11 NCAC 20 .0404             APPLICATION

For all providers who submit applications to be added to a carrier's network:

(1)           The definitions in G.S. 58-3-167 are incorporated into this Rule by reference. Each carrier that is an insurer 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 required information shall be current upon final approval of the provider 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.

(l)            A signed and dated statement by the provider attesting that the information provided is true, accurate, and complete, and authorizing the release of information and materials related to the provider's qualifications and competence.

(m)          Letters of reference or recommendation or letters of oversight from supervisors, or both, that attest to the qualifications or competence of the provider or otherwise recommend approval of the provider's application.

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

(a)           The Joint Commission's certification or certification from other accrediting agencies.

(b)           State licensure.

(c)           Medicare and Medicaid certification.

(d)           Evidence of active 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; 58-67-10; 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;

Readopted Eff. December 1, 2017.