CHAPTER 6 NETWORK REQUIREMENTS 6.1 CREDENTIALING AND RECREDENTIALING APPLICATION PROCESS Once it has been determined that credentialing is needed, requests can be emailed t the Health Chice Integrated Care Credentialing Department. Requests are t be n the state required AzAHP Practitiner Data Frm r Organizatinal Data Frm and Facility Applicatin. Practitiners must be registered with CAQH. Additinal infrmatin and applicatin frms can be lcated n the Health Chice Integrated Care website at www.healthchiceintegratedcare.cm. GENERAL PROCESS FOR CREDENTIALING/RECREDENTIALING Credentialing Decisins made by the Credentialing Cmmittee and/r the Chief Medical Officer (r designee) are reviewed mnthly. Prviders have the fllwing rights related t the credentialing prcess and credentialing applicatins: T review the infrmatin submitted t supprt their Credentialing applicatin fr evaluatin. Evaluatin includes infrmatin btained frm any utside surce with the exceptin f references, recmmendatins r ther peer-review prtected infrmatin. T crrect errneus infrmatin submitted by anther surce. Health Chice Integrated Care will ntify credentialing applicants if infrmatin btained frm ther surces (e.g. licensure bards, Natinal Practitiner Data Bank, etc.) varies substantially frm that prvided by the applicant. The right t receive the status f their credentialing r recredentialing applicatin, upn request. Health Chice Integrated Care des nt discriminate against a prvider slely n the basis f the prfessinal s license r certificatin; r due t the fact that the prvider serves high-risk ppulatins and/r specializes in the treatment f cstly cnditins. The Credentialing Cmmittee des nt make credentialing decisins based n an applicant s race, ethnicity, natinal identity, gender, age, sexual rientatin r the types f cnditins treated, prcedures perfrmed r patients seen by the applicant. Health Chice Integrated Care shall ensure cmpliance with Federal requirements that prhibit emplyment r cntracts with prviders excluded frm participatin under Medicaid r that emply individuals r entities that are excluded frm participatin. Streamlining Prcess Health Chice Integrated Care is dedicated t imprving and streamlining credentialing prcesses and timelines fr thse prviders credentialed and recredentialed directly thrugh Health Chice Integrated Care. In additin, cntractual relatinships have been develped t delegate credentialing and recredentialing activities t apprved, qualified utside entities thrughut the Health Chice Integrated Care regin (Nrthern Arizna). This practice has been put int place t decrease the time spent cmpleting multiple credentialing applicatins fr prviders belnging t ne f these entities, and t ensure a cmplete and cmprehensive netwrk fr Health Chice Integrated Care members. When delegating any f credentialing/recredentialing respnsibilities t anther entity, Health Chice Integrated Care retains the right t apprve, suspend r terminate any prvider selected by that entity and meet any regulatry requirements regarding delegatin. Retentin des nt mean that Health Page 1 f 6
Chice Integrated Care needs t review each individual prvider credentialed by a delegate. If Health Chice Integrated Care has reasn t reject a prvider frm its netwrk, Health Chice Integrated Care has the right t d s. Health Chice Integrated Care will present reprts f credentialed and recredentialed prviders wh have received any type f adverse actin by the delegated entity t the Health Chice Integrated Care Credentialing Cmmittee. Delegate reprting will be presented t bth the Credentialing and Quality Cmmittees fr review and apprval, at least n a quarterly basis. Prviders are recredentialed every three years and must maintain a current CAQH prfile in rder t be eligible fr recredentialing. Updates f malpractice cverage, state licenses and Drug Enfrcement Agency (DEA) certificates, if applicable, are als required. Organizatinal prviders shall, n a mnthly basis, cnfirm the identity and determine the exclusin status thrugh rutine checks f: The List f Excluded Individuals (LEIE). The System fr Award Management (SAM). The AHCCCS-OIG List f Excluded Prviders. Any ther databases as directed by AHCCCS r CMS. Organizatinal prviders must immediately ntify AHCCCS-OIG f any cnfirmed instances f an excluded prvider, emplyee r subcntractr that is r appears t be in a prhibited relatinship with Health Chice Integrated Care r its subcntractrs. TEMPORARY/PROVISIONAL CREDENTIALING PROCESS Health Chice Integrated Care shall have 14 calendar days frm receipt f a cmplete applicatin t render a decisin regarding temprary r prvisinal credentialing. Once prvisinal/temprary credentialing is apprved, prvider infrmatin must be entered int Health Chice Integrated Care s infrmatin system t allw payment t the prvider effective the date the prvisinal credentialing is apprved. Prviders wrking in a Federally Qualified Health Center (FQHC) and FQHC Lk-alike Center must be credentialed using the temprary r prvisinal credentialing prcess even if the prvider des nt specifically request their applicatin be prcessed as temprary r prvisinal. CREDENTIALING REQUIREMENTS FOR INDIVIDUALS NOT LICENSED OR CERTIFIED Individuals wh are nt licensed r certified must be included in the credentialing prcess and prfiled as utlined in A.A.C. R9-20-204. RECREDENTIALING Health Chice Integrated Care will ensure that all credentialed prviders are recredentialed. The recredentialing prcess must: Occur at least every three years; and Update infrmatin btained during the initial credentialing prcess with the exceptin f: Histry f lss f license and/r felny cnvictins; Minimum five-year wrk histry; and Page 2 f 6
Bard certificatin, if the prvider is Bard certified. The recredentialing f individual prviders must include a prcess n n-ging mnitring and interventin, and if apprpriate, prvider sanctins, cmplaint and quality issues, which include at a minimum, reviews f: Medicare/Medicaid sanctins; State sanctins r limitatins n licensure; Member cncerns including grievances (cmplaints) and appeals infrmatin; Utilizatin management infrmatin (such as: hspital length f stay, pharmacy utilizatin); Perfrmance imprvement and mnitring (such as perfrmance measure rates); Results f any medical recrd review audits; and Quality f care issues (including trend data). If an adverse actin is taken with a prvider due t a quality f care cncern, Health Chice Integrated Care must reprt the adverse actin t AHCCCS within ne (1) business day. COMMUNITY SERVICE AGENCIES TITLE XIX CERTIFICATION Cmmunity Service Agencies (CSAs) were develped t prvide rehabilitatin, supprt and transprtatin services t behaviral health recipients. CSAs are a unique prvider type that allw behaviral health recipients t participate in prgrams and activities in cmmunity settings. CSAs prvide services that enhance r supplement behaviral health services that persns receive thrugh ther, licensed agencies. Agencies perating licensed prgrams that prvide services r intend t prvide services as Tier I r Tier II services must capture these services under their license. Licensed agencies must nt apply fr Title XIX Certificatin. AHCCCS plicy prvides a standardized prcess fr Title XIX Certificatin f CSAs, describes the certificatin applicatin prcess and Health Chice Integrated Care and ADHS review prcess fr apprval f CSAs, specifies requirements fr the cntinued peratin f CSAs, and establishes Health Chice Integrated Care respnsibilities in auditing and nging mnitring f CSAs. See AHCCCS AMPM Chapter 961 Peer, Family and CSA Training, Credentialing, and Oversight Requirements fr additinal infrmatin. ADDITIONAL CREDENTIALING STANDARDS FOR HOSPITALS AND BEHAVIORAL HEALTH FACILITIES Hspitals and behaviral health facilities licensed by DLS, utpatient clinics and ADHS Title XIX certified Cmmunity Service Agencies) must ensure the fllwing: The prvider is licensed/certified t perate in Arizna as applicable and is in cmpliance with any ther applicable state r federal requirements; and The prvider is reviewed and apprved by an apprpriate accrediting bdy, r if nt accredited, Centers fr Medicare and Medicaid Services (CMS) certificatin, ADHS Title XIX certificatin r state licensure review may substitute fr accreditatin. In this case, the prvider must prvide a cpy f the reprt t Health Chice Integrated Care that verifies that a review was cnducted and cmpliance was achieved. Initial Credentialing f Organizatinal Prviders As a prerequisite t cntracting with the prvider, Health Chice Integrated Care must ensure that the rganizatinal prvider has established plicies and prcedures that meet AHCCCS requirements. The Page 3 f 6
requirements described in this chapter must be met fr all prviders included in the Health Chice Integrated Care netwrk (including, but nt limited t, hspitals, hme health agencies, attendant care agencies, grup hmes, nursing facilities, behaviral health facilities, dialysis center, transprtatin cmpanies, dental and medical schls, and free standing surgical centers; see AHCCCS Medical Plicy Manual, Chapter 950 Credentialing and Recredentialing Prcesses). Prir t cntracting with the prvider, Health Chice Integrated Care must: Cnfirm that the prvider has met all the state and federal licensing and regulatry requirements (a cpy f the license r letter frm the regulatry agency will meet this requirement); Cnfirm that the prvider is reviewed and apprved by an apprpriate accrediting bdy as specified by the Centers fr Medicare and Medicaid Services (CMS) (a cpy f the accreditatin reprt r letter frm the accrediting bdy will meet this requirement). Health Chice Integrated Care must state in plicy which accrediting bdies it accepts; Cnduct an nsite quality assessment if the prvider is nt accredited. Health Chice Integrated Care must develp a prcess and utilize assessment criteria fr each type f unaccredited rganizatinal prvider fr which it cntracts which must include, but is nt limited t, cnfirmatin that the rganizatinal prvider has the fllwing: A prcess fr ensuring that they credential their practitiners; Liability insurance; Business license; r CMS certificatin r state licensure review/audit may be substituted fr the required site visit as lng as the site visit was within the past three (3) years prir t the Credentialing date. In this circumstance, Health Chice Integrated Care must btain the review/audit dcumentatin frm CMS r the state licensing agency and verify that the review/audit was cnducted and that the prvider meets Health Chice Integrated Care s standards. A letter frm CMS that states the rganizatinal prvider was reviewed/ audited and passed inspectin is sufficient dcumentatin when Health Chice Integrated Care has dcumented that they have reviewed and apprved the CMS criteria and they meet Health Chice Integrated Care s standards. Review and apprve the prvider thrugh Health Chice Integrated Care s Credentialing Cmmittee. Fr transprtatin vendrs, a maintenance schedule fr vehicle used t transprt AHCCCS members and the availability f age apprpriate car seats when transprting children. Recredentialing f Organizatinal Prviders Health Chice Integrated Care must recredential rganizatinal prviders at least every three years. Recredentialing must include the fllwing cmpnents and all infrmatin utilized by Health Chice Integrated Care must be current: Cnfirmatin that the rganizatinal prviders remain in gd standing with State and Federal bdies, and, if applicable, are reviewed and apprved by an accrediting bdy. T meet this cmpnent, Health Chice Integrated Care must validate that the rganizatinal prvider meets the cnditins listed belw: Federal requirements as applicable; and Is licensed t perate in the State, and is in cmpliance with any ther State requirements. If an rganizatin prvider is nt accredited r surveyed r licensed by the Page 4 f 6
State, an n-site review must be cnducted; Assess data available t Health Chice Integrated Care including: The mst current review cnducted by the ADHS Divisin f Licensing and/r summary f findings (please include date f review); Recrd f n-site inspectin f nn-licensed rganizatinal prviders t ensure cmpliance with service specificatins. Supervisin f staff and required dcumentatin f direct supervisin/clinical versight as required in R9-10-114, this prcess must include a review f a valid sample f clinical charts. Mst recent audits results f the rganizatinal prvider. Cnfirmatin that the service delivery address is verified as crrect. Review f staff t verify credentials, and that the staff persn meets the credentialing requirements. Evaluate rganizatinal prvider specific infrmatin including, but nt limited t, the fllwing: Member cncerns which include grievances (cmplaints); Utilizatin management infrmatin (if applicable); Perfrmance imprvement and mnitring (if applicable); Results f medical recrds review audits (if applicable); Quality f care issues and, if an adverse actin is taken with a prvider due t a quality f care cncern, Health Chice Integrated Care must reprt the adverse actin t AHCCCS; Onsite assessment; and Review and apprval by Health Chice Integrated Care s Credentialing Cmmittee with frmal dcumentatin that includes any discussin, review f threshlds, and cmplaints r grievances. Ntificatin Requirements Health Chice Integrated Care will reprt (in writing) t apprpriate authrities including the AHCCCS Clinical Quality Management Unit, the prvider s regulatry Bard r Agency, the Arizna Department f Health Services Licensure Divisin, and the Office f the Attrney General. Health Chice will reprt within ne (1) business day t the AHCCCS Clinical Quality Management Unit issues/quality deficiencies that result in a prvider s suspensin r terminatin frm the netwrk. If the issue is determined t have criminal implicatins, including allegatins f abuse r neglect, a law enfrcement agency will be prmptly ntified as well as Adult Prtective Services r the Department f Child Safety. Health Chice Integrated Care will reprt prviders t licensing and ther regulatry entities all allegatins f inapprpriate r misuse f prescribing including allegatins f adverse utcmes that may have been avided shuld the prvider have reviewed the CSPMP and crdinated care with ther prescribers. Health Chice Integrated Care will reprt t the AHCCCS Clinical Quality Management Unit all credentialing, prvisinal credentialing, recredentialing and rganizatinal credentialing denials. We shall indicate in ur ntificatin t AHCCCS the reasn r cause f the adverse/denial decisin and when restrictins are placed n the prvider s cntract, including, but nt limited t denials r restrictins which are the result f, licensure issues, quality f care cncerns, excluded prviders, and which are due Page 5 f 6
t alleged fraud, waste r abuse. The AHCCCS Clinical Quality Management Unit shall refer cases, as apprpriate, t the AHCCCS Office f the Inspectr General (AHCCCS-OIG), in accrdance with 42 CFR 455.14. The AHCCCS-OIG shall cnduct a preliminary investigatin t determine if there is sufficient basis t warrant a full investigatin. [42 CFR 455.14] [42 CFR 455.17][42 CFR 455.1(a)(1)]. Health Chice Integrated Care will: Maintain dcumentatin f implementatin f the prcedure, as apprpriate; Have an appeal prcess fr instances in which Health Chice Integrated Care chses t alter the prvider s cntract based n issues f quality f care and/r service; and Infrm the prvider f the Quality Management (QM) dispute prcess thrugh the QM department. Ntify the AHCCCS Clinical Quality Management (CQM) within ne (1) business day fr all reprted events. In alignment with state and federal ntificatin requirements, Health Chice Integrated Care will reprt, in writing, any final adverse actin taken against a health care prvider, supplier, r practitiner. A final adverse actin des nt include any actin with respect t a malpractice ntice r settlements in which n findings r liability has been made. Health Chice Integrated Care will submit t the Natinal Practitiner Data Bank (NPDB) and the Healthcare Integrity and Prtectin Data Bank (HIPDB): a. Within 30 calendar days frm the date the final adverse actin was taken r the date when Health Chice became aware f the final adverse actin, r b. By the clse f Health Chice Integrated Care s next mnthly reprting cycle, whichever is later. Exceptin: A reprt will nt be made fr cases in which a prvider was terminated fr purely cntract reasns such as the Plan n lnger having a need fr the services f that individual. Page 6 f 6