Page 1 of 6 ADMINISTRATIVE POLICY AND PROCEDURE

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1 Page 1 of 6 SECTION: Contracts SUBJECT: Credentialing DATE OF ORIGIN: 6/1/08 REVIEW DATES: 8/1/15, 2/8/17 EFFECTIVE DATE: 12/1/17 APPROVED BY: EXECUTIVE DIRECTOR I. PURPOSE: To have a written system in place for credentialing, temporary/provisional credentialing, and re-credentialing of individual practitioners within Network180 contract agencies. II. REFERENCES: 42 CFR Provider Selection (b) Credentialing and re-credentialing requirements (2) Each MCO, PIHP, and PAHP must follow a documented process for credentialing and re-credentialing of providers who have signed contracts or participation agreements with the MCO, PIHP or PAHP. Medicaid Managed Specialty Supports and Services Concurrent 1915(b)/(c) Waiver Program FY 16: Attachment P The PIHP must have a written system in place for credentialing and re-credentialing individual practitioners included in their provider network who are not operating as part of an organizational provider. III. DEFINITIONS: A. Individual Practitioner: A health care professional; someone practicing a skilled profession for which special education or licensing is required. B. Contract Agency: An organization that has a contract with Network180 to provide services to recipients. IV. PROCEDURE: A. Overview As an affiliate of the Lakeshore Regional Entity PIHP (LRE), Network180 is responsible for ensuring any of its contractors rendering specialty behavioral healthcare services within Michigan s Medicaid program meet all applicable licensing, scope of practice, contractual, and Medicaid Provider Manual requirements.

2 Page 2 of 6 B. Credentialing Individual Practitioners 1. Credentialing and re-credentialing must be conducted and documented for at least the following individual practitioners: a. Physicians (M.D.s or D.O.s) b. Physician s Assistants c. Psychologists (Licensed, Limited License or Temporary License) d. Licensed Master s Social Workers, Licensed Bachelor s Social Workers, Limited License Master s Social Workers, Limited License Bachelor s Social Workers or Registered Social Service Technicians e. Licensed Professional Counselors f. Nurse Practitioners, Registered Nurses, or Licensed Practical Nurses g. Occupational Therapists or Occupational Therapist Assistants h. Parent Support Partners i. Peer Specialists j. Physical therapists, or Physical Therapist Assistants k. Speech Pathologists 2. Credentialing and re-credentialing processes shall not discriminate against: a. An individual practitioner, solely on the basis of license, registration or certification; or b. An individual practitioner who serves high-risk populations or who specializes in the treatment of conditions that require costly treatment. 3. The contract agency must ensure compliance with federal requirements that prohibit employment or contracts with providers excluded from participation under either Medicare or Medicaid. a. A complete list of Centers for Medicare and Medicaid Services (CMS) sanctioned providers is available at b. A complete list of sanctioned individuals is available on the System for Award Management website ( Click on search records. c. For Michigan Substance Abuse Certification (CAC and ARMS): micbap@aol.com (3474 Alaiedon Parkway, Suite 500, Okemos, Michigan, phone , fax The responsibilities for credentialing and re-credentialing are delegated to the contract agency. Network180, however, is responsible for oversight regarding delegated credentialing or re-credentialing decisions. 5. If a contract agency with a Network180 authorization enters into a contract with an individual or agency to provide a Network180 service as a part of that authorization, the contract agency will be responsible to credential that staff or ensure that staff is appropriately credentialed prior to beginning a new service. 6. Compliance with the standards outlined within this policy must be demonstrated through the contract agency s own credentialing policies and procedures. 7. The contract agency s credentialing policy may be audited as part of a Network180 administrative review process. The agency s credentialing policy must: a. Identify staff member(s) responsible for oversight and implementation of the credentialing process and delineate their role.

3 Page 3 of 6 b. Describe any use of participating providers in making credentialing decisions. c. Describe the methodology to be used by staff members or designees to provide documentation that each credentialing or re-credentialing file is complete and reviewed prior to presentation of credentialing committee and ongoing. d. Indicate criteria and timeliness for the credentialing and re-credentialing of licensed staff. 8. The contract agency must ensure that a credentialing/re-credentialing file is maintained for each credentialed individual practitioner. Each file must contain: a. The initial credentialing and all subsequent re-credentialing applications. b. Information gained through primary source verification. c. Any other pertinent information used in determining whether or not the individual practitioner met the credentialing and re-credentialing standards. C. Initial Credentialing At a minimum, the initial credentialing of an individual practitioner requires: 1. A written application that is completed, signed and dated by the individual practitioner and attests to the following elements: a. Lack of present illegal drug use. b. Any history of loss of license and/or felony convictions. c. Any history of loss or limitation of privileges or disciplinary action. d. Attestation by the applicant of the correctness and completeness of the application. 2. An evaluation of the individual practitioner s work history for the prior five years. 3. Verification from primary sources a. State licensure or certification at: 1) 2) b. Board certification, or highest level of credential attained if applicable, or completion of any required internships/residency programs, or other postgraduate training. c. Documentation of graduation from an accredited school. d. National Practitioner Databank (NPDB)/Healthcare Integrity and Protection Data Bank (HIPDB) query at or, in lieu of the NPDB/HIPDB query, all of the following must be verified: 1) Minimum five-year history of professional liability claims resulting in a judgment or settlement; 2) Disciplinary status with regulatory board or agency; and 3) Medicare/Medicaid sanctions. e. If the individual practitioner undergoing credentialing is a physician, then physician profile information obtained from the American Medical Association may be used to satisfy the primary source requirements of a, b, and c above. f. Prior to employment, verification of background checks shall include: 1) Criminal 2) Driving Record, if applicable 3) Sex Offender Registry

4 Page 4 of 6 4) Reference Checks D. Temporary/Provisional Credentialing of Individual Practitioners 1. Temporary or provisional credentialing of individual practitioners is intended to increase the available network of individual practitioners in underserved areas, whether rural or urban. Contract agencies must have policies and procedures to address granting of temporary or provisional credentials when it is in the best interest of Medicaid Beneficiaries that individual practitioners be available to provide care prior to formal completion of the entire credentialing process. Within the Network180 provider panel, temporary or provisional credentialing shall not exceed 150 days. 2. The contract agency shall have up to 31 days from receipt of a complete application, accompanied by the minimum documents below, within which to render a decision regarding temporary or provisional credentialing. 3. For consideration of temporary or provisional credentialing, at a minimum, an individual practitioner must complete a signed application that includes the following items: a. Lack of present illegal drug use. b. History of loss of license, registration or certification, and/or felony convictions. c. History of loss or limitation of privileges or disciplinary action. d. A summary of the individual practitioner s work history for the prior five years. e. Attestation by the applicant of the correctness and completeness of the application. 4. The contract agency must conduct primary source verification of the following: a. Licensure or certification. b. Board certification, if applicable, or the highest level of credential attained; and c. Medicare/Medicaid sanctions. 5. The contract agency must review the information obtained and determine whether to grant provisional credentials. Following approval of provisional credentials, the process of verification shall be completed. E. Credentialing of Interpreters 1. If a contract agency is providing an interpreter as a legal accommodation for a person who is deaf, blind, or hard of hearing, the law requires the use of an interpreter who is Michigan Certified to be qualified to interpret at the Standard Practice Level (outlined below) appropriate for the type of setting that will be taking place. a. Interpreters must possess the necessary credentials for a Standard Level 2 to be qualified to interpret. If an individual is both deaf and blind, the interpreter must possess credentials for a Standard Level 2. b. In addition to the three general Standard Levels, there is a separate Educational Standard. This standard applies to accommodations provided to a student up to grade 12. Interpreters within the education standard are further divided into those qualified to work in elementary or secondary educational settings.

5 Page 5 of 6 c. Specific types of proceedings also require a valid Michigan endorsement. An interpreter must possess a Medical/Mental Health endorsement to interpret in a medical or mental health setting, and a DeafBlind endorsement in order to interpret for an individual who is both D/deaf and B/blind. d. The Interpreter must be Michigan Certified (search site below) e. Michigan law requires that an interpreter who is qualified AND effective be made available. All providers have a responsibility to act appropriately if it appears an interpreter is not effective, regardless of whether they are qualified. f. Interpreters are required to be trained in: Corporate Compliance, False Claims, HIPAA, and Recipient Rights. 2. Michigan certified interpreters are issued identification cards that indicate, their current skill level, and any endorsements they hold. It is standard practice to ask interpreters to show their cards. All Michigan Certified interpreters are bound by the NAD-RID Code of Professional Conduct which stresses the confidentiality of interpreted information. 3. Deemed Status for Interpreters: Network180 contracts with Voices for Health, Liaison Linguistics, and CyraCom to provide interpreter services. Network180 will ensure interpreters within these companies are credentialed. Network180 contract agencies may choose to accept this credentialing. F. Additional Requirements 1. National Provider Identifier (NPI)-All persons eligible to obtain an NPI must do so. The document below is a crosswalk designed to categorize the type, classification, and/or specialization of health care providers. Certification/MedicareProviderSupEnroll/Taxonomy.html 2. Persons eligible to register with CHAMPS must do so. G. Re-credentialing Individual Practitioners At a minimum, the re-credentialing policies for physicians and other licensed, registered, or certified health care providers must identify procedures that address the re-credentialing process and include requirements for each of the following: 1. Re-credentialing at least every two years. 2. An update of information obtained during the initial credentialing. 3. A process for ongoing monitoring, and intervention if appropriate, of sanctions, complaints, and quality issues pertaining to the individual practitioner, which must include, at a minimum, review of: a. Medicare/Medicaid sanctions. b. State sanctions or limitations on licensure, registration or certification. c. Member concerns that include grievances, complaints, and appeals. d. Any quality issues identified.

6 Page 6 of 6 H. Network180 Credentialing of Contract Agencies The LRE will validate, and re-validate at least every two years, that the contract agency is licensed as necessary to operate in the State, and has not been excluded from Medicaid or Medicare participation. I. Deemed Status Individual practitioners or contract agencies may deliver healthcare services to more than one PIHP. Network180 will allow a Network180 contract agency to accept the credentialing of another PIHP. In those instances where a Network180 agency chooses to accept the credentialing decision of another PIHP, the contract agency must keep copies of the credentialing PIHP s decisions in their administrative records. J. Notification of Adverse Credentialing Decision An individual practitioner or contract agency that is denied credentialing or recredentialing shall be informed within ten (10) days of the reasons for the adverse credentialing decision in writing as well as the appeals process. K. Appeal Process for Adverse Credentialing Decision An appeal process shall be available when credentialing or re-credentialing is denied, suspended or terminated for any reason other than lack of need. The appeal process will be consistent with federal and state requirements. L. Training The contract agency must have a mechanism to ensure required trainings are completed and documented in a timely manner. This includes the training of non-professional staff to guarantee they meet the requirements found in PIHP-MHSP Provider Qualifications as well as additional PIHP requirements. M. Reporting Requirements The contract agency will maintain written procedures for reporting improper known conduct that may result in suspension or termination from the Network180 provider organization network to appropriate authorities (i.e., MDHHS, the Network180 Board, the Attorney General). Procedures will be consistent with current federal and state requirements, including those specified in the MDHHS Medicaid Managed Specialty Supports and Services contract.