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Credentialing/Recredentialing for Independent Practitioners Published: October, 2001 Required Elements Preferred Elements Provider Termination Process Key Points to Remember PacifiCare Behavioral Health has developed and maintains a practitioner/provider network as an integral part of the delivery system for PBH members. Only independently licensed/certified practitioners who are professionally competent and continuously meet the credentials, qualifications, standards and requirements established by PBH will be approved to provide behavioral health care services to PBH members. Credentialing is the formal process through which PBH collects, verifies and evaluates the professional credentials and qualifications of licensed individual practitioners against the criteria, standards and requirements established by PBH for providing health care services to PBH members. PBH has written policies and procedures for credentialing and recredentialing behavioral health care practitioners, contracted group providers, and organizational providers who render treatment to PBH members across all levels of care. In order for a practitioner to become fully credentialed they must submit a credentialing application to PBH with the required information and documents. PBH endeavors to complete credentialing of practitioners within five (5) months after the date PBH receives the practitioner's complete application. The time period for credentialing will not exceed 180 days. PBH will request all information necessary for proper evaluation of the practitioner's professional competence, character and other qualifications. PBH collects required Primary Source Verification from issuing sources or designated monitoring entities and needed explanations to any discrepancies identified. PBH's credentialing staff will maintain a complete and accurate credentials file for each applicant. PBH has an established Credentialing Committee which reviews and considers the professional credentials and qualifications of each practitioner who applies to PBH. Practitioners credentialed by PBH are recredentialed at least every three (3) years. At that time the Credentialing Staff furnishes a recredentialing application to the practitioner. The practitioner must fill out, sign and return the complete recredentialing application to PBH within 30 days. By completing a recredentialing application, the provider signifies his or her continuing agreement to abide by all of PBH's policies and procedures. Back to Top Required Elements PBH has set forth certain minimum criteria that must be met for a practitioner to become credentialed. Without this a practitioner will not be considered for credentialing or recredentialing. The minimum criteria are as follows: 1. Applicant's practice location meets PBH standards for individual practice sites: Includes waiting room. Adequate soundproofing. Accessible to the physically handicapped. Medical records are maintained so as to guarantee patient confidentiality, and in a manner that meets PBH's treatment record standards. Medications securely stored (double-locked). Office is located in a business/professional/commercial zone (approval of sites located in "home offices" require a specific waiver of foundation criteria). Site visits will be conducted for all offices of potential high-volume behavioral health care practitioners prior to their acceptance to the PBH network. High volume practitioners will have subsequent site visits upon relocation or addition of a new office or if a deficiency or concern is identified through the Quality Improvement process. A high-volume practitioner is defined as any contracted group or any individual practitioner who is among, or is expected to be among the top five (5) percent of providers to whom PBH refers. These site visits will involve an audit of the physical practice location as well as the practitioner's record keeping practices (see Documentation Requirements). 2. Applicant is available for emergencies, by pager, or has established emergency coverage procedures. 3. Applicant demonstrates experience in crisis intervention and brief, solution or goal focused therapy. 4. Applicant practices a minimum of 20 hours per week. 5. Applicant is licensed to practice independently in all states for which contract shall apply, and has been licensed in practicing specialty for at least two (2) full years; license is in good standing and free from restriction and/or without probationary status. 6. Applicant has professional liability coverage at $1,000,000/3,000,000 (or other level as required by law). 7. Applicant (clinicians with prescriptive authority) submits a copy of a current and non-restricted DEA or CDS Certificate. 8. Applicant graduated from an accredited professional school, and/or highest training program applicable to the academic degree, discipline, and licensure of the practitioner. 9. If the applicant is a physician addictionologist they must be certified by ASAM or possess Added Qualifications in Addiction Psychiatry through ABPN. 10. If the applicant is a physician they must have admitting privileges in at least one facility or they must provide a description of an adequate process for providing emergency care for patient's requiring inpatient treatment. 11. Resume or curriculum vitae must include at least 5 years work history (any gaps must be adequately explained). 12. Application, as submitted, is complete with all required documentation, attestations and signatures. Attestations include: The reason for any inability to perform the essential functions of the position with or without accommodation. Lack of present illegal drug use. History of loss of license and/or felony conviction. History of loss or limitation of privileges or disciplinary activity. An attestation as to the correctness and completeness of the application. Back to Top Preferred Elements The following preferred elements are considered wherever the number of applicants exceeds PBH's need in a given geographic area: Applicant works in a group setting, or shares an office with other practitioners. Applicant has current experience with the delivery of managed care and EAP services as evidenced by membership on at least one managed care or EAP panel. Physician applicants are board certified in a specialty relevant to the practice of psychiatry (as verified through ABMS or ASAM). Physician applicants have admitting privileges at other than their primary admitting facility. Applicant has oral and written competency in one or more languages that address the needs of the local PBH membership. Applicant represents or has experience with different racial/cultural heritages. Applicant has documented training/experience in specialty areas and/or specific patient populations (i.e. children/adolescents, chronically mentally ill, geriatrics, addictions). In addition to the required elements listed above, a number of other elements are also reviewed at the time an application for recredentialing is submitted. Information such as quality of care complaints and member complaints are reviewed along with other data to determine whether a practitioner should be recredentialed and retained on the PBH panel. PBH also receives information from various monitoring organizations which include the State Board of Licensure or Certification, The National Practitioner Data Bank, State Board of Medical Examiners, Federation of State Medical Boards, and regional Medicare and Medicaid offices. An on site assessment of high volume practitioners is conducted via practice and treatment record audits and the results are considered in the recredentialing review. Back to Top Provider Termination Process PacifiCare Behavioral Health has established policies and procedures, as part of the Quality Improvement Program and in accordance with applicable legal requirements and accreditation standards, by which to deny credentialing/recredentialing, and/or limit, suspend or terminate a contracted practitioner from providing services to PacifiCare Behavioral Health members. Such actions are based upon reasons including, but not limited to, the following: (1) practitioner's or provider's failure to meet the minimum credentialing/recredentialing standards and qualifications established by PacifiCare Behavioral Health's Quality Improvement Committee or its subcommittees; (2) failure to provide care in a manner consistent with community standards and/or quality of clinical care and service standards established by PacifiCare Behavioral Health's Quality Improvement Committee or its subcommittees; or (3) violation of any of the terms of the provider agreement. All PBH practitioners and providers are subject to PacifiCare Behavioral Health's policies and procedures as specified in the provider agreement. PacifiCare Behavioral Health's policies and procedures include, but are not limited to, procedures under which the Medical Director, and/or the Peer Review Committee, have the authority and discretion to immediately restrict, suspend or terminate a provider's ability to provide behavioral health services to PBH's members or take any action deemed necessary to protect the interests of members, including, but not limited to, ceasing all referrals to the provider. Such actions are based upon a determination of deficiencies in the practitioner's or provider's quality of care, professional competence or conduct and/or that the practitioner has failed to meet PacifiCare Behavioral Health's Quality Improvement or credentialing standards and/or has failed to provide treatment in a manner consistent with accepted community standards. PacifiCare Behavioral Health's termination process, and any appeals process that may be available to the practitioner or provider, are fully described in PacifiCare Behavioral Health's policies and procedures. Key Points Providers and practitioners must meet PBH minimum criteria to become credentialed. PBH will endeavor to complete the credentialing process within 5 months, and will not exceed 180 days from receipt of a completed application. Applications for credentialing and recredentialing must be filled out completely and accurately, with all requested attachments. Applications must be signed and returned to PBH within 30 days of signature. PBH has established policies and procedures for the denial of credentialing/recredentialing, and limiting, suspending or termination of practitioners and providers. Back to Top