Subject: Initial Credentialing Verification (Page 1 of 5)

Transcription

1 Subject: Initial Credentialing Verification (Page 1 of 5) Objective: I. To ensure that Health Share/Tuality Health Alliance (THA) practitioners/providers have the legal authority and relevant training and experience to provide quality care to THA members. II. To ensure that THA conducts primary source verification of practitioners state licensure and other credentialing information within specified credentialing time limits. Policy: I. Initial Credentialing Application As part of the THA Quality Management Program, all applicant practitioners must successfully complete an initial Oregon Practitioner Credentialing Application. a. The initial credentialing process incorporates a 90-day credentialing period from the receipt of a completed Oregon Practitioner Credentialing Application to the date that THA approves or rejects the practitioner applicant. b. The Tuality Healthcare Medical Staff Office (MSO) may carry out credentialing processes and verification for THA Full and Associate Providers; the date on which the applicant is approved for Tuality Healthcare MSO privileges by the Tuality Healthcare Board is considered the THA receipt date of the Oregon Practitioner Credentialing Application. THA will approve or reject the Full or Associate Provider complete application within 90 days of receipt. c. The THA Administrative Coordinator or designated THA staff member will carry out credentialing processes and verification for ancillary providers, including preferred or extended physicians, podiatrists, nurse practitioners, or other licensed independent contractors or providers. THA will receive the Oregon Practitioner Credentialing Application; THA will approve or reject the ancillary provider application within 90 days of receipt. II. Primary Source Verification A complete application must include the following, all of which will be primary source verified by Tuality Healthcare MSO Coordinators or the THA Administrative Coordinator or designated THA staff member: Proof that the provider is licensed by a health professional regulatory Board as defined in ORS o Board certification is required by various health plans, and therefore it is required by THA for Full and Associate Providers; Board certification is not required for Preferred or Extended Contracted Providers. o For THA Full and Associate Providers, Tuality Healthcare MSO

2 Subject: Initial Credentialing Verification (Page 2 of 5) Coordinators will verify valid and current licensure through a query of the appropriate licensing division of the Oregon State Board or other relative certification agency. Primary source verification is completed online or via telephone and must be in effect at the time of the THA Quality Management Committee credentialing decision. o For Preferred and Extended Providers, the THA Administrative Coordinator or designated THA staff member conducts primary source license verification using the same verification process as above. o Query of the American Board of Medical Specialties (ABMS) Official Directory of Board Certified Medical Specialists will be conducted as appropriate, along with a query of the following: 1. American Medical Association (AMA) Master Profile; 2. AOA Official Osteopathic Physician Profile Report of AOA Physician Master File; 3. The appropriate specialty Board; 4. The appropriate Oregon licensing agency. Physicians who apply for THA membership on or after June 2000 must be certified as recognized by the ABMS or the AOA at the time of initial credentialing and/or re-credentialing. Physicians who are not Board certified and have completed an approved residency program prior to 1980 may be exempt from this requirement, provided that all other credentialing criteria are met. Participating status may be granted to a physician who has completed an accredited residency program and has applied to take the certification examination. It is expected that Board certification is obtained within four (4) years of becoming qualified to take the examinations, and that it is maintained thereafter. Physicians must maintain their Board certification status in order to maintain their medical staff membership and privileges at Tuality Healthcare. Should recertification not be maintained, the Physician shall retake their Board re-certification examination, minimally, on an annual basis and must obtain re-certification within two years. If Board certification is not re-attained within this period, it is considered a voluntary resignation from THA and is not eligible for appeal or hearing. Verification that the Board certification is current and documentation of the date of verification is required in the practitioner s credentialing file. Documentation of the practitioner s Board certification expiration date must be in the practitioner s credentialing file. If the practitioner s Board certification does not expire, the MSO Coordinator will verify a lifetime certification status and document it

3 Subject: Initial Credentialing Verification (Page 3 of 5) in the practitioner s credentialing file. Proof of current registration with the Drug Enforcement Administration (DEA) of the United States Department of Justice (if applicable to the provider's practice) o DEA registration must be effective at the time of the THA credentialing decision. o THC/THA must have a copy of the Oregon DEA from the provider, THA/THA will date stamp and initial the copy upon receipt. o THA may credential a provider whose Oregon DEA certificate is pending, provided there is a provider with a valid Oregon DEA who will write all of the pending provider s prescriptions until the pending provider has a valid Oregon DEA certificate; a current, valid DEA number for the interim prescribing provider must exist. Proof of Education and Training o Verification time limit: none. o THC/THA verifies, through primary source verification, the highest of the three levels of education and training obtained: 1. Graduation from medical or professional school; 2. Residency or fellowship, if appropriate; 3. Board certification, if appropriate. For providers who are not Board certified, verification of completion of Medical School and residency or other professional school is accepted. For international medical graduates licensed after 1986, THA/THC will verify education and training through the Educational Commission for Foreign Medical Graduates. THC/THA may verify education through applicant submission of sealed transcripts with an unbroken institution seal. THC/THA may verify education through the Federation Credentials Verification Service (FCVS) for closed residency programs. Proof of Work History o Verification Time Limit: 180 days. o A minimum of five (5) years relevant work history must be described through the provider s application or curriculum vitae; relevant experience includes work as a health professional. o If the practitioner has practiced fewer than five (5) years from the date of verification of work history, work history description begins with the initial licensure. This must include the beginning and ending month and year for each position in the practitioner s employment experience. o Gaps of two (2) months or greater need to be reviewed and clarified,

4 Subject: Initial Credentialing Verification (Page 4 of 5) either verbally or in writing; gaps greater than one year require clarification in writing. o All work histories provided in initial credentialing files are to be initialed and dated by the reviewer within 180 days of presentation to the QMC. History of professional liability claims that resulted in settlements or judgments paid on behalf of the practitioner. o THC/THA must have written confirmation of the past five (5) years of history of malpractice settlements from the malpractice carrier. Otherwise, THC/THA will query the NPDB. o CredentialsOnLine is the acting Credentialing Verification Organization (CVO). o THA requires a dated and signed or initialed note by the Tuality Healthcare (THC) Medical Staff Coordinator who verified the credentials. o THC/THA will review the latest cumulative report and periodic updates released by the approved liability/sanctioning source. THC/THA must note the date of the report query in the provider s file. o THA uses the date of the official document (the date on the letter or report), not the receipt date, to determine compliance with timeliness requirements. Proof that the Provider Is Covered by a Professional Liability Insurance Policy o Verification Time Limit: 180 days. o Current dates and amount of professional liability/malpractice insurance coverage (all practitioners, regardless of classification, must at all times maintain full force and effect professional medical liability insurance as defined in ORS in an amount not less than $1,000,000 per occurrence and $3,000,000 aggregate). o A liability insurance cover sheet may be submitted as proof of coverage. III. Queries for Excluded Providers Prior to initial credentialing, Tuality Healthcare MSO Coordinators and/or THA staff will complete queries of the Medicare Part B Opt-Out List, the Office of Inspector General (OIG) Sanction List, and the Excluded Parties List System (EPLS) to ensure that providers are not excluded from Medicare/Medicaid participation. References: 42 CFR (b)(2)(iii) Health Share RAE Participation Agreement NCQA CR 1 Overview of Credentialing Policies OAR THA Policy X-5: Site Review

5 Subject: Initial Credentialing Verification (Page 5 of 5) THA Policy X-6: Practitioner Appeal Rights THA Policy X-8: Delegation of Credentialing/Re-Credentialing THA Policy X-10: Medical Director Role and Responsibilities NCQA CR 3 Initial Credentialing Verification URAC P-CR-5 Credentialing Application Formulated: February 1994 Reviewed: July 2005 September 2013 Revised: April 1995 January 1996 August 1996 February 1999 April 1999 August 1999 June 2000 December 2001 November 2002 November 2003 July 2004 July 2006 September 2007 September 2008 September 2009 August 2010 June 2011 June 2012 THA Plan Director THA Medical Director