PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MP CR #4
Policy/Procedure Title: Initial Credentialing Requirements
Lead Department: Provider Relations
☒External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
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: 08/12/2015
I.
RELATED POLICIES:
A. N/A
II.
IMPACTED DEPTS:
A. N/A
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. Addendum to CPPA "Notice to Practitioners of Credentialing Rights and Responsibilities."
V.
PURPOSE:
A. To describe the Credentialing Requirements for Medical Doctor (M.D.), Doctor of Osteopathy (D.O.),
Doctor of Podiatric Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Doctor of Dental Surgery (DDS),
Certified Acupuncturist
B. The purpose of the practitioner credentials review is to ensure that participating practitioners possess the
practice experience, licenses, certifications, privileges, professional liability coverage, education, and
professional and other 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. All practitioners or groups of practitioners that have an independent relationship with PHC 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. Primary Care Physicians and OB/GYN Specialist Physician
must have had an office site audit, as defined in the Practitioner Facility Site Review Policy, prior to
having credentials presented to the Credentialing Committee.
Document1
Page 1 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
☒ Medi-Cal
Applies to:
The following types of licensed independent practitioners shall be credentialed:
1.
2.
3.
4.
5.
6.
Medical Doctor (M.D.)
Doctor of Osteopathy (D.O.)
Doctor of Podiatric Medicine (D.P.M.)
Doctor of Chiropractic (D.C.)
Doctor of Dental Surgery (DDS)
Certified Acupuncturist
B. Individual professional practitioners must meet all of the requirements outlined below. All
documentation and information required may not be more than 180 days old at the time of Credentials
Committee review.
1. Medical Doctor (M.D.)
a.
Must submit a completed signed California Participating Physician 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 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 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.
Document1
Page 2 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
2) 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 or limitations on their license from the California State
Medical Licensure Board. 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.
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 copy of 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. Privileges at a JCAHO or HFAP accredited or Medicare verified hospital, primary admitting
facility without restrictions.
h. Practitioners that do not have hospital privileges must have an agreement with a physician or
group. The practitioner must furnish PHC with written verification of this agreement.
Documents are placed in practitioner’s paper file.
i.
For Practitioners that attest to being Board Certified, Board Certification is verified through
ABMS.
j.
Practitioners must 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).
k. A query and documentation is obtained from the NPDB/HIPDB.
l.
Verification of 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
Services (DHS) to PHC.
m. 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.
Document1
Page 3 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
2. Doctor of Osteopathy (D.O.)
a.
Must submit a completed signed California Participating Physician 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 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 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.
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.
2) 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.
The Osteopathic physician must be free of any sanctions or limitations on their license from the
Osteopathic Medical Board of California. 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.
d. Must have professional liability coverage in the amount of $1,000,000 per incident and
$3,000,000 in aggregate.
e.
Document1
Must possess and submit a copy of a current, unrestricted DEA Certificate in order to prescribe
controlled substances.
Page 4 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
f.
Primary source verification of Medical school and residency is verified by the Osteopathic
Medical Board of California prior to issuing a license.
g. Privileges at a JCAHO or HFAP accredited or Medicare verified hospital, primary admitting
facility without restrictions.
h. Practitioners that do not have hospital privileges must have an agreement with a physician or
group. The practitioner must furnish PHC with written verification of this agreement.
Documents are placed in practitioner’s paper file.
i.
For Practitioners that attest to being Board Certified, Board Certification is verified through the
Osteopathic Board.
j.
Practitioners must 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).
k. A query and documentation is obtained from the NPDB/HIPDB.
l.
Verification of 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
Services (DHS) to PHC.
m. Verification of Medicare participation through query of Medicare website, www.medicare.gov
and/or other reporting agency. Verify that Provider has not opted out of Medicare.
3. Doctor of Podiatric Medicine (D.P.M.)
a.
Must submit a completed signed California Participating Physician 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 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 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.
1)
Document1
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
Page 5 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
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.
2) 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.
Podiatrist must be free of any sanctions or limitations on license from the Board of Podiatric
Medicine of California. 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.
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 copy of a current, unrestricted DEA Certificate in order to prescribe
controlled substances.
f.
Primary source verification of Medical school and residency is verified by the Board of
Podiatric Medicine prior to issuing a license.
g. Privileges at a JCAHO or HFAP accredited or Medicare verified hospital, primary admitting
facility without restrictions.
h. Practitioners that do not have hospital privileges must have an agreement with a physician or
group. The practitioner must furnish PHC with written verification of this agreement.
Documents are placed in practitioner’s paper file.
i.
For practitioners that attest to being Board Certified, Board Certification is verified through the
Board of Podiatric Medicine of California.
j.
Practitioner must 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).
k. A query and documentation is obtained from the NPDB/HIPDB.
Document1
Page 6 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
☒ Medi-Cal
Applies to:
l.
Verification of 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
Services (DHS) to PHC.
m. 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.
4.
Doctor of Chiropractic (D.C.)
a.
Must submit a completed signed California Participating Physician 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 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 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.
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.
2) 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.
1)
c.
Document1
Chiropractor must be free of any sanctions or limitations on the license from the California State
Chiropractic Board. 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.
Page 7 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
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 Chiropractic school is verified by the California Chiropractic
Board prior to issuing a license.
f.
Practitioner must 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).
g. A query and documentation is obtained from the (NPDB/HIPDB).
h. Verification of 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
Services (DHS) to PHC.
i.
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. Doctor of Dental Surgery (DDS)
a.
Must submit a completed signed California Participating Physician 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 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 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.
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.
Document1
Page 8 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
2) 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.
The Dentist must be free of any sanctions or limitations on their license from the Dental Board
of California. 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.
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 copy of a current, unrestricted DEA Certificate in order to prescribe
controlled substances.
f.
Primary source verification of Dental school and residency is verified by the Dental Board of
California prior to issuing a license.
g. Privileges at a JCAHO or HFAP accredited or Medicare verified hospital, primary admitting
facility without restrictions.
h. Practitioners that do not have hospital privileges must have an agreement with a physician or
group. The practitioner must furnish PHC with written verification of this agreement.
Documents are placed in practitioner’s paper file.
i.
For practitioners that attest to being Board Certified, Board Certification is verified through the
American Board of Oral/Maxiofacial Surgery.
j.
Practitioner must be free of Medicare/Medi-Cal and or Denti-Cal sanctions. This is done
through a query of the National Practitioner Data Bank/Healthcare Integrity and Protection Data
Bank (NPDP/HIPDB).
k. A query and documentation is obtained from the NPDB/HIPDB.
l.
Verification of 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
Services (DHS) to PHC.
m. 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.
6. Certified Acupuncturist (non-physician)
a.
Document1
Must submit a completed signed California Participating Physician 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
Page 9 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
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 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.
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.
2) 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.
1)
c.
The acupuncturist must be free of any sanctions or limitations on their license from the
California State Acupuncture Board. 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.
d. Must have professional liability coverage in the amount of $1,000,000 per incident and
$3,000,000 in aggregate.
Document1
e.
Primary source verification of completion of acupuncture school is verified by the State of
California Acupuncture Board prior to issuing a license.
f.
Practitioners must 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).
Page 10 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
g. A query and documentation is obtained from the NPDB/HIPDB.
h. Verification of 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
Services (DHS) to PHC.
i.
Physicians providing acupuncture:
In order for a physician to perform acupuncture services for PHC members the physician must
submit documentation of at least 200 hours of formal training in the field of acupuncture and
meet all the PHC credentialing requirements for Medical Doctor (M.D.) or Doctor of
Osteopathy (D.O.)
C. The process for identifying issues in the credentialing, re-credentialing process is identified in the PHC
Review Standards for Credentials, Re-credentials Policy MP CR#5.
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 regarding approval or
denial.
F. 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 Fair Hearing Process for Adverse Decisions policy.
The Partnership HealthPlan of California of Commissioners retains ultimate responsibility for final
decisions on all appeals related to practitioner credentialing activities.
G. If a practitioner's credentialing profile is denied base 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.
H. 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.
I.
Document1
The credentials files and all relevant credentialing and re-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, Health Services Director, 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.
Page 11 of 12
Policy/Procedure Number: MP CR #4
Lead Department: Provider Relations
☒ External Policy
☐ Internal Policy
Next Review Date: 08/10/2016
Last Review Date: 08/12/2015
☒ Healthy Kids
☐ Employees
Policy/Procedure Title: Initial Credentialing Requirements
Original Date: 11/01/1998
Applies to:
☒ Medi-Cal
VII.
REFERENCES:
A. - NCQA
VIII.
DISTRIBUTION:
A. PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Credentialing Supervisor
X.
REVISION DATES:
2/1/2011, 12/13/2000, 7/11/2001, 9/11/2002, 3/12/2003, 3/10/2004, 9/8/2004, 11/10/2004, 11/9/2005,
7/12/2006, 7/11/2007, 7/8/2008, 9/4/2008, 7/8/2009, 7/14/2010, 7/13/2011, 8/8/2012, 10/9/2013, 8/13/2014,
2/11/2015
PREVIOUSLY APPLIED TO:
N/A
Document1
Page 12 of 12