Policy/Procedure Number: MP CR #4A
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for Behavioral
Health Practitioners
Lead Department: Provider Relations
☒
External Policy
☐ Internal Policy
Original Date : 05/08/2002
Applies to:
Reviewing
Entities:
☐
Medi-Cal
☒ IQI
☐ OPERATIONS
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☐
Healthy Kids
☐
Employees
☐ P & T
☐ EXECUTIVE
☒ QUAC
☐ COMPLIANCE ☐ DEPARTMENT
☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☐ PAC
Approving
Entities: ☐ CEO ☐ COO ☒ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER
Approval Signature:
Approval Date: 08/12/2015
I.
RELATED POLICIES :
A.
N/A
II.
IMPACTED DEPTS :
A.
Provider Relations
III.
DEFINITIONS :
A.
N/A
IV.
ATTACHMENTS :
A.
N/A
V.
PURPOSE:
A. To describe the Initial Credentialing Requirements for Psychiatrists, Psychologists, Licensed Clinical
Social Workers (LCSW), Marriage Family Therapists (MFT) and Clinical Nurse Specialist – Psychiatric
Mental Health Nurse (PIMH). This includes the practice experience, license, certification, privileges, professional liability coverage, education, and other qualifications necessary to provide a level of care consistent with professionally recognized standards; and in accordance with the Partnership HealthPlan of
California (PHC) policies, and applicable credentialing and certification requirements of the State of
California, Department of Health Care Services (DHCS), and the National Committee of Quality Assurance
(NCQA).
VI.
POLICY / PROCEDURE :
A.
All practitioners shall be credentialed prior to joining the network and shall be re-credentialed every three (3) years thereafter. If a practitioner terminates with the Plan and later is reinstated, the Plan will initially credential the practitioner if the break is 30 days or more. All Behavioral Health Practitioners who are in private practice must have had an office site audit, as defined in the Initial Credentialing Site
Review Policy prior to having credentials presented to the Credentialing Committee.
1.
The following types of licensed independent practitioners shall be credentialed: a.
Psychiatrists b.
Psychologists c.
Licensed Clinical Social Workers (LCSWs)
Документ1 Page 1 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees d.
Marriage Family Therapists (MFTs) e.
Clinical Nurse Specialist – Psychiatric Mental Health Nurse (PIMH)
B.
Individual practitioners must meet all of the requirements outlined below. All verification of documentation and information required may not be more than 180 days old at the time of Credentialing
Committee review.
1.
Psychiatrist (M.D.) a.
Must submit a completed signed California Participating Practitioner Application (CPPA) that includes disclosure of professional liability history and a current Curriculum Vitae (CV) that details the practitioner’s work history. All confidential questions on the Attestation must be answered and the applicant must explain any exceptions in writing. A current release form must be signed and dated in order to begin the credentialing process. b.
Must possess a current, valid, unencumbered, unrestricted, and nonprobationary license in the states where he or she provides services to PHC members. Exception to this requirement may be made for those applicants whose licensure action was related to substance abuse and who have demonstrated a minimum of six months of successful participation in a treatment or monitoring program; should this exception be entertained, the HealthPlan may request specific documentation from the applicant’s treating physician or program as we deem appropriate and to the extent permitted by law. Under existing federal law, licensed health professionals employed by a tribal health program are required to be exempt, if licensed in any state, from the licensing requirements of the state in which the tribal health program performs specified services. The tribal health professional's license must be in good standing as stated above.
1) Practitioners that don’t meet criteria of an unencumbered, unrestricted, and nonprobationary license will be presented to the Credentials Committee for consideration.
Based on the review of the issues presented, the Credentials Committee will make recommendations to deny credentialing or approve credentialing. The Plan will routinely ask practitioners to send a letter to the Credentials Committee to give their narrative and explanation of the action against them and the activities the practitioner has taken as a result of restrictions placed on their medical license. Approval of credentialing would be based on specific requirements that could include but not limited to; required proctoring of practitioner, additional CME within a specified time frame, monitoring of practitioner’s restrictions by the health plan credentials staff and findings brought back to committee on a monthly or quarterly basis, and/or limiting the type of services provided by the practitioner to PHC members. This would apply to any practitioner with sanctions or limitations on their medical license from the license governing Board.
The following criteria will be used by the Credentials Committee to evaluate the practitioner. a) Assessment of risk of substandard care that might be provided to Plan members. b) The completeness and forthrightness of the provider’s narrative and explanation of the probation, restriction or other encumberment on their medical license. c.
Physician must be free of any sanctions of limitations on their license from the California State
Документ1 Page 2 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees medical Licensure Board. d.
Must have professional liability coverage in the amount of $1,000,000 per incident and
$3,000,000 in aggregate. e.
Must possess and submit a current, unrestricted DEA Certificate in order to prescribe controlled substances. f.
Primary source verification of medical school and residency program is required. Primary source verification of medical school is verified by the Medical Board of California (MBOC) prior to issuing a license. PHC may also verify physician data by searching the AMA Physician
Profile via a secure website. If practitioner is Board Certified, primary source verification of residency program is not required. If practitioner is not Board Certified PHC will verify residency. g.
For Practitioners that attest to being Board Certified, Board Certification is verified through
ABMC. h.
A query and documentation is obtained from the National Practitioner Data Bank/Healthcare
Integrity and Protection Data Bank (NPDB/HIPDB). i.
Practitioners must be free of Medicare/Medi-Cal sanctions. This is verified through a query of
NPDB/HIPDB. j.
Verification of Medicare participation through query of Medicare website, www.medicare.gov and/or other reporting agencies. Verify that Provider has not opted out of Medicare.
2.
Psychologist a.
Must submit a completed signed California Participating Practitioner Application (CPPA) that include disclosure of professional liability history and a current Curriculum Vitae (CV) that details the practitioners work history. All confidential questions on the Attestation must be answered and the applicant must explain any exceptions in writing. A current release form must be signed and dated in order to begin the credentialing process. b.
Must possess a current, valid, unencumbered, unrestricted, and nonprobationary license in the states where he or she provides services to PHC members. Exception to this requirement may be made for those applicants whose licensure action was related to substance abuse and who have demonstrated a minimum of six months of successful participation in a treatment or monitoring program; should this exception be entertained, the HealthPlan may request specific documentation from the applicant’s treating physician or program as we deem appropriate and to the extent permitted by law. Under existing federal law, licensed health professionals employed by a tribal health program are required to be exempt, if licensed in any state, from the licensing requirements of the state in which the tribal health program performs specified services. The tribal health professional's license must be in good standing as stated above.
1) Practitioners that don’t meet criteria of an unencumbered, unrestricted, and nonprobationary license will be presented to the Credentials Committee for consideration.
Based on the review of the issues presented, the Credentials Committee will make recommendations to deny credentialing or approve credentialing. The Plan will routinely
Документ1 Page 3 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees ask practitioners to send a letter to the Credentials Committee to give their narrative and explanation of the action against them and the activities the practitioner has taken as a result of restrictions placed on their medical license. Approval of credentialing would be based on specific requirements that could include but not limited to; required proctoring of practitioner, additional CME within a specified time frame, monitoring of practitioner’s restrictions by the health plan credentials staff and findings brought back to committee on a monthly or quarterly basis, and/or limiting the type of services provided by the practitioner to PHC members. This would apply to any practitioner with sanctions or limitations on their medical license from the license governing Board.
The following criteria will be used by the Credentials Committee to evaluate the practitioner:
1) Assessment of risk of substandard care that might be provided to Plan members.
2)
The completeness and forthrightness of the provider’s narrative and explanation of the probation, restriction or other encumberment on their medical license. c.
The Psychologist must be free of any sanctions or limitations on their license from the Board of
Psychology, Medical Board of California. d.
Must have professional liability coverage in the amount of $1,000,000 per incident and
$3,000,000 in aggregate. e.
Primary source verification of education and residency program is required. The Board of
Psychology, Medical Board prior to issuing a license, verifies primary source verification of education and residency. Verification will be done by obtaining a letter from the Board of
Psychology stating that education and residency are verified prior to licensure and retaining a copy of letter in file or querying the school and residency program directly. If letter not available, PHC will primary source education and residency. f.
A query and documentation is obtained from the National Practitioner Data Bank/Healthcare
Integrity and Protection Data Bank (NPDB/HIPDB). g.
Practitioners must be free of Medicare/Medi-Cal sanctions. This is verified through a query of
NPDB/HIPDB. h.
Verification of Medicare participation through query of Medicare website, ww.medicare.gov and/or other reporting agencies. Verify that Provider has not opted out of Medicare.
3.
Licensed Clinical Social Worker (LCSW) a.
Must submit a completed signed California Participating Practitioner Application (CPPA) that includes disclosure of professional liability history and a current Curriculum Vitae (CV) that details the practitioner’s work history. All confidential questions on the Attestation must be answered and the applicant must explain any exceptions in writing. A current release form must be signed and dated in order to begin the credentialing process. b.
Must possess a current, valid, unencumbered, unrestricted, and nonprobationary license in the states where he or she provides services to PHC members. Exception to this requirement may be
Документ1 Page 4 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees made for those applicants whose licensure action was related to substance abuse and who have demonstrated a minimum of six months of successful participation in a treatment or monitoring program; should this exception be entertained, the HealthPlan may request specific documentation from the applicant’s treating physician or program as we deem appropriate and to the extent permitted by law. Under existing federal law, licensed health professionals employed by a tribal health program are required to be exempt, if licensed in any state, from the licensing requirements of the state in which the tribal health program performs specified services. The tribal health professional's license must be in good standing as stated above.
1) Practitioners that don’t meet criteria of an unencumbered, unrestricted, and nonprobationary license will be presented to the Credentials Committee for consideration.
Based on the review of the issues presented, the Credentials Committee will make recommendations to deny credentialing or approve credentialing. The Plan will routinely ask practitioners to send a letter to the Credentials Committee to give their narrative and explanation of the action against them and the activities the practitioner has taken as a result of restrictions placed on their medical license. Approval of credentialing would be based on specific requirements that could include but not limited to; required proctoring of practitioner, additional CME within a specified time frame, monitoring of practitioner’s restrictions by the health plan credentials staff and findings brought back to committee on a monthly or quarterly basis, and/or limiting the type of services provided by the practitioner to PHC members. This would apply to any practitioner with sanctions or limitations on their medical license from the license governing Board.
The following criteria will be used by the Credentials Committee to evaluate the practitioner.
1) Assessment of risk of substandard care that might be provided to Plan members.
2) The completeness and forthrightness of the provider’s narrative and explanation of the probation, restriction or other encumberment on their medical license. c.
LCSW must be free of any sanctions or limitations on license from the Board of Behavioral
Science. d.
Must have professional liability coverage in the amount of $1,000,000 per incident and
$1,000,000 in aggregate. e.
Primary source verification of professional school training and internship are required. The
Board of Behavioral Science verifies primary source verification of professional school training and internship prior to issuing a license. Verification will be done by obtaining a letter from the
Board of Behavioral Science stating that education and internship are verified prior to licensure and retaining a copy of letter in file or querying the school and internship program directly. If letter not available, PHC will primary source education and residency. f.
A query and documentation is required from the National Practitioner Data Bank/Healthcare
Integrity and Protection Data Bank (NPDB/HIPDB). g.
Practitioner must be free of Medicare/Medi-Cal sanctions. This is done through a query of
NPDB/HIPDB. h.
Verification of Medicare participation through query of Medicare website, www.medicare.gov
Документ1 Page 5 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees and/or other reporting agencies. Verify that Provider has not opted out of Medicare.
4.
Marriage Family Therapist (MFT) a.
Must submit a completed signed California Participating Practitioner Application (CPPA) that includes disclosure of professional liability history and a current Curriculum Vitae (CV) that details the practitioners work history. All confidential questions on the Attestation must be answered and the applicant must explain any exceptions in writing. A current release form must be signed and dated in order to begin the credentialing process. b.
Must possess an unrestricted valid California State License issued by the California Board of
Behavioral Science (BBS). a current, valid, unencumbered, unrestricted, and nonprobationary license in the states where he or she provides services to PHC members. Exception to this requirement may be made for those applicants whose licensure action was related to substance abuse and who have demonstrated a minimum of six months of successful participation in a treatment or monitoring program; should this exception be entertained, the HealthPlan may request specific documentation from the applicant’s treating physician or program as we deem appropriate and to the extent permitted by law. Under existing federal law, licensed health professionals employed by a tribal health program are required to be exempt, if licensed in any state, from the licensing requirements of the state in which the tribal health program performs specified services. The tribal health professional's license must be in good standing as stated above.
1) Practitioners that don’t meet criteria of an unencumbered, unrestricted, and nonprobationary license will be presented to the Credentials Committee for consideration.
Based on the review of the issues presented, the Credentials Committee will make recommendations to deny credentialing or approve credentialing. The Plan will routinely ask practitioners to send a letter to the Credentials Committee to give their narrative and explanation of the action against them and the activities the practitioner has taken as a result of restrictions placed on their medical license. Approval of credentialing would be based on specific requirements that could include but not limited to; required proctoring of practitioner, additional CME within a specified time frame, monitoring of practitioner’s restrictions by the health plan credentials staff and findings brought back to committee on a monthly or quarterly basis, and/or limiting the type of services provided by the practitioner to PHC members. This would apply to any practitioner with sanctions or limitations on their medical license from the license governing Board.
The following criteria will be used by the Credentials Committee to evaluate the practitioner.
1) Assessment of risk of substandard care that might be provided to Plan members.
2) The completeness and forthrightness of the provider’s narrative and explanation of the probation, restriction or other encumberment on their medical license. c.
MFT must be free of any sanctions or limitations on the license from the California Board of
Behavioral Science. d.
Must have professional liability coverage in the amount of $1,000,000 per incident and
$1,000,000 in aggregate.
Документ1 Page 6 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees e.
Primary source verification of professional school training and internship are required. The
California Board of Behavioral Science verifies primary source verification of professional school training and internship prior to issuing a license.
Verification will be done by obtaining a letter from the Board of Behavioral Science stating that education and internship are verified prior to licensure and retaining a copy of letter in file or querying the professional school and internship program directly. If letter not available, PHC will primary source education and residency. f.
A query and documentation is obtained from the National Practitioner Data Bank/Healthcare
Integrity and Protection Data Bank (NPDB/HIPDB). g.
Practitioner must be free of Medicare/Medi-Cal sanctions. This is verified through a query of
NPDB/HIPDB. h.
Verification of Medicare participation through query of Medicare website, www.medicare.gov and/or other reporting agencies. Verify that Provider has not opted out of Medicare.
5.
Clinical Nurse Specialist – Psychiatric Mental Health Nurse (PIMH) a.
Submit a completed application as designated by PHC that includes disclosure of professional liability history and curriculum vitae (CV) that details the practitioners work history. All confidential questions on the Attestation must be answered and the applicant must explain any exceptions in writing. A current release form must be signed and dated in order to begin the credentialing process. b.
Possess an unrestricted valid California State License issued by the California Board of
Registered Nurses, (CBORN). a current, valid, unencumbered, unrestricted, and nonprobationary license in the states where he or she provides services to PHC members.
Exception to this requirement may be made for those applicants whose licensure action was related to substance abuse and who have demonstrated a minimum of six months of successful participation in a treatment or monitoring program; should this exception be entertained, the
HealthPlan may request specific documentation from the applicant’s treating physician or program as we deem appropriate and to the extent permitted by law. Under existing federal law, licensed health professionals employed by a tribal health program are required to be exempt, if licensed in any state, from the licensing requirements of the state in which the tribal health program performs specified services. The tribal health professional's license must be in good standing as stated above.
1)
Practitioners that don’t meet criteria of an unencumbered, unrestricted, and nonprobationary license will be presented to the Credentials Committee for consideration.
Based on the review of the issues presented, the Credentials Committee will make recommendations to deny credentialing or approve credentialing. The Plan will routinely ask practitioners to send a letter to the Credentials Committee to give their narrative and explanation of the action against them and the activities the practitioner has taken as a result of restrictions placed on their medical license. Approval of credentialing would be based on specific requirements that could include but not limited to; required proctoring of practitioner, additional CME within a specified time frame, monitoring of practitioner’s
Документ1 Page 7 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees restrictions by the health plan credentials staff and findings brought back to committee on a monthly or quarterly basis, and/or limiting the type of services provided by the practitioner to PHC members. This would apply to any practitioner with sanctions or limitations on their medical license from the license governing Board.
The following criteria will be used by the Credentials Committee to evaluate the practitioner.
1) Assessment of risk of substandard care that might be provided to Plan members.
2) The completeness and forthrightness of the provider’s narrative and explanation of the probation, restriction or other encumberment on their medical license. c.
Verification of state license is done by calling CBORN, (800) 838-6828. This information is entered into the credentials database. The verification document is filed in the practitioners paper file. d.
Have professional liability coverage in the amount of $1,000,000 per incident and $3,000,000 in aggregate. e.
Primary source verification of education is verified by the California Licensing Board prior to issuing a license. PHC has a letter or documentation from the Licensing Board that verifies this process. f.
Be free of any sanctions or limitations on their license from the California State Licensing
Board. g.
A query and documentation is obtained from the National Practitioner data Bank /Healthcare
Integrity and Protection Data Bank (NPDB/HIPDB). h.
Be free of Medicare/Medi-Cal Sanctions. This is verified through a query NPDB/HIPDB. i.
Verification of Medicare participation through query of Medicare registry www.medicare.gov and/or other reporting agencies. Verify that Provider has not opted out of Medicare.
C.
The process for identifying issues in the credentialing/re-credentialing process is defined in the Initial
Credentialing document Collection, Review, and Verification Policy.
D.
Practitioners are notified in writing when presented with a credentialing application that they have a right to be informed of the status of their application upon request, a right to review any portion of their personal credentials file related to information submitted in support of their credentialing application, and they have the right to correct any identified erroneous information, provided the information is not peer review protected. (See Addendum to CPPA “Notice of Practitioners of Credentialing
Rights/Responsibilities.”)
E.
The Credentials Committee shall review and evaluate the credentialing application and supporting documentation to determine if the practitioner meets the credentialing criteria.
F.
If the Credentialing Committee does not approve a practitioner for credentialing, the practitioner will be notified of the decision in writing.
Документ1 Page 8 of 9

Policy/Procedure Number: MP CR #4A Lead Department: Provider Relations
Policy/Procedure Title: Initial Credentialing Criteria,
Application/Attestation, and Monitoring of Sanctions for
Behavioral Health Practitioners
Original Date: 05/08/2002
☒
☐
External Policy
Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
Applies to:
☐
Medi-Cal ☐ Healthy Kids ☐ Employees
G.
The practitioner may appeal the decision using the process as identified in Fair Hearing Process for
Adverse Decisions.
H.
The Partnership HealthPlan of California Board of Commissioners retains ultimate responsibility for final decisions on all appeals related to practitioner credentialing activities.
I.
If a practitioner’s credentialing profile is denied based upon deficiencies in the practitioner’s professional competence, conduct or quality of care, PHC shall submit any all required reports to the
National Practitioner Data Bank and the State Medical Board.
J.
Upon approval the practitioner is notified of the decision in writing within 30 days. The new practitioner information is added to the member practitioner directories to include Board Certification and Specialty consistent with the information obtained during the credentialing process.
K.
The credential files and all relevant credentialing information are maintained as high level secured documents. Confidentiality is maintained via file storage in locked cabinets and access limited to the
Chief Medical Officer, Provider Relations Department Personnel, and the Quality Improvement
Personnel. Practitioner information stored in an electronic database is confidential and secure, accessible only by personnel with unique passwords.
L.
VII.
REFERENCES:
M.
- NCQA
VIII.
DISTRIBUTION :
A.
- PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE : Credentialing Supervisor
X.
REVISION DATES:
05/08/2002, 08/14/2002, 03/12/2003, 03/10/2004, 11/10/2004, 11/09/2005, 07/12/2006, 07/11/2007,
09/04/2008, 07/08/2009, 07/14/2010, 07/13/2011, 08/08/2012, 10/09/2013, 08/13/2014
PREVIOUSLY APPLIED TO:
N/A
Документ1 Page 9 of 9