Credentialing and Recredentialing. We agree to assess and verify all credentialing Applications and recredentialing information and to notify the applicant of our decision within sixty (60) days of receipt of all required information.
Credentialing and Recredentialing. Contractor shall develop and maintain written policies and procedures that include initial credentialing, recredentialing, recertification, and reappointment of physicians including PCPs and specialists in accordance with the DHCS Policy Letter 02-03, check to see if a provider is suspended or excluded suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from the Medi- Cal program pursuant to WIC Section 14043.61 and 42 C.F.R. § 455.436;, and adhere to managed care standards at 42 C.F.R. § 422.204. Contractor shall ensure those policies and procedures are reviewed and approved by the governing body, or designee. Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body.
2.10.5.1.1. Contractor shall ensure those policies and procedures are reviewed and approved by the plan governing body, or designee.
2.10.5.1.2. Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body.
Credentialing and Recredentialing. (1) The Health Plan shall be responsible for the credentialing and recredentialing of its Provider network. Hospital ancillary Providers are not required to be independently credentialed if those Providers only provide services to the Health Plan Enrollees through the Hospital.
(2) The Health Plan shall establish and verify credentialing and recredentialing criteria for all professional Providers that, at a minimum, meet the Agency's Medicaid participation standards. The Agency’s criteria includes:
(a) A copy of each Provider's current medical license pursuant to Section 641.495, F.S
(b) No receipt of revocation or suspension of the Provider's State License by the Division of Medical Quality Assurance, Department of Health.
(c) No ongoing investigation(s) by Medicaid Program Integrity, Medicaid Fraud Control Unit, Medicare, Medical Quality Assurance, or other governmental entities.
(d) Conduct a background check with the Florida Department of Law Enforcement (FDLE) for all treating providers not currently enrolled in Medicaid’s Fee-for-Service program.
(i) If exempt from the criminal background screening requirements, a copy of the screen print of the Provider’s current Department of Health licensure status and exemption reason must be included.
(ii) The Health Plan shall not contract with any Provider who has a record of illegal conduct; i.e., found guilty of, regardless of adjudication, or who entered a plea of nolo contendere or guilty to any of the offenses listed in Section 435.03, F.S.
(e) Proof of the Provider's medical school graduation, completion of residency and other postgraduate training. Evidence of board certification shall suffice in lieu of proof of medical school graduation, residency and other postgraduate training.
(f) Evidence of specialty board certification, if applicable.
(g) Evidence of the Provider's professional liability claims history.
(h) Any sanctions imposed on the Provider by Medicare or Medicaid.
(3) The Health Plan's credentialing and recredentialing files must document the education, experience, prior training and ongoing service training for each staff member or Provider rendering Behavioral Health Services.
(4) The Health Plan's credentialing and recredentialing policies and procedures shall be in writing and include the following:
(a) Formal delegations and approvals of the credentialing process.
(b) A designated credentialing committee.
(c) Identification of Providers who fall under its scope of authority.
(d) A proc...
Credentialing and Recredentialing. Contractor shall implement, and maintain written policies and procedures concerning the initial credentialing, re-credentialing, recertification, and reappointment of Network Providers, developed by the Department in accordance with 42 CFR 438.214 and APL 16-012, and including but not limited to: Primary Care Physicians (PCPs); Specialists; Providers for acute, behavioral health, and substance use disorders; and MLTSS Providers as appropriate per the requirements in Exhibit A, Attachment 21, Managed Long Term Services and Supports, Provision 4, Provider Network. Contractor shall ensure those policies and procedures are reviewed and approved by the governing body, or designee. Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body.
Credentialing and Recredentialing. 2.1 By virtue of the PPO Agreement and this Addendum A, Ameritas hereby delegates to Dentist and Dentist agrees to perform the credentialing/ recredentialing functions for the Additional Providers in accordance with Ameritas’ credentialing or recredentialing requirements (“Ameritas Credentialing Policies”), as the same may be updated by Ameritas from time to time upon notice to Dentist. Notwithstanding such delegation, Ameritas retains the ultimate credentialing decision. Dentist shall maintain current and complete credentialing files for each of the Additional Providers as required by Ameritas Credentialing Policies. Dentist may further delegate all or any part of its credentialing responsibility to another party only with Ameritas’ prior written consent.
2.2 Dentist agrees that for the term of this PPO Agreement, all Additional Providers shall meet all requirements set forth in Ameritas Credentialing Policies. Upon request, Dentist shall promptly confirm the complete credentialing status of an Additional Provider in writing (if requested) and provide to Ameritas in a timely manner the information necessary for Ameritas to make a decision regarding the PPO network status of a particular Additional Provider. In the event an Additional Provider does not continue to meet the Ameritas Credentialing Policies, Dentist shall notify Ameritas as soon as reasonably possible after becoming aware of such noncompliance. Such Additional Provider shall immediately cease rendering services to Covered Persons. Notwithstanding anything herein or any subsequently adopted procedure to the contrary, Ameritas reserves the right to terminate, suspend, revoke, or reduce any Additional Provider’s participation in the Ameritas PPO as provided in Ameritas Credentialing Policies, and Dentist agrees to cooperate with Ameritas to implement the foregoing.
2.3 Dentist shall promptly notify Ameritas of any material change in the Dentist’s ability to perform delegated credentialing. Ameritas may withdraw the delegation set forth in this Addendum A at any time upon advance written notice to Dentist.
2.4 Ameritas is responsible for the oversight of its delegated credentialing functions. As such, Ameritas shall have the right to verify Dentist’s continuous compliance with Ameritas’ Credentialing Policies either through surveys to be completed by Dentist or otherwise require Dentist to submit periodic reports to Ameritas regarding the performance of its delegated credentialing responsibilitie...
Credentialing and Recredentialing. Contractor shall develop and maintain written policies and procedures that include initial credentialing, recredentialing, recertification, and reappointment of physicians including PCPs and specialists in accordance with the DHCS Policy Letter 02-03, check to see if a provider is suspended or excluded suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from the Medi- Cal program pursuant to WIC section 14043.61 and 42 C.F.R.
2.10.5.1.1. Contractor shall ensure those policies and procedures are reviewed and approved by the plan governing body, or designee.
2.10.5.1.2. Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body.
Credentialing and Recredentialing. Contractor shall develop and maintain written policies and procedures that include initial credentialing, recredentialing, recertification, and reappointment of physicians including Primary Care Physicians and specialists in accordance with the MMCD Policy Letter 02-03, Credentialing and Recredentialing. Contractor shall ensure those policies and procedures are reviewed and approved by the governing body, or designee. Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body.
Credentialing and Recredentialing. Contractor, or Subcontractor on behalf of Contractors, shall develop and maintain written policies and procedures that include initial credentialing, recredentialing, recertification, and reappointment of physicians including Primary Care Physicians (PCP).
Credentialing and Recredentialing. Contractor shall develop, and maintain written policies and procedures that include initial credentialing, recredentialing, recertification, and reappointment of Physicians including Primary Care Physicians and specialists in accordance with the MMCD Policy Letter 02-03, Credentialing and Recredentialing. Contractor shall ensure those policies and procedures are reviewed and approved by the governing body, or designee. Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body.
A. Standards All providers of Covered Services must be qualified in accordance with current applicable legal, professional, and technical standards and appropriately licensed, certified or registered. All providers must have good standing in the Medicare and Medicaid/Medi-Cal programs. Providers that have been terminated from either Medicare or Medicaid/Medi-Cal cannot participate in Contractor’s provider network.
B. Delegated Credentialing Contractor may delegate credentialing and recredentialing activities. If Contractor delegates these activities, Contractor shall comply with provision 6. Delegation of Quality Improvement Activities, above.
C. Credentialing Provider Organization Certification Contractor and their subcontractors (e.g. a medical group or independent physician organization) may obtain credentialing provider organization certification (POC) from the National Committee on Quality Assurance (NCQA). Contractor may accept evidence of NCQA POC certification in lieu of a monitoring visit at delegated physician organizations.
Credentialing and Recredentialing. Contractor shall ensure the qualifications of all network practitioners, approve new providers and sites, and terminate or suspend individual providers. Contractor shall develop, and maintain written policies and procedures which include initial Credentialing, recredentialing, recertification, and reappointment of providers. Contractor shall ensure that policies and procedures are reviewed and approved by the governing body, or its designee. Contractor shall ensure that the responsibility for recommendations regarding Credentialing decisions shall rest with a Credentialing committee or other peer review body.
