including but not limited to MDs, DOs, chiropractors, nurse midwives, nurse practitioners, oral-maxillofacial surgeons, podiatrists, psychiatrists*, psychologists *, social workers *, and therapists*.
*Includes all behavioral health practitioners who are certified or registered by the state to practice independently.
The credentialing program also applies to hospitals, skilled nursing facilities, home health agencies, ambulatory surgical centers, and behavioral health facilities.
Authority/Responsibility Credentialing Department
The Credentialing Department has responsibility of the collection of all the required documentation, reviewing the application for completeness, performing primary source verification, querying the appropriate entities and the completion of the practitioner files in preparation for review by the Chief Medical Officer or the Credentialing Sub-Committee. The Credentialing Services Manager is responsible for the day-to-day operations of the Credentialing Program.
Chief Medical Officer
CHG’s Board of Directors has delegated to the Chief Medical Officer the responsibility of annually reviewing the Credentialing Program, and to update as needed; and to ensure that the terms of the Credentialing Program are executed.
Credentialing Sub-Committee
CHG’s Credentialing Sub-Committee functions as the CHG Credentialing Committee for applicants who do not meet credentialing standards. Meeting every month, the committee is comprised of (6) practitioner members with CHG’s Chief Medical Officer serving as the Chairperson. The range of specialties represented includes Family Practice (2), Internal Medicine (1), Pediatrics (1), Obstetrics-Gynecology (1) and Nurse Practitioner (1). The following CHG staff members also participate on the Credentialing Sub-Committee - the Director, Corporate Quality and the Credentialing Services Manager.
The committee also functions as the peer-review committee for regulatory actions and quality of care issues.
Provider File
The Contracting Department is responsible for the management and maintenance of practitioner data in the network Provider Module. Upon notification of acceptance from Credentialing, the Contracting Department sets up new practitioners in the Diamond system including hospital based physicians, midlevel practitioners, ancillary practitioners and facilities. The Contracting Department processes changes to existing in-plan practitioner data and practitioner terminations upon notification from Provider Relations. The Contracting & Credentialing Departments also perform data analysis and troubleshooting on a proactive ad hoc basis to ensure the integrity of practitioner information between both systems.
Confidentiality
All credentialing information obtained during the credentialing/recredentialing process is handled in a manner that protects the confidentiality of the applicant and may not be disclosed except as permitted by applicable law. Credentialing information is kept in a secure database and access to such information is limited through systems security features and is available only to staff with a need to know. All practitioner files are stored in a locked fireproof cabinet while in process, and only designated staff members have access to the files. Provider files are scanned and kept electronically. All
Quality Improvement Program Description
credentialing/recredentialing information distributed at the Credentialing Sub-Committee meetings is collected at the conclusion of the meeting and disposed of by placing in locked shredding bins. Minutes of each Credentialing Sub-Committee meeting are maintained in a confidential and secure manner.
Annual Review
The Credentialing Program and the effectiveness of the program is reviewed, evaluated, and revised, if applicable, at least annually by the Chief Medical Officer and the Credentialing Services Manager.
Data Integrity
On a monthly basis, the Credentialing and Contracting departments perform a data comparison to ensure that the integrity of the practitioner data presented in the directories and other member materials is consistent with the credentialing data including education, training, board certification and specialty. On a daily basis, all practitioner data changes are reviewed and verified for accuracy.
Credentialing Criteria All Practitioners Each applicant must complete an application form which includes:
A signed release/authorization which grants CHG the ability to verify key information.
At the time of the credentialing decision, the signature date must not be more than 365 days old.
Otherwise, CHG will require the applicant to refresh the application prior to presenting for review.
An attestation by the applicant of the correctness and completeness of the application.
The application includes a current and signed attestation that addresses:
Reasons for any inability to perform the essential functions of the position, with or without reasonable accommodation
Lack of present illegal drug use
History of loss of license or certifications
History of felony convictions
History of loss or limitations of privileges or disciplinary actions
Current malpractice insurance coverage
An application other than CHG’s may be used if it provides all the demographic and practice information required for CHG’s credentialing requirements, or if it is a state-mandated application.
Physicians
All physician applicants must demonstrate that they meet the participation/continued participation criteria listed below:
Current, valid, unrestricted license(s) to practice medicine or osteopathy.
Current, valid, unrestricted Federal DEA certificate, if applicable.
Medical school/dental school graduation.
Completion of appropriate residency and/or fellowship training programs in the specialty for which applicant is applying.
Board Certification - CHG requires all physicians have formal training and obtain certification by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) in all specialties under which they practice and wish to be listed in the CHG Practitioner Directory.
Subspecialty certification and/or certificates of added qualifications from the ABMS are required in order for CHG to recognize and list a physician in that specialty in its practitioner directory.
CHG may waive board certification requirements at its sole discretion, for compelling network needs or other business reasons, provided that the physician meets all other requirements.
Quality Improvement Program Description
Detailed account of professional work history for the past five (5) years, with no unexplained gaps of more than six (6) months. Verbal clarification for gaps exceeding six (6) months will be accepted.
Written clarification is required for gaps greater than one (1) year.
Unrestricted clinical privileges at a CHG-participating hospital, or written documentation from the applicant outlining an admitting arrangement by which CHG members are referred for admission to a CHG-participating facility.
Documentation of current malpractice insurance coverage. Physicians are required to carry a minimum of $1,000,000/$3,000,000.
Professional liability claims history during the past five (5) years.
Absence of sanctions, restrictions, and/or limitations in scope of practice by any state licensing board or regulatory agency.
Absence of Medicare/Medicaid sanctions.
Non-Physicians
All other practitioner applicants must demonstrate that they meet the participation/continued participation criteria listed below:
Current, valid, unrestricted license(s) to practice in his/her specialty;
Current, valid, unrestricted Federal DEA certificate, if applicable;
Completion of appropriate education and training in his/her specialty;
Confirmation of Board Certification/certification, if applicable;
Detailed account of professional work history for the past five (5) years, with no unexplained gaps of more than six (6) months;
Unrestricted clinical privileges at a CHG participating hospital, if applicable;
Documentation of current malpractice insurance coverage;
Professional liability claims history during the past five (5) years;
Absence of sanctions, restrictions, and/or limitations in scope of practice by any state licensing board or regulatory agency;
Absence of Medicare/Medicaid sanctions.
Organizational Providers
CHG conducts a quality assessment for the following types of health care organizations before contracting with and at least 3 years thereafter:
Ambulatory Surgery Centers - Free Standing
Office Based Surgery Centers
Home Health Agencies
Hospitals
Skilled Nursing Facilities
Behavioral Health Care Facilities (ambulatory, inpatient and residential)
CHG confirms that the organization is in good standing with state and federal bodies, is licensed in the state as required, has been reviewed and approved by an accrediting body. Acceptable accreditation and certification entities:
Joint Commission for Accreditation of Health Care Organizations (JCAHO)
Community Health Accreditation Program, INC (CHAP)
Accreditation Association for Ambulatory Health Care (AAAHC)
The Rehabilitation Accreditation Commission (CARF)
Continuing Care Accreditation Commission (CCAC)
Quality Improvement Program Description
The Commission on Accreditation of Birth Centers
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
If the organization is not accredited, a site visit is required. A state or federal (DHCS, CMS) review may be substituted for a site visit. On a triennial basis, CHG will reassess facilities for continued participation in the network by confirming that it continues to be in good standing with state and federal regulatory bodies and the appropriate accrediting body.
Non-Discrimination
CHG’s credentialing process does not discriminate in the selection or termination of practitioners on the basis of sex, age, national origin, race, religion, color, marital status, or sexual preference or orientation.
CHG does not discriminate in the selection or termination of practitioners who serve high-risk populations or who specialize in the treatment of costly conditions. In order to assure non-discrimination, CHG annually reviews denied applications and reviews what the decisions were based on.
Application Review
Upon receipt of the application and any supporting documentation, the Credentialing Specialist will review the application timeliness and completeness. The signature date should not be older than sixty (60) days in order to begin the credentialing process. If the application is complete, the documentation received will be date stamped and data will be entered into the Credentialing Database. If not, the Credentialing Specialist will contact the applicant or IPA/PHO representative via telephone or fax with a request for missing items. Once it has been established than an application is complete, the Credentialing Specialist will initiate processing and conduct primary source verification.
Primary Source Verification
Primary source verifications are conducted on all applicants. Verifications must be completed within 180 days from the date of the decision.
Licensure – via appropriate state agency or the Internet
DEA – via the NTIS database or certificate copy
Board Certification – via ABMS publications, Certifacts, or appropriate specialty board
Medical School/Dental School Graduation & Residency – verified per licensure in CHG service areas according to documented policies of the respective state licensing boards
Fellowship – via educational primary source
Clinical Privileges –via primary source
Malpractice Insurance Coverage – via primary source
Professional Liability Claims History/Disciplinary Activity – query of the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) or primary source
Sanctions/Limitations on Licensure within the past five years – information will be obtained from applicable state regulatory agency
Sanctions/Limitations on Licensure outside the CHG service area –query of the Federation of State Medical Boards (FSMB) on physician applicants at the time of credentialing or applicable state regulatory agency
Medicare/Medicaid Sanctions – query the National Practitioner Data Bank (NPDB) or Cumulative Sanctions Report
Work History - professional work history for the past five (5) years, with no unexplained gaps of more than six (6) months. Gaps exceeding six (6) months must be reviewed and clarified either verbally or in writing. Written clarification is required for gaps greater than one (1) year.