Credentialing...2 Credentialing, Recredentialing, Appointment, Re-Appointment... 3 Delegation of Credentialing and Recredentialing...

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1 Credentialing...2 Credentialing, Recredentialing, Appointment, Re-Appointment... 3 Delegation of Credentialing and Recredentialing A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association BCBSIL Provider Manual Rev 9/09 1

2 Credentialing BCBSIL Provider Manual Rev 9/09 2

3 Policy Name: Credentialing, Recredentialing, Appointment, Re-Appointment Policy Number: Credentialing - 2 Effective Date: 1/1/02 Revision Date: 3/1/09 Review Date: Signature Approval: Senior Medical Director Vice President Professional Network Management HMO, BA HMO, BlueChoice Approved QI: 3/4/09 Approved P&P: 2/26/09 Policy: Blue Cross and Blue Shield of Illinois (BCBSIL) is dedicated to facilitate the provision of, cost-effective and accessible health care by providers in its networks. A key component of the Program is the formal process of credentialing, recredentialing, appointment, reappointment, and departicipation of network providers. The Credentialing / Recredentialing Program will be conducted in a manner to ensure that all credentialing requirements are uniformly applied and shall be non-discriminatory in areas of race, ethnic/national identity, gender, age, or sexual orientation or reimbursement for all applicants to the HMOs of Illinois or BlueChoice/ BlueChoice Select Networks. Networks to which this Policy apply use requirements and processes derived from and in compliance with the State of Illinois and the National Committee for Quality Assurance (NCQA) Credentialing standards as outlined in Addendum I. I. Definitions: Practitioners are physicians or other licensed individual providers of covered services who are listed in the directories of any credentialed network. The credentialing process reviews evidence relating to the eligibility of a practitioner for participation in any credentialed network. In this process, information relating to credentialing elements and requirements are reviewed by the Provider Selection Committee (PSC) or the Medical Director, and a credentialing determination is made regarding the practitioner i.e. eligibility for participation in a credentialed network. Appointment is the action taken by a specific network to effect participation in that network by a practitioner. At the time of recredentialing, the eligibility of a practitioner for continued participation in any credentialed network, with respect to information relating to recredentialing elements and requirements, is reviewed by the PSC. Reappointment is the action taken by a specific network to effect continued participation in that network by a practitioner. The PSC reviews and makes a recommendation, coincident with recredentialing, to the network regarding reappointment actions based on information obtained through the practitioner s participation in the applicable network. Departicipation means termination of participation of a practitioner from a network. BCBSIL Provider Manual Rev 9/09 3

4 Page 2 of 26 II. Organizational Structure The Board of Directors of Health Care Service Corporation (HCSC) has delegated to its Illinois Affiliate Board oversight of the Corporate Quality Improvement Program. The Illinois Affiliate Board has delegated this function to the Managed Care Quality Improvement Committee. The Quality Improvement Committee has delegated the process of practitioner credentialing, re-credentialing, appointment, and reappointment to the Provider Selection Committee. The Committee is responsible for the following: Credentialing and Recredentialing determinations, reviewing and providing recommendations regarding reappointment determinations which the networks make, facilitating appropriate exchange of information and action with respect to departicipation, conducting appeal adjudication related to its actions, reviewing the credentials of practitioners who do not meet the organization established criteria and offering advice which the organization considers, annually signing a non discriminatory statement Addendum XI In addition to the PSC, the Medical Director also has the authority to sign off on all practitioners who meet the established credentialing criteria (i.e. clean files). The designated Medical Director may use a handwritten signature, or electronic identifier as documentation of sign off. The Medical Director s sign off date is the credentialing decision date. The role and participants of the PSC is outlined in Addendum VI. Procedure III. Credentialing A. Elements and Requirements for Practitioners 1. Application The credentialing criteria for practitioners is detailed in Addendum II. BCBSIL credentials the following practitioner types: MDs, DOs, DDS, DCs, CNMs, DPMs, Ph.Ds, LCSWs, LCPCs and LMFTs. B. Process 1. The Credentialing Department (CD) compiles the information related to the credentialing elements (Addendum II). The CD will contact the Independent Physician Association (IPA) or Provider Group by phone or , to secure any missing elements. Missing documentation must be received within 48 hours. If the required elements are not received within the required timeframe the incomplete application will be returned to the sender. Once a complete application is received, queries will be requested. Once results of the queries are returned, the CD will complete the credentialing process within 60 calendar days of receipt for those complete applications. BCBSIL Provider Manual Rev 9/09 4

5 Page 3 of A practitioner has the right to review the information compiled. A practitioner will be notified by the CD in the event that during the credentialing process, information obtained varies substantially from the information provided by the practitioner. This notification takes place prior to the review by the Medical Director or the PSC. The practitioner has the right to submit supplemental explanatory information. The practitioner has the right to correct erroneous information. If this occurs, the time necessary to gather additional information from the practitioner is not included in the 60 calendar days required to complete the credentialing process. 3. The Credentialing / Recredentialing Program will be conducted in a manner to ensure the credentialing requirements are uniformly applied to all applying practitioners and shall be nondiscriminatory in areas of race, ethnic/national identity, gender, age, sexual orientation or the type of procedure, patient, or specialty in which the practitioner specializes. Applications are worked based on date received in the CD and the aging of date-sensitive documents. 4. The CD is responsible for responding to all inquiries regarding the status of a Credential / Recredential application. IPAs / Practitioners may contact the CD via phone, fax, or , to request the status of their credentialing or recredentialing application and CD staff will on average respond within 24 hours. IPAs / Practitioners are notified through correspondence, the Website and by the Network Consultants of phone numbers for contacting appropriate CD staff. 5. For practitioners, the CD screens the application and query results relative to the thresholds for Professional History Occurrences (PHO) Addendum III. When the threshold is met, the information regarding the practitioner is reviewed by the Senior Medical Director who makes a recommendation to the PSC. The recommendation would be to: a. pass the practitioner through credentialing without PHO status, b. mark the practitioner s file with PHO status during the credentialing process, c. seek additional information from the practitioner, or d. deny the practitioner credentialing. The PSC reviews this recommendation, and may accept or alter it. If the decision is to deny the practitioner credentialing, the practitioner is informed by the CD, and may appeal the decision using the appeals process set forth in Addendum IV. If the decision is to seek additional information, the CD communicates this to the practitioner, and the Senior Medical Director rereviews the additional information within 30 calendar days and makes another recommendation to the PSC. If the determination is to pass the practitioner through credentialing, with or without PHO status, the networks are informed by their participation in the PSC meeting. 6. For practitioners meeting credentialing requirements, a listing or electronic file of practitioners recommended for credentialing is brought weekly to the Medical Director by the CD. The Medical Director reviews the listing or electronic file and makes a determination as to whether to credential, which creates eligibility for appointment to a credentialed network. Newly appointed practitioners will be added to the directory, Website and notified within 60 calendar days of the Credentialing decision (reference the Practitioner Directories Policy). If the practitioner does not meet credentialing requirements, or is determined not to be credentialed by the PSC, the CD informs the practitioner within 14 calendar days from the PSC decision date. BCBSIL Provider Manual Rev 9/09 5

6 Page 4 of 26 Health Care Management Policy and Procedure 7. For a practitioner not meeting credentialing requirements, the management of any network to which the practitioner is applying may review the credentialing information and bring it to the Senior Medical Director for temporary waiver based on considerations specific to that network. The Senior Medical Director makes a recommendation as to whether the practitioner should be granted a wavier. 8. The PSC reviews the information and makes a determination as to whether the practitioner is credentialed. A temporary waiver may be granted on a one-time basis for a period of up to one year. If the determination is made not to credential a practitioner, a letter is sent to the practitioner. The practitioner has the opportunity to appeal this determination using the procedure set forth in Addendum IV. IV. Appointment A. Elements and Requirements Each network sets its own elements and requirements for appointment (Addendum VII), which include having been credentialed as described in Section III. These elements and requirements are provided to the PSC for informational purposes, and do not require approval by the PSC. The elements and requirements for each network are set forth in Addendum VII. B. Process Practitioners seeking to participate in a credentialed network require appointment to that network. The management staff of the network reviews the credentialing information, along with any additional information required for the appointment determination, and makes a decision about appointment. A list of practitioners appointed is brought to the PSC by the network. The PSC reviews the list but does not take action with respect to it. IPAs/ Practitioners are notified of the appointment decision within 60 calendar days. If the network s decision is not to appoint, the practitioner has the opportunity to appeal the decision using the appeals policy for that network. V. Recredentialing A. Elements and Requirements for Practitioners 1. The elements and requirements for recredentialing including the primary sources used to verify the information are set forth in Addendum V. 2. Primary source verification for recredentialing is identical to that for credentialing. 3. Recredentialing will be initiated by the CD consistent with NCQA and State of Illinois requirements. Effective 7/1/2002, the State of Illinois requires recredentialing to be conducted in accordance with the Health Care Professional Credentials Data Collection Act 410 ILCS 517 which stipulates recredentialing to be completed every three years based on the last digit of the Health Care Professional s social security number. BCBSIL Provider Manual Rev 9/09 6

7 Page 5 of 26 B. Process The CD will initiate recredentialing by notifying the IPAs/ Practitioners in the first month of the quarter in which the practitioner is due for recredentialing. See Addendum IX for the State of Illinois cycle. The process of recredentialing is identical to that for credentialing. VI. Reappointment A. Elements and Requirements Each network defines its own elements and requirements for reappointment (Addendum VIII), which include having been recredentialed as described in Addendum IV, and acceptable performance within the network during the current period. Reappointment elements and requirements are provided for informational purposes to the PSC, and do not require approval by the PSC. The elements and requirements for each network are set forth in Addendum VIII. B. Process Appointed practitioners seeking to continue to participate in a credentialed network require reappointment consistent with Addendum IV & V. The Committee reviews the information and may request detail for further review. On that basis, the Committee either recommends reappointment or non-reappointment. The management staff of the network has final responsibility for making a determination as to whether the practitioner is reappointed to the network. IPAs/ Practitioners are notified via the Website of the reappointment decision within 60 calendar days. Practitioners have the opportunity to appeal a determination not to reappoint using the appeals policy for that network. VII. Monitoring and Departicipation A. Network Performance Criteria The administration of the individual managed care networks is solely responsible for the episodic and concurrent determination of practitioner and participation, continued participation and departicipation. Practitioners will be continuously evaluated against network-specific performance criteria by the network management. Those participants not meeting performance thresholds will be placed on monitoring or required to undertake corrective action, or both, or be departicipated from the network. The management of the individual networks will report network-specific decisions regarding departicipation to the PSC for informational purposes. B. Process When Network Management or the CD obtains information which meets the thresholds for PHO (Addendum III) review or a Level 3 Quality of Care Complaint regarding a practitioner who has previously been credentialed and is not in the process of current recredentialing, the information is reviewed by the Senior Medical Director. BCBSIL Provider Manual Rev 9/09 7

8 Page 6 of 26 The Medical Director makes a recommendation to the PSC regarding any change in credentialing status. The PSC may then change credentialing status or leave it unaltered. When performance by a practitioner does not meet network standards, the network may place the provider on monitoring and undertake corrective action. Monitoring persists until the issues creating the action have been resolved, or the network takes other action, including involuntary departicipation. Practitioners may be either voluntarily or involuntarily departicipated from a network. Departicipation is voluntary when initiated by the practitioner. Examples would be retirement, relocation, not meeting Board Certification requirements within 24 months of the initial credentialing decision date or failure to provide a credentialing application within 30 days of termination from a delegated entity. Involuntary departicipation is effected by the management staff of BCBSIL Network / Quality Improvement (QI) Department under the terms of its contract with the practitioner (or his/her agent). Network / QI / or Special Investigations Department (SID) management report to the PSC any practitioners placed on monitoring / corrective action or departicipated as a result of conduct or practice that could impair the integrity of other networks or is deemed to be unprofessional, unethical or illegal. Such conduct or practice, includes, but is not limited to: loss, suspension, or probation of license or hospital privileges felony charges a quality of care or member satisfaction issue failure to meet site visit requirements refusal to cooperate with BCBSIL and/or contracted network policies and procedures suspected fraud financial insolvency The other networks review the situation to assess the appropriateness of maintaining participation by the practitioner. The management staff of each network subsequently reports its determination as to continued participation by that practitioner to the PSC. C. Reporting When monitoring or departicipation is occasioned by an issue of conduct or practice which is solely or primarily related to substantial findings of professional incompetence or professional misconduct which adversely affects, or could adversely affect the health or welfare of a patient, the network identifies and presents the findings to the other networks through the PSC. The CD files a report with the appropriate authorities such as the respective state licensing agency, State Department of Professional Regulations as applicable, other local authorities as required by law, or the federal HealthCare Integrity and Protection DataBank (HIPDB). All involuntary departicipations will be evaluated by the CD to determine if reporting to HIPDB is required. The CD represents the Illinois Plan on the HCSC HIPDB Certification Committee and follows the corporate policy & procedures. BCBSIL Provider Manual Rev 9/09 8

9 Page 7 of 26 When a provider is terminated for administrative and/or performance issues related to network performance standards and unrelated to the physician s or professional provider s ability to practice, reporting is not required. In those cases that involve suspected fraud by a physician or provider, the individual is reported to the SID. It is the responsibility of the SID to report the situation to the appropriate authorities. VIII. Ongoing Monitoring of Sanctions, Member Complaints and Quality of Care Issues The CD will conduct regular reviews of the credentialed provider networks using information regarding Medicare & Medicaid sanctions, sanctions or limitations on licensure, and member complaints. This information will be reviewed between recredentialing cycles as follows: The CD & Corporate Compliance Department will monitor government sanctions by reviewing the OIG, FEP, GSA, Illinois Department of Public Aid-Medicaid Sanction Database, and the OFAC databases at the time of credentialing, as well as, monitoring the monthly change report compiled by the Corporate Compliance Department. The CD will review sanctions or limitations on state licensure using data obtained from the appropriate state licensing agency on a monthly basis. The Senior Medical Director will review member complaints and quality of care issues as identified by the BCBSIL Consumer Services Management area which is responsible for resolving quality of care issues. The CD will provide a monthly report of closed cases to the Network Medical Directors (reference the Ongoing Monitoring of Credentialed Practitioners policy). IX. Confidentiality All information submitted and personally attested to by practitioners for the purpose of participation determinations is confidential and is not disclosed unless reporting is determined to be required as described in Addendum VI. Such information is collected and maintained in paper files and in a computerized database by the CD. X. Annual Review This policy, as well as related BCBSIL credentialing policies and procedures, is reviewed, and any necessary revisions made, on at least an annual basis by the PSC. BCBSIL Provider Manual Rev 9/09 9

10 Page 8 of 26 ADDENDUM I NETWORKS INCLUDED IN THIS POLICY Network Credentialed Credentialing Requirements and Process BlueChoice/BlueChoice Select Yes NCQA-based credentialing HMO Illinois Yes NCQA-based credentialing BlueAdvantage Yes NCQA-based credentialing PPO+ is a non-credentialed BCBSIL network that coordinates with other networks the activities described in Addendum VI-Monitoring and Departicipation. BCBSIL Provider Manual Rev 9/09 10

11 Page 9 of 26 ADDENDUM II ITEM/ ELEMENT Contracting Application State Board License CREDENTIALING ELEMENTS AND REQUIREMENTS (NCQA-BASED) CREDENTIALING TIME FRAME REQUIREMENTS REQUIREMENTS Practitioners must have signed a contract with a network. Practitioners must submit: The State of Illinois Health Care Professional Credentialing and Business Data Gathering Form. Practitioners must submit: Current copy of the license for the state(s) in which the practitioner practices Any occurrences meeting PHO thresholds must be reviewed and accepted as consistent with credentialing by the PSC. Prior to credentialing None Signature date on BCBSIL attestation to be within 365 calendar days of the PSC meeting date Verification to occur within 180 calendar days of PSC meeting date License to be current at the time of PSC meeting date PRIMARY SOURCE VERIFICATION REQUIREMENTS None Illinois Department of Regulations Indiana State Licensing Boards Wisconsin Department of Regulations and Licensing. Clinical Privileges Practitioners must submit clinical admitting privileges information. Practitioner types exempt from this requirement may include: Allergist Chiropractor Clinical Psychologist Dermatologist Licensed Clinical Prof Counselor Licensed Clinical Social Worker Licensed Marriage & Family Therapist Ophthalmologist PCPs part of a hospitalist group. Information must be submitted on or with credentialing application. None Federal DEA All admitting privileges information must be obtained for any occurrence meeting PHO criteria. Practitioners must submit: Current copy of the DEA certificate for each state in which they practice DEA certificate must be in effect at the time of the PSC meeting date Verification obtained from National Technical Information Services (NTIS), CD-ROM or internet, or a current copy of the DEA certificate. BCBSIL Provider Manual Rev 9/09 11

12 Page 10 of 26 ADDENDUM II ITEM/ ELEMENT Education and training CREDENTIALING ELEMENTS AND REQUIREMENTS (NCQA-BASED) CREDENTIALING TIME FRAME REQUIREMENTS REQUIREMENTS Practitioners must submit Information relating to professional education and training. The following practitioner types are credentialed: MD, DO, CNM, DC, DDS, DPM, PhD, LCSW, LCPC and LMFT. PRIMARY SOURCE VERIFICATION REQUIREMENTS None If board certified, verification of American Board Certification through the American Board of Medical Specialties (ABMS) fully meets this requirement If not board certified the education and training is verified by the Illinois State Licensing Board or; Confirmation from the AMA Physician Master File or; Confirmation from the AOA Physician Master File Board Certification Not a requirement at the time of credentialing. If MD / DO / DPM Board certified, will verify from primary source. Verification to occur within 180 calendar days of PSC meeting Verification obtained from the ABMS or the AOA Website. Copy of American Board Certificate (If applicable) or; Copy of congratulation letter from the American Board of Medical Specialties or; Copy of letter from American Board of Medical Specialties confirming the passing of part one of a two part exam. Verification from the American Board Podiatric Orthopedics or American Board of Podiatric Surgery BCBSIL Provider Manual Rev 9/09 12

13 Page 11 of 26 ADDENDUM II ITEM/ELEMENT Work History CREDENTIALING ELEMENTS AND REQUIREMENTS (NCQA-BASED) CREDENTIALING TIME FRAME REQUIREMENTS REQUIREMENTS Practitioners must submit or Provide via application / curriculum vitae the last five years of relevant work history. Gaps of greater than 30 days must be explained, in writing. Information confirmed to be complete within 365 calendar days of PSC meeting date. PRIMARY SOURCE VERIFICATION REQUIREMENTS None Malpractice Insurance Coverage Malpractice History Practitioners must submit: Copy of malpractice insurance certificate or Malpractice insurance carrier / coverage information on the application including the period of coverage, the insurance carrier name, and the coverage limits. Copy of federal tort letter or an attestation from the practitioner stating that he or she has federal tort coverage. The application does not need to contain the current amount of malpractice insurance coverage. Practitioners must complete: The Professional History section of the application as well as Form B if applicable Malpractice certificate must be in effect at the time of the PSC meeting date. Verification to occur within 180 calendar days of PSC meeting date None NPDB Any occurrences meeting PHO thresholds must be reviewed and accepted as consistent with credentialing by the PSC. State, Medicare and/or Medicaid Sanctions Practitioners must complete: The Professional History section of the application as well as Form A if applicable Any occurrences meeting PHO thresholds must be reviewed and accepted as consistent with credentialing by the PSC. Verification to occur within 180 calendar days of PSC meeting date NPDB OIG, GSA, FEP, OFAC, Illinois Dept. Public Aid Medicare and Medicaid Sanctions and Reinstatement Report Chiropractic Information Network/Board Action Databank (CIN-BAD) State Board of Dental Examiners BCBSIL Provider Manual Rev 9/09 13

14 Page 12 of 26 ADDENDUM III PROFESSIONAL HISTORY OCCURRENCES THRESHOLDS Thresholds for professional history occurrences (PHO) review are as follows. NCQA-Based Credentialing If the practitioner is PCP (i.e., practicing in the area of internal medicine, family practice or pediatrics) a history within the past five years of: 2 or more malpractice settlements or judgments 1 or more malpractice settlement(s) or judgment(s) of $500,000 or more any loss or limitation of license or hospital privileges involuntary departicipation from any BCBSIL network (including Subsidiaries & Affiliates) If the practitioner is a PSP or OB/GYN, a history within the past five years of: 3 or more malpractice settlements or judgments 1 or more malpractice settlement(s) or judgment(s) of $500,000 or more any loss or limitation of license or hospital privileges involuntary departicipation from any BCBSIL network (including Subsidiaries & Affiliates) BCBSIL Provider Manual Rev 9/09 14

15 Page 13 of 26 ADDENDUM IV APPEALS PROCESS FOR CREDENTIALING/RECREDENTIALING Practitioners appealing a credentialing or recredentialing determination must notify the CD in writing of the reason for appealing within 30 calendar days of receipt of the letter from CD denying credentialing. An appeal follows the process below: A. The CD passes the appeal letter, and the credentialing / recredentialing information, on to the First Level Appeals Subcommittee of the PSC, which consists of one Medical Director from the PSC, two Provider Affairs representatives, and one representative from Corporate Credentialing. B. The Subcommittee reviews the information within 30 calendar days of receipt of the appeal request and makes a determination as to whether to uphold the original decision and deny credentialing / recredentialing, or to reverse it and credential/recredential the practitioner. C. If the decision is to uphold the original determination, the practitioner has the opportunity, within 30 calendar days of receipt of notification, to a second level appeal. This may be requested by submission of a written statement as to the reason for appealing further. D. The CD brings this letter and relevant information to a meeting of the PSC at which time the practitioner may be present, within 30 calendar days of the appeal request. E. The PSC reviews the matter and the Second Level Appeals Subcommittee (consisting of PSC members not on the First Level Subcommittee) makes a final determination to either uphold the original decision and deny credentialing / recredentialing, or to reverse it and credential / recredential the practitioner. BCBSIL Provider Manual Rev 9/09 15

16 Page 14 of 26 ADDENDUM V ITEM/ELEMENT Recredentialing Application State Board License RECREDENTIALING ELEMENTS AND REQUIREMENTS (NCQA-BASED) RECREDENTIALING TIME FRAME REQUIREMENTS REQUIREMENTS Practitioners must submit: The State of Illinois Health Care Professional ReCredentialing and Business Data Gathering Form. Practitioners must submit: Current copy of the license for the state(s) in which the practitioner practices Any occurrences meeting PHO thresholds must be reviewed and accepted as consistent with credentialing by the PSC. Signature date on BCBSIL attestation to be within 365 calendar days of the PSC meeting date Verification to occur within 180 calendar days of PSC meeting date License to be current at the time of PSC meeting date PRIMARY SOURCE VERIFICATION REQUIREMENTS None Illinois Department of Regulations Indiana State Licensing Boards Wisconsin Department of Regulation and Licensing Clinical Privileges Practitioners must submit clinical admitting privileges information. Practitioner types exempt from this requirement may include: Allergist Chiropractor Clinical Psychologist Dermatologist Licensed Clinical Prof Counselor Licensed Clinical Social Worker Licensed Marriage & Family Therapist Ophthalmologist PCPs part of a hospitalist group. Information must be submitted on or with recredentialing application. None Federal DEA All admitting privileges information must be obtained for any occurrence meeting PHO criteria. Practitioners must submit: Current copy of the DEA certificate for each state in which they practice DEA certificate must be in effect at the time of the PSC meeting date Verification obtained from National Technical Information Services (NTIS), CD-ROM or internet, or a current copy of the DEA certificate. BCBSIL Provider Manual Rev 9/09 16

17 Page 15 of 26 ADDENDUM V ITEM/ELEMENT Board Certification Malpractice Insurance Coverage Malpractice History RECREDENTIALING ELEMENTS AND REQUIREMENTS (NCQA-BASED) RECREDENTIALING TIME FRAME REQUIREMENTS REQUIREMENTS Board Certification is required within two years of the initial credentialing decision date. Non-board certified MD, DO and other practitioners have no requirement. (e.g. grandfathered providers) Practitioners must submit: Copy of malpractice insurance certificate or; Malpractice insurance carrier / coverage information on the application including the period of coverage, the insurance carrier name, and the coverage limits. Copy of federal tort letter or an attestation from the practitioner stating that he or she has federal tort coverage. Practitioners must complete: The Professional History section of the application as well as Form B if applicable Verification to occur within 180 calendar days of PSC meeting Malpractice certificate must be in effect at the time of the PSC meeting date. Verification to occur by the time of the of PSC meeting date PRIMARY SOURCE VERIFICATION REQUIREMENTS Verification obtained from the ABMS or the AOA Website. Copy of American Board Certificate (If applicable) or; Copy of congratulation letter from the American Board of Medical Specialties or; Copy of letter from American Board of Medical Specialties confirming the passing of part one of a two part exam. Verification from the American Board Podiatric Orthopedics or American Board of Podiatric Surgery None NPDB State, Medicare and/or Medicaid Sanctions Any occurrences meeting PHO thresholds must be reviewed and accepted as consistent with credentialing by the PSC Practitioners must complete: The Professional History section of the application as well as Form A if applicable Any occurrences meeting PHO thresholds must be reviewed and accepted as consistent with credentialing by the PSC Verification to occur within 180 calendar days of PSC meeting date NPDB Chiropractic Information Network/Board Action Databank (CIN-BAD) State Board of Dental Examiners BCBSIL Provider Manual Rev 9/09 17

18 Page 16 of 26 ADDENDUM VI Provider Selection Committee The PSC consists of a diverse and heterogeneous membership which includes the following responsibilities: credentialing and recredentialing determinations, receiving information regarding network appointment determinations, reviewing and making recommendations regarding network reappointment determinations, assuring appropriate exchange of information and action with respect to departicipation, conducting appeals adjudication s related to its actions, adopting and overseeing compliance with the Policy which governs these activities, reviewing the credentials of practitioners who do not meet the organization established criteria and providing information to the practitioner related to the deficiencies, annually signing of the non discriminatory statement (reference Addendum XI). The PSC meets on a monthly basis. Its membership includes: Assistant General Counsel I, Legal Department Director, Provider Data Management Director, Operations, Communication & Education Manager Professional Network Management Medical Directors II, Medical Management (2) Physicians from BCBSIL networks (2-5) Senior Manager, Credentialing Senior Manager, Operations, Communication & Education Senior Manager, Quality Administration Senior Manager, Special Investigation Department Senior Manager, Utilization Management (UM) /Onsite Audits Senior Medical Director, Medical Management (Chair) Senior Supervisor, Credentialing Senior Supervisor, Professional Network Management Senior Supervisor, Provider Operations UM/ Onsite Project Consultant, UM/HEDIS/Onsite BCBSIL Provider Manual Rev 9/09 18

19 Page 17 of 26 ADDENDUM VII Appointment Requirements Item/Element Defined Contracting BlueChoice/BlueChoice Select Appointment Requirements HMO Appointment Requirements Appointment is the action taken by a specific network to effect participation in that network by a practitioner. All providers, within the scope of this policy, will be credentialed and appointed before participation in the network. All BlueChoice/BlueChoice Select practitioners must sign a BlueChoice/BlueChoice Select contract prior to credentialing. Primary Care Physicians (PCP) are limited to one BlueChoice /BlueChoice Select PCP contract. PCPs include Family Practice, General Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology and Certified Nurse Midwife. All HMO providers must be participating with an IPA that is contracted with HMO Illinois or BlueAdvantage HMO. Primary Care Physicians (PCPs) are limited to contracting with one IPA unless added value is identified by the IPA and approved by the network. See the PCP Affiliation with Multiple IPA Policy. PCPs include Family Practice, General Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology and Chiropractors. (The PCP designation for Chiropractors is dependent on a request by the IPA.) Participating Specialist Physicians (PSPs) may have multiple contract affiliations. Physician specialties not included in addendum X in the BlueChoice /BlueChoice Select column will not be appointed by BlueChoice. Physicians who see patients only in the hospital setting (Hospitalists) and are contracted with BlueChoice /BlueChoice Select will be credentialed but will not be listed in a BlueChoice/BlueChoice Select directory and will be appointed as a specialist. Participating Specialist Physicians (PSPs) may have multiple IPA affiliations. Physician specialties not included in addendum IX in the HMO column will not be appointed by HMO. Physicians who see patients only in the hospital setting (Hospitalists) and are contracted with HMO will be credentialed but will not be listed in an HMO directory. High-volume behavioral healthcare providers will be identified by the IPA through an annual survey. Practitioner must be contracted with a multi-specialty group to be considered a Hospitalist. BCBSIL Provider Manual Rev 9/09 19

20 Page 18 of 26 ADDENDUM VII Appointment Requirements Item/Element Clinical Privileges Education and training BlueChoice/BlueChoice Select Appointment Requirements Practitioners must submit clinical admitting privileges information from a network hospital. Practitioners who only see patients in an office setting and do not have hospital privileges will be exempt from the hospital admitting privilege requirement. The network will identify these providers for the Credentialing department. All BlueChoice /BlueChoice Select practitioners must have one of the following degrees: MD, DO, or CNM. HMO Appointment Requirements Practitioners must submit clinical admitting privileges information from a network hospital. Practitioners who only see patients in an office setting and do not have hospital privileges will be exempt from the hospital admitting privilege requirement. The IPA will notify HMO when this occurs as well as provide credentialing information for the practitioner covering inpatient admissions. All HMO practitioners must have one of the following degrees: MD, DO, PhD, DC DDS, DPM, LCSW, LCPC, LMFT Board Certification Practitioners joining BlueChoice /BlueChoice Select HMO Products are not required to be Board Certified at the time of appointment but should be in the process of attaining Board Certification. Board Certification is required within two years after initial credentialing and will be based on the effective date with the product. BCBSIL Provider Manual Rev 9/09 20

21 Page 19 of 26 ADDENDUM VII Appointment Requirements Item/Element Appointment BlueChoice/BlueChoice Select Appointment Requirements HMO Appointment Requirements Practitioners must meet BCBSIL corporate credentialing requirements or must meet the BCBSIL program requirements for delegated credentialing. Practitioners may participate as both a PCP and a PSP. Network Management will evaluate applicants with respect to the credentialing information along with other information including but not limited to network location, size and access criteria. The practitioner is required to meet the appointment requirements relative to the provider type designation. Each practitioner is required to be appointed to the contracted network. The criteria for appointment will be presented by Network Management to the PSC at the time of the proposed appointment. Network management has final responsibility for making the determination as to whether a credentialed practitioner or provider is appointed to that network. The recommendation to appoint a provider for one of the following actions is based on credentialing documents and the results of primary source verification. Action taken includes Appointment; Pend for further review; Deny application. Notification A letter from the Network Medical Director is sent to the practitioner notifying him/her of the decision within 60 calendar days of the Credentialing decision. The same information is also available on the BCBSIL Website. A letter or report of appointed practitioners is sent to the HMO Group Administrator or Credentialing Coordinator within 60 calendar days of the Credentialing decision. The same information is also available on the BCBSIL Website. Appeals The IPA / practitioner has the right to appeal the denial of the appointment as well as termination decisions. The appeal must be sent in writing to the BCBSIL Network Medical Director within 30 calendar days of the notice of the decision and must state the reasons for appealing the decision. Appeals will be reviewed by the Network Provider Affairs management team comprised of, at a minimum, the Senior Manager of Operations, and the Medical Directors. This committee will review the appeal within 30 calendar days of receipt of the appeal request and make a determination to uphold the original decision or to reverse it. No additional appeal level is available. BCBSIL Provider Manual Rev 9/09 21

22 Page 20 of 26 ADDENDUM VIII Reappointment Requirements Item/Element BlueChoice/BlueChoice Select Reappointment Requirements HMO Reappointment Requirements Defined Reappointment Is the action taken by a specific network to effect continued participation in that network by a practitioner. All providers, within the scope of this policy, are required to be recredentialed and reappointed every 3 years. Contracting See appointment requirements. See appointment requirements. Clinical See appointment requirements. See appointment requirements. Privileges Education & See appointment requirements See appointment requirements Training Board Certification Requirements for any practitioner participating with BlueChoice/BlueChoice Select, HMO Illinois, or BlueAdvantage HMO are as follows: Board Certified in the specialty in which the physician practices and is listed in the directory within 2 years from completion of initial credentialing. Listed in the American Board of Medical Specialties directory. Any practitioner who does not meet this requirement will be departed from the network(s) after 2 years from the date of the effective date with the product. If a practitioner has taken the Board examination but has not successfully passed within 2 years after the initial credentialing, the practitioner would be departed. The practitioner may appeal the departicipation decision using the steps outlined in Addendum VII. The provider should include the number of times the exam has been taken, dates for rescheduled exam, extenuating circumstances for added value to network. Exceptions to the Board Certification requirement are: 1. Practitioners whose specialty boards require a period of practice as a prerequisite to board certification. 2. Practitioners appointed to the network prior to 1/1/94 are not required to seek board certification if they were not board certified at the time of appointment. 3. Board certification of practitioners in their sub-specialty is not required if appointed to the network prior to 1/1/01. Board Certification of practitioners is required in each primary specialty if the practitioner desires to participate under multiple primary specialties. 4. Network Management may exempt a practitioner, IPA from the Board Certification requirement due to geographical location. 5. BlueChoice/BlueChoice Select Certified Nurse Midwifes must have certification through the American College of Nurse Midwives Certification Council, Inc. 6. Marketing exception. Board certified MD and DO practitioners must submit: Copy of American Board Certificate (if applicable or; Copy of congratulatory letter from the American Board of Medical Specialties or; For # 1 above, copy of letter from American Board of Medical Specialties confirming the passing of part one of a two-part exam. Non-board certified MD, DO and other practitioners have no requirements. BCBSIL Provider Manual Rev 9/09 22

23 Page 21 of 26 ADDENDUM VIII Reappointment Requirements Item/Element Reappointment BlueChoice/BlueChoice Select Reappointment Requirements Practitioners must meet BCBSIL corporate recredentialing requirements or must meet the BCBSIL requirements for delegated recredentialing. The reappointment process is identical to the appointment process. HMO Reappointment Requirements Practitioners must meet BCBSIL corporate recredentialing requirements or must meet the BCBSIL requirements for delegated recredentialing. The reappointment process is identical to the appointment process BCBSIL Provider Manual Rev 9/09 23

24 Page 22 of 26 ADDENDUM VIII Reappointment Requirements Item/Element BlueChoice/BlueChoice Select Reappointment Requirements HMO Reappointment Requirements Notification See appointment requirements. See appointment requirements. Appeals See appointment requirements. See appointment requirements. BCBSIL Provider Manual Rev 9/09 24

25 Page 23 of 26 ADDENDUM IX State of Illinois Recredentialing Single Cycle Year Notify Notify Notify Month January 8's 0's 4's February March April 9's 1's 5's May June July Open 2's 6's August Open September Open October Open 3's 7's November Open December Open Year Notify Notify Notify Month January 8's 0's 4's February March April 9's 1's 5's May June July Open 2's 6's August Open September Open October Open 3's 7's November Open December Open BCBSIL Provider Manual Rev 9/09 25

26 Page 24 of 26 ADDENDUM X BlueChoice/BlueChoice Select / HMO Products Targeted Specialties BCBSIL TARGETED SPECIALTIES...ABMS unless noted BY ** BlueChoice/BlueChoice Select HMO Illinois & BlueAdvantage HMO Allergy-Immunology X X Certified Nurse Midwives** X X Chiropractor** X X Colon-Rectal Surgery X X Dermatology X X Family Practice X X Geriatric Medicine -- X Sports Medicine -- X General Practice** -- X Internal Medicine X X Cardiovascular Disease X X Critical Care Medicine -- X Endocrinology (1) X X Gastroenterology X X Geriatric Medicine -- X Hematology X X Hematology-Oncology (2) X X Infectious Disease X X Medical Oncology X X Nephrology X X Pulmonary Disease X X Rheumatology X X Sleep Medicine X X Sports Medicine -- X Licensed Clinical Professional Counselor (LCPC)** -- X Licensed Clinical Social Worker (LCSW)** -- X Licensed Marriage & Family Therapist (LMFT)** -- X Maxillofacial Surgery** -- X Neurology X X Child Neurology X X Neurological Surgery X X Obstetrics-Gynecology X X Gynecologic Oncology X X Gynecology (3) X X Maternal-Fetal Medicine X X Obstetrics (3) -- X Reproductive Endocrinology X X Ophthalmology X X Orthopaedic Surgery X X Orthopaedic Hand Surgery X X BCBSIL Provider Manual Rev 9/09 26

27 Page 25 of 26 ADDENDUM X BlueChoice /BlueChoice Select-HMO Products Targeted Specialties BCBSIL TARGETED SPECIALTIES...ABMS unless noted BY ** BlueChoice HMO Illinois & BlueAdvantage HMO Otolaryngology X X Pediatric Otolaryngology X X Pediatrics X X Allergy-Immunology X X Adolescent Medicine -- X Neonatal-Perinatal Medicine X X Pediatric Cardiology X X Pediatric Critical Care Medicine -- X Pediatric Endocrinology X X Pediatric Gastroenterology X X Pediatric Hematology-Oncology X X Pediatric Infectious Disease X X Pediatric Nephrology X X Pediatric Pulmonology X X Pediatric Rheumatology X X Sleep Medicine X X Physical Medicine & Rehabilitation X X Plastic Surgery X X Plastic Hand Surgery X X Podiatry** X X Psychiatry -- X Child-Adolescent Psychiatry -- X Geriatric Psychiatry -- X Psychology (clinical)** -- X Radiation Oncology X -- General Surgery X X Pediatric Surgery X X Surgery of the Hand X X Surgical Critical Care -- X Vascular Surgery X X Thoracic Surgery X X Urology X X ** No corresponding ABMS Certificate 1 Abbreviated the ABMS Certificate name which is Endocrinology, Diabetes & Metabolism. 2 Combination for those providers Board Certified in both Hematology & Oncology. 3 Providers Board Certified in Obstetrics-Gynecology but practice only one specialty. BCBSIL Provider Manual Rev 9/09 27

28 Page 26 of 26 Addendum XI CREDENTIALING COMMITTEE NON DISCRIMINATORY STATEMENT To: Provider Selection Committee From: Corporate Credentialing Date: RE: Non Discriminatory Statement Each Provider Selection Committee member affirms: The Credentialing / Recredentialing Program is conducted in a manner to ensure that all credentialing requirements are uniformly applied and shall be non-discriminatory in areas of race, ethnic/national identity, gender, age, sexual orientation or reimbursement to all applicants of the BCBSIL Networks. Signed Dated BCBSIL Provider Manual Rev 9/09 28

29 Policy Name: Delegation of Credentialing and Recredentialing Policy Number: Credentialing 4 Effective Date: 1/1/04 Revision Date: 9/1/09 Review Date: Approval Signature: HMOI, BA HMO, BlueChoice, BlueChoice Select Policy: Senior Medical Director Approved QI: 9/2/09 Approved P&P: 8/27/09 Blue Cross and Blue Shield of Illinois (BCBSIL) is dedicated to facilitate the provision of quality, costeffective and accessible health care by providers in its networks. The Credentialing / Recredentialing Program will be conducted in a manner to ensure that all credentialing requirements are uniformly applied and shall be non-discriminatory in areas of race, ethnic/national identity, gender, age, or sexual orientation or reimbursement for all applicants to the HMOs or BlueChoice/ BlueChoice Select Networks. Purpose: To outline the process used to evaluate delegation of the Professional Provider Credentialing and Recredentialing functions to an external organization. To outline oversight of delegated organizations per accreditation requirements. Guidelines: 1. The delegation of credentialing activities may be considered for Credentialing Verification Organizations (CVOs), Independent Physician Associations (IPAs), or other organizations that employ and/or contract with practitioners. Organizations must be in good standing with all elements of their contract. Organizations must demonstrate there is a credentialing program in place and its ability to maintain a program that continuously meets the BCBSIL Credentialing program requirements. 2. BCBSIL standards and criteria are reviewed and revised at least annually. The delegate will be promptly notified and expected to adopt changes within reasonable timeframes mutually agreed upon. Evaluation of compliance with update / revised standards and criteria will be on a prospective basis. 3. When credentialing activities are delegated, BCBSIL retains the right to approve new practitioners and sites and to terminate or suspend individual practitioners in accordance with BCBSIL credentialing procedures. 4. BCBSIL retains the right to approve or deny an organization s request for delegated credentialing. The Credentialing Department (CD) will present to the Provider Selection Committee (PSC) the results of the pre-assessment review and on-site audit for evaluation and final approval or denial. 5. Delegates prior to 1/1/2001 will be grandfathered under policy in effect prior to 1/1/2001 with the intent for the delegate to meet the standards of this policy within a mutually agreed upon time frame. BCBSIL Provider Manual Rev 9/09 29

30 Delegation of Credentialing and Recredentialing Page 2 of 3 6. BCBSIL will review the delegate s performance at least annually. Should the delegate not meet the requirements outlined in this policy and the delegation amendment, BCBSIL may revoke the delegation status as outlined in the amendment. Procedure: A. Elements and Requirements BCBSIL may delegate the credentialing / recredentialing functions to an organization that meets the following requirements: 1. conducts a process that demonstrates actual performance in credentialing / recredentialing which meets or exceeds the BCBSIL policies, standards, and criteria; 2. has a written credentialing program description that meets or exceeds the BCBSIL Corporate Credentialing / Recredentialing policy; 3. agrees in writing to submit quarterly reports of their credentialing activities including all adverse determinations, reasons, and appeal decisions; 4. agrees to periodic (at a minimum, annually) on-site reviews for evaluation of the process and the effectiveness of their credentialing activities; 5. has been contracted with BCBSIL and has a Credentialing program that has been operational for a minimum of two years or 24 months prior to delegation being considered; 6. is compliant with HIPAA requirements and has signed a Medical Services Agreement or Business Associate Agreement with BCBSIL; if applicable. 7. provides to BCBSIL high level flow charts of the credentialing and recredentialing procedures; 8. if any, credentialing activities are delegated to another organization; the delegate must provide BCBSIL with the formal delegation agreement and perform due-diligence review. B. Initial Request Process 1. Network management and the CD review the application for delegation along with the policies and procedures of the group requesting delegation. This will determine compliance or non-compliance and the requesting group will be notified of the determination. 2. If requirements are met, an on-site audit will be performed to ensure credentialing / recredentialing documents are compliant with this policy. (This may be waived for requesting delegates that have received certification by National Committee for Quality Assurance (NCQA) under the CVO Certification program.) 3. The CD will conduct the on-site review. The review is intended to evaluate the organization s understanding of the standards, delegated tasks, capabilities, and current performance. If the organization meets the compliance standard of 90%, they are considered for delegation. Areas of deficiency are handled with a corrective action plan that includes timelines. 4. Organizations that do not meet the 90% minimum aggregate compliance designation will not be considered for delegation until they can demonstrate that their program meets or exceeds the minimum compliance requirement. Pre-assessment oversight audits will only be conducted once every 12 months. BCBSIL Provider Manual Rev 9/09 30