Practitioner Credentialing

HealthPlus has utilized the Council for Affordable Quality Healthcare (CAQH Universal practitioner Datasource (CAQH UPD) as the application for credentialing and recredentialing practitioners for participation with HealthPlus.

The UPD is the industry standard for collecting practitioner data used in credentialing. By streamlining data collection electronically, UPD reduces duplication of paperwork and administrative costs for many physicians and other health professionals. When practitioners review and re-attest to their information through the UPD on a regular basis, the recredentialing process is virtually seamless.

HealthPlus accepts only the UPD for initial credentialing or recredentialing of HealthPlus practitioners. If you are not currently registered through the CAQH UPD, please do so prior to beginning the credentialing process with HealthPlus. Be sure to designate HealthPlus as a recipient of your information.

The HealthPlus credentialing process includes a thorough peer review of the following criteria to evaluate the qualifications of practitioners applying for affiliation:

  • Education
  • Training and relevant experience
  • Current licensure status
  • Liability coverage
  • Hospital privileges
  • Board certification
  • Professional liability and sanctions history

HealthPlus evaluates all practitioners every three (3) years to reassess their current clinical competence and ongoing capabilities to care for HealthPlus members. This evaluation includes a review of the practitioner’s:

  • Current licensure status
  • Liability coverage
  • Hospital privileges
  • Board certification status
  • Professional liability and sanctions history (for the past 3 years)
  • Data from utilization management records
  • Quality reviews
  • Member complaints

Practitioners have the right to be informed of the status of their credentialing or recredentialing application and may review non peer-protected information obtained during the credentialing process that varies substantially from that submitted by the applicant, including the following:

  • Actions on a license
  • Professional liability history
  • Sanctions by Medicare/Medicaid
  • Pending past actions involving hospital staff privileges
  • Board certification decisions on information about professional training participation

*The applicant also has the right to correct discrepancies in the review.

All HealthPlus practitioners must remain compliant with HealthPlus Practitioner Office Site and Medical Record Documentation Standards. To ensure continued compliance, HealthPlus may conduct office or medical reviews in response to a member complaint or report of potential non-compliance. Practitioners who do not meet HealthPlus thresholds are educated and re-evaluated after a specified period of time, to determine if the required improvements have been implemented.

For more information about reviewing the status of an application, information obtained and evaluated during the process, and to correct discrepancies, please contact the HealthPlus Credentialing Department at 810-230-2058.