Credentialing/Recredentialing Standards for Practitioners
Provider Administrative Policy
Commercial Managed Care
DisclaimerOur 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.
Credentialing is a review of qualifications and other relevant information pertaining to a health care professional who seeks a contract with Blue Cross of Idaho. Credentialing is required for physicians and health care professionals who provide services to members and who are permitted to practice independently under state law. Credentialing is not required for health care professionals who are permitted to furnish services only under the direct supervision of another practitioner or hospital-based health care professionals who provide services incident to hospital services (unless those health care professionals are separately indentified in literature such as the provider directory as contracted).
The goal of our credentialing/recredentialing program is to:
- Ensure high-quality providers for members
- Provide an optimal number and distribution of providers
- Minimize health and safety risks for members
- Minimize legal risks
To begin the credentialing process, each physician or healthcare professional submits an application. A credentials specialist performs the primary source verification. The credentials committee, which consists of the Blue Cross of Idaho chief medical officer and generally, three primary-care physicians and three specialists, reviews the information. Providers must meed credentialing standards and criterial and be approved by the credentials committee at least every 36 months.
Blue Cross of Idaho’s credentialing/recredentialing standards are criteria that all healthcare professionals must meet (as applicable) and maintain. Healthcare professionals must uphold these standards to be accepted, or continue, as network providers. The credentials committee applies the following standards when making credentialing decisions:
Application, Attestation and Release
Information on a provider’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. Providers may attach a curriculum vitae, but it is not considered a substitute for completing the application. The provider must attach current copies of his/her license, DEA registration, certification, certificate of insurance for professional liability, and Educational Commission for Foreign Medical Graduates certificate, if a foreign graduate, to his/her application. The provider must sign and date an unaltered attestation and release.
License (initial, recredentialing, and ongoing):
The provider must have a current license in good standing from the appropriate Idaho licensing agency. The license cannot be revoked, terminated, expired, restricted, suspended, imposed with conditions, stipulations, disciplinary actions, probation or otherwise modified in any way at the initial credentials committee review or the recredentialing review.
Hospital Admitting Privileges (applies to physicians, nurse practitioners, clinical nurse specialists and certified nurse-midwives):
- Primary Care Physicians (PCP) and primary care Advanced Practice Professional Nurses (APPN) should have active or courtesy privileges in good standing at a Medicare certified hospital.
- Physician specialists should have courtesy or comparable privileges at a Medicare certified hospital.
- APPN specialists should have allied health (or comparable) privileges at a Medicare certified hospital.
- *If the PCP, physician specialist, primary care APPN, or specialist APPN fails to meet these standards, he or she must provide documentation showing 40 hours of continuing medical education in the previous 24 months, as well as a scope of practice document. The scope of practice document should include a listing of all procedures including endoscopic procedures, treadmill testing, other diagnostic testing, and an explanation of admitting procedures. The provider may be required to identify a specific resource for admitting members to the hospital verified by a signed admitting agreement.
- *One year after initial credentialing, a review is performed comparing claims to scope of practice. A site visit and/or medical records review may be performed if discrepancies are found.
*NOTE: Certified nurse anesthestists are not required to have privileges or to submit the alternative documentation listed above.
Drug Enforcement Agency (DEA) Certificate:
- No DEA revocation allowed.
- Verification of a valid current certification at initial credentialing and recredentialing is required.
Board Certification and Education (MDs and DOs):
- Board certification is not required.
- A completed residency is required for physicians listed as specialists.
- Listings for physicians that are board certified by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) are sometimes separate from residency trained, non-board certified physicians.
- Physicians listed as “General Practice” in the provider directory are not ABMS or AOA certified or have not completed a residency but are medical school graduates and completed an internship.
Certification and Education (all other practitioners as applicable):
Verification of certification is required if a provider indicates that he/she is certified. The institution granting the degree or the state licensing agency can verify completion of education if they perform primary source verification.
Providers cannot have unexplained lapses in work history for the previous five years. Providers may be required to explain gaps in work and education history beyond the previous five years.
- 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.
Malpractice History, Professional Liability Claims History, Civil Judgments, Federal/State Criminal Convictions, Adverse Actions:
- The credentials committee grants acceptance into the Blue Cross of Idaho network if they determine the pattern of litigation, conviction(s), civil judgment(s), or adverse action(s) is not predictive of significant patient risk in the future.
- The credentials committee does not review malpractice cases that occurred during internship or residency.
- The credentials committee will review two or more open cases; single closed cases over $500,000; two or more closed cases over $25,000; all adverse actions, civil judgments and convictions.
Twenty-four Hour Coverage:
- All managed care physicians must have 24-hour coverage by themselves or with an on-call arrangement.
- Referral to the local emergency room is not acceptable.
The provider must not have any physical or mental impairment that prevents adequate patient care.
Alcohol or Drug Abuse:
The provider must not have any evidence of ongoing substance abuse.
The provider must not have any felony convictions or guilty pleas.
Medicare/Medicaid Sanctions, Federal Exclusions or Fraud (internal or external information, initial, recredentialing and ongoing):
The provider must not have any sanctions, federal exclusions, or evidence of fraud.
Office Site Review (initial credentialing of PCPs and others at the discretion of the medical director):
The primary care provider’s clinic must have a passing score within 36 months of the time of the credentials committee review.
Medical Record Review:
The Blue Cross of Idaho Quality Department reviews medical records in accordance with quality management policies and procedures.
Our quality management department investigates, monitors, and tracks quality concerns and forwards reports to the credentials committee as indicated in the quality management policies and procedures. The credentials committee will review the quality report and use its judgment in determining a course of action.
Utilization Management (recredentialing):
- The quality management department reviews utilization management.
- Utilization management information goes to the credentials committee as indicated in the quality management policies and procedures.
Addictive Drug Prescribing Habits:
The credentials committee reviews the provider’s history and restrictions on prescribing habits from the Idaho State Medical Board of Discipline to determine whether the provider’s history and prescribing habits as restricted, pose unacceptable patient risk.
State Disciplinary Board:
The credentials committee reviews disciplinary board actions or ongoing sanctions to determine if the behavior poses an unacceptable risk to patients.
No sexual misconduct, as defined by the Idaho State Medical Board of Discipline under misconduct and the standard of care rules.
Eligibility (Applies to physicians, nurse practitioners, clinical nurse specialists and certified nurse-midwives):
- The provider’s practice must represent his or her specialty training.
- Credentialed providers may be listed in the directory as either:
- Primary care providers with a specialty in family practice, internal medicine, obstetrics and gynecology, pediatrics, or a general practice that provides comprehensive care to Blue Cross of Idaho members.
- Non-primary care providers who have training in a specialty approved by the ABMS, AOA or Board of Nursing, that do not wish to have patients assigned to them because their practice is referral/specialty based.
|March 2012||Revised||Noted CNA are not required to have priveleges or to submit alternative documentation.|
|March 2009||Revised||Policy rewritten|
|November 2008||Revised||Language clarification|
|August 2008||Revised||Language clarification|