PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MP CR #10
Policy/Procedure Title: Organizational Providers Assessment
Criteria
Lead Department: Provider Relations
☒External Policy
☐ Internal Policy
Next Review Date: 09/14/2016
Last Review Date: 09/09/2015
Original Date: 12/01/1998
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: 09/09/2015
I.
RELATED POLICIES:
A. N/A
II.
IMPACTED DEPTS:
A. Provider Relations
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. N/A
V.
PURPOSE:
To describe the process of the initial and ongoing assessment of contracted organizational providers which
include hospitals, skilled nursing facilities, free-standing surgical centers and home health agencies, acute
rehab facility behavioral health Care/Substance Abuse Providers and Community Based Adult Services
(CBAS).
VI.
POLICY / PROCEDURE:
The purpose of this review is to ensure the organizations are in good standing with State and Federal
regulatory bodies, and are accredited by a recognized accrediting organization or meet the Partnership
HealthPlan of California (PHC) policy requirements for compliance with NCQA, DHCS, DMHC and
CMS standards.
Organizational providers are required to submit licensure and accreditation documents to PHC prior to
contracting. The organizational provider will go through a re-credentialing process every three years
thereafter. At the time of re-evaluation, the PHC Credentialing Worksheet will be forwarded to the Peer
Review Lead to verify the status of any potential quality of care issues. Any items identified will be
forwarded to the PHC Chief Medical Officer and/or Credentials Committee Chairperson for review. This
policy applies but is not limited to the following organizational providers:
1.
2.
3.
4.
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Hospital
Skilled Nursing Facility
Free-Standing Surgical Center
Home Health Agency/Hospice Provider
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Policy/Procedure Number: MP CR #10
Lead Department: Provider Relations
Policy/Procedure Title: Organizational Providers Assessment ☒ External Policy
Criteria
☐ Internal Policy
Next Review Date: 09/14/2016
Original Date: 12/01/1998
Last Review Date: 09/09/2015
☐ Healthy Kids
☐ Employees
Applies to: ☐ Medi-Cal
5. Acute Rehab Facility
6. Behavioral Health Care/Substance Abuse Providers
7. Community Based Adult Services (CBAS)
All providers must meet the requirements as outlined below. All documents and information may not be
more than 180 days old at the time of final approval. A report of those providers that meet the
requirements is forwarded to the Credentialing Committee for review and approval.
A. Hospitals
1. Copy of a current Accreditation from one of the following:
a. The Joint Commision (TJC)
b. HFAP (Healthcare Facilities Accreditation Program)
c. DNV▪GL (Det Norske Veritas)
d. CIHQ (Center for Improvement in Healthcare Quality)
2. If facility is not Accredited PHC will accept a copy of a current CMS or State review (within 3
years). If the site does not have a current CMS or State review PHC will conduct an onsite quality
assessment.
3. Copy of a valid State License
4. Copy of a current Liability Coverage Certificate
5. Verify has current Medi-Cal License Number.
6. Verification of Medicare participation.
B. Skilled Nursing Facilities/Long Term Care Facility
1. Copy of a current TJC Accreditation
2. If facility is not Accredited PHC will accept a copy of a current CMS or State Review (within 3
years) if the site is not accredited. If the site does not have a current CMS review PHC will conduct
an onsite quality assessment.
3. Copy of a valid State License
4. Copy of a current Liability Coverage Certificate
5. Verify has current Medi-Cal License Number.
6. Verification of Medicare participation.
C. Free-Standing Surgical Center
1. Copy of a current Accreditation from
a. TJC
b. AAAHC (Accreditation Association for Ambulatory Health Care)
2. If facility is not Accredited, PHC will accept a copy of a current CMS or State Review (within 3
years) if the site is not accredited. If the site does not have a current CMS review PHC will conduct
an onsite quality assessment.
3. Copy of a valid State License
4. Copy of a current Liability Coverage Certificate
5. Verify has current Medi-Cal License Number.
6. Verification of Medicare participation.
D. Home Health Agencies/Hospice Providers
1. Copy of a current Accreditation from
a. TJC
b. CHAP (Community Health Accreditation Program)
c. ACHC (Accreditation Commission for Health Care)
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Policy/Procedure Number: MP CR #10
Lead Department: Provider Relations
Policy/Procedure Title: Organizational Providers Assessment ☒ External Policy
Criteria
☐ Internal Policy
Next Review Date: 09/14/2016
Original Date: 12/01/1998
Last Review Date: 09/09/2015
☐ Healthy Kids
☐ Employees
Applies to: ☐ Medi-Cal
2. If provider is not Accredited PHC will accept a copy of a current CMS or State Review (within 3
years). If the site does not have a current CMS review PHC will conduct an onsite quality
assessment. Copy of a valid State License
3. Copy of current Liability Coverage Certificate
4. Verify has current Medi-Cal License Number.
5. Verification of Medicare participation.
E. Acute - Rehab Facility
1. Copy of current Accreditation from
a. TJC
b. CARF (Commission on Accreditation of Rehabilitation Facilities)
2. If facility is not Accredited PHC will accept a copy of a current CMS or State Review (within 3
years) if the site is not accredited. If the site does not have a current CMS review PHC will conduct
an onsite quality assessment.
3. Copy of valid and current Accreditation State License
4. Copy of a current Liability Coverage Certificate
5. Verify has current Medi-Cal License Number.
6. Verification of Medicare participation.
F. Behavioral Health Care/Substance Abuse Providers
1. Copy of a valid State License
2. Copy of current Liability Coverage Certificate
3. Verify has current Medi-Cal License Number.
4. Verification of Medicare license.
5. A Facility Site Review (FSR) with a score ≥80%.This review is not repeated.
G. Community Based Adult Services (CBAS)
1. Copy of a valid State License
2. Copy of current Liability Coverage Certificate
3. Copy of CBAS approval from DHCS
If at the time of re-evaluation, the organization's TJC or CMS review has not been completed, the
HealthPlan will require in writing, the scheduled date of the next survey and that information will be
presented to the Credentials Committee. PHC will follow-up to insure compliance based on that date.
PHC recognizes industry survey scheduling delays, and the HealthPlan will monitor the timeliness of
compliance. PHC Credentials Committee will review the organizational provider again, when all current
documents are received.
VII.
REFERENCES:
A. - NCQA, DHCS, DMHC, CMS
Enter N/A if not applicable
VIII.
DISTRIBUTION:
A. - PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Credentialing Supervisor
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Policy/Procedure Number: MP CR #10
Lead Department: Provider Relations
Policy/Procedure Title: Organizational Providers Assessment ☒ External Policy
Criteria
☐ Internal Policy
Next Review Date: 09/14/2016
Original Date: 12/01/1998
Last Review Date: 09/09/2015
☐ Healthy Kids
☐ Employees
Applies to: ☐ Medi-Cal
X.
REVISION DATES:
2/1/200, 4/5/2000, 6/7/2000, 2/14/2001, 2/13/2002, 9/11/2002, 5/14/2003, 3/10/2004, 2/9/2005, 10/12/2005,
7/12/2006, 7/11/2007, 7/9/2008, 7/8/2009, 7/14/2010, 7/13/2011, 1-11-2012, 9/12/2012, 9/11/2013,
9/10/2014
PREVIOUSLY APPLIED TO:
N/A
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