Program overview (practitioners & HDOs)
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 Provider Data Portal to help streamline the initial application and recredentialing process for providers.
- Application submitted through the Council for Affordable Quality Healthcare's (CAQH) CAQH Provider Data Portal.
- 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.
- The 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 practitioners).
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 to meet member access standards or 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 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.
ConnectiCare asks all contracted practitioners to volunteer their own language and race/ethnicity information. This information is not used in contracting or credentialing decisions or for any discriminatory purpose. Data may be collected directly from practitioners or from sources such as, but not limited to, forms and the provider portal. If you prefer to not provide this information, please indicate “prefer not to provide” when this information is requested.
Languages available at a provider location are published in our provider directories. Members may request your language, race, and ethnicity. If the information is available, it can be provided to members by ConnectiCare Customer Service or by contacting your office.
Health Delivery Organizations (HDOs)
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 possibly 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 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.
Home health agency
State license, as required
Office-based surgical center
State license, as required
Skilled nursing facility