11 NCAC 20 .0404             APPLICATION

For all providers who submit applications to be added to a carrier's network on or after October 1, 2001:

(1)           The definitions in G.S. 58-3-167 are incorporated into this Rule by reference. Each carrier that is an insurer and that issues a health benefit plan shall obtain and retain on file each provider's signed and dated application on the form approved by the Commissioner under G.S. 58-3-230.  All other carriers shall obtain and retain on file the provider's signed and dated application on a form provided by the carrier. All required information shall be current upon final approval by the carrier.  The application shall include, when applicable:

(a)           The provider's name, address, and telephone number.

(b)           Practice information, including call coverage.

(c)           Education, training and work history.

(d)           The current provider license, registration, or certification, and the names of other states where the applicant is or has been licensed, registered, or certified.

(e)           Drug Enforcement Agency (DEA) registration number and prescribing restrictions.

(f)            Specialty board or other certification.

(g)           Professional and hospital affiliation.

(h)           The amount of professional liability coverage and any malpractice history.

(i)            Any disciplinary actions by medical organizations and regulatory agencies.

(j)            Any felony or misdemeanor convictions.

(k)           The type of affiliation requested (for example, primary care, consulting specialists, ambulatory care, etc.).

(l)            A statement of completeness, veracity, and release of information, signed and dated by the applicant.

(m)          Letters of reference or recommendation or letters of oversight from supervisors, or both.

(2)           The carrier shall obtain and retain on file the following information regarding facility provider credentials, when applicable:

(a)           Joint Commission on Accreditation of Healthcare Organization's certification or certification from other accrediting agencies.

(b)           State licensure.

(c)           Medicare and Medicaid certification.

(d)           Evidence of current malpractice insurance.

(3)           No credential item listed in Items (1) or (2) of this Rule shall be construed as a substantive threshold or criterion or as a standard for credentials that must be held by any provider in order to be a network provider.


History Note:        Authority G.S. 58-2-40(1); 58-2-131; 58-3-167; 58-3-230; 58-65-1; 58-65-25; 58-65-105; 58-67-5; 58-67-10; 58-67-20; 58-67-35; 58-67-65; 58-67-100; 58-67-140; 58-67-150;

Eff. October 1, 1996;

Temporary Amendment Eff. October 1, 2001;

Amended Eff. May 1, 2008; August 1, 2002.