BACKGROUND:
MSNJ sought legislation in 2001 to save physicians time and expense in the managed care credentialing process. Regulations to implement the uniform credentialing application process were adopted in 2003.

The regulations were intended to allow physicians to complete one form for managed care credentialing applications. In order to achieve this goal the dhss developed a "New Jersey Universal Physician Application." Physicians may submit the application in either paper or electronic form. Because this is a uniform document to be used by all managed care companies, physicians will not have to submit different credentialing applications for each managed care company. A company may still use its own credentialing application, but it is the physician's choice which application to submit, the carrier's or the uniform application.

A managed care company may also elect not to use either application, but to access information supplied by a physician on a recognized, national credentialing database. Physicians will not, however, be required to participate in this database.

The regulations also sought to simplify re-credentialing. A "New Jersey Physician Re-credentialing Application" was developed to be used in the same manner as described above for initial applications. If a company wants to use its own form, it must pre-populate that form with data previously provided and supply room for any physician corrections. Carriers are allowed to request additional information as may be necessary and may still ask for verification of certain supplied information.

Information on how to complete the New Jersey Universal Physician Application

Physician Credentialing Rule

STATUS: Unfortunately, since the managed care companies are not required to provide the universal form there has been a very low utilization rate and the uniformity has not brought about the desired cost and time savings. In addition, there is growing support to adopt a third-party credentialing process that was not successful in the first round of legislation.

MSNJ ACTION: MSNJ successfully pursued the problems associated with credentialing and recredentialing in the national class-action lawsuits. MSNJ will partner with other interested stake-holders to improve the credentialing process in New Jersey.

CLASS-ACTION LAWSUIT PROVISION: The Aetna, CIGNA, and HealthNet settlement agreements all address credentialing with an eye toward streamlining the process, particularly recredentialing and making minor changes, such as a change of address or practice affiliation. The settlement agreements provide that physicians may submit credentialing applications prior to the time that a change (employment, location) takes place and the insurer is to process completed applications within 90 days. For changes in employment or location, the physician need only provide the new information. Significantly, if a physician is credentialed under NCQA standards by a contracted physician group or physician organization that is delegated to perform such credentialing, then the physician need not be separately credentialed. (Paragraph 7.13 (a)).