Introduction
The credentialing process is mandatory for network provider participation. During this process, the provider’s credentials are verified and the complete application is reviewed against the Plan’s policies and procedures. Any issue identified such as malpractice claims history, licensure or Medicare or Medicaid sanction is reviewed by the Credentialing Committee, which is the Peer Review Committee of the Plan. It is the provider’s responsibility to fill-out the entire credentialing application and supply a written explanation to any item of negative information. Acceptable credentialing applications include the Plan’s own applications as well as the Council for Affordable Quality Healthcare (CAQH) application. The CAQH application must have a current attestation and be updated with all supporting documents. An application cannot be processed until all areas are completed and all documents are provided to the Plan. Further, a site visit is required for all Primary Care Providers and OB/GYN specialists.
Please note that providers have the following rights in connection with the credentialing process: The right to review information submitted to support their credentialing application;
x Upon request to Credentialing, a provider has the right to review information that is obtained by the Plan from outside sources and which it uses to evaluate the credentialing application. The exception to the information that may be reviewed is peer references and information that is peer review protected.
The right to correct erroneous information;
x When information is obtained by the Plan from other sources, and the information
substantially varies from that supplied by the provider, in accordance with Policy CR 1 the Plan will notify the provider of the right to correct the erroneous information; provide the timeframe for making the changes; the format for submitting the changes; and the name of the person to whom, and the location where the corrected information must be sent. The right to receive the status of their credentialing or re-credentialing application upon request;
x The Plan will respond to a provider’s request for status on their credentialing application within fifteen (15) business days. The information provided will advise of any items still needed, or any difficulty or non-response in obtaining a verification response.
The application is then taken through the initial credentialing process and brought to the credentialing committee, (composed of practicing Providers credentialed by the Plan). Any committee need for additional information will be immediately requested from the Provider. Providers are initially credentialed for a thirty-six month credentialing period, after which re- credentialing is required. Periodically, the Plan may request updates for expired documentation such as malpractice insurance. If there are changes to any of the information/documentation submitted in support of the application such as board certification status, please let the Plan know. Freedom Health has a defined provider appeal process for cases in which it chooses to alter the conditions of a provider’s participation, based on issues of quality of care or service. Providers are notified of any instances where there is an impending action related to a provider’s participation status. The notification will include an explanation of the appeal process.
Credentialed Providers
The following licensed provider types are required to be credentialed. Following is a list Providers who must be credentialed in order to provide medical services to Freedom Health Members: x Medical Doctors (MD’s);
x Osteopathic Doctors (DO’s); x Podiatric Doctors (DPM’s); x Chiropractic Doctors (DC’s); x Optometric Doctors (OD’s); x Psychologists (Psych.D’s);
x Advanced Registered Nurse Practitioners (ARNP); x Physician Assistants (PA);
x Certified Physician Assistants (PAC); x Certified Nurse Midwifes (CNM);
x Physical Therapists (PT) - if contracting directly with us. If through a facility, then only the facility needs to be credentialed;
x Speech Therapists - Same as PT; x Licensed Clinical Social Workers (LCSW); x Masters in Social Work (MSW);
x Licensed Mental Health Counselors (LMHC); x Licensed Marriage & Family Therapists (LMFT’s).
The Credentialing Committee must approve practitioners before they begin to deliver health care services to Members. Physicians and Providers who deliver services before they have completed the credentialing process and bill directly for these services will not receive payment unless an authorization was obtained to perform the services as a non-participating provider.
Freedom Health also credentials certain facilities and ancillary Providers. An application and the following supporting documents are required but not limited to: AHCA certificate; CMS Certificate Accreditation certificate; and Commercial and Professional insurances. These facilities are: x Hospitals;
x Freestanding Ambulatory Surgery Centers (ASC); x Skilled Nursing Facilities (SNF);
x Diagnostic Facilities;
x Inpatient Hospice Facilities; x Dialysis Centers;
x Home Health Agencies;
x Durable Medical Equipment (DME) Providers; and x Comprehensive Outpatient Rehabilitation Facilities;
x Outpatient Physical, Occupational & Speech Therapy (PT, OT, ST) Facility Groups.
NOTE: Hospital and other facility-based Physicians and Providers do not require credentialing and re-credentialing by the Plan.
Initial Credentialing Process
The Initial Credentialing Process is as follows:
Step 1. The Physician/Provider fully completes all necessary sections of the initial credentialing application and submits the required documents to Freedom Health. A CAQH application is acceptable provided that all the information and documents are up to date. Primary Care Physicians must also submit an Attestation of Patient Load. PCP and OB/GYN Specialists will need to participate in a Site Survey. If a provider has signed a Medicare contract, the Plan will verify the provider’s name does not appear on the listing of Medicare Opted Out providers; If a provider has signed a Medicaid contract, the provider is required to prominently display a copy of the summary of the Florida Patient’s Bill of Rights and Responsibilities in the waiting room or reception area, and must have copies available upon the request of members; also the Agency for Health Care Administration’s (AHCA’s) Statewide Consumer Call Center and Consumer Assistance Notice including telephone number and hours of operation must be prominently displayed.
Step 2. Primary source verification is performed concerning education, licenses and other submitted documents.
Step 3. The Physician Chairperson of the Credentialing Committee reviews the file prior to the next scheduled meeting. The Chairperson of Credentialing Committee may ask for additional explanations if needed before the application is presented to the Credentialing Committee. Step 4.The Provider’s file is then presented to the Credentialing Committee.
Step 5. If approved, the file is noted accordingly and proceeds to step 6. If additional information is requested by the Committee, the request is conveyed to the Provider and the file is placed in a pending status, awaiting the requested information. Once received, the committee will re-evaluate the application.
Step 6. Upon approval, the provider information is loaded into the Freedom Health database for purposes of claims payment and directory listing.
Step 7. The Physician/Provider is notified in writing of their status and the effective date of their contract within 60 calendar days following the Committee’s decision.
Step 8. The assigned Provider Relations Representative will conduct an in-service visit with the Physician/Provider and selected staff.
The credentialing process takes approximately 90 days from receipt of complete application through presentation to the Credentialing Committee.
Re-Credentialing
Credentialed Providers must be re-credentialed every thirty-six months. The Credentialing Department establishes this date as 36 months following the provider’s approval. The Physician/ Provider will be notified approximately 120 days prior to the expiration of credentialing. The re- credentialing review process involves the following:
x Completion of a re-credentialing application or CAQH application that includes a statement regarding: 1) correctness and completeness of the application; 2) physical or mental health problems, 3) history of chemical dependency/substance abuse, 4) history of loss of license or felony convictions, 5) history of loss or limitation of privileges; or 6)state or federal disciplinary activity;
x Verification of current license;
x Evidence of current malpractice/liability insurance coverage; x Verification of current DEA Certificate (as applicable); x Verification of Board Certification Status (as applicable);
x History of professional liability claims that resulted in settlement or judgment paid by or on behalf of the practitioner;
x Review of the National Practitioner Data Bank (NPDB); Review for any sanctions imposed by Medicare or Medicaid; x Evidence of good standing privileges at a participating hospital;
x Participation in a subsequent Site Survey by Primary Care and Obstetric and Gynecology Physicians;
x Medical record review as indicated, by specialty; and Internal evaluations from Provider Services, Member Services (Complaints/Grievances) and Quality Management, if applicable.
If a Provider fails to return the re-credentialing application in a timely fashion and their credentialing period lapses, the Provider may not render services to a Plan Member until the initial credentialing process is completed.
In the rare event that the committee denies a Provider credentialed status, the Provider has the right to appeal the decision within 30 days of receiving the denial notice. The appeal rights are provided by the Medical Director, as Chairman of the Credentialing Committee. Any Provider denied credentialing will be reported to the appropriate State agency as required by Florida Statute.
Professional Liability Insurance
Freedom Health credentialing policies concerning liability coverage conform to Florida Statutes Providers will be asked to sign a financial responsibility form as part of their credentialing packet. This will allow Freedom Health to confirm compliance with these guidelines.
Upon request, a Provider must provide the Plan with evidence of coverage and any renewals, replacements or changes.
Updated Documents
Freedom Health is required to maintain verification of certain documents that expire throughout the Provider’s participation with the Plan. These documents include but are not limited to Medical License, and Board Certification. The Plan is also required to obtain an “Attestation of Patient Load” from all Primary Care Physicians.
Practitioner Appeal Rights – Quality of Care or Conduct
In the event the Plan makes an adverse participation decision against a practitioner for the reasons noted above, the affected practitioner will be notified in writing within 30-days of the adverse
decision, and will be provided notice of rights to appeal. The letter will specify the reason for the restriction, suspension or termination, and will include if relevant the data used to evaluate the practitioner. The letter will include the timeframe of 30-days from the practitioners receipt of the Plan’s letter for an appeal request to be submitted to the Plan; the name of the person to whom the appeal should be submitted; the practitioner’s right to submit any additional information in support of the appeal; the right to representation by an attorney; and if an appeal is requested, the appeal hearing will be held via teleconference.