[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.214]



[Page 230]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

        Subpart D_Quality Assessment and Performance Improvement

 

Sec.  438.214  Provider selection.



    (a) General rules. The State must ensure, through its contracts, 

that each MCO, PIHP, or PAHP implements written policies and procedures 

for selection and retention of providers and that those policies and 

procedures include, at a minimum, the requirements of this section.

    (b) Credentialing and recredentialing requirements. (1) Each State 

must establish a uniform credentialing and recredentialing policy that 

each MCO, PIHP, and PAHP must follow.

    (2) Each MCO, PIHP, and PAHP must follow a documented process for 

credentialing and recredentialing of providers who have signed contracts 

or participation agreements with the MCO, PIHP, or PAHP.

    (c) Nondiscrimination. MCO, PIHP, and PAHP provider selection 

policies and procedures, consistent with Sec.  438.12, must not 

discriminate against particular providers that serve high-risk 

populations or specialize in conditions that require costly treatment.

    (d) Excluded providers. MCOs, PIHPs, and PAHPs may not employ or 

contract with providers excluded from participation in Federal health 

care programs under either section 1128 or section 1128A of the Act.

    (e) State requirements. Each MCO, PIHP, and PAHP must comply with 

any additional requirements established by the State.



[67 FR 41095, June 14, 2002; 67 FR 54532, Aug. 22, 2002]