Ohio Code 3963.05 – Standard provider credentialing application – form
(A) The department of insurance shall prescribe the credentialing application form used by the council for affordable quality healthcare (CAQH) in electronic or paper format for physicians. The department of insurance also shall prepare the standard credentialing form for all other providers and shall make the standard credentialing form as simple, straightforward, and easy to use as possible, having due regard for those credentialing forms that are widely in use in the state by contracting entities and that best serve these goals.
Terms Used In Ohio Code 3963.05
- Contracting entity: means any person that has a primary business purpose of contracting with participating providers for the delivery of health care services. See Ohio Code 3963.01
- Credentialing: means the process of assessing and validating the qualifications of a provider applying to be approved by a contracting entity to provide basic health care services, specialty health care services, or supplemental health care services to enrollees. See Ohio Code 3963.01
- Health care services: means basic health care services, specialty health care services, and supplemental health care services. See Ohio Code 3963.01
- Participating provider: means a provider that has a health care contract with a contracting entity and is entitled to reimbursement for health care services rendered to an enrollee under the health care contract. See Ohio Code 3963.01
- Provider: means a physician, podiatrist, pharmacist, dentist, chiropractor, optometrist, psychologist, physician assistant, advanced practice registered nurse, occupational therapist, massage therapist, physical therapist, licensed professional counselor, licensed professional clinical counselor, hearing aid dealer, orthotist, prosthetist, home health agency, hospice care program, pediatric respite care program, or hospital, or a provider organization or physician-hospital organization that is acting exclusively as an administrator on behalf of a provider to facilitate the provider's participation in health care contracts. See Ohio Code 3963.01
- state: means the state of Ohio. See Ohio Code 1.59
(B) No contracting entity shall fail to use the applicable standard credentialing form described in division (A) of this section when initially credentialing or recredentialing providers in connection with policies, health care contracts, and agreements providing basic health care services, specialty health care services, or supplemental health care services.
(C) No contracting entity shall require a provider to provide any information in addition to the information required by the applicable standard credentialing form described in division (A) of this section in connection with policies, health care contracts, and agreements providing basic health care services, specialty health care services, or supplemental health care services.
(D) The credentialing process described in this section does not prohibit a contracting entity from limiting the scope of any participating provider‘s basic health care services, specialty health care services, or supplemental health care services.
(E) The requirement that the department of insurance prepare the standard credentialing form for all other providers does not include preparing the standard credentialing form for a hospital.