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PAP633

Credentialing Appeal Rights


Provider Administrative Policy

Section
Commercial Managed Care
Policy Date
December 2005
Status/Date
Revised/March 2009
Provider Type(s)
All Providers  

Disclaimer

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.

Policy

Credentialing Appeal Rights

If a provider fails to meet the credentialing /recredentialing standards (see PAP606 ) at any time, Credentials Committee may take action to deny, terminate, suspend credentialing or sanction the provider. Such actions may be appealed to a panel of practitioners selected by the Credentials Committee, as provided in this policy.

There are no appeal rights for initial credentialing denials or terminations for Medicare Advantage.

Procedures for Action by Credentials Committee

1. If a provider fails to meet the standards and criteria for credentialing or recredentialing, the Credentials Committee may act to deny, terminate, suspend credentialing, or sanction the provider. The Credentials Committee shall make reasonable efforts to obtain facts relevant to its determination prior to taking action.

2. In cases where the Chief Medical Officer or his/her designee and/or Credentials Committee determines that the circumstances may pose an immediate danger to the health or safety of members, a provider may be suspended or terminated from the network immediately, subject to subsequent notice and hearing or other adequate procedures.

3. The Credentials Committee shall notify a provider in writing within 30 days of a decision to deny, terminate, suspend credentialing or sanction the provider. Such notification will outline:

a) the decision;

b) the reason(s) for the decision, including facts upon which the decision is based; and

c) appeal rights, if applicable.

4. The Credentials Committee will report all actions against a provider based on the provider’s professional competence or conduct to the National Practitioner Data Bank. Issues are not reported until after any applicable appeal rights have been exhausted and a final decision has been made.

       Appeals Procedure

1. A provider may appeal a decision of the Credentials Committee to deny, sanction, suspend, or terminate credentialing by submitting a written appeal and any additional information the provider would like to include for consideration, to the Chief Medical Officer within 30 days of receipt of the Credentials Committee’s decision to deny, sanction or terminate credentialing.

2. The Credentials Committee shall have the right to reconsider its decision by notifying the provider of its intent to do so and requesting additional information, if necessary, within 30 days of the Chief Medical Officer’s receipt of the appeal. The provider shall receive written notice of the Credentials Committee’s decision upon reconsideration within 30 days of its receipt of additional information. If the Credentials Committee upholds its prior decision, the provider will receive written notice of the decision, the reasons for the decision, the facts upon which the decision is based, and appeal rights, including the right to request an appeal hearing. If the Credentials Committee declines reconsideration, the provider will receive notification of additional appeal rights, including the right to request a hearing. The provider may request an appeal in writing by acknowledging he/she voluntarily waives his/her right to a hearing. The provider can be a person or facility.

3. Upon timely receipt of a written appeal and request for hearing, the Chief Medical Officer shall appoint an appeal panel of at least three practitioners who are not in direct economic competition with provider, and designate one of them the committee chair. One panelist shall be a Blue Cross of Idaho Medical Director who has not previously been involved in the case and one panelist shall be of the same clinical specialty as the appellant.  The Chief Medical Officer who appoints the appeals panel may also appoint a hearing officer to preside over the hearing. The hearing officer will not take part in the appeal panel’s deliberations, but will direct the proceedings.

4. The committee chair, or the hearing officer (if one is selected), shall notify the provider of the hearing’s time, place and date. The hearing shall be scheduled on a date no sooner than 30 days after the date appearing on the notification of hearing.

5. The notice of hearing shall state:

(a) the place, time and date of the appeal hearing, and the date shall not be less than 30 days after the date of notice of hearing;

(b) the practitioners who will constitute the appeal panel;

(c) a list of the witnesses (if any) expected to testify at the hearing on behalf of Blue Cross of Idaho;

(d) that the provider has the right to representation by an attorney or other person of choice at his/her expense;

(e) that the provider has the right to have a record made of the proceedings, copies of which may be obtained by the requesting party upon payment of any reasonable charges associated with the preparation thereof;

(f) that the provider has the right to call, examine, and cross-examine witnesses;

(g) that the provider has the right to present evidence determined to be relevant by the panel, regardless of its admissibility in a court of law;

(h) that the provider has the right to submit a written statement at the close of the hearing; and

(i) that the provider shall receive a written decision after the hearing.

6. Within 10 days after the provider has received the hearing notice, the provider may deliver to the committee chair, or hearing officer (if one is appointed), a written challenge to the impartiality of any appeal panel members for demonstrated bias or direct economic competition and for no other cause.

Within 10 days of receipt of the challenge, the committee chair or hearing officer shall notify all parties in writing of the decision regarding the challenge. The notification, which must be no more than 30 days from the original hearing date, will include the basis for the challenge, the names of the replacements, if any, and the rescheduling of the hearing date, if required, to accommodate new panel members.

7. At least 10 days prior to the hearing, the provider shall provide the committee chair or hearing officer a list of witnesses, if any, expected to testify at the appeal hearing on behalf of the provider.

8. The provider may forfeit the right to the hearing if the provider fails, without good cause, to appear.

9. Within 15 days after final adjournment of the hearing, the appeal panel shall prepare and send to the provider and the Chief Medical Officer, a written decision that includes findings of fact and explaining its conclusions with regard to the issues at the hearing.

10. The appeal panel’s decision shall be final and binding on all parties.

References

42 CFR 422.202, 42 CFR 422.204, 64 FR 7968, 42 CFR 1395w-22; 42 U.S.C. § 11112.

 


Policy History

Date Action Reason
March 2009 Revised Policy rewrite
August 2008 Revised Title change/language clarification

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