Lakeshore RE AFP POLICY # 4.4. APPROVED BY: Board of Directors

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1 Lakeshore PIHP POLICY TITLE: CREDENTIALING, RECREDENTIALING, STAFF QUALIFICATIONS, AND BACKGROUND CHECKS Topic Area: Provider Network Management POLICY # 4.4 Page: 1 of ISSUED BY: Chief Executive Officer REVIEW DATES Adapted from Lakeshore Behavioral Health Alliance Applies to: Lakeshore Regional Entity (LRE) staff and all member CMHSPs APPROVED BY: Board of Directors Developed and Maintained by: PIHP Provider Network Management Workgroup Effective Date: Revised Date: Supersedes: N/A I. Policy: The LRE provider network management functions will assure that all affiliate members meet all requirements for credentialing, privileging, and primary source verification of professional staff. In addition, the LRE shall require all provider organizations to adopt, maintain and follow a policy for the completion of background checks. The LRE CEO or other designated LRE staff person will provide oversight of these functions to assure that each CMSHP is adhering to LRE policy and procedure. CMHSPs will credential, privilege, and verify providers as appropriate and when possible allow reciprocity with common providers. II. Purpose: To ensure that the LRE has an established policy for its provider network to assure that all consumers receive quality services in accordance with the mission and values of the affiliation, and are safe from predictable harm or risk. The LRE intends to provide qualified staff and organizations that meet or surpass all standards, and to assure that consumers are served by individuals who have been screened for good moral character and other regulatory standards. III. Applicability and Responsibility: This policy applies to LRE and its member CMHSPs. IV. Monitoring and Review: CMHSPs will assure that organizational and practitioner credentialing and monitoring occurs for all providers directly operated by or under sub-contract to the CMHSP. LRE shall annually conduct a compliance review of each CMHSP, and shall assure that all aspects of this policy are consistently implemented. Based on this compliance review, LRE may request corrective action from CMHSP. LRE

2 may request information regarding compliance with this policy at any time. LRE will provide rationale for the request, and will provide a reasonable timeline for provision of the information. CMHSPs shall minimally assure the following: A. CMHSPs shall assure that all individuals, whether employed or contracted by the CMHSP to provide clinical or medical services, will be credentialed consistent with their position. B. Credentials shall be verified, by primary source, prior to employment. C. Verification shall occur at the time of license renewal and renewal of provider agreement. D. Copies of all licenses, registrations, and/or certifications shall be kept in the employees or contractors files. E. Prior to employment, the CMHSP shall verify that the individual is not included in any excluded or sanctioned provider lists. This includes Medicaid/Medicare Exclusion lists and National Practitioner Data Bank lists. This verification process shall also occur at the time of recredentialing or contract renewal. F. Background checks shall include criminal, recipient rights, corporate compliance, driving record, Sex Offenders Registry, reference checks. G. The CMHSP incorporates its findings on credentialing, background checks, and exclusionary data into the LRE Quality Assessment Performance Improvement Program. Such findings will also be incorporated into the re-credentialing process. H. When applicable, all clinicians and physicians, whether employed or contracted by the CMHSP, will be privileged for each specific function to be performed. Privileging shall be age and disability specific according to the populations served. Clinical privileging shall occur at the time of employment and at least bi-annually thereafter. I. Monitor sub-contractors, at least annually, with adherence to above. V. Related Policies and Procedures: A. Network Development and Procurement B. Provider Contract Management and Oversight C. Network Policy Development D. MDCH Credentialing and Re-Credentialing Process, September 2006 E. CFR (b) (2) F. MDCH G. CFR H. CFR (c) VI. Definitions: Credentialing process by which the PIHP and its Affiliates ensure providers meet certain criteria and remain in compliance with the criteria in order to be accepted as a network provider. Re-credentialing process by which the PIHP and its Affiliates ensure that providers meet certain criteria and remain in compliance with the criteria in order to continue as a network provider. VII. Procedures

3 A. The members will have a written system in place for credentialing and re-credentialing individual practitioners included in their provider network that are not operating as part of an organizational provider. 1. Credentialing and re-credentialing will be conducted and documented for at least the following health care professionals: Physicians (M.D.s or D.O.s), Physician s Assistants, Psychologists (Licensed, Limited License or Temporary License), Licensed Master s Social Workers, Licensed Bachelor s Social Workers, Limited License Social Workers, or Registered Social Service Technicians Licensed Professional Counselors, Nurse Practitioners, Registered Nurses, or Licensed Practical Nurses, Occupational Therapists, or Occupational Therapist Assistants, Physical Therapists, or Physical Therapist Assistants, and Speech Pathologists. 2. LRE or its members will ensure that the credentialing and re-credentialing processes does not discriminate against: a. A health care professional, solely on the basis of license, registration, or certification. b. A health care professional who serves high-risk populations or who specializes in the treatment of conditions that require costly treatments. 3. LRE retains the right to approve, suspend, or terminate a provider selected by the members. 4. CMHSPs shall have a written credentialing policy and procedure that will reflect the scope, criteria, timeliness and process for the credentialing and re-credentialing of all of its providers, licensed and non-licensed. Policy will specify the administrative staff person and entity (e.g., credentialing committee) responsible for oversight and implementation of the credentialing/re-credentialing processes and delineate their roles. 5. CMHSPs shall ensure that an individual credentialing/ re-credentialing file is maintained for each credentialed provider. Each file must include: a. The initial credentialing and all subsequent re-credentialing applications; b. Information gained through primary source verification; and c. Any other pertinent information used in determining whether or not the provider met the Member s credentialing and re-credentialing standards. 6. CMHSPs credentialing/re-credentialing policy shall describe the methodology used to document and ensure that each credentialing/re-credentialing file was reviewed for completeness prior to presentation to their respective credentialing/re-credentialing authority, (e.g. credentialing committee). 7. The LRE Medical Director provides consultation to the LRE Executive Director regarding credentialing/re-credentialing of medical staff. Each Member s policy shall specify the role of providers in the credentialing/re-credentialing process.

4 B. Initial Credentialing 1. CMHSP policies and procedures for the initial credentialing of the individual practitioners must require: a. A written application that is completed, signed and dated by the provider and attests to the following elements: i. Lack of present illegal drug use. ii. Any history of loss of license and/or felony convictions. iii. Any history of loss or limitation of privileges or disciplinary action iv. Attestation by the applicant of the correctness and completeness of the application. b. An evaluation of the provider s work history for the prior five (5) years. c. Verification from primary sources of: i. Licensure or certification. ii. Board Certification, or highest level of credentials attained if applicable, or completion of any required internships/residency programs, or other postgraduate training. iii. Documentation of graduation from an accredited school. iv. National Practitioner Databank (NPDB), Healthcare Integrity and Protection Databank (HIPDB) query or, in lieu of the NPDB/HIPDB query, all of the following must be verified: v. Minimum five year history of professional liability claims resulting in judgment or settlement; vi. Disciplinary status with regulatory board or agency; and vii. Medicare/Medicaid sanctions. 2. If the individual practitioner undergoing credentialing is a physician, the physician profile information obtained from the American Medical Association may be used to satisfy the primary source requirements of (a), (b), and (c) above. C. Temporary/Provisional Credentialing of Individual Practitioners 1. Temporary or provisional credentialing of individual practitioners is intended to increase the available network of providers in underserved areas, whether rural or urban. Affiliates must have policies and procedures to address granting of temporary or provisional credentials when it is in the interest of Medicaid beneficiaries that providers be available to provide care prior to formal completion of the entire credentialing process. Temporary or provisional credentialing shall not exceed 150 days. CMHSPs shall have up to 31 days from receipt of a complete application, accompanied by the minimum documents identified below, within which to render a decision regarding temporary or provisional credentialing. 2. For consideration of temporary or provisional credentialing, at a minimum, a provider must complete a signed application consistent with requirements from the initial

5 credentialing process (VI.B.1.a, VI.B.1.b). 3. CMHSPs must conduct primary source verification of the following: a. Licensure or certification; b. Board certification, if applicable, or the highest level of credential attained; and c. Medicare/Medicaid sanctions. 4. CMHSPs must review the information obtained and determine whether to grant provisional credentials. Following approval of provisional credentials, the process of verification as outlined in this Section, should be completed. D. Re-credentialing Individual Practitioners 1. CMHSPs must identify policies and procedures that address the re-credentialing process for physicians and other licensed, registered or certified health care providers and include requirements for each of the following: a. Re-credentialing at least every two years. b. An update of information obtained during the initial credentialing; c. A process for on-going monitoring, and intervention if appropriate, of provider, which must include, at a minimum, review of: i. Medicare/Medicaid sanctions. ii. State sanctions or limitations on licensure, registration or certification. iii. Member concerns which include grievances (complaints) and appeals. iv. Any quality issues identified by affiliates or LRE. E. LRE Credentialing of Organizational Providers and Delegation of Credentialing to the Members of its Provider Network 1. LRE will validate and re-validate at least every two years that the organizational provider (community mental health agency or coordinating agency for substance abuse services) is licensed as necessary to operate in the State of Michigan and has not been excluded from Medicare or Medicaid participation. 2. LRE will delegate to the Members the function of credentialing and re-credentialing. The Affiliate s policy will specify the role of providers in the credentialing and recredentialing process. 3. LRE retains the right to approve, suspend, or terminate a provider selected by the Member. 4. The LRE Executive Director or designate is responsible for oversight of the delegated credentialing or re-credentialing decisions. F. Deemed Status 1. LRE will accept the credentialing decisions of other Prepaid Inpatient Health Plans (PIHPs) for individual practitioners and organizational providers, and will maintain

6 copies of the credentialing PIHP s decisions. G. Notification of Adverse Credentialing Decision 1. An individual practitioner or organizational provider that is denied credentialing or recredentialing shall be informed of the reasons for the adverse credentialing decision in writing by LRE or the Member and the appeals process within ten (10) business days of rendering the decision. H. Appeal of Adverse Credentialing Decision 1. LRE, and each CMHSP, shall develop a written process for responding to appeals of credentialing decision. Providers will submit a written request for reconsideration of the decision. LRE or CMHSPs will review the written request and inform the provider of their decision in writing within thirty (30) days. The LRE Executive Director will provide additional steps with timelines for appeal up to the LRE Board of Directors, whose decision will be considered final. 2. If the provider fails to submit a complete and timely request for a reconsideration or a request for a hearing with the Credentialing Appeals Board or the PIHP Board of Directors, the provider will be deemed to have accepted the PIHP s determination of the issues raised by the provider and to have waived all further internal or external processes regarding the issues. I. Reporting Requirements 1. The LRE and all affiliates shall report improper organizational provider or individual practitioner conduct that results in suspension or termination from the Member s provider network to the appropriate authorities such as; MDCH Bureau of Health Professions, Health Investigative Division; MDCH Office of Attorney General, Health Care Fraud Division/Program Investigations Section; and the individual or organization s Regulatory/Licensing Board. Criminal offenses should be reported to law enforcement. Such procedures shall be consistent with current Federal and State requirements, including those specified in the MDCH Medicaid Specialty Supports and Services Contract and the Balanced Budget Act of 1996.

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