A Medicaid managed care organization must set up an expedited credentialing process for certain providers, and the commission must identify which providers are covered.
Sec. 540.0656. EXPEDITED CREDENTIALING PROCESS FOR CERTAIN PROVIDERS. (a) In this section, "applicant provider" means a physician or other health care provider, including a federally qualified health center as defined by 42 U.S.C. Section 1396d(l)(2)(B) or a health care provider for the federally qualified health center, applying for expedited credentialing. (b) Notwithstanding any other law and subject to Subsection (c), a Medicaid managed care organization shall establish and implement an expedited credentialing process that allows an applicant provider to provide services to recipients on a provisional basis. (c) The commission shall identify the types of providers for which a Medicaid managed care organization must establish and implement an expedited credentialing process. (d) To qualify for expedited credentialing and payment under Subsection (e), an applicant provider must: (1) have a current contract with a Medicaid managed care organization or be a member of or a health care provider for one of the following that has a current contract with a Medicaid managed care organization: (A) an established health care provider group; or (B) a federally qualified health center as defined by 42 U.S.C. Section 1396d(l)(2)(B); (2) be a Medicaid-enrolled provider; (3) agree to comply with the terms of the contract described by Subdivision (1); and (4) submit all documentation and other information the Medicaid managed care organization requires as necessary to enable the organization to begin the credentialing process the organization requires to include a provider in the organization's provider network. (e) On an applicant provider's submission of the information the Medicaid managed care organization requires under Subsection (d), and for Medicaid reimbursement purposes only, the organization shall treat the provider as if the provider were in the organization's provider network when the provider provides services to recipients, subject to Subsections (f) and (g). (f) Except as provided by Subsection (g), a Medicaid managed care organization that determines on completion of the credentialing process that an applicant provider does not meet the organization's credentialing requirements may recover from the provider the difference between payments for in-network benefits and out-of-network benefits. (g) A Medicaid managed care organization that determines on completion of the credentialing process that an applicant provider does not meet the organization's credentialing requirements and that the provider made fraudulent claims in the provider's application for credentialing may recover from the provider the entire amount the organization paid the provider. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611), Sec. 1.01, eff. April 1, 2025. Amended by: Acts 2025, 89th Leg., R.S., Ch. 613 (H.B. 3151), Sec. 1, eff. September 1, 2025.