Provider Credentialing

Size: px
Start display at page:

Download "Provider Credentialing"

Transcription

1 I. Purpose The purpose of this Policy and Procedure is to establish the process including written guidelines and standards for the credentialing and re-credentialing of all clinicians defined in this policy. Also, to assure compliance for credentialing providers in adherence to standards enacted by the National Committee for Quality Assurance (NCQA), and required by third party payers. Lastly, to ensure that processes include nondiscriminatory review and credentialing, including monitoring and audits of credentialing files. II. III. IV. Scope All clinicians participating in Ochsner Physician Partners. Definitions A clinician is defined as: 1. Physician (MD or DO); 2. Podiatrist (DPM). Policy Statements It is the policy of Ochsner Physician Partners to assure compliance for credentialing providers in adherence to standards enacted by the National Committee for Quality Assurance (NCQA), and required by third party payers. All Ochsner Physician Partners (OPP) clinicians must meet the minimum eligibility and credentialing criteria and performance standards at the time of initial credentialing and maintained continuously. V. Procedures/Standards and Roles & Responsibilities 1. Time Limits - Time limits referred to in this Policy, the Bylaws and related policies and manuals are advisory only and are not mandatory, unless it is expressly stated. Medical Staff leaders will strive to be fair under the circumstances and to comply with the Page 1 of 14

2 provisions of the Health Care Quality Improvement Act of 1986, 42 U.S.C. Credentialing Committee ion et seq. ( HCQIA ). 2. Confidentiality a. All professional review activity and recommendations will be strictly confidential. Any breach of confidentiality may result in appropriate sanctions. b. No disclosures of any such information(discussions or documentation) may be made outside of the meetings of peer review committees, except: i. to another authorized individual and for the purpose of conducting professional review activity; ii. (a)as authorized by a policy; or iii. as authorized, in writing, by legal counsel. c. Credential files are confidential and maintained in locked file cabinets with restricted access. Electronic files will require security access. d. Access to the Credentialing/Re-credentialing documents is limited to the OPP credentialing staff, the OPP Medical Director, and the OPP Assistant Medical Officer. Exceptions to this rule must be approved by the OPP Medical Director. e. Documents in these files may not be reproduced or distributed. An exception is made for confidential peer review and credentialing purposes consistent with the law. f. All documents containing practitioner specific information are destroyed at time of disposal. g. Per contractual agreement, credential files may be reviewed by contracting health plan representatives with a current confidentiality statement on file with the Credentialing Department. 3. Qualifications Threshold Eligibility Criteria a. To be eligible to apply for initial appointment or reappointment the clinician must, as applicable: i. have an unrestricted license to practice in the State of Louisiana and in any other state where ii. license(s) was granted; iii. hold a license which is not currently nor has been subject to any probationary terms, revocation or suspension or conditions not generally applicable to all licensees; Page 2 of 14

3 iv. where applicable to their practice, have a current, unrestricted DEA registration and state controlled substance license; v. have current, and maintains uninterrupted valid professional liability insurance coverage in a form and in amounts satisfactory to the OPP; vi. have never been convicted of Medicare, Medicaid, or other federal or state governmental or privatethird-party payer fraud or program abuse, nor have been required to pay civil monetary penalties forthe same; vii. have never been, and not currently be, excluded or precluded from participation in Medicare, Medicaid, or other federal or state governmental health care program; viii. have never had Medical Staff appointment, clinical privileges, or status as a participating provider denied, revoked, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct; ix. been convicted of, or entered a plea of guilty or no contest, to any felony; or to any misdemeanor relating to insurance or health care fraud, abuse, violence; or misdemeanor relating to controlled substances or illegal drugs within 10 years of date of application; x. demonstrate recent clinical activity in their primary area of practice during at least two of the last four years; and xi. (for physicians and podiatrists, at initial appointment only) have successfully completed a residency training program approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association in the specialty in which the applicant seeks clinical privileges, or a podiatric surgical residency program accredited by the Council on Podiatric Medical Education of the American Podiatric Medical Association; 4. Waiver of Threshold Eligibility Criteria a. Waivers of threshold eligibility criteria will not be granted routinely. b. No one is entitled to a waiver. c. An application from an applicant who does not meet the threshold criteria for appointment or reappointment will not be processed unless the Operating Committee has granted the requested waiver. Page 3 of 14

4 d. A request for a waiver will only be considered if the applicant provides information sufficient to demonstrate that his or her qualifications are equivalent to, or exceed the criterion in question and that there are exceptional circumstances that warrant a waiver. e. The Credentialing Committee may consider supporting documentation submitted by the applicant and any relevant information from third parties. f. The Credentialing Committee will forward its recommendation, including the basis for such, to the Operating Committee. g. The Operating Committee s determination regarding whether to grant a waiver is final. h. A determination not to grant a waiver is not a denial of appointment and the applicant who requested the waiver is not entitled to a hearing. i. A determination to grant a waiver in a particular case is not intended to set a precedent. j. A determination to grant a waiver does not mean that appointment will be granted; only that processing of the application can begin. k. No Entitlement to Appointment l. No one is entitled to receive an application, be appointed or reappointed to the OPP merely because he or she: i. is licensed to practice a profession in this or any other state; ii. is a member of any particular professional organization; iii. has had in the past, or currently has, OPP appointment or privileges at any Ochsner hospital or health care facility; or iv. is affiliated with, or under contract to, any managed care plan, insurance plan, HMO, PPO, or other entity. m. Nondiscrimination: i. No one will be denied appointment, nor shall there be any discrimination, on the basis of gender, race, creed, age, disability, sexual orientation, marital status, military reserve status, national origin, for acts within the scope of a provider s state license (solely on the basis of that license or certification), or provision of care/services to high-risk populations or patients with conditions that require costly treatment. ii. OPP Network Development and Credentialing Sub-Committee members annually sign a statement affirming that they do not discriminate. Page 4 of 14

5 5. Clinician Provider Rights and Responsibilities a. The Credentialing Specialist shall notify the clinician when information obtained during the initial credentialing or recredentialing process varies substantially from the information originally submitted; and/or if there are omissions in the information provided. b. The Credentialing Specialist shall report any discrepancies or omissions to the OPP Medical Director and/or Assistant Medical Director. c. The Medical Director,Assistant Medical Director, or designee may contact the clinician to discuss and request clarification of the omission or discrepancy. d. The clinician shall have five (5) calendar days to respond to a request for clarification. e. Clarifications must be provided by the clinician in writing (which can include electronic mail). f. The Credentialing Specialist shall document all telephone conversations via a memo to the appropriate credentialing file. g. The clinician has the right to review information submitted to the Credentialing Department. h. With 24 hours notice and during regular business hours, the clinician may review the information contained in his/her credentialing file. i. The clinician may not review peer references or recommendations. j. The clinician shall submit any amendment or correction, in writing (electronic mail is also acceptable), to the Credentialing Department within 10 days of notification or in-person review. k. The Credentialing Specialist shall date stamp the information received and file in the clinician s credentials file. l. The clinician has the right to request an update as to the status of his/her initial credentialing or re-credentialing application. m. These rights shall be communicated via the application packet cover letter and OPP Policy and Procedure manual. n. The clinician is responsible to immediately report any change of status in the information maintained in his/her credential file to the Credentialing Department. o. A leave of absence of up to six months must be requested in writing to the Medical Director, stating the beginning and ending dates of the leave and the Page 5 of 14

6 reasons for the leave. Except in extraordinary circumstances, this request will be submitted at least 30 days prior to the anticipated start of the leave p. A clinician with a break in service of 30 or more calendar days must notify the Medical Director if the reason for such absence is related to their physical or mental health or otherwise to their ability to care for patients safely and competently. q. Leaves of absence are matters of courtesy, not of right. In the event that it is determined that an r. individual has not demonstrated good cause for a leave, or where a request for extension is not granted, or where reinstatement is denied for reasons other than professional competence or conduct, the determination will be final, with no recourse to a hearing and appeal. s. Under such circumstances, the Medical Director may trigger an automatic medical leave of absence. t. Individuals requesting reinstatement will submit a written summary of their professional activities during the leave and any other information that may be requested by the OPP. u. Requests for reinstatement will then be reviewed by the Medical Director. v. If a favorable recommendation on reinstatement is made, the individual may immediately resume clinical practice. w. However, if any of the individuals reviewing the request have any questions or x. concerns, those questions will be noted and the reinstatement request will be forwarded to the Credentialing Committee and the Operating Committee. If any request for reinstatement is not granted for reasons related to clinical competence or professional conduct, and if a report to the National Practitioner Data Bank is determined to be required, the individual will be entitled to request a hearing and appeal. y. If an individual s current appointment is due to expire during the leave, the individual s appointment will expire at the end of the appointment period, and the individual will be required to apply for reappointment upon his/her return from leave. 6. PROCEDURE INITIAL CREDENTIALING a. Requests for membership in OPP are reviewed by the OPP Medical Director and/or the Assistant Medical Director for network panel needs. Page 6 of 14

7 b. If clinician holds current privileges at an Ochsner or affiliated hospital, clinician is considered credentialed for OPP. c. If clinician does not hold current privileges at an Ochsner or affiliated hospital, an application packet is sent to the clinician and includes, but is not limited to: i. Cover letter with instructions, application, and additional items needed for credentialing and notification of rights. d. Upon receipt of a completed application packet, the Credentialing Specialist shall conduct a preliminary review of the application for completeness. e. If additional/clarifying information is required, if any questions are left blank, or if any required documents are missing, the application is considered incomplete and will not be processed until the application packet is complete. f. The Credentialing Specialist will ask the applicant to provide in writing the missing/clarifying information. g. The applicant is responsible to submit the requested/missing information to the Credentialing Specialist within thirty (30) calendar days. Any application that continues to be incomplete 30 days after the applicant has been notified of the additional information required, the application will be deemed to be withdrawn. h. If the Credentialing Specialist determines the applicant meets the Physician/Clinician Credentialing Eligibility Criteria and that the application packet is complete, the Credentialing Specialist shall initiate the credentialing and primary source verification process. i. Primary Source verification and timelines i. Primary source verification of information begins as soon as the application appears complete. ii. Primary source verifications and applications must be completed and/or dated within NCQA prescribed timeframes (180 calendar days unless otherwise noted). iii. All primary source verification is conducted in accordance with current year National Committee on Quality Assurance (NCQA) standards and guidelines. iv. All documents and primary source verifications obtained shall be date stamped with identification of staff performing the verification noted. v. For electronic verification, the as of date generated by the verification source is utilized as the verification date. Page 7 of 14

8 j. The initial credentialing process includes primary source verification (PSV) and/or review of the following: i. Current state professional license (PSV required) ii. Verification obtained by direct confirmation from the appropriate Louisiana or Mississippi licensing agency, if applicable. iii. Other active state licenses may be verified with the appropriate states licensing board, as required. iv. CDS license k. Clinicians who are not ordering/prescribing controlled substances, must state this in writing. l. Practitioners must demonstrate ongoing Professional Competency, as demonstrated through current Board Certification in their designated specialty Board or Board eligible with plans to pass their boards within two years. m. If greater than two years and not Board certified, then meets the requirements outlined in the OPP Professional Competency Policy. n. Board certification, completion of residency and/or graduation from medical school shall be verified by one of the following methods (PVS required): i. Board certification: 1. Directly from the American Board of Medical Specialties (ABMS) or its member boards; 2. CertiFACTS Online; or 3. American Medical Association (AMA) ephysician Profiles or AMA Masterfile. o. Verification of internship, residency and fellowship confirmation may be obtained: i. Directly from the institution(s) where the post graduate medical training was completed; ii. From the AMA Master file (must state verified to meet the standard) p. Verification of medical/professional school completion shall be obtained: i. Directly from the medical/professional school; ii. From the AMA Masterfile, or iii. From the Education Commission for Foreign Medical Graduates (ECFMG). 1. Graduates of foreign medical schools located outside the United States and Canada must present evidence of certification by the ECFMG or successful completion of a fifth pathway, or successful Page 8 of 14

9 passing of the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS). 2. If the AMA Masterfile is used as training verification, it must state verified to meet this standard. q. Work History i. Work History verification of relevant clinical work history for the last ten years (or from the time of licensure if less than ten years) is required. Primary source verification of work history is required. ii. The CV or application must include the beginning and ending month and year for each position in the practitioner s employment experience. iii. Any gaps must be clarified in writing. This document/statement will be filed in the Practitioner s Confidential Credentials File. r. Current, adequate malpractice insurance i. Professional liability insurance coverage and the amounts of coverage may be verified through the liability carrier. ii. The liability coverage must be current, and meet the requirements of $100 thousand per claim and $300 thousand annual aggregate, or PCF participation if coverage is only $100k/300k. iii. Carrier must be licensed in the state of Louisiana and/or Mississippi. s. Professional liability claims history (PSV required) i. Malpractice history shall be obtained from the liability insurance carrier(s) and the National Practitioner Data Bank (NPDB). t. Application for membership i. Each clinician shall complete the appropriate credentialing application. ii. The National Practitioner Data Bank (NPDB) shall be queried and the resulting report(s) included in the credential file. iii. The most recent report available to indicate Medicare and Medicaid sanctions shall be queried and the findings noted in the credential file. u. Credentialing Committee Review and Determination i. The verified file is submitted to the OPP Network Development and Credentialing Sub-Committee for review, determination and recommendation to the OPP Operating Committee for final determination. Page 9 of 14

10 ii. The OPP Network Development and Credentialing Sub-Committee will receive and review the credential file of any clinician whose file contains one or more of the elements qualifying the file as with issues. iii. The appropriate OPP leader (OPP Medical Director or OPP Assistant Medical Director) has the authority to determine that a credential file is Clean and to electronically sign off on the file as complete and approved. iv. The OPP Network Development and Credentialing Sub-Committee consider the application and may approve the application, deny the application or request additional information. v. The OPP Medical Director and/or Assistant Medical Director shall provide the decision to the applicant in writing. A copy will be forwarded to the Credentialing Department. vi. If the clinician credentialing is denied by OPP, OPP Medical Director and/or OPP Assistant Medical Director shall provide the decision to the clinician in writing. vii. A copy will be forwarded to the Credentialing Department. 7. The Operating Committee a. The Operating Committee may approve actions on appointment, reappointment if there has been a favorable recommendation from the Credentialing Committee and there is no evidence of any of the following: i. a current or previously successful challenge to any license or registration; an involuntary termination, limitation, reduction, denial, or loss of appointment or privileges at any other hospital or other entity; or ii. an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant. b. Any decision reached by the Operating Committee to appoint will be effective immediately. c. Upon receipt of a recommendation of the Credentialing Committee for appointment the Operating Committee may: i. grant appointment as recommended by the Credentialing Committee or ratify the appointment granted by the Operating Committee, as appropriate; or Page 10 of 14

11 ii. refer the matter back to the Credentialing Committee or to another source inside or outside the OPP for additional research or information; or iii. Disagree with or modify the recommendation. d. If the Operating Committee disagrees with a favorable recommendation of the Credentialing Committee, it should first discuss the matter with the chair of the Credentialing Committee. e. If the Operating Committee s determination remains unfavorable, the Medical Director will promptly send special notice that the applicant is entitled to request a hearing. f. Any final decision by the Operating Committee to grant, deny, revise, or revoke appointment is disseminated to appropriate individuals and, as required, reported to appropriate entities, including, as applicable, the NPDB or appropriate state licensure board. 8. Responsibilities a. Responsibility for the review and revision of this policy lies with the OPP Network Development and Credentialing Committee. 9. Re-credentialing Process: a. Reappointment will be for a period of not more than two years. Up to one hundred and eighty (180) calendar days prior to the end of the two (2) year initial credentialing period, the Credentialing department shall send the clinician an application for re-credentialing which is used to update the credentials information. b. All terms, conditions, requirements, and procedures relating to initial appointment will apply to continued appointment and clinical privileges and to reappointment. c. An application for reappointment will be furnished to Members at least four months prior to the expiration of their current appointment term. d. A completed reappointment application must be returned to the Credentialing Office within 30 days of receipt. e. Failure to submit a complete application at least 3 months prior to the expiration of the Member s current term may result in automatic expiration of appointment at the end of the appointment term. Page 11 of 14

12 f. The application will be reviewed by the credentialing staff to determine that all questions have been answered and that the Member satisfies all threshold eligibility criteria for reappointment. g. The credentialing staff will oversee the process of gathering and verifying relevant information and verifies through primary source verification the information that is subject to change. h. The credentialing staff will also be responsible for confirming that all relevant information has been received. i. If the Credentialing Committee or Operating Committee is considering a recommendation to deny reappointment or to reduce clinical privileges, the committee chair will notify the Member of the general tenor of the possible recommendation and may invite the Member to meet prior to any final recommendation being made. j. Prior to this meeting, the Member will be notified of the general nature of the information supporting the recommendation contemplated. k. At the meeting, the Member will be invited to discuss, explain, or refute this information. A summary of the interview will be made and included with the committee s recommendation. l. This meeting is not a hearing, and none of the procedural rules for hearings will apply. m. The Member will not have the right to be represented by legal counsel at this meeting. 10. Automatic Relinquishment a. Any action taken by any licensing board, professional liability insurance company, court or government agency regarding any of the matters set forth below, or failure to satisfy any of the threshold eligibility criteria, must be promptly reported to the Medical Director. b. An individual s appointment will be automatically relinquished, without right to hearing or appeal, if any of the following occur: i. Licensure: Revocation, probation, expiration, suspension, or the placement of conditions or restrictions on an individual s license. ii. Controlled Substance Authorization: Revocation, expiration, suspension, or the placement of conditions or restrictions on an individual s DEA or state controlled substance authorization. Page 12 of 14

13 iii. Insurance Coverage: Termination or lapse of an individual s professional liability insurance coverage, or other action causing the coverage to fall below the minimum required by the Hospital. iv. Medicare and Medicaid Participation: Termination, exclusion, or preclusion by government action from participation in the Medicare/Medicaid or other federal or state health care programs. v. Criminal Activity: Indictment, conviction, or a plea of guilty or no contest pertaining to any felony, or to any misdemeanor involving (I) controlled substances; (ii) illegal drugs; (iii) Medicare, Medicaid, or insurance or health care fraud or abuse; or (iv) violence. c. An individual s appointment will be automatically relinquished, without entitlement to a hearing and appeal, if the individual fails to satisfy any of the threshold eligibility criteria or perform his or her responsibilities. d. Situations involving the expiration of a medical license, controlled substance authorization (DEA or state) or a conviction or plea of guilty pertaining to any misdemeanor involving the use of alcohol will be evaluated on a case-by-case basis. e. Automatic relinquishment will take effect immediately upon notice to the OPP and continue until the matter is resolved and the individual is reinstated. f. If the underlying matter leading to automatic relinquishment is resolved within 90 days, the individual may request reinstatement. g. Failure to resolve the matter within 90 days of the date of relinquishment will result in an automatic resignation from the Medical Staff. h. Requests for reinstatement will be reviewed by the Medical Director. If all these individuals make a favorable recommendation on reinstatement, the individual may immediately resume clinical practice. i. This determination will then be forwarded to Credentialing Committee for ratification. j. If, however, any of the individuals reviewing the request have any questions or concerns, those questions will be noted and the reinstatement request will be forwarded to the Credentialing Committee for review and recommendation. 11. Operating Committee Action a. Final Decision of the Operating Committee: Page 13 of 14

14 i. The Operating Committee will take final action within 30 days after it (i) considers the appeal as Review Panel, (ii) receives a recommendation from a separate Review Panel, or (iii) receives the Hearing Panel s report when no appeal has been requested. b. Consistent with its ultimate legal authority for the operation of the Hospital and the quality of care provided, the Operating Committee may adopt, modify, or reverse any recommendation that it receives or refer the matter for further review. c. The Operating Committee will render its final decision in writing, including the basis for its decision, and will send special notice to the individual. A copy will also be provided to the President of the Medical Staff. d. Except where the matter is referred by the Credentialing Committee for further review, the final decision of the Operating Committee will be effective immediately and will not be subject to further review. 12. Maintenance of credentials a. The following credentials shall be kept current at all times: i. Louisiana or Mississippi professional licenses (updated prior to or at time of expiration from a primary source); ii. DEA license with Louisiana or Mississippi address. iii. CDS license. iv. Current liability insurance coverage certificate; v. Appropriate Medical Boards, if applicable. Page 14 of 14

SARASOTA MEMORIAL HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS CREDENTIALS POLICY

SARASOTA MEMORIAL HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS CREDENTIALS POLICY SARASOTA MEMORIAL HOSPITAL MEDICAL STAFF BYLAWS, POLICIES, AND RULES AND REGULATIONS CREDENTIALS POLICY Adopted by the Medical Staff: April 16, 2009 Approved by the Board: April 20, 2009 Revised by the

More information

The Plan will not credential trainees who do not maintain a separate and distinct practice from their training practice.

The Plan will not credential trainees who do not maintain a separate and distinct practice from their training practice. SUBJECT: PRIMARY CARE AND SPECIALTY PHYSICIAN INITIAL CREDENTIALING SECTION: CREDENTIALING POLICY NUMBER: CR-01 EFFECTIVE DATE: 1/01 Applies to all products administered by the Plan except when changed

More information

UNIVERSITY OF KANSAS HOSPITAL ALLIED HEALTH PROFESSIONALS POLICY Approved ECMS September 26, 2013 Approved Hospital Authority October 8, 2013

UNIVERSITY OF KANSAS HOSPITAL ALLIED HEALTH PROFESSIONALS POLICY Approved ECMS September 26, 2013 Approved Hospital Authority October 8, 2013 UNIVERSITY OF KANSAS HOSPITAL ALLIED HEALTH PROFESSIONALS POLICY Approved ECMS September 26, 2013 Approved Hospital Authority October 8, 2013 I. Generally An allied health professional ( AHP ) is a health

More information

YORK HOSPITAL CREDENTIALS POLICY AND PROCEDURE MANUAL

YORK HOSPITAL CREDENTIALS POLICY AND PROCEDURE MANUAL YORK HOSPITAL CREDENTIALS POLICY AND PROCEDURE MANUAL Updated January 25, 2012 TABLE OF CONTENTS YORK HOSPITAL CREDENTIALS POLICY AND PROCEDURE MANUAL PROCEDURE MANUAL DEFINITIONS ARTICLE I. APPOINTMENT

More information

Department: Legal Department. Approved by:

Department: Legal Department. Approved by: HAWAII HEALTH SYSTEMS C O R P O R A T I O N Touching Lives Everyday" Policies and Procedures Subject: Credentialing Requirements Department: Legal Department Issued by: Rene McWade, Esq. VP & General Counsel

More information

Practitioners may be recredentialed at any time, but in no circumstance longer than a 36 month period.

Practitioners may be recredentialed at any time, but in no circumstance longer than a 36 month period. SUBJECT: PRIMARY CARE AND SPECIALTY PHYSICIAN RECREDENTIALING SECTION: CREDENTIALING POLICY NUMBER: CR-02 EFFECTIVE DATE: 1/01 Applies to all products administered by the Plan except when changed by contract

More information

Delegated Credentialing A Solution to the Insurer Credentialing Waiting Game?

Delegated Credentialing A Solution to the Insurer Credentialing Waiting Game? Chapter EE Delegated Credentialing A Solution to the Insurer Credentialing Waiting Game? Charles J. Chulack, Esq. Horty, Springer & Mattern, P.C. Pittsburgh EE-1 EE-2 Table of Contents Chapter EE Delegated

More information

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31

EFFECTIVE DATE: 10/04. SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 SUBJECT: Primary Care Nurse Practitioners SECTION: CREDENTIALING POLICY NUMBER: CR-31 EFFECTIVE DATE: 10/04 Applies to all products administered by the plan except when changed by contract Policy Statement:

More information

Memorial Hermann Physician Network

Memorial Hermann Physician Network Memorial Hermann Physician Network NETWORK PARTICIPATION CRITERIA & POLICIES Table of Contents Page 1 I. Policy Objectives... II. Network Participation Criteria... III. Application Process... 2 2 4 4 5

More information

UnitedHealthcare of Insurance Company of New York The Empire Plan. CREDENTIALING and RECREDENTIALING PLAN

UnitedHealthcare of Insurance Company of New York The Empire Plan. CREDENTIALING and RECREDENTIALING PLAN UnitedHealthcare of Insurance Company of New York The Empire Plan CREDENTIALING and RECREDENTIALING PLAN 2013-2014 2013 UnitedHealth Group The Empire Plan All Rights Reserved This Credentialing and Recredentialing

More information

Subject: Re-Credentialing Verification (Page 1 of 5)

Subject: Re-Credentialing Verification (Page 1 of 5) Subject: Re-Credentialing Verification (Page 1 of 5) Objective: I. To ensure that initial credentialed Health Share/Tuality Health Alliance (THA) providers have the continuing legal authority and relevant

More information

HONORHealth CREDENTIALING PROCEDURES MANUAL 2017

HONORHealth CREDENTIALING PROCEDURES MANUAL 2017 HONORHealth CREDENTIALING PROCEDURES MANUAL 2017 Table of Contents Part 1 APPOINTMENT PROCEDURES 1.1 Application 1 1.2 Application Content 1 1.3 References 2 1.4 Effect of Application 2 1.5 Application

More information

2015 Complete Overview of the NCQA Standards Session Code: TU13 Time: 2:30 p.m. 4:00 p.m. Total CE Credits: 1.5 Presenter: Frank Stelling, MEd, MPH

2015 Complete Overview of the NCQA Standards Session Code: TU13 Time: 2:30 p.m. 4:00 p.m. Total CE Credits: 1.5 Presenter: Frank Stelling, MEd, MPH 2015 Complete Overview of the NCQA Standards Session Code: TU13 Time: 2:30 p.m. 4:00 p.m. Total CE Credits: 1.5 Presenter: Frank Stelling, MEd, MPH Introduction to NCQA Credentialing Standards NAMSS Educational

More information

CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS

CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS CREDENTIALING PLAN SECTION ONE INDIVIDUAL PROVIDERS I. STATEMENT OF POLICY II. SCOPE A. The purpose of Avera Credentialing Verification Service (CVS) is to provide credentialing and recredentialing primary

More information

BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS

BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS 7 1 BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF NORTH CAROLINA HOSPITALS Approved by the Executive Committee of the Medical Staff, November 5, 2001. Approved by the Medical Staff, December 5, 2001. Approved

More information

CREDENTIALING PROCEDURES MANUAL MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA

CREDENTIALING PROCEDURES MANUAL MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA MEMORIAL HOSPITAL OF SOUTH BEND, INC. SOUTH BEND, INDIANA January 16, 1984 Revised: October 18, 1984 January 19, 1989 April 17, 1989 April 26, 1990 December 20, 1990 January 21, 1993 May 27, 1993 July

More information

Values Accountability Integrity Service Excellence Innovation Collaboration

Values Accountability Integrity Service Excellence Innovation Collaboration n00256 Recredentialing Process Values Accountability Integrity Service Excellence Innovation Collaboration Abstract Purpose: The purpose of recredentialing is to assure that Network Health Plan/Network

More information

Medical Staff Credentialing Policy

Medical Staff Credentialing Policy Medical Staff Credentialing Policy Revised: January 29, 2018 CREDENTIALING POLICY Table of Contents ARTICLE I. APPOINTMENT TO THE MEDICAL STAFF... 1 1.1. Qualifications for Appointment... 1 1.1.1 General...

More information

CREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process.

CREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process. CREDENTIALING APPLICATION Please complete all sections. Incomplete applications may delay the credentialing process. PERSONAL IDENTIFICATION DATA Last Name: First: MI: Degree: Date of Birth: Social Security

More information

UnitedHealthcare. Credentialing Plan

UnitedHealthcare. Credentialing Plan UnitedHealthcare Credentialing Plan 2015-2016 Table of contents Section 1.0 Introduction... 1 Section 1.1 Purpose...1 Section 1.2 Credentialing Policy...1 Section 1.3 Authority of Credentialing Entity

More information

COMMUNITY HOWARD REGIONAL HEALTH KOKOMO, INDIANA. Medical Staff Policy POLICY #4. APPOINTMENT, REAPPOINTMENT AND CREDENTIALING POLICY

COMMUNITY HOWARD REGIONAL HEALTH KOKOMO, INDIANA. Medical Staff Policy POLICY #4. APPOINTMENT, REAPPOINTMENT AND CREDENTIALING POLICY COMMUNITY HOWARD REGIONAL HEALTH KOKOMO, INDIANA Medical Staff Policy POLICY #4. APPOINTMENT, REAPPOINTMENT AND CREDENTIALING POLICY 1.1 PURPOSE The purpose of this Policy is to set forth the criteria

More information

Practitioner Credentialing Criteria for Participation and Termination

Practitioner Credentialing Criteria for Participation and Termination Practitioner Credentialing Criteria for Participation and Termination I. Statement of Purpose Regence (referred to hereinafter as the Company ) is firmly committed to the development of networks with practitioners

More information

Credentialing and. Recredentialing. Plan

Credentialing and. Recredentialing. Plan Credentialing and Recredentialing Plan This Credentialing and Recredentialing Plan may be distributed to applying or participating Licensed Independent Practitioners, Hospitals and Ancillary Providers

More information

Provider Rights. As a network provider, you have the right to:

Provider Rights. As a network provider, you have the right to: NETWORK CREDENTIALING AND SANCTIONS ValueOptions program for credentialing and recredentialing providers is designed to comply with national accrediting organization standards as well as local, state and

More information

Medicare Manual Update Section 2 Credentialing (pg 15-23) SECTION 2: CREDENTIALING. 2.1 : Credentialing Policies & Procedures

Medicare Manual Update Section 2 Credentialing (pg 15-23) SECTION 2: CREDENTIALING. 2.1 : Credentialing Policies & Procedures SECTION 2: CREDENTIALING The credentialing program applies to all direct-contracted and those who are affiliated with Care1st through their relationship with a contracted PPG (delegated IPA/MG). Care1st

More information

Credentialing and. Recredentialing. Plan

Credentialing and. Recredentialing. Plan Credentialing and Recredentialing Plan This Credentialing and Recredentialing Plan may be distributed to applying or participating Licensed Independent Practitioners, Hospitals and Ancillary Providers

More information

UH Medical Staff Bylaws April Medical Staff BYLAWS. Last Updated: April Page 1 of 72

UH Medical Staff Bylaws April Medical Staff BYLAWS. Last Updated: April Page 1 of 72 Medical Staff BYLAWS Last Updated: Page 1 of 72 The University Hospital Medical Staff Bylaws PREAMBLE WHEREAS, University Hospital is a health care entity of the University of Medicine and Dentistry of

More information

Bylaws. of the. Medical Staff. Crouse Health Hospital, Inc. including amendments approved through June 28, 2016

Bylaws. of the. Medical Staff. Crouse Health Hospital, Inc. including amendments approved through June 28, 2016 Bylaws of the Medical Staff of Crouse Health Hospital, Inc. including amendments approved through June 28, 2016 Crouse Health Hospital, Inc. 736 Irving Avenue, Syracuse, New York 13210 {H1058039.33} MEDICAL

More information

USABLE CORPORATION TRUE BLUE PPO NETWORK PRACTITIONER CREDENTIALING STANDARDS

USABLE CORPORATION TRUE BLUE PPO NETWORK PRACTITIONER CREDENTIALING STANDARDS USABLE CORPORATION TRUE BLUE PPO NETWORK PRACTITIONER CREDENTIALING STANDARDS ELIGIBLE DISCIPLINES: Chiropractors Optometrists Podiatrists Advance Nurse Practitioners Certified Nurse-Midwives Clinical

More information

Delegation Oversight 2016 Audit Tool Credentialing and Recredentialing

Delegation Oversight 2016 Audit Tool Credentialing and Recredentialing Att CRE - 216 Delegation Oversight 216 Audit Tool Review Date: A B C D E F 1 2 C3 R3 4 5 N/A N/A 6 7 8 9 N/A N/A AUDIT RESULTS CREDENTIALING ASSESSMENT ELEMENT COMPLIANCE SCORE CARD Medi-Cal Elements Medi-Cal

More information

This policy applies to: Stanford Health Care Stanford Children s Health. Date Written or Last Revision: Oct 2017

This policy applies to: Stanford Health Care Stanford Children s Health. Date Written or Last Revision: Oct 2017 Providers Page 1 of 15 I. PURPOSE To establish mechanisms for gathering relevant data that will serve as the basis for decisions regarding credentialing and privileging of licensed independent practitioners

More information

DOCTORS HOSPITAL, INC. Medical Staff Bylaws

DOCTORS HOSPITAL, INC. Medical Staff Bylaws 3.1.11 FINAL VERSION; AS AMENDED 7.22.13; 10.20.16; 12.15.16 DOCTORS HOSPITAL, INC. Medical Staff Bylaws DMLEGALP-#47924-v4 Table of Contents Article I. MEDICAL STAFF MEMBERSHIP... 4 Section 1. Purpose...

More information

MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff Final Draft

MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff Final Draft MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff Final Draft 5-15-13 DEFINITIONS ADVANCED PROFESSIONAL PRACTITIONER (APP): Advanced Practice Nurses, including advanced

More information

MEDICAL STAFF BYLAWS REVISED FEBRUARY 23, 2017

MEDICAL STAFF BYLAWS REVISED FEBRUARY 23, 2017 MEDICAL STAFF BYLAWS REVISED FEBRUARY 23, 2017 DEFINITIONS Chief Executive Officer or CEO means the individual appointed by the Governing Board as the chief executive officer to act on its behalf in the

More information

SAMPLE - Verifying Credentialing Information Policy

SAMPLE - Verifying Credentialing Information Policy Subject: Number: Effective Date: Supersedes SPP# Approved by: (signature) Distribution: Verifying Credentialing Information Dated: Medical Staff, Credentialing Manual, Medical Staff Office I. STATEMENT

More information

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip SCHNEIDER REGIONAL MEDICAL CENTER 9048 SUGAR ESTATE ST. THOMAS, U.S.V.I 00802 APPLICATION FOR TEMPORARY PRIVILEGES (USED FOR URGENT PATIENT NEED AND LOCUM TENENS) COMPLETE THE APPLICATION IN FULL. PRINT

More information

Credentialing Application and Process

Credentialing Application and Process Credentialing Application and Process What is Credentialing? Credentialing is the process of obtaining, verifying and assessing the qualifications of a healthcare practitioner to provide patient care services

More information

Appendix B-1 Acceptance/continued participation criteria Primary care nurse practitioner

Appendix B-1 Acceptance/continued participation criteria Primary care nurse practitioner Appendix B-1 Acceptance/continued participation criteria Primary care nurse practitioner Amendments to this Appendix B-1 shall be effective as of August 1, 2012 (the Amendment Date ). To be initially admitted

More information

The University Hospital Medical Staff BYLAWS

The University Hospital Medical Staff BYLAWS The University Hospital Medical Staff BYLAWS October 2008 Page 1 of 77 The University Hospital Medical Staff Bylaws PREAMBLE WHEREAS, University Hospital is a health care entity of the University of Medicine

More information

Medical Staff Credentialing Procedures Manual. Reviewed: November 21, 2013

Medical Staff Credentialing Procedures Manual. Reviewed: November 21, 2013 Medical Staff Credentialing Procedures Manual Reviewed: November 21, 2013 PART ONE: APPOINTMENT PROCEDURES 1.1 PRE-APPLICATION A. No practitioner shall be entitled to membership on the medical staff or

More information

OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application)

OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application) OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application) Prior to completing this credentialing application, please read and observe the following: Healthcare Organizations may contract

More information

THE MIRIAM HOSPITAL PROVIDENCE, RHODE ISLAND THE MIRIAM HOSPITAL MEDICAL STAFF BYLAWS

THE MIRIAM HOSPITAL PROVIDENCE, RHODE ISLAND THE MIRIAM HOSPITAL MEDICAL STAFF BYLAWS THE MIRIAM HOSPITAL PROVIDENCE, RHODE ISLAND THE MIRIAM HOSPITAL MEDICAL STAFF BYLAWS Adopted: April 30, 2012 Approved: June 7, 2012 Implemented: July 1, 2012 Revised: November 27, 2012 May 20, 2014 TABLE

More information

Parkview Hospital Medical Staff Bylaws Supplement Allied Health Practitioner Manual

Parkview Hospital Medical Staff Bylaws Supplement Allied Health Practitioner Manual Parkview Hospital Medical Staff Bylaws Supplement Allied Health Practitioner Manual PVH AHP Manual December 9, 2014 Table of Contents A. Comparison of Advanced and Dependent AHP 3 B. Authorizations of

More information

NAMSS Comparison of Accreditation Standards

NAMSS Comparison of Accreditation Standards The verification requirements listed are considered minimum standards each organization must meet in order to achieve accreditation. Accreditors periodically differ as to what is considered an acceptable

More information

MEDICAL STAFF BYLAWS. for ST. JOSEPH MERCY ANN ARBOR ST. JOSEPH MERCY LIVINGSTON

MEDICAL STAFF BYLAWS. for ST. JOSEPH MERCY ANN ARBOR ST. JOSEPH MERCY LIVINGSTON MEDICAL STAFF BYLAWS for ST. JOSEPH MERCY ANN ARBOR ST. JOSEPH MERCY LIVINGSTON Approved March 22 nd, 2016 TABLE OF CONTENTS...i PREAMBLE... 1 DEFINITIONS... 2 ARTICLE I NAME... 6 ARTICLE II PURPOSES...

More information

Medi-cal Manual Update Section 9.14 Credentialing Program (pg )

Medi-cal Manual Update Section 9.14 Credentialing Program (pg ) 9.14: Credentialing Program Purpose To ensure that all network practitioners/providers meet the minimum credentials requirements set forth by Care1st and the regulatory agencies including, but not limited

More information

MEDICAL STAFF CREDENTIALS MANUAL

MEDICAL STAFF CREDENTIALS MANUAL MEDICAL STAFF CREDENTIALS MANUAL Adopted by the Medical Staff: July 27, 2009 Adopted by the Board of Directors: July 31, 2009 AHMC ANAHEIM REGIONAL MEDICAL CENTER (ARMC) CREDENTIALS MANUAL TABLE OF CONTENTS

More information

ASCENSION SAINT MARY S HOSPITAL OF RHINELANDER, WISCONSIN BYLAWS OF THE MEDICAL STAFF

ASCENSION SAINT MARY S HOSPITAL OF RHINELANDER, WISCONSIN BYLAWS OF THE MEDICAL STAFF ASCENSION SAINT MARY S HOSPITAL OF RHINELANDER, WISCONSIN PREAMBLE BYLAWS OF THE MEDICAL STAFF Revised February 2016 Revised August 2, 2016 Revised June 6, 2017 Revised August 1, 2017 Revised: June 5,

More information

CHAPTER 6: CREDENTIALING PROCEDURES

CHAPTER 6: CREDENTIALING PROCEDURES We want to help you become or continue as a participating in-network provider for our members. Please refer to this chapter for information about: Provider credentialing Provider recredentialing Provider

More information

CREDENTIALING Section 8. Overview

CREDENTIALING Section 8. Overview Overview Credentialing is the process by which the appropriate peer review bodies of the Plan evaluate an individual applicant s background, education, post-graduate training, experience, work history,

More information

NAMSS Comparison of Accreditation Standards

NAMSS Comparison of Accreditation Standards The verification requirements listed are considered minimum standards each organization must meet to achieve accreditation. Accreditors periodically differ as to what is considered an acceptable source

More information

BYLAWS OF THE MEDICAL STAFF

BYLAWS OF THE MEDICAL STAFF UNIVERSITY OF CALIFORNIA SAN FRANCISCO BYLAWS OF THE MEDICAL STAFF Revisions: Approved August 2010 by Executive Medical Board and Governance Advisory Council Approved March 2012 by Executive Medical Board

More information

Eye Medical Provider Practice Application

Eye Medical Provider Practice Application and subsidiaries Eye Medical Provider Practice Application How to Join the Avesis Network. Complete and sign the application Complete and sign the W-9 Complete and sign the Credential Verification Release

More information

Please Note: Please send all documentation related to the credentialing portion of this documentation to:

Please Note: Please send all documentation related to the credentialing portion of this documentation to: Please ote: The application process is split into different actions. Please send all documentation related to the contracting portion of this documentation to: Fax to: (916)350-8860 Or email to: BSCproviderinfo@blueshieldca.com

More information

CREDENTIALING Section 4

CREDENTIALING Section 4 Overview Credentialing is the process by which the appropriate peer-review bodies of Ohana Health Plan (the Plan) evaluate the credentials and qualifications of providers, i.e., physicians, allied health

More information

BAPTIST EYE SURGERY CENTER AT SUNRISE MEDICAL STAFF BYLAWS

BAPTIST EYE SURGERY CENTER AT SUNRISE MEDICAL STAFF BYLAWS 1 BAPTIST EYE SURGERY CENTER AT SUNRISE MEDICAL STAFF BYLAWS EFFECTIVE MARCH 28, 2014 2 PREAMBLE WHEREAS, Baptist Eye Surgery Center at Sunrise is an ambulatory surgical center owned and operated by Baptist

More information

SAMPLE MEDICAL STAFF BYLAWS PROVISIONS FOR CREDENTIALING AND CORRECTIVE ACTION

SAMPLE MEDICAL STAFF BYLAWS PROVISIONS FOR CREDENTIALING AND CORRECTIVE ACTION FOR CREDENTIALING AND CORRECTIVE ACTION [NOTE: THESE ARE RELATING TO CREDENTIALING AND CORRECTIVE ACTION. THE SAMPLE PROVISIONS MUST BE REVIEWED AND REVISED DEPENDING ON RELEVANT CIRCUMSTANCES, INCLUDING

More information

UPMC PINNACLE PROVIDER ENROLLMENT CREDENTIALING POLICIES AND PROCEDURES

UPMC PINNACLE PROVIDER ENROLLMENT CREDENTIALING POLICIES AND PROCEDURES SUBJECT: Provider Enrollment Delegated Credentialing & Recredentialing PURPOSE Credentialing/recredentialing is the process by which UPMC Pinnacle ensures the quality of all providers of health care services

More information

This letter is to let you know that you are due for re-credentialing as a participating provider for AmeriHealth Caritas Louisiana of Louisiana.

This letter is to let you know that you are due for re-credentialing as a participating provider for AmeriHealth Caritas Louisiana of Louisiana. ATTN: AmeriHealth Caritas Louisiana Providers RE: Provider Re-Credentialing CAQH ID: Dear Credentialing Contact: This letter is to let you know that you are due for re-credentialing as a participating

More information

This document describes the internal Harbor Health Plan's criteria for credentialing and recredentialing.

This document describes the internal Harbor Health Plan's criteria for credentialing and recredentialing. vc I. SCOPE: This document describes the internal 's criteria for credentialing and recredentialing. II. POLICY: 's criteria for credentialing and recredentialing will be compliant with legal and accreditation

More information

Keywords: Credentialing, Practitioner, PSV. Last Review Date: 10/11/2004, 1/31/2005, 3/28/2005, 3/13/2006, 4/24/2006

Keywords: Credentialing, Practitioner, PSV. Last Review Date: 10/11/2004, 1/31/2005, 3/28/2005, 3/13/2006, 4/24/2006 3/28/2005, Page 1 of 7 I. Purpose: A. To describe and outline the initial credentialing process for all independent practitioners and to ensure that new independent practitioners meet ValueOptions of California

More information

CLINICAL STAFF CREDENTIALING AND PRIVILEGING MANUAL

CLINICAL STAFF CREDENTIALING AND PRIVILEGING MANUAL CLINICAL STAFF CREDENTIALING AND PRIVILEGING MANUAL January 20, 2012 TABLE OF CONTENTS Introduction...1 I. Clinical Staff Membership...1 II. Clinical Staff Privileges...2 III. Procedures for Initial Appointment

More information

Hospital Crosswalk. Medicare Hospital Requirements to 2012 Joint Commission Hospital Standards & EPs

Hospital Crosswalk. Medicare Hospital Requirements to 2012 Joint Commission Hospital Standards & EPs Hospital Crosswalk CFR Number Standards and Elements of Performance 482.11 TAG: A-0020 482.11 Condition of Participation: Compliance with Federal, State and Local Laws 482.11(a) TAG: A-0021 LD.04.01.01

More information

TIFT REGIONAL MEDICAL CENTER MEDICAL STAFF POLICIES & PROCEDURES

TIFT REGIONAL MEDICAL CENTER MEDICAL STAFF POLICIES & PROCEDURES Title: Allied Health Professionals Approved: 2/02 Reviewed/Revised: 11/04; 08/10; 03/11; 5/14 Definition TIFT REGIONAL MEDICAL CENTER MEDICAL STAFF POLICIES & PROCEDURES P & P #: MS-0051 Page 1 of 7 For

More information

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax)

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax) Application Date: \ \ Date Available: \ \ Provider s Name: O MD O DO O PA O NP SS # : City: State: Zip: Home Phone ( ) Work Phone ( ) Pager ( ) Cell Phone ( ) E-Mail address: Driver s Lic. # Expires: \

More information

Medical Staff Credentials Policy

Medical Staff Credentials Policy Medical Staff Credentials Policy MOUNT CARMEL HEALTH SYSTEM A Medical Staff Document \\Mcehemcshare\mchs med staff svcs$\misc\governing Documents\MCHS\Credentials Policy\MCHS Medical Staff Credentials

More information

1) ELIGIBLE DISCIPLINES

1) ELIGIBLE DISCIPLINES PRACTITIONER S APPLICABLE TO ALL INDIVIDUAL NETWORK PARTICIPANTS AND APPLICANTS FOR THE PREFERRED PAYMENT PLAN NETWORK, MEDI-PAK ADVANTAGE PFFS NETWORK AND MEDI-PAK ADVANTAGE LPPO NETWORK of Arkansas Blue

More information

C. HUMAN RESOURCES LIASON MCCMH administrative employee who communicates with the Macomb County Human Resource and Labor Relations Department.

C. HUMAN RESOURCES LIASON MCCMH administrative employee who communicates with the Macomb County Human Resource and Labor Relations Department. IV. DEFINITIONS A. CLINICAL STRATEGIES AND CLINICAL IMPROVEMENT DIVISION The Clinical Strategies and Clinical Improvement ( CSI ) Division is the MCCMH administrative division responsible for the credentialing

More information

Medical Staff Allied Health Professional Policy

Medical Staff Allied Health Professional Policy Medical Staff Allied Health Professional Policy MOUNT CARMEL HEALTH SYSTEM A Medical Staff Document \\Mcehemcshare\mchs med staff svcs$\misc\governing Documents\MCHS\AHP Policy\MCHS Medial Staff Allied

More information

Ohio Department of Insurance

Ohio Department of Insurance Ohio Department of Insurance STANDARDIZED CREDENTIALING FORM Please complete each section thoroughly. Attach additional sheets where necessary. Type or print clearly in black ink. Sign and date the application.

More information

Molina Healthcare of Wisconsin, Inc. Practitioner Application

Molina Healthcare of Wisconsin, Inc. Practitioner Application Molina Healthcare of Wisconsin, Inc. Practitioner Application 1. INSTRUCTIONS This form should be: Typed or legibly printed in black or blue ink. Keep a copy of the application on file for future requests.

More information

SC Uniform Managed Care Provider Credentialing Application

SC Uniform Managed Care Provider Credentialing Application SC Uniform Managed Care Provider Credentialing Application I. PERSONAL INFORMATION Solo Practice Group Practice Name: Last First M.I. Suffix Degree Maiden and/or other name List W-9 name if different Place

More information

MENTAL HEALTH MENTAL RETARDATION OF TARRANT COUNTY. Operating Procedure MC-033 Effective: January 1999 Managed Care Revised: April 2008 Page 1

MENTAL HEALTH MENTAL RETARDATION OF TARRANT COUNTY. Operating Procedure MC-033 Effective: January 1999 Managed Care Revised: April 2008 Page 1 MENTAL HEALTH MENTAL RETARDATION OF TARRANT COUNTY Operating Procedure MC-033 Effective: January 1999 Managed Care Revised: April 2008 Page 1 CREDENTIALING/RECREDENTIALING OF PROFESSIONALS I. PURPOSE:

More information

UNITED BEHAVIORAL HEALTH. Clinician and Facility Credentialing Plan

UNITED BEHAVIORAL HEALTH. Clinician and Facility Credentialing Plan UNITED BEHAVIORAL HEALTH Clinician and Facility Credentialing Plan 2017-2018 CREDENTIALING PLAN TABLE OF CONTENTS Section 1 INTRODUCTION... 1 Section 1.1 Purpose... 1 Section 1.2 Discretion, Rights and

More information

BYLAWS OF THE MEDICAL STAFF BROWARD HEALTH v Broward Health Medical Staff Bylaws Effective May 30, 2013

BYLAWS OF THE MEDICAL STAFF BROWARD HEALTH v Broward Health Medical Staff Bylaws Effective May 30, 2013 BYLAWS OF THE MEDICAL STAFF OF BROWARD HEALTH 1 July 30, 2014 David DiPietro BROWARD HEALTH MEDICAL STAFF BYLAWS TABLE OF CONTENTS PREAMBLE 6 DEFINITIONS OF TERMS 7 CONSTRUCTION OF TERMS AND HEADINGS

More information

MEDICAL STAFF CREDENTIALING MANUAL

MEDICAL STAFF CREDENTIALING MANUAL MEDICAL STAFF CREDENTIALING MANUAL 2016 MOUNT CLEMENS REGIONAL MEDICAL CENTER CREDENTIALING MANUAL TABLE OF CONTENTS I. PROCEDURES FOR APPOINTMENT 4 1. GENERAL PROCEDURE 4 2. APPLICATION FOR INITIAL APPOINTMENT

More information

Hospital Crosswalk. Medicare Hospital Requirements to 2017 Joint Commission Hospital Standards & EPs. Joint Commission Equivalent Number EP 2 EP 1

Hospital Crosswalk. Medicare Hospital Requirements to 2017 Joint Commission Hospital Standards & EPs. Joint Commission Equivalent Number EP 2 EP 1 Hospital Crosswalk CFR Number 482.11 TAG: A-0020 482.11 Condition of Participation: Compliance with Federal, State and Local Laws 482.11(a) TAG: A-0021 LD.04.01.01 The hospital complies with law and regulation.

More information

Medical Staff Bylaws

Medical Staff Bylaws Medical Staff Bylaws Allen Hospital Waterloo, IA Revised/Reviewed: November 2015 Previous editions: March, 2015, December, 2013, November 2011, December 2009, November 2007, November 2006, May 2006, December

More information

MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff

MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff MEDICAL STAFF BYLAWS Volume I: Governance, Structure and Function of the Medical Staff January 2014 Table of Contents ARTICLE I - PURPOSE... 9 ARTICLE II - MEDICAL STAFF MEMBERSHIP, CATEGORIES, & RIGHTS...

More information

YORK HOSPITAL MEDICAL STAFF BYLAWS

YORK HOSPITAL MEDICAL STAFF BYLAWS YORK HOSPITAL MEDICAL STAFF BYLAWS Table of Contents ARTICLE I. NAME...4 1.1 NAME... 4 ARTICLE II. PURPOSES AND RESPONSIBILITIES OF THE MEDICAL STAFF.4 2.1 PURPOSES... 4 2.2 RESPONSIBILITIES... 4 ARTICLE

More information

SAMPLE - Medical Staff Credentialing and Initial Appointment Policy

SAMPLE - Medical Staff Credentialing and Initial Appointment Policy Subject: Medical Staff Credentialing and Initial Appointment Number: Effective Date: Supersedes SPP# Dated: Approved by: (signature) Distribution: Medical Staff, Credentialing Manual, Medical Staff Office

More information

Idaho Practitioner Application

Idaho Practitioner Application Idaho Practitioner Application To use the Idaho Practitioner Application (IPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When a request

More information

Washington Practitioner Application

Washington Practitioner Application Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When

More information

Network Participant Credentialing Application

Network Participant Credentialing Application Please: Type or print legibly Complete all items. If an item does not apply, enter NA. Do not leave any items blank. Include the following with your application, if applicable: Copy of professional license(s)

More information

2017 Complete Overview of the NCQA Standards

2017 Complete Overview of the NCQA Standards 2017 Complete Overview of the NCQA Standards Session Code: TU12 Date: Tuesday, October 24 Time: 2:30 p.m. - 4:00 p.m. Total CE Credits: 1.5 Presenter(s): Veronica Locke 2017 Complete Overview of the NCQA

More information

Page 1 of 6 ADMINISTRATIVE POLICY AND PROCEDURE

Page 1 of 6 ADMINISTRATIVE POLICY AND PROCEDURE 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

More information

BYLAWS AND GENERAL RULES & REGULATIONS OF THE MEDICAL STAFF PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO

BYLAWS AND GENERAL RULES & REGULATIONS OF THE MEDICAL STAFF PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO BYLAWS AND GENERAL RULES & REGULATIONS OF THE MEDICAL STAFF PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO Approved: Bylaws Committee: 8-8-17 Medical Executive Committee: 10-16-17 General Staff

More information

MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD.

MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD. MEDICAL STAFF CREDENTIALING APPLICATION FORM For MD; DO; DDS; DMD; DC; DPM; PharmD; PhD; PsyD; OD. APPLICANT NAME: SPECIALTY: In order to expedite the credentialing process, please complete every item

More information

GLACIAL RIDGE HEALTH SYSTEM MEDICAL STAFF BYLAWS

GLACIAL RIDGE HEALTH SYSTEM MEDICAL STAFF BYLAWS GLACIAL RIDGE HEALTH SYSTEM MEDICAL STAFF BYLAWS February 2016 Page 2 of 31 GLACIAL RIDGE HOSPITAL DISTRICT dba GLACIAL RIDGE HEALTH SYSTEM MEDICAL STAFF BYLAWS Index Preamble 3 Definitions 4 Article I:

More information

Subject: Initial Credentialing Verification (Page 1 of 5)

Subject: Initial Credentialing Verification (Page 1 of 5) 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

More information

BCBS NC Blue Medicare Credentialing Instructions

BCBS NC Blue Medicare Credentialing Instructions BCBS C Blue Medicare Credentialing Instructions Licensed Certified Social Worker (LCSW) Certified Substance Abuse Counselor (CSAC) Licensed Clinical Addiction Specialist (LCAS) Licensed Marriage and Family

More information

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( )

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( ) (Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:

More information

Provider Credentialing and Termination

Provider Credentialing and Termination PROVIDER CREDENTIALING AND TERMINATION PROVIDER CREDENTIALING Subject to limited exceptions, Fidelis Care is required to credential each health care professional, prior to the professional providing services

More information

Legal Last Name First Middle Professional Title/Degree

Legal Last Name First Middle Professional Title/Degree IOWA STATEWIDE UNIVERSAL PRACTITIONER RECREDENTIALING APPLICATION Type or print responses in ink. A CV or See CV may not be use in lieu of completing any answers on this application. Review or complete

More information

CREDENTIALING Section 5

CREDENTIALING Section 5 Overview Credentialing is the process used by the Plan to evaluate the qualifications and credentials of providers, physicians, allied health professionals, hospitals and ancillary facilities/health care

More information

Washington Practitioner Application

Washington Practitioner Application Washington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When

More information

Stanford Health Care Lucile Packard Children s Hospital Stanford

Stanford Health Care Lucile Packard Children s Hospital Stanford Practitioners Page 1 of 11 I. PURPOSE To outline individuals who are authorized to provide care as an Allied Health Provider as well as describe which categories of individuals who will be processed under

More information

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training State of Florida Department of Health Board of Osteopathic Medicine Application for Registration as an Osteopathic Physician in Training Board of Osteopathic Medicine 4052 Bald Cypress Way, #C-06 Tallahassee,

More information

TRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM

TRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM TRINITY HEALTH Minot, North Dakota MEDICAL STAFF PRE-APPLICATION FORM Application Instructions: Complete the application in full. The application must be typed or neatly printed. Attach additional sheets

More information

Medical Staff Bylaws

Medical Staff Bylaws Medical Staff Bylaws Of Scott & White Hospital - Round Rock Revised the Twenty Fourth of October 2008, Round Rock, Texas Revised the Twenty Fourth of July 2009, Round Rock, Texas Revised the Twenty Third

More information