Credentialing/Recredentialing Standards for Facilities
Provider Administrative Policy
Revised/ January 2015
Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts
The goal of our credentialing/recredentialing program is to:
- Ensure high-quality facilities for members
- Provide an optimal number and distribution of facilities
- Minimize health and safety risks for members
To begin the credentialing process, each facility submits an application. A credentialing specialist performs the primary source verification as applicable. The credentials committee consists of the Blue Cross of Idaho medical director and five physicians with various specialties from around the state. We verify information on the facility at least every three years for credentials committee review.
Blue Cross of Idaho's credentialing/recredentialing standards include criteria that all healthcare facilities must meet (as applicable) and maintain. Healthcare facilities must uphold these standards to be accepted, or continue, as Blue Cross of Idaho network providers. The credentials committee applies the standards listed below when making credentialing decisions.
Application, Attestation and Release
Information on a facility's application cannot be more than 180 days old at the time of review. All sections of the application must have complete answers or explanations. Facilities may attach documents, but Blue Cross of Idaho does not consider attachments as a substitution for a complete application. As applicable, the facility must attach to the application current copies of its license, Board of Pharmacy license, certificate of insurance for professional liability, certificate of insurance for worker's compensation, certification, most recent Medicare survey, accreditation, quality program description, ownership documentation and a list of practicing physicians and other healthcare providers. The facility must sign and date an unaltered attestation and release.
License (initial, recredentialing, and ongoing)
The facility must have a current license in good standing from the appropriate Idaho licensing agency (if applicable) that is not revoked, terminated, expired, restricted, suspended, imposed with conditions, stipulations, disciplinary actions, probation or otherwise modified in any way at the time of credentials committee review.
Board of Pharmacy License (if applicable)
Verification of a valid current certification at initial credentialing and recredentialing is required.
Verification of certification and a copy of the most recent Medicare survey, conducted within three years of the credentials committee review, is required if applicable for facility type. If a current survey is not available, the credentials committee may require a site survey by Blue Cross of Idaho personnel. For laboratories, a copy of the Clinical Laboratory Improvement Amendments (CLIA) certificate is required and must be current at the time of credentials committee review.
Accreditation (as applicable):
Verification of accreditation is required if a facility indicates that it is accredited. Ambulatory Surgery Centers (ASC) are required to be accredited by AAAHC, AAASF, or JCAHO. Medicare certification for ASC's does not meet this standard.
Coverage amounts must be at least $1,000,000 per incident; $3,000,000 aggregate or unlimited aggregate. Insurance must be current at the time of credentials committee review.
Worker's Compensation Insurance:
Coverage is required and must be current at the time of credentials committee review.
Facility shall be participating with Medicare if applying for a Medicare Advantage contract. Medicare participation is required for all facilities with more than 50 beds.
Medicare/Medicaid Sanctions, Federal Exclusions or Fraud (internal or external information, initial, recredentialing and ongoing)
The facility must not have any sanctions, federal exclusions, or evidence of fraud.
Quality Management, Patient Safety Programs, Structure and Policies:
First, the facility shall have quality management and/or patient safety programs in place at the time of credentials committee review. Second, the facility shall provide Blue Cross of Idaho a description of these programs and make the full program documentation available upon request. Third, the facility is required to demonstrate administrative structure and policies to support that structure.
Materials describing the organization:
The facility shall attach materials describing the facility and its ownership to the application.
ASC's and skilled nursing facilities are required to have a transfer agreement with an acute care hospital. Verification will be a signed agreement by the hospital. If a transfer agreement is not in place then the facility is required to provide documentation of local hospital privileges of medical staff.
Range of Services:
The, facility will provide access to an appropriate range of services for the service area.
|January 2015||Revised||Added MC requirement for hospital > 50 beds|