Tips For Successful, Timely Provider Credentialing - AAPC Knowledge Center
PAP 113 - Credentialing/Re-credentialing Standards For PractitionersÂ
Credentialing is a review of qualifications and other relevant information pertaining to a health care practitioner who seeks a contract with Blue Cross of Idaho. Credentialing is required for practitioners who provide services to members and who are permitted to practice independently under state law. Per industry standard guidelines, credentialing is also required for practitioners who have an independent relationship with Blue Cross of Idaho.
Credentialing is not required for practitioners who are permitted to furnish services only under the direct supervision of another practitioner or hospital-based health care professionals who provide services incident to hospital services. Unless those health care professionals are separately identified in literature such as the provider directory as contracted).
The goals of our credentialing/recredentialing program are to:
Ensure high-quality practitioners for members
Provide an optimal number and distribution of practitioners
Minimize health and safety risks for members
Minimize legal risks
To begin the credentialing process, each healthcare practitioner submits an application. A credentialing specialist performs the primary source verification. The credentialing committee consists of the Blue Cross of Idaho Medical Director and five practitioners of various specialties from around the state. Practitioners must meet credentialing standards and criteria and be approved by the credentialing committee at least every 36 months.
Blue Cross of Idaho's credentialing/recredentialing standards are criteria that all healthcare professionals must meet, as applicable, and maintain. Healthcare practitioners must uphold these standards to be accepted, or continue, as network practitioners. The credentialing committee applies the following standards when making decisions:
Application, Attestation and Release
Information on a practitioner's application cannot be more than 180 days old at the time of review. All sections of the application must have complete answers or explanations. Practitioners may attach a curriculum vitae, but it is not considered a substitute for completing the application. The practitioner must attach current copies of his/her license, DEA registration, certification, certificate of insurance for professional liability, and Educational Commission for Foreign Medical Graduates certificate, if a foreign graduate, to his/her application. The provider must sign and date an unaltered attestation and release.
License (initial, recredentialing, and ongoing):
The practitioner must have a current license in good standing from the appropriate Idaho licensing agency. The license cannot be revoked, terminated, expired, restricted, suspended or, imposed with conditions, stipulations, disciplinary actions, probation or otherwise modified in any way at the initial credentialing committee review or the re-credentialing review.
Drug Enforcement Agency (DEA) Certificate:
No DEA revocation allowed.
Verification of a valid current certification at initial credentialing and recredentialing is required.
Board Certification and Education (MDs and DOs):
Board certification is not required.
A completed residency is required for practitioners listed as specialists.
Listings for practitioners that are board certified by the American Board of Medical Specialties (ABMS) or American www.denmaar.com Osteopathic Association (AOA) are sometimes separate from residency trained, non-board certified practitioners.
Practitioners listed as "General Practice" in the provider directory are not ABMS or AOA certified or have not completed a residency but are medical school graduates and completed an internship.
Certification and Education (all other practitioners as applicable):
Verification of certification is required if a practitioner indicates that he/she is certified. The institution granting the degree or the state licensing agency can verify completion of education if they perform primary source verification.
Work History:
Practitioners cannot have unexplained lapses in work history for the previous five years. Practitioners may be required to explain gaps in work and education history beyond the previous five years.
Malpractice Insurance:
Coverage amounts must be at least $1,000,000 per incident; $3,000,000 aggregate or unlimited aggregate.
Insurance must be current at the time of credentialing committee review.
Malpractice History, Professional Liability Claims History, Civil Judgments, Federal/State Criminal Convictions, Adverse Actions:
The credentialing committee grants acceptance into the Blue Cross of Idaho network if they determine the pattern of litigation, conviction(s), civil judgment(s), or adverse action(s) is not predictive of significant patient risk in the future.
The credentialing committee does not review malpractice cases that occurred during internship or residency.
The credentialing committee will review two or more open cases; single closed cases over $500,000; two or more closed cases over $25,000; all adverse actions, civil judgments and convictions.
Twenty-Four Hour Coverage:
All managed care practitioners must have 24-hour coverage by themselves or with an on-call arrangement.
Referral to the local emergency room is not acceptable.
Practitioner Impairment:
The practitioner must not have any physical or mental impairment that prevents adequate patient care.
Alcohol or Drug Abuse:
The practitioner must not have any evidence of ongoing substance abuse.
Felony Convictions or Guilty Pleas:
The practitioner must not have any felony convictions or guilty pleas.
Medicare/Medicaid Sanctions, Preclusions, Federal Exclusions or Fraud (internal or external information, initial, re-credentialing and ongoing):
The practitioner must not have any active sanctions, current federal and/or state exclusions, current debarments or evidence of ongoing fraud.
Medical Record Review:
The Blue Cross of Idaho Quality Department reviews medical records in accordance with quality management policies and procedures.
Quality Concerns:
Our quality management department investigates, monitors, and tracks quality concerns and forwards reports to the credentialing committee as indicated in the quality management policies and procedures. The credentialing committee will review the quality report and use its judgment in determining a course of action.
Utilization Management (re-credentialing):
The quality management department reviews utilization management.
Utilization management information goes to the credentialing committee as indicated in the quality management policies and procedures.
Addictive Drug Prescribing Habits:
The credentialing committee reviews the practitioner's history and restrictions on prescribing habits from the Idaho State Medical Board of Discipline to determine whether the practitioner's history and prescribing habits as restricted or pose unacceptable patient risk.
State Disciplinary Board:
The credentialing committee reviews disciplinary board actions or ongoing sanctions to determine if the behavior poses an unacceptable risk to patients.
Sexual Misconduct:
The practitioner must not have a history of sexual misconduct, as defined by the Idaho State Medical Board of Discipline under misconduct and the standard of care rules.
Eligibility (Applies to practitioners, nurse practitioners, clinical nurse specialists, certified nurse-midwives and physician assistants as appropriate):
The practitioner's practice must represent his or her specialty training.
Credentialed practitioners may be listed in the directory as either: - Primary care practitioners with a specialty in family practice, internal medicine, obstetrics and gynecology, pediatrics, or a general practice that provides comprehensive care to Blue Cross of Idaho members.
