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 training and experience to provide quality care to THA members. II. III. To ensure that THA identifies any issues within the provider re-credentialing cycle that may affect the care of members. To ensure that THA conducts re-credentialing verification within the specified time limits and through primary sources, unless otherwise indicated. Policy: I. This THA re-credentialing policy applies to THA Full, Associate, Preferred or Extended Contract, and Ancillary Providers. THA evaluates all re-credentialing candidate providers for continuing participation, corrective action/improvement, or termination. II. III. IV. THA practitioners will be re-credentialed in compliance with National Committee on Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) standards. THA will utilize the three (3) year URAC re-credentialing cycle standard. Exceptions to the three year re-credentialing cycle may occur under the following circumstances: a. The practitioner is on active military assignment; or b. The practitioner is on maternity leave or sabbatical. If one of the above circumstances applies, the contract between the practitioner and THA will remain in place and THA will re-credential the practitioner upon his/her return. a. The reason for the re-credentialing delay must be documented in the practitioner s file. b. THA will verify that the practitioner who returns from military duty, maternity leave, or sabbatical has a valid license to practice before he/she resumes seeing patients. c. THA will complete the re-credentialing process within 60 calendar days of the date that the practitioner resumes seeing patients. The Oregon Practitioner Re-Credentialing Application is the approved application form used for re-credentialing; primary source verification for the following criteria is included in this form.
Subject: Re-Credentialing Verification (Page 2 of 5) a. License verification THA verifies valid and current State licensure or certification through a query of the appropriate Oregon State Board or certification agency; the query may occur via telephone verification or Website verification (if primary source verification is an approved method of the Website). b. A current, valid Oregon DEA certificate, if applicable Verification Time Limit: None. For practitioners who prescribe medications, the DEA or CDS certificate must be effective at the time of the re-credentialing decision; it must be verified through one of the following methods: o A copy of the DEA or CDS certificate; o Documented visual inspection of the original certificate; o Confirmation from the DEA or CDS agency; o Practitioner entry in the National Technical Information Service (NTIS) database; o Practitioner entry in the American Medical Association (AMA) Practitioner Master File; or o Confirmation from the State pharmaceutical licensing agency, where applicable. THA may re-credential a practitioner whose DEA certificate is pending, provided that there is a practitioner with a valid DEA who will write all prescriptions requiring a DEA number for that pending prescribing practitioner (until he/she receives a valid DEA certificate). c. Board Certification, if applicable The Board certification expiration date must be documented in the practitioner s credentialing file. o If a lifetime Board certification status exists, it must also be documented in the practitioner s credentialing file and verified within 180 days. Verification may occur through the Official Osteopathic Practitioner Profile Report of the AOA Practitioner Master File or the appropriate specialty board of the American Board of Medical Specialties. Upon obtaining Board certification status, physicians must maintain the status in order to maintain Tuality Healthcare medical staff membership and privileges. o Should re-certification not be maintained, the physician shall retake their Board re-certification examination at least 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
Subject: Re-Credentialing Verification (Page 3 of 5) from THA and is not eligible for appeal or hearing. d. History of professional liability claims that resulted in settlements or judgments paid by, or on behalf of, the provider Confirmation of the past five (5) years of history of professional liability settlements via NPDB query. e. Sanction information State sanctions, restrictions on licensure, and/or limitations on scope of practice within the most recent five (5) year period will be identified through the appropriate data source. o Written verification must come from the National Practitioner Data Bank (NPDB), Healthcare Integrity and Protection Databank (HIPDB), Federation of State Medical Boards (FSMB), or appropriate State certification or accreditation agency. o Verification must be from the most recent, cumulative report released by the approved source, as well as all subsequent periodic report updates. Medicare and Medicaid sanctions or exclusions will be verified through a query of one of the following NCQA/URAC-approved Primary Sources: o NPDB; o Cumulative Sanctions Report; o State Medicaid agency or intermediary; o Medicare intermediary Noridian exclusion listing; o Office of Inspector General (OIG) List of Excluded Individuals and Entities; or o Excluded Parties List System (EPLS). f. A current and signed attestation The practitioner s signed attestation must address the following: o Reasons for any inability to perform the essential functions of the position, with or without accommodation; o Lack of present illegal drug use; o History of loss of license or felony convictions; o History of loss or limitation of privileges or disciplinary action; o Current professional liability insurance coverage (should include the dates and amount of current professional liability insurance coverage); and o The correctness and completeness of the application.
Subject: Re-Credentialing Verification (Page 4 of 5) V. THA has zero tolerance for practitioner licensing restrictions that result from unprofessional conduct as described in Oregon ORS 677.188 and 677.190. VI. VII. VIII. IX. Re-credentialing information is provided to the THA Quality Management Committee (QMC) for review; the THA QMC will determine if the practitioner/provider meets all established criteria. If all criteria are met, the THA QMC practitioner will be re-credentialed according policy; otherwise, the THA QMC may institute corrective action or termination. a. Additional practitioner re-credentialing criteria, as adopted by the THA QMC, are reviewed with respect to utilization, quality, access, and administrative issues. This additional review process provides an opportunity for informative and educational feedback to the re-credentialed providers. b. All THA QMC discussions relating to review of the practitioner/provider s file are held in closed session and considered confidential. c. A practitioner/provider may be re-appointed at any time during the recredentialing cycle as determined by the THA QMC. Applicant practitioners are given the opportunity to review and correct information used in the re-credentialing process at any time during the re-credentialing process. a. In the event that information obtained during the re-credentialing process varies substantially from the information provided as part of the application process, the THA Medical Director will contact the applicant for information clarification. The applicant practitioner has the right, upon request, to be informed of the status of his/her re-credentialing application. Ultimate authority and responsibility for the oversight of the re-credentialing process resides with the THA Board. X. Applicant practitioners are notified of the re-credentialing decision, in writing, within 10 business days. XI. XII. All re-credentialing processes are conducted in a manner that is nondiscriminatory, as discussed in THA Policy X-1: Overview of Credentialing. All information obtained in the re-credentialing process is considered confidential and will be maintained as such according to the THA Confidentiality Policy. a. THA will maintain a credentialing file separate from the hospital credential file for each individual provider. b. Credentialing files are maintained in locked file cabinets with restricted
Subject: Re-Credentialing Verification (Page 5 of 5) access. c. All credentialing staff and credentialing file auditors are required to sign a confidentiality and non-discriminatory statement. d. Credentialing files are not to be left unattended in open office areas. References: Health Share RAE Participation Agreement NCQA CR 7 Recredentialing Verification OAR 410-141-0120 THA Policy VII-4: Confidentiality Policy THA Policy X-1: Overview of Credentialing THA Policy X-5: Site Reviews THA Policy X-9: Delegation of Credentialing URAC P-CR-13 Credentialing Determination Notification Formulated: January 1996 Reviewed: August 2010 June 2012 September 2013 Revised: August 2004 August, 1996 February, 1999 April 1999 August 1999 July 2006 June 2000 December 2001 November 2002 November 2003 September 2004 September 2007 September 2008 September 2009 June 2011 THA Plan Director THA Medical Director