Credentialing and Recredentialing Policies

Credentialing is the process of obtaining, verifying, and assessing the qualifications of a healthcare provider in order to provide patient care services. Credentials are documented evidence of licensure, education, training, experience, or other qualifications. It allows members to confidently place their trust in their chosen healthcare providers.

PURPOSE

Provide a mechanism by which to obtain, verify, review, and evaluate a licensed practitioner’s professional credentials, qualifications and other criteria to determine whether the practitioner should be approved to provide health care services to Embright members.  

POLICY

Only licensed practitioners who are professionally competent and continuously meet the credentials, standards, and requirements established by Embright shall be approved to provide health care services to its members.  

DEFINITION

The scope of this policy and procedure shall apply to all contracted independent, licensed practitioners to whom Embright members are directed for medical care and services.  

Licensed practitioner is defined as physicians (MD, DO), nurse practitioners (CRNA, ARNP, CNM, FNP), optometrists (OD), physician assistants (PA), podiatrists (DPM), chiropractors (DC), oral surgeons (DDS, DMD), Pharmacists (PharmD),  Masters in Social Work (LCSW, MSW), acupuncturists (LAc), physical therapists (PT),  and any other independent, licensed practitioner as required by law and/or licensure who are authorized and approved to provide medical care services to Embright members.  

The scope of this policy does not include licensed practitioners who exclusively practice within the inpatient hospital setting or provide care only as a result of members being directed to a contracted hospital or other inpatient setting or other organizational provider setting and see members only as a result of members being directed to the facility.  

PROCEDURE

Governing Body and Credentialing Committee

1.    The Clinical Integration Committee (governing body) retains ultimate accountability for the quality of care and service received by its members.  The governing body delegates the responsibility, accountability and oversight of the peer review, credentialing, and recredentialing, to its Credentialing Committee.  

2.    The Credentialing Committee is the formal committee that has the responsibility for reviewing the effectiveness of the credentialing program and oversight of any delegation activity.  The Credentialing Committee is accountable to the governing body and, as such, reports credentialing activity to the governing body on a regular basis.  The Credentialing Committee shall consist of a Chairperson and a minimum of four additional participating Embright physician members, including both primary care physicians and specialists.  A list of the Credentialing Committee members and their specialties is included in this policy and procedure in Attachment A.  The Credentialing Committee meets no less than every three months.  

3.    The Credentialing Committee performs activities to monitor, evaluate and improve the quality of care of Embright members.  The Credentialing Committee also performs credentialing and recredentialing activities designed to evaluate a licensed practitioner’s professional credentials and qualifications. The Credentialing Committee is responsible for:

3.1.    review and approval of credentialing policies and procedures;

3.2.    review and approval or denial of clean Category 1 credentialing and recredentialing applications;

3.3.    review and recommendation of approval or denial of ‘exception’ (Category 2) credentialing and recredentialing applications; 

3.4.    making participation decisions on licensed practitioners, including, but not limited to restriction and suspension, and making termination recommendations; and

3.5.    peer review of member complaints and quality of care concerns identified between recredentialing cycles and taking appropriate action. 

Embright’s Chief Medical Officer serves as Chairperson of the Credentialing Committee and is directly accountable for the credentialing program. Embright utilizes a comprehensive cover page for all initial and recredentialed files. Embright’s Chief Medical Officer signs off on all file cover pages which represents the file to be complete and in accordance with all NCQA criteria. The credentialing file cover page is reevaluated annually in accordance with NCQA guidelines. All changes will be reviewed by the Chief Medical Officer and approved through the Credentialing Committee.   Files meeting Category 1 criteria outlined in this policy and procedure may be reviewed and approved by the Chief Medical Officer, and then no longer require review by the Credentialing Committee.  The Chief Medical Officer’s signature signifies the file is complete, clean, and approved. 

4.    Non-Discrimination:  Age, sex, religion, race, creed, color or national origin, types of procedures or types of patients shall not be considered by Embright in determining a licensed practitioner’s qualifications to provide health care services to Embright members.  To monitor and prevent discrimination:

4.1.    Credentialing Committee members shall sign, on an annual basis, a statement affirming they do not discriminate when they make credentialing and recredentialing decisions.

4.2.    Sr Provider Network Manager will monitor member and licensed practitioner complaints regarding possible discrimination at least annually.  Sr. Provider Network Manager will research the issue thoroughly and if it is found to have merit, the issue will be brought to the Credentialing Committee for review.  

Network and Business Needs

Embright’s network and other business needs shall be considered, along with the licensed practitioner’s professional credentials and qualifications, in making decisions whether to approve or deny the practitioner to provide health care services to Embright members.  

Embright Discretion

The credentialing criteria, standards and requirements set forth in this Policy and Procedure are not intended to limit Embright’s discretion in any way or create rights on the part of licensed practitioners who seek to provide health care services to Embright members.  

Confidentiality

Embright shall maintain the confidentiality of all licensed practitioners protected health information as required under the privacy standards of the Health Insurance Portability Act and all information obtained about licensed practitioners in the credentialing and recredentialing process as required by law.  Embright shall implement procedures and safeguards to ensure that the confidentiality of all licensed practitioners credentialing and recredentialing information and files is maintained.  Only Embright credentialing staff, Chief Medical Officer, Credentialing Committee members and other authorized persons who must have access to confidential licensed practitioner credentialing and recredentialing information in order to perform their functions relating to this Policy and Procedure shall have access to such information.  Embright shall not disclose confidential licensed practitioner credentialing and recredentialing information to any person or entity except with the written permission of the licensed practitioner or as otherwise permitted or required by law.

Delegated Activities

Embright may delegate primary source verification to a Credentialing Verification Organization (CVO).  Any such delegation will be described in an executed Credentialing Delegation Agreement with the CVO.  Embright shall continuously monitor and oversee the appropriateness and effectiveness of the CVO’s performance of the delegated credentialing and recredentialing functions.  Embright reserves the right to approve, deny, terminate, or suspend individual licensed practitioners.  If the CVO is certified by the National Committee for Quality Assurance (NCQA) in all applicable elements, no oversight is required by Embright.  

Periodic Review

The Credentialing Committee shall review and revise this Policy and Procedure as necessary and no less than annually in order to maintain compliance with the credentialing and recredentialing standards of contracted health plans, NCQA and any applicable federal or state regulatory requirements.  

Criteria for Providing Health Care Services to Embright Members

All licensed practitioners will be reviewed against the following criteria and qualifications established by Embright:

1.    The licensed practitioner is currently licensed or certified, without restrictions, to practice in the state where he/she will provide care to Embright members.  

2.    The licensed practitioner has a current valid Drug Enforcement Agency (DEA) certificate, if applicable.

3.    The licensed practitioner has graduated from an acceptable medical school or training program in his/her profession.  Physicians have completed post-graduate programs.  

4.    If a Primary Care Provider has completed post-graduate training during or after 1988, it is recommended he/she become certified, consistent with his/her current practice, by a board approved by the American Board of Medical Specialties or The American Osteopathic Association.  

5.    If a Consulting Specialist has completed post-graduate training during or after 1988, it is recommended he/she become certified, consistent with his/her current practice, by a board approved by the American Board of Medical Specialties or The American Osteopathic Association.  

6.    Non-physician licensed practitioners are excluded from criteria 4 and 5.

7.    The licensed practitioner has professional liability insurance in the minimum amounts of $1,000,000 per occurrence/$3,000,000 in the aggregate, covering the procedures and/or services the licensed practitioner expects to perform as a provider of health care services to Embright members, as attested to by the practitioner.  

8.    The licensed practitioner has on-call practice coverage in place to cover urgent and emergent care when the practitioner is not available.  

9.    The licensed practitioner has current clinical privileges in good standing or appropriate inpatient coverage arrangements, as applicable, as attested to by the practitioner.  

10.    The licensed practitioner has a satisfactory history with respect to state and federal licensing agencies; hospital medical staff membership; clinical privileges at any facility; Medicare, Medicaid, or any public program; professional society membership or fellowship; participation/membership in an HMO, PPO, IPA, PHO or other entity; and academic appointments.  

11.    The licensed practitioner has a satisfactory history with respect to employment.

12.    The licensed practitioner has a satisfactory history with respect to malpractice claims, both pending and closed.  

13.    The licensed practitioner has not engaged in conduct that violates state law or standards of ethical conduct governing the practice of his/her profession, as attested to by the practitioner.  

14.    The licensed practitioner has adequate physical and mental health status (subject to any necessary reasonable accommodation), as attested to by the practitioner.

15.    The licensed practitioner lacks impairment due to chemical dependency/substance abuse as attested to by the practitioner.  

16.    The licensed practitioner has not been convicted of or committed a felony or other act involving dishonesty, fraud, deceit or misrepresentation that could have been related to or have an impact on their professional practice, as attested to by the practitioner.  

17.    The licensed practitioner demonstrates the ability and willingness to deliver quality and efficient medical care.  

18.    The licensed practitioner demonstrates the ability to participate in and properly discharge Embright responsibilities, including adherence to Embright’s peer review/credentialing, utilization management, and quality improvement programs.  

19.    The licensed practitioner demonstrates the ability to work harmoniously and cooperatively with other Embright practitioners and administrative personnel.  

Credentialing Process

1.    Credentialing Application Form

1.1.    The licensed practitioner must submit a completed, signed and dated credentialing application form to Embright.  The practitioner shall provide all information requested on the application form and any other information that may be requested by Embright.  

1.2.    The application form shall include the following information, documentation, items, or statements/attestations from the licensed practitioner:

1.2.1    A current valid state professional license;

1.2.2    Clinical privileges in good standing at the hospital designated by the licensed practitioner as the primary admitting facility, as applicable.  Embright must be notified of inpatient coverage arrangement for all practitioners who do not have documented hospital admitting privileges.  

1.2.3    A valid Drug Enforcement Agency (DEA) or Controlled Dangerous Substance (CDS) certificate, as applicable, and whether such certificate(s) have ever been suspended, revoked, or limited;

1.2.4    Graduation from medical school (or other applicable professional school) and completion of a residency, as applicable:  

  • MD and DO:  graduation from medical school and completion of residency training.  
  • ARNP:  graduation from nursing school and completion of post-graduate specialty training.  
  • PA:  graduation from college with a bachelor’s degree in science and graduate specialty training.  
  • DC:  graduation from accredited chiropractic college.  
  • DDS:  graduation from dental school and completion of specialty training, as applicable.  
  • DPM:  graduation from podiatry school and completion of a residency, as applicable.  
  • OD:  graduation from optometry college.
  • Non-physician licensed practitioner:  graduation from professional school and completion of any special training, as applicable to or required by a practicing specialty.  

1.2.5    Board certification, if applicable;

1.2.6    Work history for at least the past five (5) years;

1.2.7    Current, adequate malpractice insurance in the amounts required by Embright, as stated in this policy, Section 7, Criteria for Providing Health Care Services to Embright Members”;

1.2.8    Professional liability claims history for, at a minimum, the past five (5) years, with detail of any claims/lawsuits that resulted in settlements or judgments paid by or on behalf of the licensed practitioner, as well as the outcome (if the suit or claim has been resolved);

1.2.9    A statement by the licensed practitioner regarding lack of physical or mental impairment that would substantially impede the practitioner’s ability to carry out the scope of his or her duties on behalf of Embright. 

1.2.10    A statement by the licensed practitioner regarding lack of present illegal drug use;

1.2.11    A statement by the licensed practitioner regarding history of loss or limitation of professional license and/or felony convictions;  

1.2.12    A statement by the licensed practitioner regarding history of loss or limitation of privileges or disciplinary activity;

1.2.13    A signed attestation by the licensed practitioner of the correctness and completeness of the application dated within prior 180 days; and 

1.2.14    A signed consent and release form  dated within the previous 180 days.  

1.3    By completing a credentialing application, the licensed practitioner:

1.3.1    Authorizes Embright to consult with other managed care companies, hospitals or other health care facilities, persons or entities who have been associates with him or her and/or who may have information bearing on his or her competence and qualifications or that is otherwise relevant to the pending review.  

1.3.2    Consents to the inspection and copying, by Embright or of all records or documents that may be relevant to the pending review, including medical records.  

1.3.3    Releases from any and all liability Embright and its officers, directors, employees, representatives, and agents (including without limitation, the members of the Credentialing Committee) for acts performed in connection with evaluating the licensed practitioner’s application.  

1.3.4    Releases from any and all liability all individuals and organizations who provide information concerning the licensed practitioner, including otherwise privileged or confidential information, to Embright representatives.  

1.3.5    Signifies his or her willingness to abide by all conditions applicable to Embright licensed practitioners, as may be stated on the credentialing application, in this Policy and Procedure for the Credentialing and Recredentialing of licensed practitioners, the Embright Provider Agreement or the Provider Manual.  

1.4    Embright's Credentialing Staff will promptly notify a licensed practitioner of any problems regarding an incomplete credentialing application.  If the practitioner does not provide the missing information within ten (10) business days of the request, the application will be returned to the applicant as incomplete.  

1.5    Embright’s credentialing staff will promptly notify a licensed practitioner of any difficulty in collecting requested information.  

1.6    Falsification of the credentialing application may result in denial of the licensed  practitioner’s participation in Embright’s network.  

2.    Credentials File

2.1.    Embright shall maintain a credentials file for each licensed practitioner and shall ensure the confidentiality of all information obtained in the credentialing process as described in this policy and procedure, under “Confidentiality.”

2.2.    The credentials file shall be organized in a standardized format.  

2.3.    The credentials file shall include at a minimum:  

2.3.1    a completed, signed and dated credentialing application, as described in this policy, “Credentialing Application Form”;

2.3.2    a signed and dated consent/release form;

2.3.3    evidence of primary source verification as specified in Attachment B of this policy.  

3.    Primary Source Verification

Upon receipt of a completed credentialing application, Embright credentialing staff or CVO staff shall review for completeness.  For purposes of this Policy and Procedure, “verify” or “verification” shall mean confirmation and evidence from the issuing source or designated monitoring entity of the requested information.  The licensed practitioner’s professional credentials and qualifications are verified through sources of verification as outlined in Attachment B.  

4.    Credentialing Committee Action on the Application

4.1.    Review of the Application: Upon receipt of the completed credentialing application and verification of the credentialing information, the credentialing staff shall perform a comprehensive audit of the application and supporting documentation.  The information will be evaluated according to the established criteria.

4.1.1    Category 1 Initial Applications:  Initial applications meeting in all ways Embright’s established criteria under the above Section “Criteria for Providing Health Care Services to Embright Members” will be considered clean Category 1 initial applications.  Category 1 files may be reviewed and approved by the Chief Medical Officer and/or Credentialing Committee.  

4.1.2     Category 2 Initial Applications:  Initial applications that do not meet all of Embright’s established criteria under the above Section “Criteria for Providing Health Care Services to Embright Members” will be considered Category 2 applications.  Category 2 files may be reviewed by the Chief Medical Officer and Credentialing Committee. 

4.2.    A list of licensed practitioners shall be presented at the Credentialing Committee meeting.  The Credentialing Committee shall review the information contained in the credentialing files.  Committee discussion will be documented in its meeting minutes. The Credentialing Committee may request that further information be obtained from any persons or organizations, including the licensed practitioner, in order to assist the committee with the evaluation process.  The Credentialing Committee may defer consideration of the application for up to ninety (90) days.  This deferral shall not constitute grounds for appeal.  

4.3.    The Credentialing Committee may, but is not required to, personally interview the licensed practitioner and address any questions that may have arisen about the application.  

4.4.    Upon completion of its review and evaluation of all of the licensed practitioner’s credentialing information, including health status, and all verifications of credentialing information from primary sources, the Credentialing Committee shall approve or deny Category 1 and Category 2 initial applications.  Licensed practitioners will be notified within 60 calendar days of the Credentialing Committee credentialing decision.  

4.5.    Licensed practitioners may not provide care to members until a final decision has been made by the Credentialing Committee.  On or after the date of application, a practitioner may receive reimbursement for services rendered to an Embright member prior to the Credentialing Committee’s final decision.  If the Credentialing Committee takes adverse action on the practitioner’s application, practitioners may no longer provide care to Embright members until their application status is corrected.

Recredentialing Process

Recredentialing shall mean the formal process, through which Embright updates, re-verifies and reviews all pertinent licensed practitioner credentialing information and qualifications over the previous thirty six months (36) through multiple sources in order to determine whether to approve the licensed practitioner’s continued provision of health care services to Embright members.  Embright shall identify and evaluate any changes in the practitioner’s license, clinical privileges, training, experience, current competence, or the health status that may affect the licensed practitioner’s ability to perform the services he or she is providing to Embright members.  Recredentialing shall be conducted at least every thirty-six (36) months.  

1.    Recredentialing Application Form

1.1.    Embright will mail the recredentialing application including the Attestation and Release thirty-two (32) months after the licensed practitioners last credentialing cycle or request the application be provided through One Health Port/Provider Source or CAQH.  The recredentialing application form shall request updates to any information that has changed since the practitioner was last credentialed or recredentialed.

1.2.    The licensed practitioner must complete, sign, and return the recredentialing application, including copies of license, DEA, and malpractice insurance certificate, to Embright within thirty (30) days.  If the application is not received within thirty (30) days, a follow up phone call and second request will be sent out thirty (30) calendar days after the first request.  If the application is still not received, a third request will be sent out by the Chief Medical Officer fifteen (15) calendar days after the second request.  This letter will notify the licensed practitioner that the Credentialing Committee will review his/her file at the next Credentialing Committee meeting and may recommend termination as non-responsive.  

1.3.    By completing a recredentialing application, the licensed practitioner signifies his or her continuing agreement to abide by all of Embright’s policies and procedures, including this Policy and Procedure.  

1.4.    If the licensed practitioner is on active military assignment, maternity leave, or a sabbatical and cannot be reached to supply recredentialing information, but the contract remains in place, Embright may recredential the licensed practitioner upon his or her return. Embright will document the reason for being past three (3) years or thirty-six (36) months in the licensed practitioner’s file. The licensed practitioner’s recredentialing will be completed within sixty (60) calendar days of his or her return to work.  Upon return to work Embright will confirm, at a minimum, valid licensure while his or her recredentialing is in process.

2.    Collection and Verification of Information

2.1.    Upon receipt of a completed recredentialing application, the licensed practitioner’s professional credentials and qualifications are re-verified through sources of verification, as outlined in Attachment B.  

2.2.    The Embright credentialing staff will promptly notify the licensed practitioner of problems regarding an incomplete recredentialing application, difficulty collecting requested information or of any information obtained during the recredentialing process that varies substantially from the information provided by Embright by the licensed practitioner.  

2.3.    Falsification of the recredentialing application may result in immediate termination of the licensed practitioner’s participation in Embright’s network.  

3.    Licensed practitioner/Provider Performance Evaluation

Embright staff shall coordinate the collection of information related to professional performance, judgment, and clinical competence over the previous three (3) years for each participating licensed practitioner who is a provider of primary care services.  The performance evaluation shall include review of the following:  

3.1.    Member complaints:  such complaints may include quality of care, quality of service, art of caring, site complaint, or licensed practitioner changes due to member dissatisfaction. 
 
3.2.    Information from quality improvement activities:  such activities may include one or more of the following:  access studies, medical record reviews, or quality of care investigations.  

4.    Recredentialing File

Embright shall maintain a recredentialing file for each licensed practitioner and shall ensure the confidentiality of all information obtained in the recredentialing process as described in this policy and procedure, “Confidentiality.”  

5.    Credentialing Committee Action

5.1.    Review of Recredentialing Application: Upon receipt of the completed recredentialing application and primary source verification, the credentialing staff shall perform a comprehensive audit of the application and supporting documentation.  The information will be evaluated in the same manner as required for the initial credentialing process and shall document the information in the licensed practitioner’s credentialing file.  

5.1.1    Category 1 Recredentialing Applications:  Recredentialing applications meeting in all ways Embright’s established credentialing criteria will be considered clean Category 1 recredentialing applications.

5.1.2    Category 2 Recredentialing Applications:  Recredentialing applications that do not meet all of the Embright’s established credentialing criteria will be considered Category 2 recredentialing applications.

6.    A list of licensed practitioners who have met Embright’s established criteria shall be presented at the Credentialing Committee meeting.  The Credentialing Committee shall review the information contained in the recredentialing files.  Credentialing Committee discussion will be documented in its meeting minutes. The Credentialing Committee may request that further information be obtained from any persons or organizations, including the licensed practitioner, in order to assist the committee with the evaluation process.  The Credentialing Committee may defer consideration of the application for up to ninety (90) days.  This deferral shall not constitute grounds for appeal.  

7.    Licensed practitioners who do not meet Embright’s established criteria are presented to the Credentialing Committee as an “Exception.”  The information provided to the Credentialing Committee includes the licensed practitioner’s profile outlining his/her training, education and professional credentials and all documentation related to the issue or issues in question.  The Credentialing Committee may request further information from any persons or organizations, including the licensed practitioner, in order to assist the Credentialing Committee with the evaluation process.  Exception criteria are as follows:

7.1.    History of adverse licensure activity

7.2.    History of disciplinary action by any professional review body including loss or limitation of privileges

7.3.    Physical or mental impairment that adversely affects or could adversely affect the licensed practitioner’s ability to carry out the scope of his or her duties on behalf of Embright, with or without accommodation  

7.4.    Current illegal drug use

7.5.    History of malpractice occurrences within the past five years which exceed two separate events resulting in payment(s) on behalf of the licensed practitioner; or a single event resulting in payment(s) exceeding $500,000 on behalf of the licensed practitioner  

7.6.    Information from quality improvement activities and member complaints for PCPs

7.6.1    History of significant member complaints at recredentialing

7.6.2    History of quality of care and service investigations (peer review) at recredentialing specific to the licensed practitioner in which the severity outcome level resulted in the following:

•    Level I outcomes  => 5 in 3 years
•    Level II outcomes => 2 in 3 years
•    Level III outcome = > 1 in 3 years

7.6.3    Interview with the Practitioner    The Credentialing Committee may, but is not required to, personally interview the licensed practitioner and address any questions that may have arisen about the application.  

8.    Upon completion of its review and evaluation of the licensed practitioner’s recredentialing information, the Credentialing Committee shall approve or deny Category 1 and Category 2 recredentialing applications.  Licensed practitioners will be notified within 60 calendar days of the Credentialing Committee decisions.  

9.    If a practitioner’s recredentialing application is denied based upon deficiencies in the practitioner’s professional competence, conduct or quality of care, or is terminated based upon a final adverse action taken upon the practitioner, Embright shall submit any and all required reports to the National Practitioner Data Bank and the State Medical Board.  

Licensed Practitioner Rights

1.    Right to Review Information—Licensed practitioners have the right to review information obtained by Embright in support of their personal credentialing and recredentialing application.  This information is limited to public information and does not include information protected by state or federal law.  Licensed practitioners are notified of this right in the cover letter contained in the practitioner credentialing and recredentialing packet. 

2.    Right to Notification and Correction of Information—Licensed practitioners will be notified, in writing, via certified mail within 10 business days in the event that credentialing information obtained from other sources varies substantially from that provided by the practitioner.  The mailing envelope will be stamped “Confidential.”  The licensed practitioner will be given no less than 10 days and no more than 30 days to correct erroneous information.  All responses must be mailed directed to Attn:  Credentialing Department, Physicians of Southwest Washington, 319 Seventh Ave SE, Suite 201, Olympia, WA 98501.  The credentialing department will document and initial on the licensed practitioner profile, for each element impacted, that the practitioner corrected the information.  

2.1.    Right to Know Status of Application—Licensed practitioners have the right, upon request, to be informed of the status of their credentialing or recredentialing application.  Questions can be directed in writing to Attn:  Provider Network, Embright LLC, 1114 Post Avenue, Seattle, WA 98101 or by calling 206-223-4000.  Licensed practitioners are notified of this right in the cover letter contained in the practitioner credentialing and recredentialing packet

Provider Directories and Other Materials

Embright will use information gathered from the licensed practitioner’s credentialing application and primary source verification to ensure the practitioner’s education, training, and designated specialty are listed accurately on all internal and external materials.  Provider Network staff will verify regularly that a contracted plan’s website and licensed practitioner directories contain accurate information.

Reactivating Terminated Licensed practitioners

If a licensed practitioner terminates his /her relationship with Embright, whether as a result of terminating an independent contract or leaving the employ of a group under contract and later requests a new contract or becomes employed under another group contract which results in a break of more than 30 days, the practitioner will be considered a new practitioner and must be credentialed as such prior to seeing members under the new contract.  Embright may, at its discretion, re-verify only those elements that have expired or will expire according to regulatory or accreditation standards prior to Credentialing Committee review.  Re-verification of static information such as education will not be required.  

Storing Credentialing and Recredentialing Files

1.    All active credentialing and recredentialing files will be stored in a secured network folder.

2.    All terminated practitioner credentialing and recredentialing files will be stored in a secured network folder for 12 months from the termination date. 

3.    Terminated files of more than 12 months will be archived in a secure folder.  Embright may elect to disposed after 7 years.

Tracking Credentialing Modifications

1.    Modifications made to credentialing information:

1.1.    Modified when new information is presented via primary source websites for monthly expirables, from clinical source, and by credentialing.

1.2.    The information is updated electronically and physically documented in the individual files from source, when applicable.

1.3.    Authorization to modify credentialing information is limited to Sr Manager of Provider Network and the Director of Network Development.   

1.4.    Modifications are sent to the health plans weekly and/or monthly in the Standardized Delegated Roster (SDR).

Security Information

1.    Limiting physical access to credentialing information, to protect the accuracy of information gathered from primary sources and NCQA approved sources.

2.    Preventing unauthorized access, changes to and release of credentialing information.

3.    Password-protecting electronic systems, including user requirements to:

3.1    Use strong passwords

3.2    Avoid writing down passwords

3.3    Use different passwords for different accounts

3.4    Change passwords periodically

4.    Disable or remove passwords of employees who leave the organization

Internal Credentialing Audit Process
    
Credentialing will perform a quarterly mock audit of 3-5 initial and recredentialed files in accordance with the NCQA checklist to ensure risk assessment.  The audit results will be shared with the Credentialing Committee.
 

ATTACHMENT A

Credentialing Committee Members

NAME SPECIALTY ROLE
Shawn H. West, M.D. Family Medicine Chairperson and Chief Medical Officer
Timothy H. Dellit, M.D. Infectious Disease Member
David C. Dugdale, M.D. Internal Medicine Member
Michael Myint, M.D. Infectious Disease Member
Zak Ramadan-Jradi, M.D. Internal Medicine Member


 

ATTACHMENT B

CRITERIA ACCEPTABLE VERIFICATION SOURCE

State Professional License

Credentialing, Recredentialing

Time Limit: 180 calendar days

Current at time of credentialing decision

  • Written or verbal confirmation from state licensing board 
Documentation of state licensing agency on-line or telephone query (include date of contact, person spoken to, licensure status information, name, or initials of Embright staff person performing query)

Malpractice Claims History

Initial, Recredentialing

Time Limit: 180 calendar days

All health care practitioners –

Either:

  • Written verification from carrier of the last five years of malpractice settlements/judgments

- OR - 

  • Evidence of NPDB query (copy of the report directly from NPDB) 

- OR - 

  • Evidence of NPDB Proactive Disclosure Service (PDS)

Note: If practitioners were covered by a hospital insurance policy during residency or fellowship, confirmation from the carrier is not required.

DEA Certificate, as applicable

Credentialing, Recredentialing

Time Limit: 180 calendar days

Current at time of credentialing decision

  • Copy of valid, unrestricted DEA, which DEA must be registered in the state in which the practitioner is practicing.
  • Documentation of web query of the DEA or CDS Agency.

Pending DEA certificate:
A practitioner whose DEA certificate is pending may be credentialed when an application or supplemental documentation is submitted to demonstrate that a covering practitioner who has a valid DEA certificate is available to write all prescriptions until the pending DEA certificate is available.  Supplemental documentation must include covering practitioner’s DEA number and expiration date.

No DEA Certificate
If a practitioner does not have a DEA certificate, practitioner must provide an explanation and indicate what arrangements are in place for their patients who need prescriptions requiring a DEA.

NPDB Query
Credentialing, Recredentialing

Time Limit: 180
calendar days

  • Copy of the report directly from NPDB

NPDB Proactive Disclosure Service (PDS)

Work History

Credentialing

Time Limit: 180
calendar days

Note: Verification is not required, documentation is required.

  • Application that requests the most recent five years of work history; or
  • Curriculum Vitae that includes at least the most recent five years of work history; and
  • Clarification of work history documented as outlined above is acceptable as long as the date of the conversation, name of person providing the clarification and initials of person obtaining the clarification is clearly documented.
  • Gaps exceeding six months must be reviewed. Gaps exceeding 12 months must be clarified in writing.

Education and Training

Credentialing

Time Limit: None

  • Not required for board certified MDs and DOs.
  • If practitioner is not board certified, he/she must meet the Education and Training Requirements established by Embright’s Credentialing Committee.
  • Verification of the highest level of credentials obtained meets this requirement.

Physicians-(MD, DO)

Completion of residency training:

  • Confirmation from the residency training program (written or verbal) Documentation of on-line or telephone inquiry of residency training program (include date of contact, person spoken to, residency program information, name, or initials of Embright staff person performing query)
  • Entry in the AMA Physician Master File
  • Entry in the American Osteopathic Association (AOA) Official Osteopathic Physician Profile Report or AOA Physician Master File
  • Confirmation from an association of schools of the health professions if the association performs primary source verification.
  • Confirmation from the state licensing agency if the state agency performs primary source verification of residency training.

Graduation from Medical School:

  • Written or verbal confirmation from the medical school
  • Documentation of on-line or telephone inquiry of medical school (include date of contact, person spoken to, medical school information, name, or initials of Embright staff person performing query)
  • Entry in the AMA Physician Master File (MDs) or the AOA Official Osteopathic Physician Profile Report or AOA Physician Master File (DOs)
  • Confirmation from Educational Commission for Foreign Medical Graduates for international medical graduates licensed after 1986
  • Confirmation from an association of schools of the health professions if the association performs primary source verification.
  • Confirmation from the state licensing agency if the state agency performs primary source verification of residency training.

Chiropractors

Graduation from chiropractic college:

  • Confirmation from a chiropractic college whose graduates are recognized as candidates for licensure by the regulatory authority issuing the license 
  • Confirmation from the state licensing board if the state agency performs primary source verification.
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, and the name or initials of Embright staff person-performing query.

Dentists -- (applies only to those providing medical services)

Graduation from dental school:

  • Confirmation from the dental school
  • Confirmation from the appropriate specialty program of residency training
  • Confirmation from the state licensing board if the state agency performs
  • primary source verification

Optometrists--

Graduation from optometry college:

  • Confirmation from an optometry college whose graduates are recognized as candidates for licensure by the regulatory authority issuing the license 
  • Confirmation from the state licensing board if the state agency performs
  • primary source verification

Podiatrists--For board certified podiatrists, verify the podiatry school graduation and residency from one of the following:

  • Confirmation by the appropriate specialty board if the specialty board conducts primary source verification of graduation and residency
  • Confirmation from the state licensing board if the state agency performs
  • primary source verification of board status
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person-performing query.

For podiatrist who are not board certified, verify completion of residency training from one of the following:

  • Confirmation from the residency training program.
  • Entry in a podiatry specialty board master file if the specialty board performs primary source verification of graduation and completion of residency.
  • Confirmation by the state licensing agency, if the state agency performs primary source verification of residency training
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person-performing query.  

For podiatrist who have not completed a residency, verify graduation from podiatry school from one of the following:

  • Confirmation by the podiatry medical school.
  • Entry in a podiatry specialty board master file, if the specialty board perform primary source verification of graduation
  • Confirmation by the state licensing agency, if the state agency performs primary source verification of podiatry school
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person-performing query.

Board Certification

Credentialing, Recredentialing

Time Limit: 180 calendar days

(may be valid for up to one year)

Note:

  • Board certification is recommended as stated in this policy, Sections 4 and 5 “Criteria for Providing Health Care Services to Embright Members.” 
  • Board certification must be verified if a practitioner states he or she is board certified within 180 calendar days. The board certification expiration date will also be documented.
  • Board certification meets all education and training requirements for MDs and DOs, ONLY

MDs and DOs – 

  • Entry into the ABMS Official Directory of Board-Certified Medical Specialists
  • Entry into the AOA Directory of Osteopathic Physicians
  • Entry in the AMA Physician Master file
  • Confirmation from the appropriate specialty board
  • Confirmation from the state licensing board, if the state agency performs primary source verification of board status
  • For foreign board certification, confirmation from the Accreditation Council for Graduate Medical Education (ACGME) if the board performs primary source verification of education and training of every board-certified practitioner

Chiropractors -- Not Applicable

Optometry   -- Not Applicable

Podiatrists – Does NOT meet education and training requirements

  • Confirmation from the appropriate specialty board if the board performs primary verification of graduation and residency
  • Entry in a podiatry specialty board master file if the board performs primary verification of graduation and completion of residency

  • Confirmation from the state licensing board if the board performs primary source verification

  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Dentists -- Does NOT meet education and training requirements

  • Confirmation from the appropriate specialty board

Non-Physician Practitioners -- Does NOT meet education and training requirements

  • Confirmation from the appropriate specialty board
  • Confirmation from the state licensing agency if the agency performs primary source verification
  • Confirmation from a registry if the registry performs primary source verification
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Malpractice Insurance

Credentialing, Recredentialing

Time Limit: Current
at time of credentialing decision

SEE “CURRENT AND SIGNED ATTESTATION”: The application includes a current and signed attestation by the applicant regarding current malpractice insurance coverage; and

  • Copy of Certificate of Insurance with dates, amount of coverage and name of covered practitioner(s), or
  • Confirmation of coverage from carrier
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Or NPDB Proactive Disclosure Service (PDS) 

Note: Practitioners must attest to the dates and amounts of current malpractice coverage, even if the amount is zero.

Hospital Privileges

Credentialing, Recredentialing

Time Limit: 180 calendar days

Written or verbal confirmation from the affiliated hospital

Current and Signed Attestation

Initial and Recredentialing

Time Limit: 180 calendar days

The application includes a current and signed attestation and addresses:

  • Reasons for any inability to perform essential functions of the position, with or without accommodation
  • Lack of present illegal drug use
  • History of loss of license and felony convictions
  • History of loss or limitation of privileges or disciplinary activity
  • Current malpractice coverage (including limits of liability)
  • Correctness and completeness of the application

Note: Only the practitioner may attest to any updates to the application and attestation, a staff member may not.

Sanctions or Limitations on
Licensure

Credentialing, Recredentialing

Time Limit: 180 calendar days

  • Confirmation from the relevant state licensing board
  • Confirmation from NPDB or NPDB PDS
  • Confirmation from the Federation of State Medical Boards (FSMB)
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Chiropractors 

  • Confirmation from the State Board of Chiropractic Examiners
  • Confirmation from the Federation of Chiropractic Licensing Boards (CINBAD)
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Dentists

  • Confirmation from the State Board of Dental Examiners
  • Confirmation from NPDB
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Podiatrists 

  • State Board of Podiatric Examiners or the Federation of Podiatric Medical Boards

Optometrists

  • Confirmation from the State Board of Optometry Examiners 

Non-Physician Practitioners 

  • Confirmation from the appropriate state agency or state licensure or certification
  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Medicare/Medicaid
Sanctions History

Credentialing, Recredentialing

Time Limit: 180 calendar days

A review of Medicare and Medicaid sanctions must cover the most recent three-year period available through the following data sources: 

  • Verification through the NPDB, or NPDB PDS
  • Systems for Awards management (SAM) formerly the EPLS
  • Verification through the FSMB
  • Cumulative sanction report available over the internet
  • Confirmation through review of the Medicare and Medicaid Sanctions and Reinstatement List of Excluded Individual/Entities released by the US Department of Health and Human Services Office of Inspector General.
  • Confirmation through review of the Federal Employees Health Benefits Program debarment record published by the Office of Personnel Management, Office of the Inspector General.
  • Verification by the state Medicaid agency or intermediary and the Medicare intermediary 
  • Verification through the American Medical Association (AMA) Physician Master file

  • Where the above verifications are performed on-line or by telephone, document the date of contact, person spoken to, the information obtained, name or initials of Embright staff person performing query.

Medicare Opt-Out Monitoring

Credentialing, Recredentialing

Time Limit: 180 calendar days

  • Review Medicare Opt Out list at initial & recredentialing via the Medicare Participating Provider and Opt-Out websites.  Documentation will be provided in the credentialing file and documented on the credentialing checklist.
  • Any provider listed on the opt-out website will be verified and the appropriate health plans will be notified.

NPI Number

Credentialing

Time Limit: None