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Practitioner Credentialing and Recredentialing

Corporate Procedure

 

Policy Name

Practitioner Credentialing/Recredentialing

Policy Number

4404

Policy Manual Section

Health Care Services

Related Policies

Policy 4409

Policy 4410

Issuing Department

Quality Management/Credentialing

Approving Authority

Original Policy Date

05/92

Revision Date(s)

9/98, 4/99, 7/99, 8/01, 9/02, 2/04; 7/05, 01/25/2007, 10/25/2007,

01/29/2009, 05/2009, 01/2010

Review Date(s)
(No revisions)

Replaces Policy Number

P1297A.03, 4403

I.       Policy Purpose and Statement of Intent

  • To establish a clearly defined mechanism for evaluating and periodically re-evaluating the professional credentials of practitioners for which HealthPlus performs credentialing/recredentialing.
  • “HealthPlus” shall refer to HealthPlus of Michigan, Inc. and its affiliated entities, HealthPlus Partners, Inc., HealthPlus Options, Inc., and HealthPlus Insurance Company, unless otherwise stated.
  • The policy shall pertain to the Commercial, Medicaid, MIChild, County Health Plan, and Medicare product lines and their respective products e.g., HMO, PPO, TPA, and Medicare Part D.
  • To assure that the organization complies with all applicable state and federal laws and regulations, including, but not limited to, those pertaining to the Medicaid, Medicare, and Medicare Part D programs.

II.      Policy Statement

It is the policy of HealthPlus to review and evaluate all applicants for credentialing/recredentialing on a consistent basis using specific criteria developed by the National Committee for Quality Assurance (NCQA), the Office of Financial and Insurance Regulation (OFIR), the Michigan Department of Community Health (MDCH), the Centers for Medicare and Medicaid Services (CMS), and the Federal Employees and Health Benefits Program (FEHBP). The qualifications of all participating practitioners are re-evaluated every three years (36 months). The credentialing/recredentialing process is conducted in a non-discriminatory manner; credentialing decisions are not made on the basis of an applicant’s race, ethnic/national identity, gender, age, religion, sexual orientation, or the types of procedures or patients in which the practitioner specializes, but solely on the criteria referenced by this policy and associated procedures.

III.     Scope of Credentialing Program

The scope of practitioners credentialed and recredentialed includes allopathic and osteopathic physicians, dentists, oral surgeons, podiatrists, chiropractors, behavioral health practitioners, nurse midwives, nurse practitioners, physician assistants, and other independently licensed practitioners who treat HealthPlus members in other than the inpatient setting or free-standing ambulatory facilities (e.g., anesthesiologists performing pain management). Practitioners who may become credentialed or recredentialed as a primary care physician/practitioner (PCP) include pediatricians, family practitioners, internists, geriatricians, nurse practitioners and physician assistants.

IV.    Practitioner Rights

All practitioners have a right to be informed (upon request to the Credentialing Department) of the status of their application, a right to review non-protected information obtained during the credentialing or recredentialing process and the right to correct erroneous information. In the event that information is obtained that varies substantially from that submitted by the applicant, including actions on license, professional liability claims history, sanctions by Medicare and Medicaid, pending or past actions involving hospital staff privileges, board certification decisions or information about professional training participation, the applicant is notified and has the right to correct the discrepancy. All applicants are informed of these rights in the credentialing application packet issued by Provider Network Management and in the HealthPlus Provider Manual.

V.     Credentialing/Recredentialing Criteria

All practitioners within the scope of this policy are required to submit a completed application with the supporting documentation that meets the requirements as outlined in this policy. The completed application must be signed, dated, and attested to be current and complete. Completion of an application does not guarantee credentialing/recredentialing by the Plan. In order to be considered for credentialing or recredentialing, applicants must meet the following requirements:

  1. Allopaths (MDs), Osteopaths (DOs), Podiatrists (DPMs), Chiropractors (DCs), and Dentists (DDSs) must meet the following:
    1. Possess current, valid, and unrestricted licensure to practice in the State of Michigan or other state(s) in which they are treating HPM members, if applicable. Licenses that have non-clinical restrictions will be reviewed on a case by case basis.
    2. Possess current, valid, and unrestricted controlled substance licensure in the State of Michigan or other state(s) in which they are treating HPM members (if applicable).
    3. Possess current, valid, and unrestricted federal controlled substance (DEA) licensure (if applicable).
    4. Possess current professional liability coverage with minimum coverage limits of no less than $100,000/$300,000.
    5. During initial credentialing, submit a complete five (5) year work history (if applicable). Breaks or gaps in work history of greater than six (6) months must be fully documented/explained in writing (verified during initial credentialing only).
    6. Submit a ten (10) year history of professional liability activity, including professional liability cases closed with and without payment, verdicts, and dismissed and pending cases. Applicants for recredentialing need only supply liability claims history for the three-year period preceding the current recredentialing instance.
    7. When applicable, possess hospital staff membership (Active, Associate, Provisional, Courtesy, or Consulting) in good standing at a HealthPlus participating hospital; an exception may be made to meet geographic access.
      1. Office-based practitioners who do not maintain hospital privileges must provide hospital coverage arrangements with clear delineation of responsibilities.
      2. HealthPlus reserves the right to require non-hospital based covering practitioners to become contracted and credentialed HealthPlus practitioners. It is the responsibility of the PCP to manage and coordinate the care of patients at all times.
       
    8. Graduation from an allopathic or osteopathic school of medicine/osteopathy, approved college of chiropractic medicine, podiatric medicine, or dentistry (verified during initial credentialing only).
    9. Completion of a residency training program accredited by the American Council on Graduate Education (ACGME), the American Osteopathic Association (AOA), or post-graduate training as required by the respective profession, and in preparation for board certification (verified during initial credentialing only).
      1. Primary Care Physicians (PCPs) must have satisfactorily completed a recognized residency training program in family practice, pediatrics, or internal medicine. Family practice physicians who have not completed a residency program may satisfy this requirement with board certification.  
      2. Specialist physicians must have satisfactorily completed a residency program accredited by the ACGME, the AOA, or an approved fellowship training program in the specialty for which s/he is seeking credentialing. DCs, DDSs, and DPMs must have completed post-graduate training as required by the respective profession. DPMs must have completed a two-year podiatric residency (a qualification for HealthPlus approved podiatric board certification).
      3. The practitioner’s specialty listing in the HealthPlus Provider Directory is determined by his/her board certification/eligibility status or residency training.
      4. Chiropractors must successfully complete the National Board of Chiropractic Examiners examination to be licensed in the State of Michigan.
      5. Possess board certification as follows:
      6. Board certification or verifiable active pursuit of board certification by one of the following:
        • A recognized board of the American Board of Medical Specialties (ABMS)
        • A recognized board of the AOA
        • College of Family Physicians of Canada (CFPC)
        • Royal College of Physicians and Surgeons of Canada (RCPSC)
        • American Board of Podiatric Surgery
        • American Board of Podiatric Orthopedics and Primary Podiatric Medicine
        • American Board of Oral and Maxillofacial Surgery *
        • American Board of Pediatric Dentistry*
          * or other dental boards approved by the American Dental
             Association
         
      7. Attainment and maintenance of board certification:
        Initial board certification must be achieved within five (5) years of completion of residency, fellowship, or post graduate training.
        • Physicians who do not attain initial board certification within five (5) years of completion of residency, fellowship, or post graduate training may qualify for an exception to the board certification requirement or may be subject to departicipation with the Plan.
        • Physicians must maintain board certification in the specialty for which they are primarily credentialed with HealthPlus. Physicians whose board certification has lapsed may qualify for an exception to the board certification requirement or may be subject to departicipation with the Plan.
        • In instances of a documented, verified medical condition that prevents the physician from meeting the board certification requirements in a timely manner, the Credentialing Committee, at its discretion, may recommend that up to a two year extension for completion of the certification or recertification be granted to the physician.
         
       

    c.   Physicians who have been continuously contracted with HealthPlus as specialty or primary care physicians since prior to January 1, 1995, are exempt from the board certification requirement and from the requirement to maintain board certification.

    d.   Podiatrists who have been continuously contracted with HealthPlus since prior to November 17, 2004, who do not possess a two-year podiatric residency, (a required qualification for HealthPlus approved podiatric board certification), are exempt from the podiatric board certification requirement.

    e.   For physicians who do not meet the board certification requirement during the initial credentialing process, following review, evaluation, and discussion of their credentialing information, the Credentialing Committee formulates a recommendation on the applicants’ application to the Plan and submits the recommendation to the Medical Affairs Committee. An exception to the HealthPlus board certification requirement for initial credentialing may be made, based upon items (1), (2), or (3) below:

    • An applicant’s board eligibility status as a result of being within five (5) years of completion of residency, fellowship, or post graduate training.
    • Letter of recommendation from physician’s department chair at a participating HPM hospital.
    • Three (3) letters of recommendation from physician’s peers:
      • Letters shall be from physicians practicing in the applicant’s specialty.
      • At least one shall be from a board certified physician in applicant’s specialty.
      • No more than one shall be from applicant’s current practice partners or associates.
      • Letters shall come from individuals who are directly familiar with applicant’s current clinical abilities in applicant’s specialty area, either through clinical observation or a close working relationship.
      • Letters shall not be from relatives of applicant or applicant’s spouse.
       

    f.    For physicians who do not meet board certification requirements during the recredentialing process, following review, evaluation, and discussion of their recredentialing information, the Credentialing Committee formulates a recommendation on the physician’s behalf and submits the recommendation to the Medical Affairs Committee. The Credentialing Committee may formulate a recommendation for continued acceptance of the physician, based on items (1) or (2) below:

    • Letter of recommendation from physician’s department chair at a participating HPM hospital.
    • Three (3) letters of recommendation from physician’s peers:
      • Letters shall be from physicians practicing in the applicant physician’s specialty.
      • At least one shall be from a board certified physician in applicant physician’s specialty.
      • No more than one shall be from applicant physician’s current practice partners or associates.
      • Letters shall come from individuals who are directly familiar with applicant physician’s current clinical abilities in applicant physician’s specialty area, either through clinical observation or a close working relationship.
      • Letters shall not be from relatives of applicant physician or applicant’s spouse.
       
    • In addition to either item (1) or (2) above, the following factors may be taken into consideration  at the time of recredentialing:
        • The physician’s performance (PCP only) on HEDIS measures is at least comparable to other regional HPM physicians in his/her specialty.
        • There are no significant potential quality issues reported involving the physician, nor an identified trend of confirmed quality issues greater than the HPM Plan average.
        • The physician’s continued participation has been endorsed by the Medical Director of the physician’s PPG/PHO, if applicable.
          • Mid-Level Practitioners
           
       

    HealthPlus may credential nurse practitioners and physician assistants with whom it has an independent relationship and who work in conjunction with a HealthPlus credentialed physician. Applicants must meet the following:

    1. Possess current, valid, and unrestricted license to practice in the State of Michigan.
    2. Submit evidence of post-graduate training, as applicable.
      1. Nurse Practitioners must have completed a formal advanced graduate nursing program preparing nurse practitioners and hold a current, active nurse practitioner specialty certification, as issued by the national certification entity for the specialty, in the specialty field for which the practitioner has applied to HealthPlus.
      2. Physician Assistants must have completed a Physician’s Assistant Educational Program recognized by the State of Michigan licensing board and hold a current active certification by the National Commission on Certification of Physician Assistants.
       
    3. Possess current, valid, and unrestricted controlled substance licensure in the State of Michigan or other state(s) in which they are treating HPM members (if applicable).
    4. Possess current, valid, and unrestricted federal controlled substance (DEA) licensure (if applicable).
    5. Possess professional liability insurance coverage with minimum limits of no less than $100,000/300,000.
    6. Possess hospital staff membership in good standing at a HealthPlus participating hospital. Applicants who do not maintain hospital privileges must provide hospital coverage arrangements with clear delineation of responsibilities.
    7. During initial credentialing, submit a complete five (5) year work history (if applicable). Breaks or gaps in work history of greater than six (6) months must be fully documented/explained in writing (verified during initial credentialing only).
    8. Submit a ten (10) year history of professional liability activity, including professional liability cases closed with and without payment, verdicts, and dismissed cases. Applicants for recredentialing need only supply liability claims history for the three-year period preceding the current recredentialing instance.
    9. Submit evidence of collaborative or supervision agreement between applicant and a designated HealthPlus credentialed physician.
        • Other Independently Contracted Practitioners
       

    Other independently contracted practitioners may include, but are not limited to, the following:  behavioral health practitioners, nurse midwives, and optometrists. In order to be considered for credentialing/recredentialing with HealthPlus as an independently contracted practitioner, the following requirements must be met:

    1. Applicant must possess current, valid, and unrestricted license to practice in the State of Michigan.
    2. Applicant must submit evidence of post-graduate training, as applicable.
      1. During initial credentialing, nurse midwives must submit evidence of completion of a nurse midwifery program approved by the American College of Nurse Midwives (verified during initial credentialing only).
      2. Nurse midwives must submit proof of current certification as a nurse midwife by the American College of Nurse Midwives or other equivalent certifying body, whose certification program is adopted by the Michigan Department of Licensing and Regulation.
      3. Nurse midwives must possess hospital privileges/membership in good standing with a HealthPlus participating hospital.
       
    3. Applicant must possess professional liability insurance coverage with minimum limits of no less than $100,000/300,000.
    4. During initial credentialing, applicant must submit a complete five (5) year work history (if applicable). Breaks or gaps in work history of greater than six (6) months must be fully documented/explained in writing (verified during initial credentialing only).
    5. Applicant must submit a ten (10) year history of professional liability activity, including professional liability cases closed with and without payment, verdicts, and dismissed cases. Applicants for recredentialing need only supply liability claims history for the three-year period preceding the current recredentialing instance.
     

VI.    Sanction and Performance Data Review

A.  HealthPlus reviews and evaluates sanction information on an ongoing basis and prior to making a credentialing/recredentialing decision using information provided from each of the following agencies/organizations. HealthPlus includes such information in the practitioner’s recredentialing file or in an aggregated format from the source:

  1. The National Practitioner Data Bank Report
  2. OIG Medicare/Medicaid Sanction Report
  3. Michigan Department of Licensing/Regulation; verification of license and Disciplinary Action Report

B.  When available, HealthPlus reviews and evaluates the following information on all credentialed practitioners on an ongoing basis and aggregates the information for use in the recredentialing decision making process: 

  1. Quality Improvement activities
  2. Member complaints/service concerns
  3. Performance data
  4. Medical record review or other studies, if available
  5. Other adverse clinical, practice or administrative information

VII.   Peer Review Process and Credentialing Committee

  1. Chief Medical Officer and Plan Medical Directors

The Chief Medical Officer (CMO) is responsible for the HealthPlus Credentialing Program. Upon completion of the credentialing or recredentialing verification process, a Plan Medical Director performs the first level of peer review on each completed credentials file, including performance data (during recredentialing only). If indicated, the credentials file is also reviewed by the Chief Medical Officer, and a practitioner in the same specialty as the practitioner being considered. The Chief Medical Officer makes a recommendation to the Credentialing Committee regarding the consideration of the applicant for initial credentialing or recredentialing.

  • “Clean File” Process

Those credentialing or recredentialing files which are deemed to be “clean” (see criteria below) following the completed verification process and review by a Plan Medical Director are presented to the Credentialing Committee as a list (see list elements below) for consideration by the committee. All other credentialing or recredentialing files are presented to the committee as a profile summary, with accompanying additional information as warranted.

To qualify as a “clean” file, the practitioner must meet all of the following criteria:

  1. Current active license with no restrictions or limitations
  2. No sanctions (license, Medicare or Medicaid)
  3. Current active DEA with no restrictions or limitations (if applicable)
  4. Current malpractice coverage at the required level ($100,000/$300,000)
  5. No gaps in work history greater than 6 months (initial credentialing only)
  6. Lack of present illegal drug use
  7. Ability to perform the essential functions of the position, with or without accommodation
  8. No felony or misdemeanor convictions*
  9. No professional liability settlements equal to or greater than $200,000 or more than two (2) cases settled with or without payment (ten years for initial credentialing, three years for recredentialing)
  10. No adverse findings on NPDB or HIPDB*
  11. No restricted hospital privileges or other disciplinary activity*
  12. No adverse actions or disciplinary activity by another health plan*
  13. HPM's minimum credentialing guidelines met for education, training, and board certification
  14. No miscellaneous credentialing red flags
  15. No reported complaints or potential quality concerns since the previous recredentialing cycle

*Historical for initial credentialing, or since previous recredentialing cycle

Following completion of verifications and review by a Plan Medical Director, a list of credentialing and recredentialing applicants who meet the criteria for a “clean” file is presented to the Credentialing Committee for consideration and approval. The list of applicants contains the following elements:

  1. Practitioner Name
  2. Practitioner credentials (MD, DO, etc.)
  3. Specialty
  4. Board Certification status
  5. Region
  6. Practitioner Type (PCP, Specialist, etc.)
  7. Original effective date with HealthPlus (recredentialing only)
    • Credentialing Committee
     

The HealthPlus Credentialing Committee is the multidisciplinary peer review body responsible for the evaluation of the credentials of all applicants; it includes practicing primary care and specialist practitioners, as well as the Plan Medical Directors and the Chief Medical Officer. As noted above, applicants who meet the clean file criteria are presented as a list. For those applicants who do not meet the clean file criteria (i.e. those whose verifications identify potential concerns), a practitioner profile/summary and additional information as needed are presented to the Credentialing Committee.

  1. Prior to making a credentialing/recredentialing decision, the Credentialing Committee reviews a summary of each applicant’s credentials. In addition to individual applicant credentials summaries, the credentials files, in their entirety, are available for review by the Credentialing Committee. The Credentialing Committee may also elect to request additional information regarding the applicant’s qualifications for credentialing/recredentialing with the Plan, or invite the applicant to appear before the Credentialing Committee to provide additional information.

During recredentialing the Credentialing Committee considers all elements of the practitioner’s performance during the preceding three years, including disciplinary action by any entity, professional liability history, adverse events, member complaints regarding care and service, compliance with HealthPlus preventive health and medical record/facility guidelines and any quality improvement performance indicators deemed appropriate by HealthPlus.

HealthPlus reserves the right to take corrective action with any practitioner, at any time, when the health, safety, and welfare of its members may be jeopardized.

  1. Following review, evaluation, and discussion of the clean file applicants’ credentialing/recredentialing information, the Credentialing Committee formulates a decision on the applicants’ credentialing or recredentialing with the Plan. In instances in which the clean file criteria have been met, the Board of Directors has granted authority to the Credentialing Committee regarding the approval of the applicants’ credentialing/recredentialing with the Plan.

3.   Following review, evaluation, and discussion of the remaining applicants’ credentialing/recredentialing information, the Credentialing Committee formulates a recommendation on the applicants’ credentialing or recredentialing with the Plan and submits the recommendation to the Medical Affairs Committee (MAC). After review, the MAC makes a recommendation on the applicants’ credentialing/recredentialing with the Plan to the HealthPlus Board of Directors. The Board of Directors has the final authority regarding the approval of the applicant’s credentialing/recredentialing with the Plan in instances in which the clean file criteria have not been met.

4.   The practitioner is notified of the decision/acceptance for initial credentialing within sixty (60) calendar days of the Credentialing Committee’s decision.

  1. Recredentialing applicants who have not been approved for the full three year recredentialing cycle are notified of this action within 60 days of the Credentialing Committee’s decision. If the decision is to recredential a practitioner for the full three years without conditions or limitations, no notice is required.
  2. If the Credentialing Committee recommends, and the Board of Directors approves, denial of an applicant for initial credentialing for quality concerns based on his/her professional conduct that affects or could affect the health or welfare of HealthPlus members, s/he is notified (as specified in VII.C.4) and offered a hearing in accordance with the “Appeal of Adverse Professional Review Actions Policy.”  If the action taken by the Board of Directors is not appealed or is upheld upon appeal, this action is reported to the appropriate authorities.
  3. If the Credentialing Committee recommends, and the Board of Directors approves, reduction, suspension or departicipation of a participating practitioner from HealthPlus for quality concerns based on his/her professional conduct that affects or could affect the health or welfare of HealthPlus members, s/he is notified (as specified in VII.C.5) and offered a hearing in accordance with the “Appeal of Adverse Professional Review Actions Policy”. If the action taken by the Board of Directors is not appealed or is upheld upon appeal, this action is reported to the appropriate authorities.

VIII.  Product Specific Network Section

Practitioners who apply for or participate in only the PPO network must meet all credentialing/recredentialing criteria listed in this policy and associated procedures, with the following exception:

  1. The board certification requirement may be waived.

IX.    Implementation

Administrative staff is responsible for establishing, publishing, and maintaining procedures and work rules to implement this policy.

Additional Resources: