CREDENTIALING 101
Why do we credential practitioners? Compliance with accreditation standards such as the American Accreditation Healthcare Commission (AAHC/URAC) and the National Committee for Quality Assurance (NCQA) requires that the Health Plan implement a mechanism to provide for review and approval of the credentialing application prior to any applicant s designation as a participating provider. Compliance with CMS regulations requires the credentialing process to begin with a completed application and attestation to its correctness signed/dated by the practitioner. The information must be no more than six months old at the time that the practitioner is determined to be eligible for appointment by the Credentialing Committee or contract. All items must be verified prior to the appointment of the practitioner, with the exception of a pending Drug Enforcement Agency (DEA) number. Source: 42 CFR 422.204(b)(2)(i) and (ii) Risk management Quality Assurance 2
Why is credentialing required prior to Network Participation? Our participating providers are marketed to our members as preferred providers and we recognize that strong provider networks are essential for the delivery of quality health care services and appropriate management of health care resources. Credentialing our physicians and other health care professionals ensures the quality of our networks. Participating providers are listed in the provider directory and all specialty listings are based on verification of the practitioner s accredited training or board certification. This insures appropriate member selection. 3
Basic Steps of Credentialing 1 Credentialing Data Collection* 2 Credentials Verification (PSV) 3 Credentialing Review and Decision 1. Collect self-reported data from providers (education, training, experience, etc.) 2. Verification of certain provider-reported data against primary sources (Primary Source Verification or PSV) either internally or via a Credentials Verification Organization (CVO). 3. Review committee makes an independent decision about whether provider meets that organization s standards for participation. 4
Credentialing Structure and Process-Highmark Highmark Provider Data Services/Camp Hill, PA: Generates, mails, and processes all initial and recredentialing applications; Conducts all primary source verification; Contacts practitioners/groups for additional or missing information; If the application is complete and all credentialing criteria are met, the credentialing file is processed as routine; If the application is incomplete, the practitioner is notified of the potential impact on network status in writing; If credentialing criteria is not met, it is sent to Mt. State Network Credentialing as an exception. 5
Credentialing Structure and Process-Mt. State Mt. State Network Credentialing/Charleston, WV: Practitioners who do not meet credentialing criteria are sent to Network Credentialing as an exception; All exceptions are assigned to a Network Credentialing Specialist-RN for further research and development; The Specialist will contact the practitioner to obtain additional or missing information and provide education regarding credentialing criteria; After intervention by the Specialist, if the practitioner meets criteria, the file will be reviewed with the Medical Director for potential approval; If the practitioner still does not meet criteria, the file will be presented to the Regional Credentials Committee for review (meets once per month). Network Credentialing is responsible to notify the practitioner by letter of the credentialing decision. Network Credentialing is also responsible for handling all practitioner appeals. 6
Regional Credentialing Committees All initial and recredentialing practitioner exceptions are presented to two Credentialing Committees for review; For the HHIC/Medicare Advantage Network: the practitioner is reviewed by the Highmark Credentialing Committee. For the Mt. State Networks: the practitioner is reviewed by the appropriate Regional Credentialing Committee (Northern or Southern). Both Committees include physicians who are participating and practicing network practitioners, representing network specialties and are the voting members of the Committees. It is possible to have two different credentialing decisions from the two credentialing bodies. 7
Basic Practitioner Credentialing Criteria License in the state in which the practitioner practices DEA in the state in which the practitioner practices Active clinical privileges at a participating facility Board certification Accredited training, if not board certified Professional liability insurance 5 years of work history for initial credentialing National Provider Databank (NPDB) query OIG query (CMS) for exclusions and a UPIN or PTAN number for participation Medicare Part B Opt Out query (CMS) 24/7 coverage PCPs available at least 20 hours a week Malpractice history Collaborative agreements/job descriptions for nurses and physician assistants Ongoing sanctions monitoring Continuing education credits ****-more detail is available on the credentialing criteria grid**** 8
Hospital Based Practitioners Hospital based practitioners are those who practice solely in an acute care inpatient or outpatient setting and who provide care for Plan members only as a result of members being directed to the hospital. These providers who practice in this setting at a participating hospital may be added to the Plan s networks without going through the credentialing process as long as the following documents are on file: A completed and signed Affirmation of Medical Practice Statement (Attestation) for each hospital based group the provider practices with. Verification of group s participation, network agreement(s), Participating Provider Agreement signed by the provider and dated. A completed Authorization for Billing form (AFB). Copy of the provider s current and valid state medical license. 9
Frequently Asked Questions What is required for 24/7 coverage? What are the requirements for a DEA if the practitioner is providing service to members in more than one state? Why is the practitioner listing different than what was requested on the credentialing application? What hospital privileges or coverage arrangements are required? 10
24/7 Requirements Practitioners must have the ability, directly or through on-call arrangements with another qualified plan-participating practitioner of the same or similar specialty, to provide coverage 24 hours a day, seven days a week. The 24/7 coverage can be accomplished through an answering service, pager or via direct telephone access whereby the practitioner (or his/her designee) can be directly accessed, if needed. A referral to a crisis line or ER is not acceptable coverage unless there is an arrangement made between the practitioner (or his/her designee) can be contacted directly, if needed. It is not acceptable for any non-pcp practitioner to refer patients to their PCP after normal business hours. 11
DEA Requirements Practitioners are required to have a DEA for each state in which they provide care to the Plan s members. The Drug Enforcement Administration amended, effective January 2, 2007, its registration regulations to clarify that when an individual practitioner practices in more than one state, he or she must obtain a separate DEA registration for each state. DEA individual practitioner registrations are based on state authority to dispense controlled substances. Since a DEA registration is based on a state license, it cannot authorize controlled substance dispensing outside that state. Practitioners with a pending DEA may be approved as a participating practitioner, as long as proof of application is submitted for review. 12
Specialty Listing Requirements Board Certification in the specialty in which the practitioner is requesting to be credentialed or... Initial M.D. and D.O. applicants must complete a residency accredited by the Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA). Initial podiatrist applicants must complete a residency accredited by The Council on Podiatric Medical Education. The approved specialty listing determines how the practitioner will be listed in the Provider Directory. 13
Hospital Privilege/Coverage Requirements Primary Care Physicians must have full admitting privileges in good standing at a participating network or Blue Cross Blue Shield Association hospital. Applicable physician specialists must have clinical privileges in good standing at a participating hospital. Primary Care Physicians are required to have coverage for hospital admissions and hospital care of members with a network(s) participating practitioner or group who has/have admitting privileges at a network participating facility and are of the same specialty type. *These arrangements must provide for timeliness of information and communication to facilitate the admission, treatment, discharge planning and follow-up care necessary to ensure continuity of services and care to members.* 14
Credentialing Time Frames Credentialing statistics reported for January through June 2009: 95% of initial applications were completed in 30 days or less and <1% exceeded 90 days. 94% of re-credentialing applications were completed in 30 days or less and only 1.4% exceeded 90 days. **These statistics include all applications processed from the time received until the case is closed. These include those applicants that do not complete the entire credentialing process. 15
Process Improvements for turn around times The percentage of practitioners utilizing the CAQH database has increased, which has resulted in a decrease in mailing, receiving, and processing paper applications. Routine practitioners with a clean application have a listing generated and approved by the Medical Directors twice a week vs. review by the Credentialing Committee which meets monthly. Only exceptions to credentialing criteria are presented to the Credentials Committee. 16
Suggestions to Practitioners Utilize the Council of Affordable Quality Healthcare (CAQH) database to submit your application electronically. WV practitioners are still required to utilize the state mandated Uniform Credentials Form which is available through CAQH. Submit a clean application. Respond to phone calls, faxes, and written correspondence from PDS and/or Network Credentialing promptly during the credentialing process. Designate a staff member in your group that will handle the credentialing process and respond to requests. 17
Data Collection Is the Most Inefficient Step 40% Obtaining a complete application 25% Primary Source Verification 35% File preparation, committee review, appeals, etc. 0% 20% 40% 60% 80% 100% Manual process, usually involving combination of mail, fax, phone, and sometimes even office visits Requires long lead time, and is primary reason why process begins 4-6 months before actual decision is made Once application is complete, remaining steps proceed quickly Automated process in most larger plans Sometimes involves expensive licensing fees and strict sharing restrictions Third-parties often involved Moving toward automation; business rules enable plans to identify providers who require further research Major component of file preparation is ensuring time-sensitive information meets freshness standards when presented to committee *Based on discussions with health plan representatives 18
What is the advantage of utilizing CAQH? (Source: CAQH) Decreased average processing turnaround time by 8-10 days; Reduced frequency of returned provider correspondence due to poor address quality from 30-40% to 6%; Discontinued sending initial credentialing packets via mail to 97% of new providers; Reduced re-credentialing mailings. 19
Additional features of CAQH (Source CAQH) CAQH features include:» Completely free for providers» Providers can complete application online or via fax» Supporting documents are imaged and attached to electronic record» The Plan can access data in electronic format at any time if authorized by provider» Data refreshed periodically to avoid recredentialing cycle problems» Updates can be made at any time and are immediately available to authorized organizations» Toll-free help desk to assist providers 20
How It Works (Source: CAQH) A B C Providers submit their information online (or via fax) much like online tax preparation software Participating organizations retrieve provider data in their preferred format: (A) ASCII (B) XML (C) static PDF images of applications 21
What is a clean application? Application is completed in its entirety; Current Attestation/Release is submitted; Application confirms that the practitioner is able to perform job duties; Meets all credentialing criteria; No entries found upon query of the National Practitioner Databank (NPDB); No current sanctioning/corrective action. 22
Discontinued Credentialing (Initial Credentialing) Credentialing is discontinued for an INITIAL practitioner when he/she fails to send in a completed application. If applicant has missing information, Highmark Provider Data Services will contact the practitioner by phone and/or fax to obtain the information. If the practitioner does not respond within 5 days, a letter is sent allowing 10 days for the missing info to be returned. If the practitioner still does not respond, a second letter is sent informing the applicant that the application has been withdrawn and their application is no longer being considered. The practitioner may reapply as an initial. 23
Voluntary Withdrawal (Recredentialing) If a RECREDENTIALING practitioner fails to submit a completed application, it may be considered as a voluntary withdrawal from the networks for this practitioner. If a completed application is not returned, a letter is sent to the practitioner by Highmark Provider Data Services (PDS). If the missing information is still not returned, a second letter is sent allowing 10 days to submit the information. If the missing information is still not returned, a phone call is made to the practitioner by Highmark PDS. If there is still no response to the request for information, a final letter is sent informing the practitioner of the voluntary withdrawal from the networks, allowing another 10 days. If the practitioner does not respond, he/she may reapply for network participation but will be considered as an initial applicant. 24
Denial or Termination for Network Participation If the Credentialing Committee makes the decision to deny or terminate network participation as a result of not meeting credentialing criteria, the practitioner will be notified promptly by the Medical Director via certified letter. The letter will include the reason for the decision and provide the appeal process for the practitioner. The letter will include the final termination date for practitioners for network participation, which will be 90 days from the date of the Credentialing Committee decision. 25
Practitioner Appeal Process-Stage I Initial and recredentialing practitioners have the right to an appeal. After the Credentialing Committee s decision to deny or terminate a practitioner, there will be 30 days from the date the practitioner receives our letter, to submit additional information as a request for reconsideration. The practitioner will be notified of the Committee s decision to uphold or overturn the previous decision based on the reconsideration request. The practitioner will be notified by the Medical Director of the decision via certified mail, and the letter will include information regarding the right to a second level appeal. 26
Practitioner Appeal Process-Stage II The practitioner may submit a second level appeal within 30 days after receipt of the reconsideration decision. This request may include the right to appear in person to present pertinent information in a hearing. If the practitioner requests a hearing, the second level appeal will be reviewed by a different appeal body. The Medical Director will notify the practitioner of the outcome of the second level appeal in writing via certified letter. The decision of the second level appeal body is final. 27
QUESTIONS? 28