services a participating provider can offer. The Insurance Commissioner must prescribe the form by July 1, 2026.

Providers must submit Medicaid enrollment and credentialing filings electronically. This rule covers providers participating in Medicaid or a Medicaid managed care plan and applies to their applications, renewals, documents, and supporting materials. The electronic-only requirement begins July 1, 2026.