31.10.26.03

.03 Uniform Credentialing Form — Carrier and Credentialing Intermediary Requirements.

A. A carrier or its credentialing intermediary shall:

(1) Accept the uniform credentialing form as the sole application for a health care provider to become credentialed or recredentialed for a provider panel of the carrier; and

(2) Make the uniform credentialing form available to any health care provider that is to be credentialed or recredentialed by the carrier or credentialing intermediary.

B. A carrier may not, for purposes of credentialing or recredentialing, require a health care provider to:

(1) Modify the uniform credentialing form;

(2) Submit additional credentialing forms;

(3) Use any other credentialing form not designated by the Commissioner; or

(4) Submit any additional information not specified by the uniform credentialing form, except as stated in §F of this regulation.

C. A carrier may preprint the designated carrier information on the uniform credentialing form.

D. A carrier may not deny a uniform credentialing form because the form does not include the designated carrier information of the carrier.

E. A carrier may require a health care provider to submit a new Authorization to Release Information and Affirmation page, with an original signature and date, for the purpose of credentialing or recredentialing.

F. A carrier that is a managed care organization may require a provider to make the disclosure required by 42 CFR §1002.3.