Commercial - Credentialing Recredentialing |
Program Overview (Practitioners & HDOs)
Practitioners
To ensure the integrity of its participating practitioner panel,
ConnectiCare has developed policies and procedures for credentialing
applicants for participation and recredentialing current practitioners.
ConnectiCare participates in the CAQH "Universal Credentialing Datasource" (UCD)
to help streamline the initial application and recredentialing process for
providers.
• Application submitted through the Council for Affordable Quality Healthcare's (CAQH)
Universal Credentialing Datasource (www.caqh.org)
• Verification of unrestricted license to practice their specialty in the state(s) in which the
applicant practices
• Verification of current, unrestricted DEA certificate, if applicable
• Verification of education and training
• Review of work history
• Review of malpractice coverage
• Review of malpractice claims history
• Review of Medicare/Medicaid sanctions
• Review of disciplinary or other sanction activity
• National Practitioner Data Bank activity
• Unrestricted clinical admitting privileges at a participating hospital, or an admitting
arrangement by which members are referred for admission to a participating
hospital.
• Board Certification by the American Board of Medical Specialties or American
Osteopathic Association
• Coverage provided by a ConnectiCare participating provider of the same specialty
• 24-hour coverage (required for PCPs and OB/Gyns, preferred for all other practi-tioners)
Note: In most
circumstances, ConnectiCare requires that all members of a group practice,
including mid-level practitioners, participate with ConnectiCare in order for
the group to participate. The status of an individual member of a group practice
may disqualify the rest of the group. ConnectiCare may, at its discretion, waive
application of this requirement in order to meet member access standards or to
meet other business needs.
A ConnectiCare medical director, or other designated physician, is
responsible for, and participates in, the credentialing program. Once the
credentialing process is complete, all applications that meet ConnectiCare’s
established criteria will be forwarded to the senior medical director for review
and approval. All other applications will be presented to ConnectiCare’s Quality
Improvement Committee, comprised of participating practitioners, for a
recommendation. Applicants have the right, upon request, to be informed of the
status of their credentialing/recredentialing application.
You have the right to review the information submitted from other
sources in support of your application and to correct erroneous information.
ConnectiCare will notify you of any information obtained during the
credentialing process that varies substantially from the information you
provided. All information gained during the credentialing process will be kept
strictly confidential, unless otherwise provided or permitted by law. However,
we may disclose tax ID numbers to our customers, their consultants, or our
vendors who need such information in order to evaluate network adequacy.
ConnectiCare does not discriminate in the selection or termination
of practitioners on the basis of sex, age, national origin, race, religion,
color, marital status, or sexual preference or orientation.
Health Delivery Organizations (HDOs)
Assessment
To ensure the integrity of its participating
provider panel, ConnectiCare has developed policies and procedures for the
assessment of applicants for participation in the ConnectiCare network and for
the re-assessment of current health delivery organizations (HDOs).
In certain circumstances, the assessment or re-assessment process
may require a site visit, which includes a structured review of the facility,
environment and practices, a review of medical record-keeping practices, and may
include interviews with key personnel. Site visit standards and medical record
standards are available upon request.
A ConnectiCare medical director is responsible for and
participates in the assessment process. As a participating HDO, you may be asked
to submit specific documentation to the Credentialing Department. ConnectiCare
will notify you of any information obtained during the assessment and
reassessment process that varies substantially from the information you provided
to us. You have a right to review the information submitted from other sources
during the assessment and reassessment process in order to correct erroneous
information. All the information provided to us will be kept strictly
confidential, unless otherwise mandated by applicable law.
Credentialing Requirements for HDOs
The following is a brief outline of many of the key credentialing
requirements. There may be other requirements in addition to those listed.
|
Organization
|
Credentialing Requirements
|
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Home Health Agency
|
State License, as required
JCAHO or CHAP
Accreditation
Medicare Certification
|
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Hospital
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State License
JCAHO Accreditation
Medicare Certification
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Surgical Center
(free-standing)
|
State License
Medicare Certification
JCAHO, AAAHC, ADD, or AAAASF Accreditation
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Office-Based Surgical Center
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State License, as required
Medicare Certification or
Accreditation
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Skilled Nursing Facility
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State License
JCAHO, CARF or CCAC Accreditation
Medicare
Certification
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