Provider Validation Information:

Transcription

1 Provider Validation Information: Health Care Providers with which we contract (e.g. your PCP or a hospital) submit to COMMUNITY HEALTH OPTIONS, the information contained in our Provider Directory. This information is verified through the credentialing process and may be supplemented by additional verification processes required by law or regulation. Credentialing is a process of checking the accuracy of the qualifications submitted by a Provider to COMMUNITY HEALTH OPTIONS. Checking includes checking of licensure or certifications. It also involves a review of a health care Provider s education and training, to ensure the Provider meets professional requirements. Initial credentialing occurs when the Provider first contracts with COMMUNITY HEALTH OPTIONS. Recredentialing occurs every three years thereafter. Between credentialing and Recredentialing COMMUNITY HEALTH OPTIONS monitors Provider for sanctions and licensure restrictions. COMMUNITY HEALTH OPTIONS also obtains information about a Provider through the contracting process. The contracting process is a process whereby COMMUNITY HEALTH OPTIONS and a Provider enter into an agreement for the Provider to become a participating network Provider to render services to COMMUNITY HEALTH OPTIONS Members. An explanation of some of the terms used in our Provider Directory as well as how the information is verified, how often verified and any limitations with the information that you should be aware of appears below. If you need additional information about a professional qualifications, please call the Member Services number on your ID card. Health Care Provider name. This is the name reported to us by the Provider on the contract or the credentialing application. It is verified at initial contracting and every three years at recredentialing. If a name changes between the credentialing and recredentialing process, the Provider is required to report this change to COMMUNITY HEALTH OPTIONS. COMMUNITY HEALTH OPTIONS makes changes within 30 days of receipt of this information. Gender: This is self reported to COMMUNITY HEALTH OPTIONS by the Provider on the credentialing application. Specialty: The listed specialty for a Provider is the medical specialty for which the health care Provider, e.g. a physician, is credentialed. This information is submitted by the Provider on the credentialing application. Specialty qualifications are verified through appropriate specialty board or residency training program. This information is verified at initial credentialing and every three years thereafter. It is changed and verified between these two processes if COMMUNITY HEALTH OPTIONS receives updated information from the Provider. The specialty

2 listed for a Provider is limited by those recognized by COMMUNITY HEALTH OPTIONS and for which the Provider has met the required education and training. Hospital Affiliations: This is the hospital in the COMMUNITY HEALTH OPTIONS network where the health care Provider has admitting or attending privileges. This information is self reported by the Provider through the credentialing application or contracting process. A Provider affiliated with a non network hospital will not show the non network affiliation on the COMMUNITY HEALTH OPTIONS Directory. Medical Group Affiliations: This is the medical group with which the Provider is associated, if applicable. This information is self reported by the Provider or the medical group on the credentialing application or through the contracting process. COMMUNITY HEALTH OPTIONS receives this information at the initial credentialing and at re credentialing. If the Provider does not report a Medical Group Affiliation, no affiliation will appear in the Directory. Board Certification: Board certification is achieved when a doctor has successfully completed a program and testing for a particular specialty. Board certification indicates a physician s expertise in a particular specialty and/or a subspecialty of medical practice. A physician s board certification status, including expiration date (if applicable) is verified directly with one of the following listed agencies: American Board of Medical Specialties (ABMS) American Osteopathic Association (AOA) The American Board of Podiatric Surgery (ABPS) Accepting of New Patients: This indicates if a Provider is currently accepting new patients. This information is self reported by the Provider through the credentialing application or contracting process. It is validated when initially contracting with COMMUNITY HEALTH OPTIONS and updated as reported to COMMUNITY HEALTH OPTIONS by the Provider. Questions about this subject should be directed to Member Services. Languages Spoken by Provider or Staff: A Provider or staff in the office may speak languages other than English. This information is self reported on the credentialing application and may be periodically updated by Provider. Location: The address of the Provider is self reported to COMMUNITY HEALTH OPTIONS through the credentialing or Recredentialing process. It is also updated when the Provider submits a change to a location to COMMUNITY HEALTH OPTIONS. Hospital Accreditation: Accreditation is a voluntary process that evaluates if a hospital meets standards for health and safety. Accreditation status is verified through one of the following: The Joint Commission (TJC)

3 Health Care Facilities Accreditation Program (HFAP) Centers for Medicare & Medicaid Services (CMS) Survey Accreditation Commission of Health Care (ACHC) Accreditation is verified during initial credentialing and every three years thereafter. Any changes to a hospital s accreditation is updated in the Directory as soon as possible after it becomes known to COMMUNITY HEALTH OPTIONS.

4 Accreditation is verified during initial credentialing and every three years thereafter. Any changes to a hospital s accreditation is updated in the Directory as soon as possible after it becomes known to COMMUNITY HEALTH OPTIONS.

5