PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MP PR PL CR #401A
Policy/Procedure Title: Initial Credentialing Document Collection,
Review, and Verification for Behavioral Health Practitioners
Lead Department: Provider Relations
☒External Policy
☐ Internal Policy
Next Review Date: 02/10/2016
Last Review Date: 02/11/2015
Original Date: 05/08/2002
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: 02/11/2015
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 procedure for practitioner credentialing document collection, review, and processing for
presentation to the Credentialing Committee. This policy applies to the following practitioners:
Psychiatrists
Psychologists
Licensed Clinical Social Workers (LCSWs)
Marriage Family Therapists (MFTs)
Clinical Nurse Specialist – Psychiatric Mental Health Nurse (PIMH)
VI.
POLICY / PROCEDURE:
A. The Provider Relations Credentialing Specialist or designee mails an application packet to a requesting
practitioner. The packet shall contain a cover letter with instructions for submitting credentialing
information to Partnership HealthPlan of California (PHC), a California Participating Practitioner
Application (CPPA), and a release of information form.
B. The Provider Relations Staff are responsible for monitoring the return of credentialing materials from
practitioners. The Specialist ensures confidentiality of practitioner information by keeping all
documents in locked files. The application is reviewed to determine practitioner type. If a practitioner is
in private practice, the QI Performance Improvement Specialist or designee is notified in order to
schedule an office site visit and review of client treatment record keeping review practices as defined in
the PHC Initial Credentialing Site Review Policy.
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Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
C. Provider Relations Credentialing Specialist assembles the credentials file by reviewing the CPPA to
ensure it is current, completed, signed, dated and accompanied by a current signed release form and all
applicable credentialing information. The application includes disclosure of professional liability
history, a current Curriculum Vitae (CV) and all questions on the Attestation answered “yes” with
written explanation of any exceptions. The applicant’s information is logged into the Credentialing/Recredentialing binder and application and documents are stored in locked file cabinets accessed only by
authorized personnel. If the application and/or the release forms are not current or complete, information
is annotated in the Credentialing/Re-credentialing log, a letter is generated identifying missing
information, attached to the application packet, and returned to the practitioner. All subsequent contact
with the practitioner is documented and maintained on file. All required verification of documentation
and information may not be more that 180 calendar days old at the time of the Credentialing Committee
decision.
The following verification is done for each file: 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.
1. Psychiatrists (M.D.)
a.
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.
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:
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Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
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.
b. Verification of State License is done via website to the California State Medical Licensure
Board. This information is entered into the credentialing database. A print out of license
verification is placed in the practitioner’s credentials file.
c.
Physician must be free of any sanctions or limitations on their license from the California State
Medical Licensure Board. This will be done at the time the license is verified.
d. Must have professional liability (malpractice insurance) 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.
Must possess a current unrestricted DEA Certificate in order to prescribe controlled substances.
Verification of current DEA will be done with NTIS via website. This information is entered
into credentialing database. A print out of NTIS verification is placed in the practitioner's
credentials file.
f.
Primary source verification of Medical school is verified by the Medical Board of California
(MBOC) prior to issuing a license and by virtue of issuing a license, this criteria is fulfilled. A
letter from the State Licensing Board verifying this process is on file with PHC. PHC may also
verify physician data by searching the AMA Physician Profile via a secure website. If
practitioner is not Board Certified, a letter from the residency program documenting completion
of the three (3) year program will verify residency.
g. If the practitioner indicates Board Certification, Board Certification is verified electronically
through the American Board of Medical Specialties (ABMS). The information is entered into
the database. A copy of the ABMS verification is placed in the practitioner’s credentials file
and reflected on the practitioner’s profile sheet.
h. Practitioner must be free of Medicare/Medi-Cal sanctions. This will be verified by query of the
National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank
(NPDB/HIPDB).
i.
A query from the NPDB/HIPDB via website is documented and added to the practitioner file.
Claims history will be reviewed. The hard copy printout is filed in the practitioner’s credentials
file.
j.
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 Care
Services (DHCS) 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.
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Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
l.
The Credentialing Specialist reviews file to ensure all documents are verified and forwards file
to the Provider Relations Auditor for the final review process.
2. Psychologist
a.
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.
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.
b. Verification of State License is done via website with the California State Medical Licensure
Board. This information is entered into the credentialing database. A print out the license
verification sheet is filed in the practitioner’s credentials file.
c.
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The Psychologist must be free of any sanctions or limitations on their license from the
California Board of Psychology. This is identified at the time the license is verified.
Page 4 of 11
Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
d. Must have professional liability (malpractice insurance) coverage in the amount of $1,000,000
per incident and $1,000,000 in aggregate. Practitioner must submit a current copy of
malpractice coverage. The copy is retained in practitioner’s credentials file.
e.
Primary source verification of Professional Education and internship is verified by the Board of
Psychology, Medical Board of California prior to issuing a license and by virtue of issuing a
license, this criteria is fulfilled. A letter from the State Licensing Board verifying this process is
on file with PHC. If letter not available from Board, PHC will primary source verify education
by contacting the professional school of education.
f.
Practitioner must be free of Medicare/Medi-Cal sanctions. This will be verified by a query of
the National Practitioners Data Bank/Healthcare Integrity and Protection Data Bank
(NPDB/HIPDB).
g. A query from the NPDB/HIPDB via website is documented and added to the practitioner file.
Claims history will be reviewed. If information is found through the NPDB/HIPDB search, it is
noted on the practitioner’s profile sheet. The hard copy printout is filed in the practitioner’s
credentials file.
h. Verification of Medi-Cal status (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) Department of Health Care Services (DHCS)
to PHC.
i.
Verification of participation through query of Medicare website www.medicare.gov and/or other
reporting agencies. Verify that the Provider has not opted out of Medicare.
j.
The Credentialing Specialist reviews file to ensure all documents are verified and forwards file
to the Provider Relations Auditor for the final review process. Once this review process is
completed, the PHC Provider Profile is printed and placed on the left hand side of the
practitioner’s credentials file.
3. Licensed Clinical Social Worker (LCSW)
a.
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.
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
Document1
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Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
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.
b. Verification of State License is done via website with the State Licensure Board. The
information is entered into the credentialing database. The verification form is filed in the
practitioner’s credentials file.
c.
LCSW must be free of any sanctions or limitations on license from the Board of Behavioral
Science. This is identified at the time the license is verified.
d. Must have professional liability (malpractice insurance) coverage in the amount of $1,000,000
per incident and $1,000,000 in aggregate. Practitioner must submit a current copy of
malpractice coverage. The copy is retained in the practitioner’s credentials file.
e.
Primary source verification of professional school training and residency is verified by the
Board of Behavioral Science prior to issuing a license and by virtue of issuing a license, this
criteria is fulfilled. A letter from State Licensing Board verifying this process is on file with
PHC. If letter not available from Board, PHC will primary source verify education by
contacting the professional school of education.
f.
Practitioners must be free of Medicare/Medi-Cal sanctions. This will be verified by a query of
the National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank
(NPDB/HIPDB).
g. A query from the NPDB/HIPDB via website is documented on the practitioner’s profile sheet.
Claims history will be reviewed. The hard copy printout is filed in the practitioner’s credentials
file.
h. Verification of Medi-Cal status (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) Department of Health Care Services (DHCS)
to PHC.
Document1
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Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
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.
j.
The Credentialing Specialist reviews file to ensure all documents are verified and forwards file
to the Provider Relations Auditor for the final review process. Once this review process is
completed, the PHC Provider Profile is printed and placed on the left hand side of the
practitioner’s credentials file.
4. Marriage Family Therapist (MFT)
a.
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.
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.
b. Verification of State License is done via website with the State Licensure Board. The
information is entered into the credentialing database. The verification form is filed in the
practitioner’s credentials file
Document1
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Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
c.
MFT must be free of any sanctions or limitations on the license from the California State BBS.
This is identified at the time the license is verified.
d. Must have professional liability coverage in the amount of $1,000,000 per incident and
$1,000,000 in aggregate. Practitioner must submit a current copy of malpractice coverage. The
copy is retained in practitioner’s credentials file.
e.
Primary source verification of professional school training is verified by the California BBS
prior to issuing a license and by virtue of issuing a license, this criteria is fulfilled. A letter from
the State Licensing Board verifying this process is on file with PHC. If letter not available from
Board, PHC will primary source verify education by contacting the professional school of
education.
f.
MFT must be free of MediCare/Medi-Cal sanctions. This will be verified by a query of the
National Practitioner Data Bank/Healthcare Integrity Protection and Data Bank
(NPDB/HIPDB).
g. A query from the NPDB/HIPDB via website is documented on the practitioner’s profile sheet.
Claims history will be reviewed. The hard copy print out is filed in the practitioner’s credentials
file.
h. Verification of Medi-Cal status (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) Department of Health Care Services (DHCS)
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.
j.
The Credentialing Specialist reviews file to ensure all documents are verified and forwards file
to the Provider Relations Auditor for the final review process. Once this review process is
completed, the PHC Provider Profile is printed and placed on the left hand side of the
practitioner’s credentials file.
5. Clinical Nurse Specialist – Psychiatric Mental Health Nurse (PIMH)
a.
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.
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
Document1
Page 8 of 11
Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
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.
Verification of State License is done via website with the State Licensure Board. This
information is entered into the credentials database. The verification document is filed in the
practitioner’s credentials file.
b. CNS, PIMH must be free of any sanctions or limitations on the license from the California
Board of Registered Nurses, (CBORN). This is identified at the time the license is verified.
c.
Have professional liability coverage in the amount of $1,000,000 per incident and $3,000,000 in
aggregate. The copy is retained in the practitioner’s credentials file.
d. 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.
e.
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).
f.
A query from the NPDB/HIPDB via website is documented and added to the practitioner’s file.
The hard copy print out is filed in the practitioner’s credentials file.
g. Verification of Medi-Cal status (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) Department of Health Care Services (DHCS)
to PHC.
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.
Document1
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Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
i.
The Credentialing Specialist reviews file to ensure all documents are verified and forwards file
to the Provider Relations Auditor for the final review process. Once this review process is
completed, the PHC Provider Profile is printed and placed on the left hand side of the
practitioner’s credentials file.
D. If discrepancies are identified during the file review and documentation process, the practitioner is
immediately notified. Notification will be done in writing. The practitioner is given an opportunity to
review all information related to credentialing, correct any errors and/or provide clarification.
E. The Provider Relations Specialist is responsible for the final audit review of the practitioner’s credentials
file. Complete review of file to ensure all required documents are current, valid, and dates verification
do not exceed 180 calendar days from date the application is signed by practitioner.
1. Document any exceptions or potential exception issues and flag specific issues for the Chief Medical
Officer’s review.
Issues or potential Issues for Chief Medical Officer or physician designee include:
a.
Any response on the Provider Application Attestation Questionnaire that denotes practitioner
has not met requirements.
b. Three (3) malpractice cases that have an incident date within the past five (5) consecutive years.
c.
One (1) malpractice case over $100,000 settled within the past five (5) consecutive years.
d. Any cases found through inquiry of the NPDB.
e.
Refusal to comply with a Corrective Action Plan based on a facility site or Medical chart audit,
or non-compliance with Peer Review Committee recommendations.
f.
Practitioner appears on the Medi-Cal Sanction Report, lists of parties Excluded from Federal
Procurement and Non Procurement Program, Medi-Cal Participation Exclusion Report, or the
Medical Board Hot Sheet Report.
g. Member complaints exceed threshold.
2. If there are exceptions as defined in sections a., the file is forwarded to the Chief Medical Officer or
physician designee for review.
3. Perform final function by developing a report-identifying file for Credentialing Committee as:
a.
Routine Review: Practitioner meets all PHC Credentialing Criteria.
b. Committee Review: Practitioner file does not meet all PHC Credentialing criteria, the file must
be reviewed by Credentialing Committee based on review by Chief Medical Officer or
physician designee
F. Completed files are maintained in a locked file cabinet and forwarded to the Credentialing Committee at
the next meeting for review and decision.
Document1
Page 10 of 11
Policy/Procedure Number: MP PR PL CR #401A
Lead Department: Provider Relations
Policy/Procedure Title:
Initial Credentialing Document
☒ External Policy
Collection, Review, and Verification for Behavioral Health
☐ Internal Policy
Practitioners
Next Review Date: 02/10/2016
Original Date: 05/08/2002
Last Review Date: 02/11/2015
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
G. The Credentialing Committee is presented a list of practitioners that meet all Credentialing Criteria and
identifies practitioners that have exceptions. The practitioner files are also presented for review and
decision to the Credentialing Committee. Each practitioner file is covered with a report which includes:
Practitioner Name
Degree
Specialty
Board Certification Status
Hospital Privileges
Malpractice Claims
Committee Action
Exceptions (if any)
Other (field used to flag memos)
H. The Provider Relations Specialist is responsible for confidentiality of all practitioner information.
Access to practitioner information is filed in locked file cabinets and accessed only by Provider
Relations and QI personnel. After the Credentials meeting, all lists, reports, and loose documents that
are not part of a permanent file are shredded. Practitioner files are returned to locked file cabinets.
I.
Once the practitioner has been presented to the Credentialing Committee and has been approved as a
practitioner in PHC’s Network, the practitioner information is entered into the information system to
enable referrals, authorization of services and claims adjudication.
J.
If a practitioner has been “flagged” for re-evaluation by the Committee, the practitioner file is noted and
the date for resubmission is entered into the credentialing log. Verification dates, practitioner’s signature
and date may not be more than 180 days old at the time reviewed by Credentialing Committee.
K. A letter communicating the Credentialing Committee decision will be mailed to the practitioner within
30 days of the decision.
VII.
REFERENCES:
A. - NCQA
VIII.
DISTRIBUTION:
A. - PHC Provider Manual
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Credentialing Supervisor
X.
REVISION DATES:
5/8/2002, 8/14/2002, 3/12/2003, 3/10/2004, 2/9/2005, 2/8/2006, 7/12/2006, 7/11/2007, 7/9/2008, 9/4/2008,
7/8/2009, 7/14/2010, 7/13/2011, 8/8/2012, 10/9/2013, 9/10/14
PREVIOUSLY APPLIED TO:
N/A
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