Behavioral Healthcare, Inc. 155 Inverness Drive West Suite 201 Englewood, CO 80112

Transcription

1 1 of 21 I. Policy: To maintain a quality provider network, Behavioral Healthcare Inc. (BHI) will establish credentialing and recredentialing criteria and processes to evaluate and determine participation status for the providers who are either applying for network participation (credentialing) or continued network participation (recredentialing). II. Purpose: To direct the credentialing and recredentialing of behavioral health professionals with whom BHI contracts or employs, and who render services or authorize services to members, and who fall within the Contractor s scope of authority and action. Credentialing policies and procedures are reviewed annually to insure compliance with National Committee for Quality Assurance (NCQA) Standards. III. Definitions A. Provider: a clinician who provides behavioral health care services B. Organizational Provider/Facility: an institution or organization that provides behavioral health care services; in this policy, Facility includes (but is not limited to) community mental health centers, hospitals, residential facilities, and day treatment facilities. C. Credentialing: the process by which BHI reviews and evaluates qualifications of providers and facilities to provide services to members D. Recredentialing: The process by which BHI reviews and evaluates providers and facilities continued participation in the BHI network IV. Procedures Providers have several rights while undergoing credentialing and recredentialing process. Providers are notified of these rights in the credentialing application. Providers are also notified of these rights through the Provider Manual and CRED-406 Provider Rights, both located on the BHI website. Delegation of Credentialing BHI has delegated individual provider credentialing activities to Colorado Access through its Administrative Service Organization Agreement. BHI chose to delegate the credentialing of their providers because Colorado Access is a local health plan that follows NCQA credentialing guidelines (although not NCQA accredited). BHI requires all providers to complete the Colorado Health Care Professional Credentials Application (Attachment A) to obtain and validate information attested to by the provider that allows CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 1 of 21

2 2 of 21 thorough evaluation for participation or continued participation. Colorado Access utilizes the Counsel for Affordable Quality Healthcare (CAQH) to obtain applications as well as the traditional paper copies of applications for credentialing and recredentialing. BHI retains the right to approve and to terminate individual providers for the Contracted Provider Network. BHI has delegated the following activities to Colorado Access: A. Application mail out B. Application follow up C. Application review for completeness D. Application review for signature and attestation date E. Verification of licensure in the state where the provider has an office F. Obtain copy of DEA and when appropriate a CDS certificate for providers and facilities that can prescribe or dispense controlled substances. The 180-day limit does not apply; however, the provider's certificate must be effective at the time of the credentialing decision or verified from the NTIS as current. G. Verification of education when not board certified (The 180-day time limit does not apply to verification of education and training, but must be verified in accordance with NCQA and URAC standards) H. Verification of board certification for providers from the state they are board certified. I. Document a minimum of five (5) years work history. This can be collected on the application or curriculum vitae with dates that include the month and year. The Delegated Agency will identify any gaps in work history of six (6) months or greater. Verification of work history is not required from primary sources. J. Verification of malpractice claims history. Can be completed by collecting five (5) years of history of malpractice settlements from the National Practitioner s Data Bank (NPDB) or the insurance carrier when available. K. Verification of Medicare and Medicaid sanctions (Need to verify the status of the provider in regard to Medicare and Medicaid sanctions, which can be done by completing a query of the NPDB) CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 2 of 21

3 3 of 21 Types of Providers Credentialed by BHI BHI s provider network generally consists of (but is not limited to): A. Doctors of Medicine (MDs) and Doctors of Osteopathic Medicine (DOs) B. Doctorate level clinicians (PhD, PsyD, LPsy) C. Licensed master s-level clinicians (LCSW, LPC, LMFT) D. Licensed nurses (RN, NP, CNS, or RXN) E. Other licensed independent providers with whom it contracts or employs, who render services or authorize services to members, and who fall within BHI s scope of authority and action. Certain providers that are exempt from the credentialing process are listed below. A. Covering providers B. Locum tenens C. Providers who practice exclusively within the inpatient setting or are hospitalbased and who provide care to BHI members only as a result of the member being directed to the hospital or another inpatient setting D. Providers who practice exclusively within freestanding facilities and who provide care to BHI members only as result of members being directed to the facility; these facilities are subject to the Organizational Credentialing process (please reference Organizational Credentialing section of this policy. Free-standing facilities include: 1. Ambulatory behavioral healthcare facilities 2. Psychiatric and addiction disorder clinics 3. Community mental health centers E. Nurse Practitioners (with the exception of NPs, APNs, and APRNs who provide services through a direct provider agreement) F. Unlicensed Doctoral or Master s Level Providers (only as necessary to meet member linguistic/cultural needs or for service in a rural under-served area) Providers subject to this policy shall not be considered participants of the network until they have completed the credentialing process. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 3 of 21

4 4 of 21 Credentialing Requirements BHI will utilize these criteria as minimum requirements to be met by an applying network provider. A. Psychiatrists 1. Must be a Doctor of Medicine (MD) or Doctor of Osteopathy (DO) 2. Must be board certified or eligible, as defined by the American Board of Psychiatry and Neurology 3. Must be licensed by the state of Colorado 4. Must possess current DEA certificate 5. Must possess current State Controlled Substance Registration certificate 6. Must complete a training program approved by the American Council of Graduate Medical Education (ACGME) or Osteopathic approved training program in psychiatry 7. Must possess an Education Council for Foreign Medical Graduates (ECFMG) certificate, if graduate of foreign medical school B. Psychologists 1. Must be licensed independently as a clinical psychologist at the highest level in the state of Colorado 2. Must possess a Doctoral Degree in Psychology (PhD, EdD, PsyD) from an accredited college or university C. Social Workers 1. Must possess a Master s Degree in Social Work from a graduate school of social work accredited by the Council on Social Work Education 2. Must be licensed by the state of Colorado or certified to practice at the highest level of independent practice in the state of Colorado D. Psychiatric Nurses/Clinical Specialists (APN, NP, CS, CNS, RXN) 1. Must possess a Master s degree in psychiatric nursing from an accredited college or university 2. Must be licensed by the state of Colorado to practice at the highest level of independent practice in the state of Colorado 3. If RXN, must be licensed by the state of Colorado with prescriptive authority privileges CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 4 of 21

5 5 of 21 E. Other Licensed Clinicians (Licensed Marriage and Family Therapist, Licensed Professional Counselors) 1. Must possess a Master s degree in field of practice from an accredited college or university 2. Must be licensed by the state of Colorado or certified at the highest level of independent practice in the state of Colorado Clinical Experience: All eligible providers must have a minimum of three (3) years post licensure experience in a mental health/substance abuse setting providing direct patient care or otherwise approved by the Credentialing Committee. Professional Liability Coverage A. Psychiatrists: $1,000,000 per individual episode; $3,000,000 aggregate B. All other clinicians: $1,000,000 per individual episode; $3,000,000 aggregate C. General Office Liability: Comprehensive general or Umbrella Liability: $1,000,000 per individual episode; $1,000,000 aggregate Availability: All providers must be accessible 24 hours a day, seven days a week or make appropriate arrangements for client care. In addition, each provider must agree to make every effort to be available for appointments as follows: A. Emergency evaluation/face to face within 1 hour B. Urgent needs met within 24 hours C. Routine evaluations within seven (7) days CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 5 of 21

6 6 of 21 Credentialing Process (please reference Attachment C Flow Chart of Provider Credentialing Process) The initial credentialing application process begins by requesting application for credentialing from the BHI. Providers may also be sought out for credentialing in response to member need. The provider then completes an application, signed and dated attestation, and submits the requested documentation to either CAQH or Colorado Access (Attachment A). The applications include an attestation by the applicant regarding: A. Reasons for any inability to perform the essential functions of the position, with or without accommodation B. Lack of present illegal drug use C. History of loss of license and felony convictions D. History of loss or limitation of privileges or disciplinary activity E. Current malpractice insurance coverage that includes the dates and amount of the coverage F. Clinical privileges in good standing at the provider s primary admitting facility G. The correctness and completeness of the application CAQH is used to obtain a provider s credentialing or recredentialing application and supporting documentation. If a provider does not wish to utilize CAQH, a provider may contact Colorado Access directly to obtain the application. Applications are tracked in the Colorado Access credentialing database and a series of follow-up requests are made if the completed application has not been received. If these attempts are unsuccessful, the BHI will contact the provider to followup. Upon receipt of the application, the Colorado Access credentialing database is updated with the receipt date of the application, and the application and supporting documentation are date stamped as received. Colorado Access reviews the application for completeness. If documentation is missing, the provider is contacted and, if necessary, the application is returned to the provider for completion. If the application contains information that varies substantially from the information acquired during the credentialing process, the provider is given the opportunity to correct the information and/or explain the discrepancy. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 6 of 21

7 7 of 21 Primary Source Verification The application information is verified from primary sources, unless otherwise indicated, within 180 days of application submission. Verification can be obtained verbally, in writing, or electronically, as described below: A. Verbal verification is documented on a contact form and includes the information obtained, the name of the person from the primary source supplying the information, the date the information was received and the Colorado Access staff member s signature or initials. B. Written verification includes the date the information was queried by the source, the signature of the person at the primary source and/or a letterhead from the primary source supplying the information. Where applicable, BHI obtains the latest cumulative report and periodic updates released by the approved source. The date of the report query and volume are noted in the provider s file. C. Electronic verification (i.e., internet/on line) includes a hardcopy screen print that includes the source of the documentation, the date the information was generated, the date the information was verified, and the Colorado Access staff member s signature or initials. The following elements are researched and/or documentation gathered in support of the credentialing and recredentialing application. A. Licensure: Current valid license (or DORA registration for unlicensed doctoral and master s level behavioral health providers) and investigation of restrictions, limitations or sanctions. 1. The provider must have a valid license for a minimum of a master s level behavioral health providers to practice in the State of Colorado that is current on the date of the Credentials Committee review. 2. Verification of appropriate licensure for behavioral health providers is obtained via the Internet. 3. If a limitation, restriction, or other board or registration sanction is identified, the appropriate licensing board or registration entity is contacted to provide the documentation of the action (Letter of Admonition, a Stipulation/Final Board Order, etc.). 4. Sanction activity, which may have occurred in other states, is obtained through a query of the National Practitioner Data Bank (NPDB). For all licensed behavioral health providers, sanction activity that may have occurred in other states is verified by contacting the applicable registration agencies of those states. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 7 of 21

8 8 of 21 B. DEA (Drug Enforcement Agency) or CDS (Controlled Dangerous Substances) 1. Certificates are verified for providers who indicate they prescribe controlled substances (not applicable for PhDs, PsyDs, EdDs, and master s level behavioral health providers). 2. A copy or fax of the certificate from the provider, primary verification from the DEA website ( verification from the American Medical Associate (AMA) Physician profile, or documented visual inspection of the original certificate are all acceptable sources. C. Clinical Privileges 1. The provider must have clinical privileges in good standing at a hospital designated by the provider as the primary admitting facility or a documented coverage arrangement through an affiliated provider or hospitalist. Certified Nurse Midwives may or may not have privileges given the scope of their practice. Providers exempt from the requirement for clinical privileges include, Psychiatrists, Chiropractors, PhDs, PsyDs, EdDs, and master s level behavioral health providers. 2. Confirmation of clinical privileges is obtained via the signed attestation on the application or through verification with the hospital via a roster, phone verification, or internet verification. 3. The Credentialing Program Coordinator obtains additional information from the facility and/or the provider if the provider attests to a history of voluntary or involuntary change in hospital privileges or loss/restriction of privileges. D. Education and Training 1. This verification is not necessary for MDs and DOs who, through primary source verification, are confirmed to be board certified. If the provider is not board certified, only the highest level of education/training is verified, i.e., residency, graduation from medical school. Verification of fellowship is not required or accepted as verification of education and training. 2. Verification of residency training or graduation from a medical school or graduate school is obtained through verification of licensure with the applicable State board (written confirmation of primary source verification from each of the applicable State licensing boards is obtained annually by the Provider Contracting Department). CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 8 of 21

9 9 of Other acceptable sources of verification may include either verbal or written verification from the institution awarding the degree (graduate school, medical school or residency program), verification received from the American Medical Association (AMA), or American Osteopathic Association (AOA) Master File (Physician Profile). 4. For international medical graduates licensed after 1986 that are not board certified or have not completed a residency in the United States, verification of foreign medical school graduation is obtained through written confirmation received from the Educational Commission for Foreign Medical Graduates (ECFMG). E. Board Certification 1. Board certification is verified for MDs and DOs only if the provider has indicated they are board certified. 2. Board certification in each clinical specialty for which the provider is being credentialed is verified using an electronic source (Internet) that utilizes current information from the American Board of Medical Specialties (ABMS) or the American Medical Association (AMA) or American Osteopathic Association (AOA) Physician Master Files. In addition, the Credentialing Program Coordinator determines and notes if the provider is practicing in a specialty for which they are not board certified or not board certified for the specialty they have requested to be listed. F. Work History 1. Work history is not primary source verified; however, the provider is required to either submit a curriculum vitae or resume, or document a minimum of the past five (5) years of work history, on the credentialing application. If the provider has less than five years of work history from the verification date of work history, it starts from the time of the initial licensure. 2. The Credentialing Program Coordinator clarifies either verbally or in writing with the provider of any gaps in work history that exceed six (6) months and document the file. The provider must clarify in writing any gap in work history that exceeds one (1) year. Behavioral health providers with work gaps that exceed one (1) year will be requested to provide documentation detailing how the provider maintained affiliation with the profession during the work gap. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 9 of 21

10 10 of 21 G. Malpractice Insurance Coverage 1. BHI requires providers to carry minimum malpractice coverage amounts of $1 million per incident and $3 million aggregate. 2. Malpractice coverage is confirmed through the signed attestation on the application that includes the dates and amounts of the current malpractice insurance coverage or a copy of the insurance certificate that includes the provider s name, dates and amounts of coverage. If the cover sheet does not include the name of the provider, then a photocopy of those covered under the plan must be submitted on the sheet that includes the insurer s letterhead. 3. Providers who have coverage through the Self-Insurance Trust, the Federal Tort Claims Act (FTCA) or have governmental immunity are exempt from carrying the minimum amounts of malpractice insurance of $1 million and $3 million. The application need not contain the current amount of malpractice insurance coverage. A copy of the current FTCA certificate including a letter from the group the provider is joining or/with will be sufficient. 4. Proof of professional liability insurance will not be accepted through the attested credentialing application. H. Colorado Bureau of Investigation 1. BHI requires a background investigation of all behavioral health providers under the scope of this policy, to identify the potential presence of a criminal record. When Colorado Access obtains a criminal history record through the Colorado Bureau of Investigation, the verification also includes a sex offender search. If an offender is a registered sex offender in Colorado, a "Registered Sex Offender" notation will show up on their criminal history. 2. The source for this information is the Colorado Bureau of Investigation (CBI), retrieved electronically from the CBI website. Colorado Access may perform the verification on behalf of the delegate and communicate the results of the query to the delegate. BHI network participation would be contingent upon successful completion of the query and a negative finding. I. File Completion and Pre-credentialing Review: Once verification of all the elements has been completed, the Credentialing Program Coordinator will compare the information with the paper and Apogee checklist and confirm the file for completeness and timeliness of the elements as required by this policy. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 10 of 21

11 11 of 21 Criteria required at Credentialing (C) or Recredentialing (R) Completed application, including signed and dated attestation C and authorization R Licensure current and unrestricted license to practice in the C state of Colorado R Clinical Privileges (if applicable) current, unrestricted clinical privileges at a hospital designated by the provider as the primary admitting facility DEA or CDS certificates (if applicable) current and unrestricted C R C R Verification Time Limit Within 180 calendar days submission Within 180 calendar days of submission; license must be valid at time of credentialing decision Within 180 calendar days of submission None. Certificate must be effective at time of Committee decision Within 180 calendar days of Education and Training satisfactory completion of residency or C graduate program or medical school submission Board Certification if provider states they are board certified C Within 180 calendar days of and certification is in field of practice R submission Work History without gaps of greater than six (6) months C Within 180 calendar days of submission Malpractice Coverage current with minimum limits of liability of C Effective at time of $1 million and $3 million R Committee decision Malpractice History/Medicare and Medicaid Sanctions C Within 180 calendar days of absence of claims history and/or sanctions R submission Licensure/Registration Sanctions absence of sanctions or C Within 180 calendar days of grievances R submission Office Site Visit/Medical Record Review for all providers that R Upon notification of a fall under the scope of credentialing and have a complaint filed complaint meeting the Colorado Bureau of Investigation (CBI) absence of finding C R thresholds Information must be obtained within 180 calendar days of submission All credentialing applications are reviewed, verified, and sent to the Credentialing Committee for a decision within 180 days. If the signed attestation exceeds 180 calendar days before the credentialing decision, the provider must attest only that the information in the application remains correct and complete and does not need to complete another application. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 11 of 21

12 12 of 21 Credentialing Application Approval/Denial Once verification has been completed, the Credentialing Program Coordinator at Colorado Access reviews the file for completeness and timeliness of the elements (as required by this policy) and the file is forwarded to the BHI Director of Provider Relations. The completed credentialing file is then reviewed against BHI Credentialing Criteria. If criteria are met, the application and report is presented to the BHI Credentialing Committee. Credentialing Determination Notification Providers undergoing initial credentialing are notified in writing within thirty (30) business days of the Credentialing Committee decisions. Providers denied participation during initial credentialing are notified in writing of the decision within thirty (30) business days and the documentation filed in the provider s credentialing file. The credentialing denial letter will include information about the credentialing appeal process (Attachment E). Providers undergoing recredentialing are notified by writing within thirty (30) business days of the Credentialing Committee decisions. Providers denied participation during recredentialing, are notified in writing within thirty (30) business days and documentation is filed in the provider s credentialing file. Notification of Discrepancies in Credentialing Information Providers have the right to review the information submitted in support of the credentialing application. Providers will be notified during the credentialing process if information obtained varies substantially from provider s information (Attachment D). Providers have the right to correct any erroneous information submitted as a part of the credentialing process, provide missing information during the verification process, and be informed, upon request, of the status of their credentialing or recredentialing application. (See policy and procedure CRED-406 Provider Rights). Credentialing Committee and Decisions BHI utilizes a multidisciplinary Credentialing Committee that includes both BHI personnel and providers from the BHI network with experience in all levels of care and behavioral health specialties, including substance use disorders. The Credentialing Committee meets monthly to review and discuss the complete credentialing files. The committee then approves or declines the credentialing request, and the provider is advised of the result. The Credentialing Committee reviews the credentials of all providers who do not meet the organization s established criteria. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 12 of 21

13 13 of 21 BHI s Chief Medical Officer is a member of the Credentialing Committee and as such, participates in all credentialing decisions. Only the BHI Chief Medical Officer has the authority to determine if the file meets the BHI credentialing criteria and to sign off on it as complete, clean, and approved by the Credentialing Committee. Only the BHI Chief Medical Officer has the authority to sign off on all credentialing decisions. The Credentialing Committee may request a review of any provider and may request additional information before rendering a decision regarding participation or continued participation. The additional information is obtained and the provider is presented again to the committee. If the provider or BHI terminates the contract or there is a break in service of more than 30 calendar days, BHI will initially credential the provider before the provider rejoins the network. Minutes are generated documenting the discussion and actions at each Credentialing Committee. The minutes are considered confidential and maintained in a locked central file. Non-Discrimination BHI does not make credentialing and recredentialing decisions based on an applicant s race, ethnic/national identity, gender, age, sexual orientation, type of practice, or types of patients the provider may specialize in treating. In addition, BHI and its Credentialing Committee will not discriminate against providers who serve high-risk populations or who specialize in the treatment of costly conditions. BHI will not discriminate in terms of participation, reimbursement, or indemnification against any healthcare professional that is acting within the scope of his or her license or certification under state law, solely on the basis of the license or certification. A. All participating committee members sign an acknowledgement form stating they do not discriminate when making credentialing and recredentialing decisions. B. Annually, the BHI Credentialing Committee reviews all providers that have been credentialed, re-credentialed, and denied credentialing. The Credentialing Committee looks for any trends that indicate possible provider discrimination based on applicant s race, ethnic/national identity, gender, age, sexual orientation, or the types of procedures or patients in which the provider specializes. This does not prevent BHI from including providers in its network who may meet certain demographic, cultural, or special needs. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 13 of 21

14 14 of 21 If BHI declines to include a provider or group of providers in its network, a written notice will be provided to the affected provider(s) of the reason for the decision. Annually, BHI reviews all declined providers to monitor for any possible discrimination in the credentialing and recredentialing process. This discrimination prohibition does not preclude BHI from refusal to grant participation to healthcare professionals in excess of the number necessary to meets the needs of its members, the use of different reimbursement amounts for different specialties or for different providers in the same specialty, or implementation of measures designed to maintain quality and control costs consistent with its responsibilities. Procedures to Maintain Confidentiality Information obtained during the credentialing/recredentialing process and Credentialing Committee meeting minutes are treated as confidential. Colorado law protects quality issues addressed under peer review. All such records and findings are maintained in a separate quality file. Annually, participants of the Credentialing Committee sign a confidentiality agreement that addresses the confidential nature of the information reviewed, subsequent decisions, and conflict of interest. Confidential handling includes securing credentialing files and credentialing minutes in locked file cabinets. Access to the credentialing files is granted on a need-to-know basis under the direction of the credentialing staff. The software used to track credentialing is password protected and access granted only to the credentialing staff. Extraneous materials gathered or generated for Credentialing Committee meetings are disposed of in locked shred bins. Provider Listing in the Directories The BHI Provider directory is generated from the credentialing database for both individual and organizational providers. The updates the database on an ongoing basis based on changes in the network secondary to credentialing activities and reviews the database quarterly to ensure accuracy and completeness. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 14 of 21

15 15 of 21 Recredentialing Process Recredentialing will take place every three years. Recredentialing applications are obtained by Colorado Access from CAQH for currently contracted and previously credentialed providers. A request is generated approximately ninety (90) calendar days prior to the recredentialing due date. The recredentialing process is identical to the credentialing process except: A. Primary source verification does not re-collect educational verification; and B. Provider utilization data, and any complaints and quality information is presented for consideration in the decision making process. The provider information/file is summarized on the recredentialing checklist. The BHI prepares the recredentialing report on provider utilization and quality information for the Credentialing Committee review. A. The application is reviewed by the Credentialing Committee for recredentialing approval. The Credentialing Committee reviews information from the NPDB, licensure board, Medicare/Medicaid sanctions report, EPLS, and performance data. B. If BHI is unable to recredential a provider within the 36-month period because the provider is on active military assignment, maternity leave or a sabbatical, but the provider contract remains in place, BHI will credential the provider upon their return. The reasons for the delayed credentialing are documented in the provider s credentialing file. At a minimum, BHI shall verify valid licensure and sanctions prior to provider seeing clients. BHI will complete the recredentialing cycle within 60 calendar days of the provider resuming their practice. If the provider or BHI terminates the contract or there is a break in service of more than 30 calendar days, BHI will initially credential the provider before the provider rejoins the network. C. Based on the decision from the Credentialing Committee, the provider will receive an acceptance or denial letter within thirty (30) days. The denial letter will include information regarding the appeal process (Attachment E). CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 15 of 21

16 16 of 21 Appeal Process Credentialing and recredentialing applications are reviewed by the Credentialing Committee (including the Chief Medical Officer) for approval or disapproval. If the Credentialing Committee and the Chief Medical Officer decide not to approve a provider for credentialing, the provider will be notified in writing of BHI s decision within thirty (30) days of the decision. The Decline to Include in Network Letter Template (Attachment E) advises the provider to contact the in writing within thirty (30) days of notification to initiate an appeal. Appropriate tracking systems will be updated to reflect the decision. Only one appellate review will be considered. Provider s Appeal Rights A. BHI will provide written notification when a professional review action has been brought against a provider, reasons for the action and a summary of the appeal rights and process. B. Providers are allowed to request a hearing within 60 days after notification. C. Providers are allowed representation by an attorney or another person of their choice. D. BHI will appoint a hearing officer or a panel of individuals (Provider Advisory Council) to review the appeal. E. BHI will provide written notification of the appeal decision that contains specific reasons for that decision. The provider will be given the opportunity to present evidence in person or by phone to the BHI Provider Advisory Council. The Provider Advisory Council will make the final decision to uphold or overturn the initial credentialing decision. BHI will notify the appropriate authorities for behaviors violating the law or ethical standards or practice. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 16 of 21

17 17 of 21 Process for Managing Credentialing Files A file is maintained through Colorado Access for each provider contracted with BHI. The information contained in the file includes but is not limited to the following: A. A current application and CV, which includes a five (5) year work history B. Current State Professional License to practice C. Current DEA license, as applicable D. Current Professional Liability Policy face sheet E. Hospital Staff Privileges, as applicable F. Evidence of professional medical education including ECFMG, as applicable G. Evidence of Board Certification, as applicable H. NPDB (National Practitioners Data Bank) query, which includes Medicare and Medicaid sanction activity, as applicable I. FSMB (Federation of State Medical Boards) query, as applicable J. Evidence of site review, as applicable K. Colorado Bureau of Investigation (CBI) Query L. Sanctions List CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 17 of 21

18 18 of 21 Organization Provider (Facility) Credentialing The applicant must complete the BHI Organizational Provider Credentialing application (Attachment B). The application must contain the original signature of the COO, Administrator, or other appropriate designated health care facility representative. The signature of the facility representative serves as an attestation of the credentials, operational, financial, and quality performance information summarized on and included with the application. The signature also serves as a release to verify credentials externally. A facility may request participation in the network. A facility may also be sought out to participate in the network is response to member need. The BHI Director of Provider Relations sends the BHI Organizational Application by mail or to the facility. The Facility provider applicants will submit the following documentation with their completed applications: A. Copy of all current facility licenses including, but not limited to: 1. Mental Health Day Program (including day treatment and partial hospitalization) 2. Outpatient Mental Health Services 3. Mental Health Residential Treatment Facilities 4. Mental Health Crisis Stabilization Units 5. Psychosocial Rehabilitation 6. Mental Health Case Management 7. Mental Health Hospital Facilities 8. All general surgical hospitals operating a unit or program to provide mental health services B. Current accreditation by an acceptable accreditation body including but not limited to JCAHO, CARF, CHAP, or COA. Completed site review reports from CMS, DMH, or DBH as well as any other requested documentation to ensure the organization complies with BHI standards. If a site visit has not been conducted by the above listed, BHI will conduct its own site visit and include a copy of the organization s credentialing or Human Resources policies for screening and verification of staff training. C. Copy of last HCFA, Health Facilities Division survey report (Hospitals only). D. Copy of Mental Health Services Designation Certificate E. Status of certification for Medicaid and Medicare participation and numbers if participating CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 18 of 21

19 19 of 21 F. State and federal regulatory status - In good standing: A screen print displaying the query results from the Office of Inspector General (OIG) Federal Program Exclusions Database (Medicaid and Medicare status). G. Copy of declaration page proving current Professional and General liability coverage demonstrating the following BHI requirements: Facility Malpractice General Liability Facility $3,000,000 $3,000,000 per occurrence Hospital $5,000,000 $5,000,000 in aggregate H. Malpractice history from the insurance carrier covering the last five (5) years I. Attestation/Release signed by a Director. J. Attestation that their organization conducts background investigations on all employees, interns, volunteers and contract agents having contact with members, consisting of at least the following, prior to hire: 1. A name search through the Colorado Bureau of Investigation 2. A reference from the licensing board for licensed persons 3. A check of the Central Registry of Child Abuse for persons having unsupervised contact with members under age A check of references of former employees for clinical staff Accreditation or Site Visit by CMS, DMH, DBH or BHI The following accreditation organizations are recognized and accepted by BHI: A. Joint Commission of Accreditation of Healthcare Organizations (JCAHO) B. The Rehabilitation Accreditation Commission (CARF) C. Council on Accreditation of Services for Families and Children, Inc. (COA) D. Community Health Accreditation Program (CHAP) Non-accredited organizational provider(s) are subject to an on-site assessment by BHI to confirm that they meet BHI quality standards. BHI will review policies and procedures related to the credentialing of direct care providers and supervisory practices, leadership interactions, evidence of criminal background checks and Child Abuse Registry checks, and licensure verifications via the Colorado Department of Regulatory Affairs if applicable. Site interviews may be conducted with the following staff: senior management; chiefs of major services; and key personnel in nursing, quality management and utilization management. Please reference CRED-408 Provider Office Site Quality. CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 19 of 21

20 20 of 21 As detailed in the table below, BHI will utilize the CMS site survey conducted by the Colorado Department of Public Health and Environment (CDHPE), the DMH site review conducted on behalf of the Department of Human Services (DHS) or the Division of Behavioral Health (DBH) Site Inspection in lieu of conducting a site visit. In these instances, BHI will require a copy of the reports from the state agency to verify that the assessment complies with BHI standards and to ensure that the organizations credentialing and personnel policies and procedures were reviewed. The CMS or state review must not be greater than three years old at the time of verification. If the organizational provider has not undergone a site visit by one of the above, or the documentation does not support BHI standards, BHI will perform a site visit. Following are the organizational providers and their associated accrediting bodies or in lieu of accreditation, the applicable CMS, DMH or DBH site review. The organizational provider must provide evidence of one of the following or have a site visit performed by BHI to be considered for participation or ongoing participation. Hospital Organizational Provider Type Community Mental Health Center/Clinic Psychiatric Residential Treatment Facility Therapeutic Residential Child Care Facility Alcohol & Drug Treatment Center Accrediting Body or Site Review JCAHO (general, psychiatric, children s and rehabilitation) DMH Survey of psychiatric hospitals CARF CMS Site Review JCAHO CMS Site Review COA CARF DMH Site Review JCAHO CARF COA DMH Site Review JCAHO CARF COA DMH Site Review JCAHO DBH Site Inspection COA DMH Site Review CARF CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 20 of 21

21 21 of 21 The reviews all information and when the application is complete, presents the application to the Credentialing Committee. The Credentialing Committee does the following: A. Reviews documents B. Makes determination regarding participation C. Chairperson documents determination in committee minutes BHI supplies the facility with the written decision by the committee to accept or deny participation within thirty (30) days. Any denial letter will include information regarding the appeal process (please reference appeal section above) Organization Provider (Facility) Recredentialing Recredentialing will take place every three years. The recredentialing process will begin at least ninety (90) days prior to the date at which initial credentialing or recredentialing will expire. All requirements and documents listed for Organization Credentialing will be current at the time of credentialing and recredentialing. Expedited Credentialing Please reference CRED-401 Out-of-Network Provider Single Case Agreements. V. Attachments: CRED-403 Attachment A - Colorado Health Care Professional Credentials Application CRED-403 Attachment B - Organizational Provider Credentialing Application CRED-403 Attachment C - Flow Chart of Provider Credentialing Process CRED-403 Attachment D - Application Information Discrepancy Letter Template CRED-403 Attachment E - Decline to Include in Network Letter Template CRED-403 Provider Credentialing and Recredentialing ppfy14 Page 21 of 21