Subject: Overview of Credentialing (Page 1 of 8)

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1 Subject: Overview of Credentialing (Page 1 of 8) Objective: I. To ensure that Health Share/Tuality Health Alliance (THA) uses a well-defined credentialing and re-credentialing process for evaluating and selecting licensed independent practitioners/providers. Practitioners identified as falling within the scope and authority and action of this policy are Doctors of Medicine (M.D.s) or Doctors of Osteopathic Medicine (D.O.s) who are contracted as Full or Associate Providers; Nurse Practitioners (NPs), Physician Assistants (PAs), or Nurse Anesthetists who are contracted as Associates; and ancillary-contracted practitioners or providers. II. To ensure that all practitioners meet criteria and requirements according to the National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission (URAC), the Centers for Medicare and Medicaid Services (CMS), and specific health plan criteria. Definition: Credentialing is the review of qualifications and other relevant information pertaining to a health care professional (practitioner/provider) who seeks appointment, contract, or participation with THA. Policy: I. Only licensed practitioners who are professionally competent and who continuously meet the credentials, standards, and requirements established in the THA credentialing and re-credentialing policies and procedures are selected and retained to provide health care services for THA enrollees/members. THA credentials physicians, physician assistants, nurse practitioners, and nurse anesthetists according to Medicare, Medicaid, NCQA standards, URAC standards and specific Health plan criteria see Attachment A: Criteria. II. As part of the THA Quality Management Program, all participating practitioners must successfully complete a regular/ongoing credentialing process. a. Initial Credentialing Tuality Healthcare/THA conducts a comprehensive review and verification of credentialing for each licensed, independent practitioner prior to his/her participation with THA. b. Re-Credentialing Tuality Healthcare/THA conducts a comprehensive review and verification of credentialing for each licensed, independent practitioner at least every three years following the practitioner s previous credentialing period.

2 Subject: Overview of Credentialing (Page 2 of 8) III. IV. Credentialing of Full and Associate Providers On behalf of THA, Tuality Healthcare (THC) Medical Staff Office (MSO) Coordinators perform the initial credentialing and re-credentialing processes for Full and Associate Providers. The date on which the Full or Associate Provider applicant is approved for THC MSO privileges by the THC Board is considered the THA receipt date of the Oregon Practitioners Credentialing Application. THC MSO Coordinators perform designated Full and Associate Provider credentialing activities, including primary source verification and queries of the National Practitioner Data Bank (NPDB). a. THC MSO Coordinators may utilize CredentialsOnLine, a Credentialing Verification Organization (CVO), to perform designated credentialing functions. b. Documentation of primary source verification may include copies of credentialing information. A detailed checklist is acceptable when signed/initialed and dated; signatures or initials must be written in ink that is non-erasable. THC MSO Coordinators will conduct primary source verification of the following: 1. A current, valid, and unrestricted Oregon State License (to practice); 2. The Oregon State Board of Medical Examiners most current cumulative report listing all practitioners holding a valid, current and unrestricted license to practice; 3. Clinical privileges in good standing at TCH; 4. A copy of the current, valid Oregon DEA certificate, if applicable; 5. Graduation from medical school and completion of a residency program (with written or verbal verification from the program), or Entry into the American Medical Association (AMA) Physician Master File, or Entry into the American Osteopathic Association (AOA) Physician Master File, or Confirmation from the Educational Commission for Foreign Medical Graduates (for international medical graduates), or For physician assistants, nurse practitioners, or nurse anesthetists, graduation from the appropriate school and written or oral confirmation from the school. Credentialing of Ancillary Providers The THA Administrative Coordinator or designated THA staff member performs the initial credentialing and re-credentialing verification processes for ancillary practitioners/providers, including preferred or extended physicians, podiatrists, nurse practitioners, or other licensed independent contractors or providers.

3 Subject: Overview of Credentialing (Page 3 of 8) V. Credentialing Application The following documents/information must be submitted to THC/THA for consideration of a practitioner applicant. a. For initial credentialing, the applicant physician, nurse practitioner, physician assistant, or nurse anesthetist must submit the Oregon Practitioner Credentialing Application, a copy of the completed and signed Release of Information, and the Attestation Statement. At re-credentialing, the applicant must submit a copy of the Oregon Practitioner Re-Credentialing Application, a signed Release of Information, and an updated Attestation Statement. The Oregon Practitioner Credentialing Application and the Oregon Practitioner Re-Credentialing Application forms include a statement by the applicant and/or documented evidence to address the following: 1. Reasons for any inability to perform essential provider functions, with or without accommodation; 2. At least a five year work history (from primary sources or curriculum vitae) with no unexplained gaps greater than two months; 3. Lack of present illegal drug use; 4. History of loss of license and felony convictions; 5. History of loss or limitation of privileges or disciplinary activity; and 6. Current dates and amount of professional liability/malpractice insurance coverage (all practitioners, regardless of classification, must at all times maintain full force and effect professional medical liability insurance as defined in ORS in an amount not less than $1,000,000 per occurrence and $3,000,000 aggregate). A liability insurance cover sheet may be submitted with the application. b. The application and attestation forms must be signed and dated within 180 calendar days of the THA credentialing decision. c. THA will accept/review primary source verification and credentialing documents completed by the THC MSO Coordinators. Board certification, if the applicant states that he/she is board certified, must be primary source verified. d. For Primary Care Providers (PCPs) and Obstetricians/Gynecologists, the initial credentialing and re-credentialing processes will include an on-site office visit/review. On-site reviews are completed by THA staff. Site reviews are to be completed prior to credentialing or re-credentialing, or as a follow-up to access complaints that have exceeded the limits described in THA Policy X-5: Office Site Quality Reviews. e. THC/THA will request information from the National Practitioner Data Bank (NPDB) for primary source verification for professional malpractice claims history that cover the most recent five years. This includes previous sanctions by Medicare or Medicaid. If there is a sanction; it will be noted on the query form from the NPDB.

4 Subject: Overview of Credentialing (Page 4 of 8) f. THC/THA does not accept practitioners who are ineligible due to opting out of Medicare/Medicaid or who are sanctioned on the Medicare Exclusion list, the Excluded Parties List System (EPLS) or the Health and Human Services (HHS) Office of Inspector General (OIG) sanction list. g. THA requires a current, appropriate, valid, and unrestricted Oregon license or certification to practice. THA s has zero tolerance for licensing restrictions as a result of unprofessional conduct described in Oregon ORS , VI. VII. Confidentiality of Credentialing Files All information obtained through the credentialing process is considered confidential. Credentialing files are maintained as confidential documents, protected under State of Oregon statutes, for the purpose of conducting education, evaluation, professional credentialing and quality management activities. THA will maintain credentialing files separate from the THC credentialing files. All credentialing files are maintained in locked cabinets; access to the files is restricted to the appropriate/necessary staff. Credentialing files are not to be left unattended in open office areas. a. All credentialing staff and members of the THA Quality Management Committee (as described below) are required to sign confidentiality statements on a yearly basis. b. Auditors are required to sign confidentiality statements prior to credentialing audits. Credentialing Decision Making: The THA Quality Management Committee The THA Quality Management Committee (QMC), with THA Board oversight, has the ultimate responsibility for initial credentialing and re-credentialing decisions. The QMC is made up of THA participating practitioners and THA Board members; the QMC meets every other month and makes credentialing decisions through a peer-review process. a. As a member of the QMC, the THA Medical Director is directly involved in the credentialing program and is authorized to make provisional credentialing decisions of a Level 1 practitioner/provider who is identified as having no exceptions to the credentialing criteria. 1. The Medical Director s signature date is the credentialing date. 2. The Level 1 file is processed for approval and start date when the professional liability insurance face sheet is in force. 3. Final Level 1 Credentialing approval lies with the THA QMC and must be completed within 60 days of initial provisional Level 1 Credentialing. b. The QMC reviews the application files of all practitioners who do not meet criteria for Level 1 credentialing. Practitioners who do not meet criteria for Level 1 Credentialing may have:

5 Subject: Overview of Credentialing (Page 5 of 8) 1. History of adverse licensure action or government program participation activity; 2. History of disciplinary action by any professional review body, including loss or limitation of medical staff membership, loss of clinical privileges, loss of professional liability insurance coverage, or loss of health plan participation; 3. Physical or mental impairment that adversely affects or could adversely affect the practitioner s ability to carry out the scope of his or her duties on behalf of THA; 4. Current illegal drug use; 5. Not meeting adequate professional experience, education, and training in the requested area of practice; 6. History of malpractice occurrences within the past five years, that exceed three separate events and result in payment(s) on behalf of the practitioner; or that include a single event and result in payment(s) exceeding $500,000 on behalf of the practitioner; and 7. Information from ongoing monitoring of Quality Improvement activities and member complaints. c. The QMC credentialing decision making process may take place in the form of real-time or virtual meeting (e.g. through video or Web conferencing); meetings may not be conducted through alone. d. All QMC discussions relating to review of the applicant s file are held in closed session and considered confidential. e. The QMC may approve, defer, modify, or deny initial or ongoing participation with THA based the criteria contained in Attachment A: Criteria. f. The QMC may evaluate reinstatement of practitioners whose licenses have been suspended and then reinstated by licensing bodies. g. The QMC may grant provisional approval, to be re-reviewed within a year. h. All credentialing decisions are documented in the QMC meeting minutes. VIII. The THC/THA and QMC credentialing and re-credentialing processes are conducted in a non-discriminatory manner. Credentialing and re-credentialing decisions are not made based on an applicant s race, ethnic/national identity, gender, age, sexual orientation, or the types of procedures (e.g. abortions) or patients (e.g. Medicaid) in which the provider specializes. In selecting practitioners, THA will not discriminate, in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of his or her license or certification under State law. If THA declines to include a given provider or group of providers in its network, THA will furnish written notice to the affected provider(s) of the reason for the decision.

6 Subject: Overview of Credentialing (Page 6 of 8) THA monitors and prevents discriminatory credentialing through the following processes: a. Members of the THA Quality Management Committee (QMC) sign annual confidentiality and nondisclosure affirmative statements, agreeing to make credentialing or re-credentialing decisions in a nondiscriminatory manner. b. THA staff may conduct periodic audits of credentialing files to ensure that practitioners are not discriminated against. IX. Practitioner applicants have the right to review submitted credentialing information, to correct erroneous information, to be informed of the status of their credentialing or re-credentialing application, and to be notified of these rights. a. Practitioners have the right, upon request, to be informed on the status of their credentialing application by contacting the THA Administrative Coordinator or the THC MSO Coordinator. These requests may be submitted either by telephone or in writing. Response to requests will be provided to the applicant within 10 business days of the request and will be documented in the credentialing file. Application status information is limited to the following: 1. Not received; 2. Returned, incomplete; 3. In process; 4. Ready, awaiting QMC review; 5. Denied; or 6. Approved physicians, nurse practitioners, and nurse anesthetists may not begin seeing THA members until they have received written notification from THA, which includes the date on which they are considered active. b. When the THC MSO or THA Administrative Coordinator identifies erroneous information within a credentialing application, staff will notify the applicant within five business days. Notification will be given verbally or in writing. The applicant has up to 15 business days to correct erroneous information from date of notification. Correction of erroneous information may be submitted either in writing or orally to the Medical Staff Office at Tuality Community Hospital. Corrected information that is provided by will be printed, dated, and initialed by the receiving staff member, and then placed in the applicant file. Verbally corrected information is documented on the verification form with date, and initialed by the receiving staff member; the documented information needs to include the details of the conversation, and the name of the person providing the information. c. In the event that information obtained during the credentialing process varies substantially from the information provided as part of the application process, the THA Medical Director will contact the applicant for clarification within 3 business days of identifying the discrepancy. The Medical Director will

7 Subject: Overview of Credentialing (Page 7 of 8) attempt to contact the provider by phone on two separate occasions. If clarification is not received at that time, one written follow-up notification will be sent via certified letter. The credentialing process will stop until clarification is received. If the provider does not respond within 30 days, this will be considered a voluntary withdrawal of the application. d. Practitioners/providers are notified of their rights as these rights are enclosed within the THA Credentialing Application(s). X. Applicant practitioners are notified in writing of the credentialing decision to approve or deny appointment to the THA provider panel within 10 business days of the QMC decision. XI. XII. XIII. In the event that the applicant is denied appointment, he/she may reapply no sooner than 12 months from the date of the denial. THA reserves the right to review the physician, physician assistant, nurse practitioner or nurse anesthetist against all credentialing criteria at the time of re-application. THA credentialing policies and criteria are reviewed by THA at least annually. Policies are revised by the THA QMC as needed. Delegation of Credentialing THA does not delegate credentialing for THA Full or Associate Providers. THA may, however, choose to delegate the credentialing process for other contracted practitioners or providers according to THA Policy X-9: Delegation of Credentialing. References: 42 CFR (b)(2)(iii) Health Share RAE Participation Agreement NCQA CR 1 Overview of Credentialing Policies OAR THA Policy X-2: Initial Credentialing Verification THA 2: Level 1 Credentialing THA Policy X-3: Application and Attestation THA Policy X-4: Initial Sanction Information THA Policy X-5: Office Site Quality Reviews THA Policy X-6: Re-Credentialing Verification THA Policy X-7: Ongoing Monitoring THA Policy X-8: Practitioner Appeal Rights THA Policy X-9: Delegation of Credentialing URAC P Credentialing Standards

8 Subject: Overview of Credentialing (Page 8 of 8) Formulated: February 1994 Revised: July 2004 April 1995 February 2005 August 1996 September 2007 April 1999 September 2009 June 2000 November 2002 November 2003 July 2004 February 2005 May 2006 September 2007 September 2008 September 2009 August 2010 June 2011 June 2012 August 2013 THA Plan Director THA Medical Director

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