This CMS standard provides:

An MAO may not discriminate, in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of his/her license.

The URAC standard that implements this standard is URAC MAP-AD3:

The Basics

This simple standard requires that your organization not discriminate against practitioners or any other healthcare professionals who are practicing within the scope of his or her respective license or certification under state law, solely based on the practitioner's or provider's license or certification.  In addition, the organization must give a reason -- in writing -- for declining to include a particular provider or group into the network.

Your organization likely has an anti-discrimination clause in its provider contracts and, likely, its provider manual.  In addition, an antidiscrimination clause may be in a credentialing policy and procedure or credentialing plan.  Make sure you know where all your organization's anti-discrimination clauses are located.

Management Tips

While it is true that you no doubt have anti-discrimination language somewhere in your documents, make sure that the particular kind of discrimination that is the subject of this standard -- discrimination based on license or certification -- is explicitly addressed in your credentialing plan and/or credentialing policies and procedures.  The most frequent failing of organizations trying to meet this standard is that their antidiscrimination language is not sufficiently specific about this particular kind of discrimination.

URAC Accreditation Tips

As always, the starting point is your credentialing plan and/or policies and procedures.  In addition, any complaints filed with CMS regarding discrimination, and how your organization resolved such complaints, should be submitted.  Finally, a template letter to providers explaining why they were not credentialed or re-credentialed should be submitted.

The on-site reviewer will interview your provider relations and credentialing staff members, as well as your medical director.  Questions that are likely to come up in that interview related to the standard include whether there are any particular specialties that are not allowed to participate in your provider network.  In addition, the reviewer may pose as a provider interested in applying to your network, and ask, from that perspective, how he/she can find out which categories of providers are allowed in your network.  Finally, the reviewer will want to know if you have closed your provider network to any specific provider or providers, and if so, how you notified the provider.  The document review during the on-site examination will include a review of provider contracts and the credentialing files of providers denied from participation in your network.