C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 438—MANAGED CARE › Subpart D—MCO, PIHP and PAHP Standards

42 C.F.R. § 438.214

Provider selection

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(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 network providers and that those policies and procedures, at a minimum, meet the requirements of this section.

(b) Credentialing and recredentialing requirements. (1) Each State must establish a uniform credentialing and recredentialing policy that addresses acute, primary, mental health, substance use disorders, and LTSS providers, as appropriate, and requires each MCO, PIHP and PAHP to follow those policies.

(2) Each MCO, PIHP, and PAHP must follow a documented process for credentialing and recredentialing of network providers.

(c) Nondiscrimination. MCO, PIHP, and PAHP network provider selection policies and procedures, consistent with § 438.12, must not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment.

(d) Excluded providers. (1) 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.

(2) States must ensure through its contracts that MCOs, PIHPs, and PAHPs terminate any providers of services or persons terminated (as described in section 1902(kk)(8) of the Social Security Act) from participation under this title, title XVIII, or title XXI from participating as a provider in any network.

(e) State requirements. Each MCO, PIHP, and PAHP must comply with any additional requirements established by the State.

[81 FR 27853, May 6, 2016, as amended at 89 FR 41278, May 10, 2024]
Notes of Decisions
Cited in 3 cases (2 in the last 5 years), 2015–2023 · leading case: Snodgrass-King Pediatric Dental Assocs., P.C. v. DentaQuest USA Ins., 79 F. Supp. 3d 753 (M.D. Tenn. 2015).
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Snodgrass-King Pediatric Dental Assocs., P.C. v. DentaQuest USA Ins., 79 F. Supp. 3d 753 (M.D. Tenn. 2015). “” 42 C.F.R. § 438.214 (c). To be sure, the statutory text makes clear that Section 1396u-2 does not create a federal guarantee or right to participation in the TennCare dental provider network.”
Peer Assocs. LLC v. DHS (Pa. Commw. Ct. 2023). “42 C.F.R. § 438.214 (a). However, nothing in the federal law governing MA managed care requires, or authorizes for that matter, the Department to monitor individualized decisions to exclude a particular provider or to oversee the decisions of the plans to 15 choose Provider A…”
Academy of Allergy & Asthma in Primary Care v. Louisiana Health Serv. & Indem. Co. (E.D. La. 2023). “” 42 C.F.R. § 438.214 (c). IT IS HEREBY ORDERED that the motion for summary judgment on Count 6 (Rec.”
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