PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MP CP #6
Policy/Procedure Title: Non-Physician Medical Practitioner
Credentialing Criteria
Lead Department: Provider Relations
☒External Policy
☐ Internal Policy
Next Review Date: 04/13/2016
Last Review Date: 05/13/2015
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
☒ Healthy Kids
☐ Employees
Reviewing
Entities:
☐ IQI
☐P&T
☐ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☐ PAC
☒ CREDENTIALING
☐ DEPT. DIRECTOR/OFFICER
Approving
Entities:
☐ CEO
☐ COO
Approval Signature: Marshall Kubota, MD
Approval Date: 05/13/2015
I.
RELATED POLICIES:
A. N/A
II.
IMPACTED DEPTS:
A. Provider Relations
III.
DEFINITIONS:
A. Supervision: As defined in Health Services Policy: MPQG 1011(if applicable).
IV.
ATTACHMENTS:
A. Addendum to CPPA “Notice to Practitioner of Credentialing Rights and Responsibilities.”
V.
PURPOSE:
A. To describe the credentialing requirements for Non-Physician Medical Practitioner including
Physician Assistants, Nurse Practitioner, Nurse Midwives, Clinical Nurse Specialists, and Certified
Registered Nurse Anesthetists (CRNA).
B. The purpose of Non-Physician practitioner credentials review is to ensure that Non-Physician
practitioner possess the practice experience, licenses, certifications, liability coverage, education, and
professional qualifications necessary to provide a level of care consistent with professionally recognized
standards and in accordance with Partnership HealthPlan of California policy, and applicable
credentialing and certification requirements of the State of California, the Department of Health Care
Services (DHCS), the Department of Managed Health Care (DMHC), and the Centers for Medicare and
Medicaid Services (CMS).
VI.
POLICY / PROCEDURE:
A. Independent professional practitioners or groups of practitioners that have an independent relationship
with PHC must meet all of the requirements outlined below. Documentation verification is
accomplished by using NCQA approved sources. Primary source verification may be obtained in
writing; by electronic access to information; by page copies of compendiums/directories; and/or by
telephone communication. Oral and electronic verifications shall bear the signature/initials and date of
the staff person who verifies the information. All documents and information required may not be more
than 180 days old at the time of Credentials Committee review. Independent professional practitioners
must:
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Policy/Procedure Number: MP CP #6
Lead Department: Provider Relations
Policy/Procedure Title: Error! No text of specified style in ☒ External Policy
document.
☐ Internal Policy
Next Review Date: 04/13/2016
Original Date: 11/01/1998
Last Review Date: 05/13/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
1. Nurse Practitioner (NP), Nurse Midwives (NM), Clinical Nurse Midwives (CNM), Licensed
Midwives (LM), Certified Midwives (CM) Clinical Nurse Specialists (CNS)
a.
Submit a completed application as designated by PHC, a current working history and curriculum
vitae (CV). All confidential questions on the Attestation must be answered and any exceptions
must be explained in writing by the applicant.
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
Registered Nurses, (CBORN) or the Medical Board of California (MBC). Verification of State
License is done via modem with State Medical Licensure Board. This information is entered
into the credentials database. The verification document is filed in the practitioner’s credential
file. 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.
c.
If practitioner possesses a DEA Certificate, verification of current DEA will be done with NTIS
via modem. This information is entered into credentialing data base. A print out of NTIS
verification is placed in the practitioner's credentials file.
d. Must have professional liability coverage in the amount of $1,000,000 per incident and
$3,000,000 in aggregate. Practitioner must submit a current copy of malpractice coverage. The
copy is retained in practitioner’s credentials file. Information is entered into credentialing
database.
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. Be free of Medicare/Medi-Cal Sanctions. This is done through a query of the National
Practitioner Data Bank/Healthcare Integrity and Protection Data Bank (NPDB/HIPDB).
h. A query from the NPDB/HIPDB via modem is documented and added to the practitioner file. If
information is found the NPDB/HIPDB search, a brief summary will be documented in the
database to assist the Chief Medical Officer in review of data. The hard copy print-out is filed
in the practitioner’s credential file.
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i.
Provide a copy of the Non-Physician Medical Practitioner Agreement that is in place under the
supervision of a PHC credentialed Physician with the Clinic, Medical Group, or Physician
where they are employed, if applicable.
j.
Verification of Medi-Cal status (and/or employer Medi-cal status) through query of PHC
Provider Master File (PMF) database. This database is updated monthly through data
submission from the Department of Health Care Services (DHCS) to PHC.
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Policy/Procedure Number: MP CP #6
Lead Department: Provider Relations
Policy/Procedure Title: Error! No text of specified style in ☒ External Policy
document.
☐ Internal Policy
Next Review Date: 04/13/2016
Original Date: 11/01/1998
Last Review Date: 05/13/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
k. 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.
l.
For Midwives that attest to being certified, certification will be verified through the American
Midwifery Certification Board (AMCB).
m. All credentialed Non-Physician Medical Practitioners licensed by CBORN will be registered by
PHC with Nursys e-Notify (National Council of State Boards of Nursing) to allow for automatic
notification of any disciplinary actions/enforcements.
2.
Physician Assistant (PA)
a.
Submit a completed application as designated by PHC, a current working history and curriculum
vitae (CV). All confidential questions on the Attestation must be answered and any exceptions
must be explained in writing by the applicant. 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 Physician Assistant
Examining Committee. Verification of State License is done via modem through the State
Medical Licensure Board. This information is entered into the credentials database. The
verification document is filed in the practitioner’s credential file. 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.
c.
If practitioner possesses a DEA Certificate, verification of current DEA will be done with NTIS
via modem. This information is entered into credentialing data base. A print out of NTIS
verification is placed in the practitioner's credentials file.
d. Have professional liability coverage in the amount of $1,000,000 per incident and $3,000,000 in
aggregate. Practitioner must submit a current copy of malpractice coverage. The copy is
retained in practitioner’s credentials file. Information is entered into credentialing database.
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. PHC may also verify PA data by searching the AMA Physician Profile via a secure
website.
f.
Be free of any sanctions or limitations on their license from the California State Licensing
Board.
g. Be free of Medicare/Medi-Cal Sanctions. This is done through a query of the National
Practitioner Data Bank/Healthcare Integrity and Protection Data Bank (NPDB/HIPDB).
h. A search and documentation from the NPDB/HIPDB. If information is found the NPDB/HIPDB
search, a brief summary will be documented in the database to assist the Chief Medical Officer
in review of data. The hard copy print-out is filed in the practitioner’s credential file.
i.
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Provide a copy of the Non-Physician Medical Practitioner Agreement that is in place with the
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Policy/Procedure Number: MP CP #6
Lead Department: Provider Relations
Policy/Procedure Title: Error! No text of specified style in ☒ External Policy
document.
☐ Internal Policy
Next Review Date: 04/13/2016
Original Date: 11/01/1998
Last Review Date: 05/13/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
Clinic, Medical Group, or Physician where they are employed, if applicable.
j.
Verification of Medi-Cal status (and/or employer Medi-cal status) through query of PHC
Provider Master File (PMF) database. This database is updated monthly through data
submission from the Department of Health Care Services (DHCS) to PHC.
k. 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.
3. Certified Registered Nurse Anesthetist (CRNA)
a. Submit a completed application as designated by PHC, a current working history and curriculum
vitae (CV). All confidential questions on the Attestation must be answered and any exceptions
must be explained in writing by the applicant. 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 Board of Certified
Registered Nurse Anesthetist (CRNA). Verification of State License is done via modem
through the State Medical Licensure Board. This information is entered into the credentials
database. The verification document is filed in the practitioner’s credential file. 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.
c.
If practitioner possesses a DEA Certificate, verification of current DEA will be done with NTIS
via modem. This information is entered into credentialing data base. A print out of NTIS
verification is placed in the practitioner's credentials file.
d. CRNA requires a letter documenting CRNA status at a JCAHO accredited hospital. A Letter
from the hospital documenting that the practitioner has clinical privileges and is in good
standing, will be requested by PHC. Documentation in placed in the practitioner’s credential
file. The type of hospital privileges and the hospital with the practitioner has privileges will be
documented in the credentialing database.
e.
Have professional liability coverage in the amount of $1,000,000 per incident and $3,000,000 in
aggregate. Practitioner must submit a current copy of malpractice coverage. The copy is
retained in practitioner’s credentials file. Information is entered into credentialing database.
f.
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.
g. Be free of any sanctions or limitations on their license from the California State Licensing
Board.
h. Be free of Medicare/Medi-Cal Sanctions. This is done through a query of the National
Practitioner Data Bank/Healthcare Integrity and Protection Data Bank (NPDB/HIPDB).
i.
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A search and documentation from the NPDB/HIPDB. If information is found the
NPDB/HIPDB search, a brief summary will be documented in the database to assist the Chief
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Policy/Procedure Number: MP CP #6
Lead Department: Provider Relations
Policy/Procedure Title: Error! No text of specified style in ☒ External Policy
document.
☐ Internal Policy
Next Review Date: 04/13/2016
Original Date: 11/01/1998
Last Review Date: 05/13/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
Medical Officer in review of data. The hard copy print-out is filed in the practitioner’s
credential file.
j.
Provide a copy of the Non-Physician Medical Practitioner Agreement (when required) that is in
place with the Clinic, Medical Group, or Physician where they are employed, if applicable.
k. Verification of Medi-Cal status (and/or employer Medi-cal status) through query of PHC
Provider Master File (PMF) database. This database is updated monthly through data
submission from the Department of Health Care Services (DHCS) to PHC.
l.
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.
B. The additional review process for credentialing is identified in the Review Standards for Credentials and
Recredentials Process Policy MP CR#5.
C. 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 Application “Notice of Practitioner of Credentialing
Rights/Responsibilities).
D. The Credentials Committee reviews and evaluates the credentialing application and supporting
documentation to determine if the practitioner meets the credentialing criteria prior to approval or denial.
The provider will be notified of the Credentials Committee decision within 30 days.
E. If the Credentialing Committee does not approve a practitioner for credentialing, the practitioner will be
notified of the decision in writing. The practitioner may appeal the decision using the process as
identified in the Fair Hearing Process for Adverse Decisions policy.
The Partnership HealthPlan of California Board of Commissioners retains ultimate responsibility for
final decisions on all appeals related to practitioner credentialing activities.
F. 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 and all required reports to the National
Practitioner Data Bank and the State Medical Board as outlined in MP CR #9A, Reporting to the
Medical Board of California and the National Practitioner Data Bank.
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Policy/Procedure Number: MP CP #6
Lead Department: Provider Relations
Policy/Procedure Title: Error! No text of specified style in ☒ External Policy
document.
☐ Internal Policy
Next Review Date: 04/13/2016
Original Date: 11/01/1998
Last Review Date: 05/13/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
G. The Provider Relations Department is responsible for confidentiality of all practitioner information.
Access to practitioner information verified and/ or stored in an electronic database is confidential and
accessed only by personnel with a unique password. The credentials files and all relevant credentialing
and re-credentialing information are maintained as high level secured documents. Confidentially is
maintained via file storage in locked cabinets and access limited to the Chief Medical Officer or
physician designee / Health Services Director, Provider Relations Department Personnel, and the Quality
Improvement Personnel.
VII.
REFERENCES:
A. NCQA
VIII.
DISTRIBUTION:
A. PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Credentialing Supervisor
X.
REVISION DATES:
02/01/2000, 04/05/2000, 12/13/2000, 08/08/2001, 09/11/2002, 03/12/2003, 03/10/2004, 11/10/2004,
11/09/2005, 07/12/2006, 07/11/2007, 07/09/2008, 09/04/2008, 03/11/2009, 03/10/2010, 03/09/2011,
03/14/2012, 05/14/2014, 08/13/2014
PREVIOUSLY APPLIED TO:
N/A
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