Underwritten By Security Health Plan of Wisconsin, Inc. P e a c e Of Mi n d Fr o m Ma r s h f i e l d Clinic

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1 Credentialing Program Manual Underwritten By Security Health Plan of Wisconsin, Inc. P e a c e Of Mi n d Fr o m Ma r s h f i e l d Clinic

2 T able o f Co n t e n t s Section I Credentialing Program Staff Credentialing program staff 1 Section II Credentialing Program Overview Introduction 1 Confidentiality 1 Committee and staff structure 2 Board of Directors Medical director Credentialing Committee Credentialing specialists/coordinator Provider credentialing 3 Application Primary Source Verification Administrative review Credentialing Committee process Appeals Provider recredentialing 8 Triennial process Recredentialing process Primary source verification Recredentialing criteria Appeals Listing in provider directories and other member materials Facility approval and reapproval 10 Administrative review New provider applicant appeal policy 13 Protocol for assessing the quality of an affiliated provider practice attachment A Section III Provider Application for Affiliation Sample credentialing application Online version of Security Health Plan s credentialing application 1 Approximate timeline for credentialing application process 2 Security Health Plan expectations of providers 2 Provider s expectations of Security Health Plan 3 Recredentialing application instructions 4 Sample recredentialing application HP (09/09) Security Health Plan of Wisconsin, Inc.

3 Section IV Practice Information Form Section V Provider Medical Record Review Medical record documentation standards 1 Definition of medical record criteria 3 Section VI Site Visit/Medical Record Keeping Review Provider (single or group) site visit/medical record keeping standards for primary care and behavioral health clinics 1 Access to facility Physical appearance of facility Waiting/exam rooms Appointment availability Policies and procedures Fire/safety Infection control policies Medications Medical record keeping standards Availability of ancillary services Sample site visit/medical record keeping tool 4 Definition of site visit criteria 8 Non-PCP and non-behavioral health provider (single or group) site visit requirements 12 Member access to care and service for primary care and behavioral health 14 Section VII Sample Policies and Procedures Confidentiality of patient information policy 1 Controlled drug procedure 3 Controlled drug record 4 Controlled drug record instructions 5 Emergency procedures (large clinic) 6 Emergency procedures (small clinic) 9 General equipment and appliances maintenance 10 Infection control plan 11 Infection control training 13 Medication distribution and storage procedures 14 Medical record documentation policy (electronic) 15

4 Medical records documentation policy (sample 1) 21 Medical records documentation policy (sample 2) 23 Medication distribution and storage standards 25 Missed patient appointments 28 On-site medical emergencies (sample 1 small clinic) 29 On-site medical emergencies (sample 2 small clinic) 30 On-site medical emergencies (large clinic) 31 On-site medical emergency equipment maintenance 33 On-site medical emergency equipment checklist 35 Patients bill of rights (sample 1) 36 Patients bill of rights (sample 2) 37 Patients responsibilities to facility 38 Process for handling complaints and quality assurance issues 39 Smoke-free environment 40 Standard/body isolation precautions in the clinic setting 41 Universal standard precautions 43 Universal standard precautions (AIDS/Hepatitis B) 44 All rights reserved. No part of this publication, except for sample policies and procedures, may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without permission in writing from Security Health Plan of Wisconsin, Inc.

5 Security Health Plan Providers: 1515 Saint Joseph Avenue P.O. Box 8000 Marshfield, WI or TTY or Fax We are pleased to provide you with Security Health Plan s (SHP) Credentialing Program Manual. The manual contains the standards, applications, policies and procedures used in Security Health Plan s credentialing process. The process was developed in compliance with standards set by the National Committee for Quality Assurance (NCQA), a nationally recognized accrediting body for managed care organizations. Security Health Plan strongly recommends that the contents of the manual be reviewed by personnel designated to oversee your facility s provider credentialing. The enhancement of our credentialing/recredentialing process for physicians and allied health providers is a critical piece of our quality improvement efforts. The process helps to ensure that providers are properly trained and qualified and are accessible to members within a reasonable geographic area. The Network Management staff is responsible for the Credentialing Program Manual and welcomes any comments or suggestions regarding the information and content of the manual. Your perspectives are extremely important to us as we strive to provide highquality care to our members. Sincerely, Lawrence McFarlane, M.D. Medical Director P e a c e Of Mi n d Fr o m Ma r s h f i e l d Clinic

6 S e c t i o n I C r e d e n t i a l i n g P rogram Staff

7 C r e d e n t i a l i n g Program Sta f f Program staff information is current at the time of publication. Every effort will be made to update this information via the Security Health Plan Web site at Lawrence McFarlane, M.D. Medical director ( , ext ) Edward Krall, M.D. Michelle Bachhuber, M.D. Michael C. Kaesbauer Scott Milach Sonny Miranda, R.N., B.S.N. Nicole Otero Robyn Schindler Kathy Schmutzer, R.N., B.S.N. Karen Blaszkowski Kari Watson Medical director ( , ext ) Medical director ( , ext ) Manager, Network Management ( , ext ) Contract manager ( , ext ) Contract manager ( , ext ) Contract manager ( , ext ) Contract manager ( , ext ) Contract manager ( , ext ) Credentialing coordinator ( , ext ) Credentialing specialist ( , ext ) SECTION I PAGE 1

8 S e c t i o n II C r e d e n t i a l i n g P rogram O verview

9 I n t r o d u c t i o n The credentialing process for Security Health Plan of Wisconsin, Inc. (SHP) enables Security Health Plan to appropriately affiliate high-quality physician and nonphysician providers of medically necessary services. The credentialing process ensures that providers are properly trained and qualified, and are accessible to participants within Security Health Plan s service area. Security Health Plan does not make credentialing and recredentialing decisions based on applicants race, ethnic/national identity, gender, age, sexual orientation or the types of procedures or types of patients the provider specializes in. The credentialing program overview outlines the standards, policies and processes for the affiliation of providers. In addition, the protocol for assessing the quality of an affiliated provider practice (due process document), outlines the process for disciplining and terminating affiliated providers. Security Health Plan may deny or restrict participation by a provider, terminate a provider s participation or take other disciplinary action in accordance with the provider s written contract, the credentialing program overview or the due process document. The credentialing program overview, along with the due process document, may be changed at the discretion of Security Health Plan s Board of Directors. Any change in legal, regulatory or accreditation requirements will be automatically incorporated into this plan as of the requirement s effective date. Changes will be effective for all new and existing providers from the effective date of the change. Security Health Plan s credentialing program includes the review of facilities and organizations contracted to provide services to Security Health Plan members, including hospitals, home health agencies, residential, inpatient and ambulatory mental health facilities, skilled nursing facilities, rehabilitation centers and free-standing ambulatory surgery centers. All Security Health Plan credentialing/recredentialing policies and procedures are reviewed on an annual basis by Security Health Plan s medical director and legal services. C o n f i d e n t i a l i t y Information acquired through the credentialing/recredentialing process is considered confidential. All individuals with file access are responsible for ensuring that all credentialing/ recredentialing information remains confidential except as otherwise provided by law. When a law enforcement agency or other government agency seeks provider credentials information, a Legal Department representative will be consulted prior to the release of any information. The release of any information obtained through the credentialing/recredentialing process is prohibited without a written, signed and dated consent to the release of the information by the provider. SECTION II PAGE 1

10 C o m m i t t e e a n d Sta f f Structure Board of Directors The Security Health Plan Board of Directors, while delegating credentialing/recredentialing responsibilities to the Credentialing Committee, retains ultimate authority over all credentialing decisions. This is applicable for all aspects defined in the credentialing/recredentialing processes. Medical director The medical director or his or her designee is chair and a member of the Credentialing Committee and is responsible for overseeing the credentialing/recredentialing processes. The medical director and his or her designee reviews and has the authority to approve provider applications that meet Security Health Plan s administrative and professional criteria and facility information that meets Security Health Plan s administrative review. The medical director acts as a resource to credentialing staff. Credentialing Committee The Credentialing Committee is a standing committee that meets twice a month. Members are nominated by Security Health Plan management and approved by the president of Security Health Plan s Board of Directors. The committee is responsible for establishing and implementing credentialing and recredentialing policies and procedures. In addition, the committee is responsible for reviewing provider credentialing/recredentialing applications that do not meet Security Health Plan s administrative and professional criteria. The committee also monitors provider performance. The committee, per Security Health Plan Board delegation, has authority to approve/disapprove provider credentialing/recredentialing. The Credentialing Committee consists of physicians practicing in family practice, behavioral health, obstetrics, and medical and surgical subspecialties, along with Security Health Plan staff including credentialing staff, legal services and administration. The Credentialing Committee and medical director or his or her designee will use good faith discretion in reviewing applications and making credentialing decisions. The committee and medical director or his or her designee will base its decisions on any facts and circumstances it deems appropriate and relevant. Annually, each voting member of the Credentialing Committee attests that all credentialing decisions will be made in a non-discriminatory manner, without regard to age, race, gender, national origin, religion and without consideration of the types of patients treated by the applicant or the types of medical/surgical procedures provided. Annually, the Credentialing Committee reports on its activities to the Quality Improvement (QI) Committee. These reports will include any changes in policies and procedures; recommendations for the reduction, suspension or termination of provider and facility participation; and summary data on credentialing efforts such as the number of site visits conducted. Credentialing specialists/coordinators Credentialing staff verify provider information through primary sources, as outlined in this document. Credentialing staff forward the files of providers to the medical director or his or her designee or to the Credentialing Committee along with specific information on each SECTION II PAGE 2

11 credentialing/recredentialing applicant for final determination. All credentialing information is available to all Credentialing Committee members. P r o v i d e r Cr e d e n t i a l i n g Application Providers subject to credentialing Security Health Plan credentials physicians (M.D.s, D.O.s), dentists, podiatrists, chiropractors, optometrists and other licensed independent providers (e.g. nurse midwives, audiologists, physical therapists, occupational therapists, speech language pathologists, nurse practitioners, physician assistants, clinical psychologists, alcohol and drug counselor II and IIIs and master s social worker prepared), with whom Security Health Plan contracts and who treat members outside the inpatient setting and who fall within Security Health Plan s scope of authority and action. In addition, any provider who disaffiliates from Security Health Plan s network (whether voluntarily, layoff or through termination) and later wishes to reaffiliate is subject to credentialing (if the break in affiliation is 30 or more calendar days). Site visits/medical record reviews Security Health Plan will conduct an initial site visit to new practices that submit an application for affiliation. This initial visit is to ascertain compliance with Security Health Plan s site visit and medical record keeping standards. The contract managers will conduct these visits. To avoid disrupting daily clinic operations, Security Health Plan will provide advance notice to provider offices of the site visit. All applicants are required to cooperate with the site visit review process. This site visit includes an assessment of the provider s office as compared to standards set by Security Health Plan (see Section VI for details). In addition, a review of medical record-keeping practices will be completed against standards set by Security Health Plan (see Section VI for details). Security Health Plan will report the results of the site visit/medical record-keeping review to the practice. This report will provide detail on all areas in which the practice is not in compliance with Security Health Plan standards. Any practice with a compliance score of less than 90 percent is required to submit an action plan within 90 days of receipt of its site visit report. When necessary, Security Health Plan will perform a revisit in 3 months to verify practice compliance with the outstanding issue(s). After completion of the initial site visit/medical record-keeping review, a Security Health Plan contract manager will conduct ad hoc site visits to affiliated practices. In addition, a contract manager will monitor member complaints monthly. This may trigger an ad hoc site visit. Upon notification that an affiliated practice is relocating or opening an additional office, a contract manager will conduct a site visit at the new site. Security Health Plan will not conduct a site visit if the provider relocates to an office that is already a Security Health Plan affiliated practice. SECTION II PAGE 3

12 Application process for physician and nonphysician providers The credentialing process requires completion of a standard application for affiliation. Any interested physician may complete an application. Nonphysician providers may complete an application if Security Health Plan determines that a business need exists for their services. Applications must contain all required information and be signed prior to submission to Security Health Plan. Security Health Plan will return all incomplete applications. Security Health Plan is not required to reimburse for services provided to members prior to credentialing approval. For new practice sites, office managers are required to complete the Practice Information form. The application includes a statement informing the applicant that the National Practitioner Data Bank (NPDB) and the relevant state licensing board will be queried and reviewed as part of the application process. A signed attestation from the applicant, indicating the application is complete and correct, is required. In addition, the attestation includes questions regarding any reason for the provider s inability to perform the essential functions of his/her position with or without accommodation, present illegal drug use, history of loss of license and history of limitation of privileges. Primary source verification Security Health Plan will collect and verify all provider credentials in accordance with NCQA standards for primary source verification. Applicants will fully cooperate with Security Health Plan in obtaining all documents requested by Security Health Plan to satisfy primary source verification requirements. Primary source verification includes the following components: Previous education, training and board certification (as applicable) Professional state appropriate licensure Copy of current state appropriate registered DEA certificate or verification of state appropriate registered DEA via National Technical Information Service (NTIS) query or CDS via copy of current certificate (as applicable) Sanctions by Medicare or Medicaid via the NPDB query or CIN-BAD query Sanctions or disciplinary actions on licensure via state appropriate licensing board and the NPDB query Hospital privileges in good standing at the hospital designated as the primary admitting facility via attestation on the application (as applicable) History of malpractice claims or denial of professional liability via NPDB query Current, adequate malpractice insurance per Security Health Plan policy and contract specifications via completed provider application or copy of malpractice face sheet Gaps in work history greater than six months identified through review of application and/or CV SECTION II PAGE 4

13 Administrative review Administrative criteria Prior to submitting an application to the medical director or Credentialing Committee, the credentialing staff determines whether the applicant satisfies all administrative and contracting requirements. Security Health Plan administrative and contracting requirements include, but are not limited to: All physician and nonphysician providers must maintain their primary office in Security Health Plan s service area. All nonphysician and nonpodiatrist providers are affiliated based on business need. The determination of business need includes, but is not limited to: whether the allied provider(s) of the practice site are an already affiliated practice the need for the allied practice site s expertise in a geographic area the network s ability to provide reasonable access to members the availability of timely appointments for members Security Health Plan s current and projected enrollment significant continuity of care issues member requests An applicant s level of professional liability insurance must meet minimum limits as determined by Security Health Plan and stated in the contract. An applicant must maintain hospital privileges in good standing to allow for necessary member hospital admissions if his or her practice requires it. An applicant must have graduated from an acceptable training program, as defined by the appropriate state licensing or registration agency of the applicant s profession, or as otherwise defined by Security Health Plan. An applicant must have completed the appropriate postgraduate training or residency program, as required by state licensing agencies or Security Health Plan. An applicant must have current unrestricted licensure or certificate/registration to practice in his or her profession in the state appropriate where they are providing services. An applicant must have a current and valid state appropriate registered DEA Certificate. An applicant must not have misrepresented, misstated or omitted relevant or material facts on the application, disclosure statements or any other documents provided as part of the credentialing process. If the primary source verification process identifies a substantial discrepancy in information, Security Health Plan will notify the applicant by telephone, follow up in writing and allow him or her to review and correct potential primary sourceverified erroneous information. Information received from the National Practitioner Data Bank (NPDB) cannot be shared per federal law. An applicant must provide information relative to after-hours and weekend coverage. SECTION II PAGE 5

14 An applicant has the right, upon request, to be informed of the status of his or her application. The credentialing staff will inform him or her of the application status. The applicant will not be allowed to review references, recommendations or other information that is peerreview protected or information obtained from the NPDB or similar restricted sources. An applicant must have demonstrated a willingness to allow Security Health Plan to conduct a site review and an audit of medical records, which will include, but is not limited to: the physical accessibility of the office the general appearance of the office the adequacy of waiting and examining room space the availability of appointments and follow-up with patients the adequacy of medical record keeping the adequacy of medical record filing and confidentiality A copy of Security Health Plan s provider office standards and medical record standards can be found in this Credentialing Program Manual (Section V and VI). Administrative action If the credentialing staff determines that an application is complete and that the applicant meets the established administrative and professional criteria, the application is forwarded to the medical director and his or her designee for consideration. If the application is complete but does not meet one or more elements of the established administrative and professional criteria, the application is forwarded to the Credentialing Committee for consideration. If the application is not complete, credentialing staff will return the application and request a completed application. Security Health Plan then requires that the applicant supply the missing information. Credentialing staff provide the Credentialing Committee with an annual summary of all application requests denied for administrative reasons (based on business need). Credentialing Committee process Professional criteria Upon receipt of a completed application and administrative review by the credentialing staff, the application will be taken before the medical director and/or Credentialing Committee for consideration and delegated approval action. The criteria contained in this section must be satisfied by each applicant. The committee reserves the right to request additional information when reviewing applications. In addition, the committee consults with affiliate providers of various specialties, as appropriate, to review any questionable credentials of providers. The committee may elect to waive one or more criteria, if the committee determines that one or more criteria are not relevant to a particular applicant or that noncompliance with one or more criteria does not indicate a potential or existing professional performance issue. The applicant has not engaged in conduct that violates state or federal law or ethical standards of professional conduct governing his or her practice. SECTION II PAGE 6

15 The applicant has not been the subject of professional disciplinary action by a managed care plan, insurer, clinic, hospital, medical review board, peer review organization or other administrative body or government agency. This includes, but is not limited to, the imposition of disciplinary or administrative sanctions for inappropriate, inadequate or tardy completion of medical records. The applicant has not been the subject of disciplinary action by a licensing board. A provider may receive disciplinary action but may obtain a stay of action enabling him or her to practice. The applicant has not been sanctioned by Medicaid or Medicare, and has not been the subject of adverse action. The applicant has not engaged in any conduct resulting in a gross misdemeanor or felony conviction, charge or indictment. The applicant does not have a history of professional liability lawsuits or other incidents that constitute a pattern and/or indicate a potential competency or quality of care problem. The applicant has not been involuntarily terminated from professional employment or a hospital medical staff or resigned from professional employment or hospital medical staff after knowledge of an investigation into his or her conduct or in lieu of disciplinary action. The applicant has no history of denial or cancellation or failure to renew professional liability insurance. The applicant has no current medical or physical condition likely to adversely affect the essential functions of his or her profession or constitute a direct threat to the health or safety of others. Credentialing Committee action The Credentialing Committee and medical director or his or her designee will use good faith discretion in reviewing applications and making credentialing decisions. The committee and medical director or his or her designee will base its decision on any facts and circumstances it deems appropriate and relevant. The credentialing process will be completed within 180 days of the date of the applicant s signature on the application. If the process exceeds 180 days, the credentialing staff will return the application to the applicant. The applicant may complete a new application or resubmit the application with an updated signature attesting to the accuracy and completeness of the information. The credentialing staff will notify the practice within 2 business days by telephone or of the Credentialing Committee s decision. Within 60 calendar days, Security Health Plan s Network Management secretary will send a letter to the provider communicating Security Health Plan s decision. Appeals Applicants who are denied initial affiliation (for reasons other than lack of business need) can appeal the denial by following Security Health Plan s New Provider Applicant Appeal Policy (Section II, page 13). While no appeal process exists for denials based on lack of business need (as determined by Security Health Plan), these applicants may reapply after 12 months. SECTION II PAGE 7

16 P r o v i d e r Re c r e d e n t i a l i n g Triennial process Security Health Plan will recredential affiliated providers using the process outlined below, every three years (36 months). Any provider not recredentialed within 36 months is considered noncompliant with Security Health Plan policy. An exception to this is if the provider is on active military leave and will not meet the 36-month recredentialing time frame. The provider s license will be verified before the provider can see members and recredentialing will be completed within 60 days of the provider s return to practice. Recredentialing process Security Health Plan will send each affiliated provider a preprinted recredentialing application, requesting review and updates of professional information. Applications must contain all required information and be signed and dated prior to submission to Security Health Plan. Security Health Plan will return all incomplete applications. A signed attestation from the applicant, indicating that the information is complete and correct, is required. In addition, the attestation includes questions regarding any reason for the provider s inability to perform the essential functions of the position with or without accommodation, the lack of present illegal drug use, history of loss of license and history of limitation of privileges. Reminders will be made by telephone or letter at 30-day and 60-day intervals to each provider who has not returned his or her recredentialing forms. The 30-day reminder letter will be signed by Security Health Plan s medical director, sent by certified mail to the provider (and a copy sent to the office manager or department head) and will indicate a 15-day return time requirement. A copy of the 60-day reminder letter will also be given to the appropriate contract manager. If the recredentialing application is not received within 15-days, this information will be reported to the Credentialing Committee. If phone calls are made in lieu of a letter, documentation will be made by the credentialing staff. The recredentialing process will be completed within 180 days of the date of the applicant s signature on the application. Primary source verification Security Health Plan will collect and verify all recredentialing information in accordance with NCQA standards for primary source verification. Providers are required to fully cooperate with Security Health Plan in obtaining all information requested by Security Health Plan to satisfy primary source verification requirements. Primary source verification for recredentialing includes the same components as in the credentialing process with the exception of work history and verification of education. (See section II, page 4 for details). Recredentialing criteria Security Health Plan will evaluate an affiliated provider based on the administrative criteria set forth in the Administrative Criteria (see section II, page 5) section and the professional criteria set forth in the Professional Criteria (see section II, page 6) section. Failure to satisfy any of the administrative or professional criteria may be grounds for disaffiliation or other disciplinary action. SECTION II PAGE 8

17 Ongoing performance monitoring If, at any time during a provider s affiliation with Security Health Plan, a member lodges a complaint or files a grievance against the provider for issues concerning quality of care or service, the medical director or his or her designee will communicate the member s complaint to the provider. The provider will be given the opportunity to respond to the member s complaint/grievance. The member s complaint/grievance and provider s response will be placed in a peer-review file and trended. If a provider has two member complaints in a 1-year period or the medical director determines a complaint needs further review, the information is presented to the Credentialing Committee for review. Security Health Plan also includes the monthly review of adverse events to identify provider trends. Appeals Providers have the right to appeal a decision by the Security Health Plan Board of Directors to deny continued affiliation with Security Health Plan. Please refer to Protocol for Assessing the Quality of an Affiliated Provider Practice (Attachment A). Listings in provider directories and other member materials Provider information that is supplied through member materials (ie, provider directories, member newsletters) will be consistent with information that was obtained during the credentialing/recredentialing process. This includes the provider s education, training and certification in regard to specialty areas. SECTION II PAGE 9

18 F acility Approval a n d Reapproval Security Health Plan has established policies and procedures for the initial approval and reapproval of facilities and organizations contracted to provide services to Security Health Plan members. The scope of facilities approved includes: hospitals, skilled nursing facilities (SNFs), rehabilitation centers (RCs), home health agencies (HHAs), ambulatory surgical centers (ASCs), durable medical equipment, orthotics and prosthetics suppliers (DMEPOS) and residential, inpatient and ambulatory mental health and alcohol and other drug abuse (AODA) facilities. All facilities are credentialed before services are provided to Security Health Plan members and are recredentialed at least every 3 years. Administrative review The Network Management Department is responsible for assessing facility credentials. Administrative criteria All facilities that intend to affiliate with Security Health Plan must provide the following: Information about the facility, including legal name, address, facility type and contact person A copy of the facility s current valid Wisconsin license (except for ASCs or DMEPOS) The facility s Medicare and Medicaid provider numbers A copy of the facility s malpractice liability insurance declaration If the facility is accredited, documentation (certificate or letter of notification) from a recognized accrediting body Security Health Plan recognizes the following accreditation: Facility type Ambulatory surgical centers (ASCs) Durable Medical Equipment, Orthotics and Prosthetics Suppliers (DMEPOS) Home health agencies (HHAs) Hospitals Mental health facilities Rehabilitation centers (RCs) Skilled nursing facilities (SNFs) Accrediting body Joint Commission (JC) or Accreditation Association for Ambulatory Health Care (AAAHC) or Bureau of Quality Assurance (BQA) Accreditation Commission for Health Care, Inc. (ACHC), American Board for Certification in Orthotics & Prosthetics, Inc. (ABC), Board of Orthotist/Prosthetist Certification (BOC), Commission of Accreditation of Rehabilitation Facilities (CARF), Community Health Accreditation Program (CHAP), The Compliance Team, Inc., HealthCare Quality Association on Accreditation (HQAA), The Joint Commission (JC), National Association of Boards of Pharmacy (NABP) JC or Continuing Care Accreditation Commission (CCAC) JC JC JC or Commission on Accreditation of Rehabilitation Facilities (CARF) JC or CARF SECTION II PAGE 10

19 Verification of credentials for accredited facilities For accredited facilities, Security Health Plan will verify that the facility has met all state and federal licensing and regulatory requirements, as applicable Security Health Plan will also verify that it has been approved by a recognized accrediting body by reviewing the documents listed in the Administrative Criteria section. In addition to the documents listed in the Administrative Criteria section, Security Health Plan requires the submission of the findings of the two most recent surveys from the Centers for Medicare and Medicaid (CMS) for SNFs and RCs. The contract manager will conduct a review of the facility s Medicare and Medicaid sanction history and will verify adequate malpractice liability insurance coverage. Verification of credentials for nonaccredited facilities If a facility is not accredited by a recognized accrediting body, Security Health Plan requires submission of the following information, in addition to the documents listed in the Administrative Criteria section: Copy of the facility s quality assurance (QA) plan Copy of the facility s medical record keeping policies and procedures Copy of the facility s medical staff service plan that includes (if applicable) the process for verifying individual provider credentials Hospital and mental health facilities only: Copy of the facility s utilization review (UR) plan SNF/RC and HHA only: Copy of the Clinical Laboratory s Improvement Amendments (CLIA) Findings of the two most recent surveys from the State of Wisconsin Bureau of Quality Compliance or CMS The contract manager will conduct a review of the facility s Medicare and Medicaid sanction history and will verify adequate malpractice liability insurance coverage. In addition, if the facility s CMS review does not meet Security Health Plan s standards, Security Health Plan will conduct an on-site facility audit, as described below. Site visits for nonaccredited facilities The contract manager will conduct a quality assessment to any site that is unable to prove acceptable JC, AAAHC, BQA, CARF or CCAC accreditation or CMS review that meets Security Health Plan s standards. Security Health Plan may conduct a site visit to any other facility. Such visits will be conducted in accordance with Security Health Plan standards for site visits. For facilities seeking initial approval, the contract manager will evaluate medical record policies and procedures. For hospitals, mental health facilities and ambulatory surgery centers, Security Health Plan will also review a sample of at least five records verifying the credentials of individual providers. SECTION II PAGE 11

20 Recredentialing Administrative review: The Network Management Department will conduct a review of the facility s credentials no less than every 3 years during the contract period. Administrative criteria: At the time of recredentialing, all facilities must provide the following: a copy of the facility s current valid Wisconsin license (except for ASCs and DMEPOS) the facility s Medicare and Medicaid provider numbers a copy of the facility s malpractice liability insurance declaration if the facility is accredited, documentation (certificate or letter of notification) from a recognized accrediting body Verification of credentials for accredited facilities: For accredited facilities, Security Health Plan will verify that the facility continues to meet all state and federal licensing and regulatory requirements as applicable and continues its accreditation status. In addition to the documents listed in the administrative criteria section, Security Health Plan requires the submission of the findings of the most recent survey from CMS for SNFs and RCs. The Network Management Department will conduct a review of the facility s Medicare and Medicaid sanction history and will verify continued adequate malpractice liability insurance coverage. Verification of credentials for nonaccredited facilities: If a facility is not accredited by a recognized accrediting body, Security Health Plan requires submission of findings of the most recent survey from CMS in addition to the documents listed in the administrative criteria section. Medical director The medical director or his or her designee reviews facility information that meet Security Health Plan s administrative review. The medical director has the authority to approve facility credentialing/recredentialing information that meet Security Health Plan s administrative review. Credentialing Committee The Credentialing Committee is responsible for reviewing facility credentialing/recredentialing information that do not meet Security Health Plan s administrative review. The committee, per Security Health Plan board delegation, has authority to approve/disapprove facility credentialing/ recredentialing. If any of the required documentation is not provided or if the assessment does not demonstrate that the facility is in good standing with regulatory bodies, the Credentialing Committee will withhold approval until further review can demonstrate that the facility meets Security Health Plan requirements. SECTION II PAGE 12

21 N ew Pr o v i d e r Applicant Appeal Po l i c y Purpose To outline an appeal process for applicants denied Security Health Plan affiliation. Scope Applies to all providers denied Security Health Plan affiliation due to credentialing issues, but does not apply to non-physician denials based on business need. Policy Provider applicants have the right to appeal denials for affiliation that are based on credentialing issues through the following process. Procedures The letter notifying the applicant that affiliation has been denied will be sent by certified mail and will state the basis for the decision, the appeals process available and the date by which the appeal request must be received. Applicants must appeal within 30 calendar days after receiving written denial for affiliation. The appeal must be submitted in writing to the Security Health Plan medical director. Security Health Plan s Credentialing Committee will conduct a thorough review of all the available information and provide a written response to applicant affiliation appeals within 30 calendar days of receipt of appeal. If the applicant is dissatisfied with the response he or she has the right to appeal the decision of the Credentialing Committee by submitting a formal appeal in writing to the Security Health Plan Board of Directors within 10 days of receiving notice of the Credentialing Committee appeal decision. Security Health Plan s Board of Directors shall address the matter within 30 days of receiving the appeal. The applicant has the right to appear before Security Health Plan s Board of Directors. Security Health Plan will notify the applicant of the date, time and location of the board meeting at least 14 days prior to the meeting. If either the applicant or Security Health Plan Board of Directors believes additional time is needed to obtain more information, an additional 30 days may be requested. The Security Health Plan Board of Directors decision is final. Security Health Plan will communicate its decision to the applicant within 7 days of the board meeting. Appeal mailing address Written appeal submitted to: Attn: Medical Director Security Health Plan 1515 Saint Joseph Avenue P.O. Box 8000 Marshfield, WI SECTION II PAGE 13

22 S e c t i o n III P r o v i d e r A pplications f o r Affiliation

23 1515 Saint Joseph Avenue P.O. Box 8000 Marshfield, WI or TTY or Security Health Plan s Expectations of Providers Security Health Plan expects affiliated providers to: act in the best interest of our members communicate fully with members regarding their illness, as well as diagnostic and therapeutic options available to them refer members for specialty care or second opinions within the Security Health Plan provider network and obtain approval from the Security Health Plan medical director when it is felt that care is necessary outside of the health plan network maintain awareness of Security Health Plan Technology Assessment and Drug Evaluation Committee decisions to the extent possible participate in Security Health Plan utilization management and quality improvement initiatives, including allowing Security Health Plan reasonable access to member medical records recognize that there are multiple, well accepted means of diagnosis and treatment for many given conditions inform the Medical Director when Security Health Plan procedures or actions are perceived as threatening the health or well-being of the member recognize that conflict occasionally occurs between providers and Security Health Plan, or members and Security Health Plan, and that these should be resolved within the appeals process outlined in Security Health Plan documents understand that Security Health Plan does not deny patient care, but simply makes payment decisions based on member s coverage through Security Health Plan communicate with members and Security Health Plan in a way that assumes that all parties are acting in good faith with the goal being good care for the member recognize that Security Health Plan is obligated to develop policies and procedures on benefit administration and to administer these in a fair and consistent manner even though this occasionally results in denial of payment for individual members understand that Security Health Plan s goal is to improve access to, and quality of, health care refrain from making comments or offering advice on payment or insurance coverage issues refer patients with payment or insurance coverage issues to Security Health Plan Customer Service Department at identify advance directive status in the medical record and implement advance directives per member s request HP (06/10) Security Health Plan of Wisconsin, Inc.

24 1515 Saint Joseph Avenue P.O. Box 8000 Marshfield, WI or TTY or Provider s Expectations of Security Health Plan Providers of care can expect Security Health Plan to: assist the provider in meeting the expectations of Security Health Plan pay claims fairly and efficiently provide due process to the provider when complaints or grievances are lodged against him or her, or when a provider wishes to appeal Security Health Plan decisions strive to interfere as little as possible with the process of care, unless there are significant issues related to quality, cost or coverage support the provider in practice by identifying opportunities to improve care when information is available on a practice basis or an individual member basis maintain an appeals process that can respond quickly and appropriately to members and providers educate and encourage members to be seen for appropriate preventive services inform providers of initiatives that may affect them or our members before such interventions occur, and before members are aware of them (i.e. educational programs which may result in questions being asked of the provider) maintain internal processes to improve service to our members and providers review clinical information when making decisions about coverage; staff do not receive financial compensation for denying benefits for health care services, nor is Security Health Plan performance measured on such denials inform providers of changes in benefit administration policies that may affect them or our members awareness provide a written copy of Security Health Plan s QI evaluation upon request HP (06/10) Security Health Plan of Wisconsin, Inc.

25 1515 Saint Joseph Avenue P.O. Box 8000 Marshfield, WI or TTY or SHP Use Only Provider Credentialing Application Security Health Plan Family Health Center Medicaid HMO Date credentialed Provider number Please: Type or print legibly. Complete all items. If an item does not apply, enter NA. Do not leave any items blank. Checklist (please complete) (If your application for your DEA certificate, Wisconsin license and/or malpractice insurance are pending, please forward application and send those documents as soon as possible.) Copy of Wisconsin license Copy of Board Certification Copy of Nurse Practitioner, Nurse Midwife, or Physician Assistant certification Copy of DEA certificate Copy of liability face sheet with effective/expiration dates and coverage limitations (only if the professional liability carrier section in this application is not completed in its entirety) Copy of curriculum vitae or resumé including month and year time frame Malpractice Litigation and Professional Complaints form, if applicable Signed and dated Agreement Relating to Credentialing Process Explained all gaps greater than six months in chronology Answered all of the Disclosure Questions and enclosed explanations for affirmative answers Signed and dated Authorization for Release of Information form Keep a copy for your records. NOTE If this application was completed more than 180 days prior to the date of your signature, information on the application must be updated and a new Authorization for Release of Information must be completed. Please review carefully and provide any current information you may have. Incomplete applications will be returned for completion. Upon advance notification, you have the right to review (in person at the Security Health Plan office during normal business hours) your credentials file. You will not be allowed to review references, recommendations, or other information that is peer-review protected or information obtained from NPDB, HIPDB or similar restricted services. You have the right to correct erroneous information. You may contact Security Health Plan Network Management Department at during normal business hours to be informed of the status of your credentialing application. HP (06/10) Security Health Plan of Wisconsin, Inc. page 1

26 Full legal name (last, first, MI) Personal information Maiden/former name (used for primary source verification, eg, license verification) Full professional credentials (used for Security Health Plan Provider Directory): M.D. D.O. D.D.S. Other (specify) Social Security number Date of birth Gender: Male Female Languages fluently spoken in addition to English: Spanish French German Italian Hmong Other Wisconsin license number Professional information Expiration date DEA number Expiration date Federal tax ID number NPI number Will you be accepting Wisconsin Medicaid patients: Yes No Wisconsin Medicaid provider number Will you be accepting Wisconsin Medicare patients: Yes No If yes, provide us with your Wisconsin Medicare billing number at each practice location, as applicable. If the number(s) have been applied for, Security Health Plan requires notification of receipt of the number(s). NOTE: Failure to provide these number(s) will result in Medicare claim rejection. Primary practice location (within Security Health Plan s service area) Office name Medicare practice number Address (street, city, state, ZIP) Medicare provider sequence number Medicare provider number applied for Telephone number Office manager Fax number Credentialing contact Start date at this location Additional practice location Office name Medicare practice number Address (street, city, state, ZIP) Medicare provider sequence number Medicare provider number applied for Telephone number Start date at this location HP (06/10) Security Health Plan of Wisconsin, Inc. page 2

27 Additional practice location Office name Professional information (continued) Medicare practice number Address (street, city, state, ZIP) Medicare provider sequence number Medicare provider number applied for Telephone number Start date at this location Indicate your after-hours coverage procedure(s): Answering service and page Nurse triage system On-call physician/dentist via answering service Answering machine On-call physician/dentist via answering machine/ Other recorded message Patients are informed of your after-hours coverage: Yes No IMPORTANT: After-hours coverage must be provided by a Security Health Plan affiliated provider. Medical/graduate/professional education (Month and year required) From To / / / / Institution name: Degree received: M.D. D.O. D.D.S. D.C. D.P.M. Ph.D. Other Address: Street City/state/country Zip code Telephone number: (Month and year required) From To / / / / Institution name: Degree received: M.D. D.O. D.D.S. D.C. D.P.M. Ph.D. Other Address: Street City/state/country Zip code Telephone number: ECFMG applicable to international medical graduates ECFMG number Date issued (mo/yr) Valid through (mo/yr) Internship/post-graduate/professional training If additional space is required, attach a separate sheet. (Month and year required) From To / / / / Institution name: Type of program/specialty (transitional, rotating, 5th pathway, etc.): Completed training: Yes No If no, expected completion date: If not successfully completed, explain and provide the following information: Program director: Address: Street City/state/country Zip code HP (06/10) Telephone number: Security Health Plan of Wisconsin, Inc. page 3

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