Upon completion of primary source verification, queries, and site visit, if applicable, the file is prepared for review. The file will include:
Completed credentialing application and checklist
Primary source verification of all elements
Work history
NPDB/FSMB query result
Sanction activity summary, if applicable
Site visit results
Any other relevant data
Decision-Making Process
The Chief Medical Officer has determined that all files, credentialing and recredentialing, that meet CHG's established criteria are considered to be "clean.” A roster of applicants that meet all of CHG’s criteria will be forwarded weekly to the Chief Medical Officer for his review and sign-off that they are complete, clean, and approved for acceptance or continued participation.
The Credentialing Sub-Committee reviews the credentials of all physicians and licensed independent practitioners being credentialed or recredentialed who do not meet the organization’s established criteria, and makes recommendations regarding credentialing decisions which the organization considers.
The confidential minutes of each meeting are recorded and reflect the recommendations/advice of the Committee and any relevant discussion pertaining to the recommendations.
The date of the Chief Medical Officer sign-off or the Committee meeting is considered the effective date.
Notification
All applicants are notified in writing within sixty (60) calendar days of the decision to accept or deny their application unless states mandate otherwise. If accepted, the file is forwarded to Provider Relations for entry into Diamond, then to Network Operations for contract execution and the sending of the welcome packet. The date of the Chief Medical Officer sign-off or the QIC meeting is the effective date. If denied, the practitioner is sent a denial letter explaining the reason(s) for the denial.
Applicant Rights CHG has policies and procedures in place that define:
The right to review information submitted to support his/her credentialing application unless the disclosure of certain information or the source of information is prohibited by law, contract or agreement with the entity that provided the information to CHG, and the right to correct erroneous information submitted by another party for use in the credentialing process.
The process for notification to a practitioner of a discrepancy in the information obtained during the credentialing process that varies substantially from the information provided to CHG by the applicant. Notification to the applicant will be made in writing within ten (10) working days of the receipt of such discrepancies. The applicant shall have ten (10) working days after receipt of notification to submit an explanation of such discrepancies in writing to the Credentialing Department. The applicant will be notified in writing within ten (10) working days that his/her
Quality Improvement Program Description
explanation has been received and will be taken into consideration while completing the application process. Discrepancies will be reviewed at the next regularly scheduled QIC meeting.
The right to be informed of the status of his/her credentialing or recredentialing application upon request. The applicant may contact the Credentialing Department to request information on the status of his/her credentialing/recredentialing application.
Practitioners are informed of their rights on the practitioner application and in the Provider Manual.
Delegation
CHG may delegate specific credentialing functions, including primary source verification and/or decision making, to an IPA/PHO or other professional healthcare organization by formal written agreement, providing the delegate agrees to adhere to CHG’s credentialing criteria. The agreement outlines the responsibilities of CHG and the delegate, the process by which CHG will evaluate the delegate’s performance, frequency of reporting requirements (at least semi-annually), and how CHG will proceed if the delegate does not fulfill its obligations.
CHG will evaluate the delegate’s performance prior to delegation following NCQA standards and will include a review of practitioner files as well as a review of the related delegate policies and procedures.
Once the delegation agreement is executed, CHG will perform oversight, including file review, policy review and report evaluation at least annually thereafter. Any identified opportunities for improvement will be addressed with the delegate and closely monitored thereafter.
CHG retains the right to approve, suspend, deny or terminate practitioners and/or providers participating in the network. None of CHG’s delegated credentialing arrangements include the use of any member protected health information.
Site Review Initial Credentialing Visit
CHG requires a site visit for all primary care practitioners, obstetricians/ gynecologists, and high volume behavioral health care practitioners prior to the initial credentialing decision. The site visit includes a structured review of the facility and of medical record-keeping practices.
The site visit component includes an assessment of:
Physical accessibility and appearance
Adequacy of waiting room and examining room space
Appointment availability
Adequacy of medical record keeping practices
Maintenance of patient confidentiality
Patient safety practices
New applicants joining existing practices with a passing site visit on file may be credentialed based on the existing site visit score. Any primary care practitioner or obstetrician/gynecologist who adds a site or moves to a new location will receive an on-site visit at the time of CHG notification.
Scoring Standards
An initial passing score of 80% is required. Scores for the Medi-Cal line of business are rated according to the California Department of Health Services’ Policy Letter 02-02 as:
Quality Improvement Program Description
Facility
Exempted Pass: 90% or above, without deficiencies in critical elements or deficiencies in infection control or pharmacy – No Corrective Action Plan (CAP) required.
Conditional Pass: 80-89%, or 90% or above with deficiencies in critical elements – CAP required.
Not Pass: Below 80% - CAP required.
Medical Records
Exempted Pass: 90% or above – No Corrective Action Plan (CAP) required.
Conditional Pass: 80-89% – CAP required.
Not Pass: Below 80% - CAP required.
Subsequent Reviews
A failing score, multiple key element failures or quality of care issues will require a corrective action plan and a reevaluation every six months until the deficiencies are corrected. Community Health Group has an ongoing process to gather information regarding the facilities of participating practitioners after the initial site visit. Additional information regarding the facilities may be received from patient complaints, practitioner representative visits or case management. If any adverse information is received, a site visit will be scheduled at the site in question. This process is monitored every 6 months or on-going. A score of 80% is required on any subsequent reviews.
Recredentialing
CHG practitioners and providers are recredentialed, at a minimum, within thirty-six (36) months of the previous credentialing/recredentialing decision. At recredentialing, CHG verifies whether there has been any sanction activity that might impact a practitioner’s ability to provide safe and appropriate care through review of state sanctions, restrictions on licensure and/or limitation of scope of practice and query of the Office of Inspector General’s web site.
Practitioners and providers must complete a recredentialing application that includes a current, signed and dated attestation that addresses:
Reasons for any inability to perform the essential functions of the practitioner with or without accommodation;
Lack of present illegal drug use;
History of loss or limitation of privileges or disciplinary activity;
Current malpractice insurance coverage; and
Correctness and completeness of the application.
Primary source verifications are conducted on all applicants. Verifications must be completed within 180 days from the date of the decision. CHG will collect and/or primary source verify the following recredentialing elements for participating physicians and other practitioners via the sources identified above.
Current, valid, unrestricted license(s)
Current, valid, unrestricted Federal DEA certificate, if applicable
Board Certification
History of liability claims history
Sanctions and restrictions and/or limitations
Medicare/Medicaid sanctions
Current malpractice coverage in the amount of $1 million per occurrence/$3 million aggregate for physicians and other practitioners
Clinical privileges at a CHG affiliated hospital
Quality Improvement Program Description
No later than 365 days following the date of the signed attestation, all files that meet CHG's standards are forwarded to the Chief Medical Officer for review and approval. Recredentialing candidates who do not meet CHG's standards are forwarded to the Quality Improvement Committee for review and recommendation of continued participation.
Practitioners and providers who do not submit recredentialing information will result in termination from CHG’s participating practitioner panel.
Ongoing Monitoring
To ensure quality and safety of care between credentialing cycles, CHG performs ongoing monitoring for practitioner complaints, sanctions or limitations on licensure, Medicare/Medicaid sanctions and adverse events and will implement appropriate interventions if instances of poor quality are identified.
Practitioner specific complaints are investigated immediately and include an evaluation of the specific complaint and the practitioner's history of issues, if applicable. The complaint will be tracked and trended, and appropriate action taken when occurrences of poor quality are identified. CHG has an ongoing process to gather information regarding the facilities of participating practitioners after the initial site visit, and if adverse information is received, a visit will be scheduled at the site in question.
CHG will review reports from state agencies regarding practitioners who have received sanctions or limitations on licensure and Medicare/Medicaid sanction reports within 30 calendar days of release. If a participating practitioner is identified on a sanction report, or there is evidence of poor quality, the practitioner's ability to provide services will be reviewed by the Chief Medical Officer. The Chief Medical Officer’s recommendation will be presented to the QIC who will review and make subsequent recommendations. If a participating practitioner is identified on the Medicare/Medicaid sanction report, termination proceedings will be initiated.
Newspaper articles will be investigated and brought to the Chief Medical Officer and Provider Relations Department for review. The Chief Medical Officer’s recommendation will be presented to the Credentialing Sub-Committee who will review and make subsequent recommendations.
The Chief Medical Officer reserves the right to suspend, or terminate a practitioner prior to review by Credentialing Sub-Committee, based on quality issues if necessary.
Terminations
CHG may terminate, suspend, restrict or limit a practitioner’s or provider’s “participating” status with CHG by providing written notice to the practitioner/provider and in accordance with the applicable practitioner/provider contract for the following reasons:
Practitioner/provider no longer complies with the CHG eligibility requirements and/or selection criteria;
Practitioner’s arrest, conviction, indictment or charge with any felony charge related to moral turpitude or the practice of medicine;
CHG determines that practitioner has provided false and/or misleading information relating to billing, services rendered, and/or credentialing or recredentialing;
CHG determines that the quality of care/quality of service may result in danger to the health and safety of CHG’s members;
Practitioner’s/provider's liability insurance as required by CHG is terminated, canceled or materially decreased;
Quality Improvement Program Description
Practitioner’s/provider’s license to practice medicine has been restricted, suspended, revoked, or reduced in the state(s) where CHG’s members may receive services from such provider/practitioner;
Practitioner/provider has been suspended or excluded from the Medicare/Medicaid program or any other federal or state health care program.
If a practitioner or provider is suspended or terminated, the affected physician will receive written notice of the reasons for the action including, if relevant, the standards used to make the decision. The physician will be given written notice of his/her right to a hearing and the process and timing for requiring a hearing. Practitioners and providers have the right to appeal CHG’s decision to take adverse action against their participation status for quality-related reasons and in accordance with the Health Care Quality Improvement Act of 1986.
Prior to the hearing, CHG has the option to initiate a range of actions depending on the nature of the circumstances. These could include but are not limited to:
Educational interventions
Limitation of privileges
Closure of practice to CHG members
Sanctioning by the committee
Requiring a corrective action plan with regular monitoring
In accordance with the requirements of federal and state law, CHG shall notify any appropriate regulatory authority, including the National Practitioner Data Bank (NPDB), of any final decision of the Credentialing Sub-Committee to take adverse action regarding a provider’s/practitioner’s participation for quality-related reasons. In reporting, CHG shall report the name of the provider/practitioner; a description of acts/omissions or other reasons for the adverse action.
The written appeal process including the right to a fair hearing is communicated to the practitioners in the practitioner manual and in the contract.