Common use of Credentialing and Recredentialing Clause in Contracts

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 process which provides for the verification of the credentialing and recredentialing criteria required under this Contract. (e) Approval of new Providers and imposition of sanctions, termination, suspension and restrictions on existing Providers. (f) Identification of quality deficiencies which result in the Health Plan's restriction, suspension, termination or sanctioning of a Provider. (5) The credentialing and recredentialing processes must also include verification of the following additional requirements for physicians and must ensure compliance with 42 CFR 438.214: (a) Good standing of privileges at the Hospital designated as the primary admitting facility by the PCP or if the PCP does not have admitting privileges, good standing of privileges at the Hospital by another Provider with whom the PCP has entered into an arrangement for Hospital coverage. (b) Valid Drug Enforcement Administration (DEA) certificates, where applicable. (c) Attestation that the total active patient load (all populations with Medicaid FFS, CMS Network, HMO, Health Plan, Medicare and commercial coverage) is no more than 3,000 patients per PCP. An active patient is one that is seen by the Provider a minimum of three (3) times per year. (d) A good standing report on a site visit survey. For each PCP and OB/GYN Provider, documentation in the Health Plan’s credentialing files regarding the site survey shall include the following: i. Evidence that the Health Plan has evaluated the Provider's facilities using the Health Plan's organizational standards. ii. Evidence that the Health Plan has evaluated the Provider's medical record keeping practices at each site to ensure conformity with the Health Plan's organizational standards. iii. Evidence that the Health Plan has determined that the following documents are posted in the Provider's waiting room/reception area: the Agency’s statewide consumer call center telephone number, including hours of operation and a copy of the summary of Florida’s Patient’s Xxxx of Rights and Responsibilities, in accordance with Section 381.026, F.S.; the Provider has a complete copy of the Florida Patient’s Xxxx of Rights and Responsibilities, available upon request by an Enrollee, at each of the Provider's offices. iv. The Provider's waiting room/reception area has a consumer assistance notice prominently displayed in the reception area in accordance with Section 641.511, F.S. (e) Attestation to the correctness/completeness of the Provider's application. (f) Statement regarding any history of loss or limitation of privileges or disciplinary activity as described in Section 456.039, F.S. (g) A statement from each Provider applicant regarding the following: i. Any physical or mental health problems that may affect the Provider's ability to provide health care; ii. Any history of chemical dependency/substance abuse; iii. Any history of loss of license and/or felony convictions; and iv. The Provider is eligible to become a Medicaid provider. (h) Current curriculum vitae, which includes at least five (5) years of work history. (6) The Health Plan shall recredential its Providers at least every three (3) years. (7) The Health Plan shall develop and implement an appeal procedure for Providers against whom the Health Plan has imposed sanctions, restrictions, suspensions and/or terminations. (8) The Health Plan shall submit a Provider Network for initial or expansion review to the Agency for approval only when the Health Plan has satisfactorily completed the minimum standards required in Section VII, Provider Network and the minimum credentialing steps required in Section VIII.A.3.h.(2), (3) and (5).

Credentialing and Recredentialing. (See Attachment II, Exhibit 7) 1) . The Health Plan shall be responsible for the credentialing and recredentialing of its Provider provider network. Hospital ancillary Providers providers are not required to be independently credentialed if those Providers only provide services to the providers serve Health Plan Enrollees enrollees only through the Hospitalhospital. (2) . The Health Plan shall establish and verify credentialing and recredentialing criteria for all professional Providers providers that, at a minimum, meet the Agency's Medicaid participation standardsstandards and shall document that such standards are met. The Agency’s criteria includesinclude: (a) a. A copy of each Providerprovider's current medical license pursuant to Section s. 641.495, F.SF.S.; (b) b. No receipt of revocation or suspension of the Providerprovider's State License 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 c. A satisfactory Level II background check with the Florida Department of Law Enforcement (FDLE) pursuant to s. 409.907, F.S., for all treating providers not currently enrolled in Medicaid’s Feefee-for-Service service program.; (i1) Upon Agency notice of implementation of a managed care electronic background screening verification process, the Health Plan shall verify the provider’s Medicaid eligibility through the Agency’s electronic background screening system. If the provider’s fingerprints are not retained in the Care Provider Background Screening Clearinghouse (see s. 435.12, F.S.) and/or eligibility results are not found, the Health Plan shall submit complete sets of the provider’s fingerprints electronically for Medicaid Level II screening following the WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract appropriate process described on the Agency’s background screening website. Until such process is implemented, the Health Plan may, for providers exempt from the criminal background screening requirements, accept a copy of the screen print of the Providerprovider’s current Department of Health licensure status and with the exemption reason must be included.included as documentation; (ii2) The Health Plan shall not contract with any Provider 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 435.03s. 435.04, F.S.; (e3) Individuals already screened as Medicaid providers or screened within the past twelve (12) months by the Agency or another Florida agency or department using the same criteria as Medicaid are not required to submit fingerprints electronically but shall document the results of the previous screening to the Health Plan; (4) Individuals listed in s. 409.907(8)(a), F.S., for whom criminal history background screening cannot be documented must provide fingerprint cards or, upon Agency notice of implementation of a managed care electronic background screening verification process, must provide fingerprints electronically following the Medicaid managed care applicable process described on the Agency’s background screening website. d. Disclosure related to ownership and management (42 CFR 455.104), business transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106); e. Proof of the Providerprovider'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) f. Evidence of specialty board certification, if applicable.; (g) g. Evidence of the Providerprovider's professional liability claims history.; (h) h. Any sanctions imposed on the Provider provider by Medicare or Medicaid; and i. The provider’s Medicaid ID number, Medicaid provider registration number or documentation of submission of the Medicaid provider registration form. (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 provider rendering Behavioral Health Servicesbehavioral health services. (4) . The Health Plan's credentialing and recredentialing policies and procedures shall be in writing and include the following: (a) a. Formal delegations and approvals of the credentialing process.; (b) b. A designated credentialing committee.; (c) c. Identification of Providers providers who fall under its scope of authority.; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (d) d. A process which that provides for the verification of the credentialing and recredentialing criteria required under this Contract.; (e) e. Approval of new Providers providers and imposition of sanctions, termination, suspension and restrictions on existing Providers.providers; and (f) f. Identification of quality deficiencies which that result in the Health Plan's restriction, suspension, termination or sanctioning of a Providerprovider. (5) . The credentialing and recredentialing processes must also include verification of the following additional requirements for physicians and must ensure compliance with 42 CFR 438.214: (a) a. Good standing of privileges at the Hospital hospital designated as the primary admitting facility by the PCP physician or if the PCP physician does not have admitting privileges, good standing of privileges at the Hospital hospital by another Provider provider with whom the PCP provider has entered into an arrangement for Hospital hospital coverage.; (b) b. Valid Drug Enforcement Administration (DEA) certificates, where applicable.; (c) c. Attestation that the total active patient load (all populations with Medicaid FFS, CMS Children’s Medical Services Network, HMO, Health PlanPSN, Medicare and commercial coverage) is no more than 3,000 patients per PCP. An active patient is one that is seen by the Provider provider a minimum of three (3) times per year.; (d) d. A good standing report on a site visit survey. For each PCP and OB/GYN ProviderPCP, documentation in the Health Plan’s credentialing files regarding the site survey shall include the following: i. (1) Evidence that the Health Plan has evaluated the Providerprovider's facilities using the Health Plan's organizational standards.; ii. (2) Evidence that the provider’s office meets criteria for access for persons with disabilities and that adequate space, supplies, proper sanitation, smoke-free facilities, and proper fire and safety procedures are in place; (3) Evidence that the Health Plan has evaluated the Providerprovider's medical record keeping practices at each site to ensure conformity with the Health Plan's organizational standards.; iii. (4) Evidence that the Health Plan has determined that the following documents are posted in the Providerprovider's waiting room/reception area: the Agency’s statewide consumer call center telephone number, including hours of operation operation, and a copy of the summary of Florida’s Patient’s Xxxx of Rights and Responsibilities, in accordance with Section s. 381.026, F.S.; the Provider has F.S. The provider must have a complete copy of the Florida Patient’s Xxxx of Rights and Responsibilities, available upon request by an Enrolleeenrollee, at each of the Providerprovider's offices.; iv. The Provider's waiting room/reception area has a consumer assistance notice prominently displayed in the reception area in accordance with Section 641.511, F.S. (e) e. Attestation to the correctness/completeness of the Providerprovider's application.; (f) f. Statement regarding any history of loss or limitation of privileges or disciplinary activity as described in Section s. 456.039, F.S.; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (g) g. A statement from each Provider provider applicant regarding the following: i. (1) Any physical or mental health problems that may affect the Providerprovider's ability to provide health care; ii. (2) Any history of chemical dependency/substance abuse; iii. (3) Any history of loss of license and/or felony convictions; and iv. (4) The Provider provider is eligible to become a Medicaid provider.; (h) h. Current curriculum vitae, which includes at least five (5) years of work history. (6) . The Health Plan shall recredential its Providers providers at least every three (3) years. (7) . The Health Plan shall develop and implement an appeal procedure for Providers providers against whom the Health Plan has imposed sanctions, restrictions, suspensions and/or terminations. (8) 8. The Health Plan shall submit a Provider Network for initial or expansion review disclosures and notifications to the Agency for approval only when federal Department of Health and Human Services (DHHS) Office of the Health Plan has satisfactorily completed Inspector General (OIG) and to MPI in accordance with s. 1128, s. 1156, and s. 1892, of the minimum standards required Social Security Act, 42 CFR 455.106, 42 CFR 1002.3, and 42 CFR 1001.1, as described in Section VIIX, Provider Network E.,11., Fraud and the minimum credentialing steps required in Section VIII.A.3.h.(2)Abuse Prevention, (3) and (5)of this Contract.

Credentialing and Recredentialing. (See Attachment II, Exhibit 7) 1) . The Health Plan shall be responsible for the credentialing and recredentialing of its Provider provider network. Hospital ancillary Providers providers are not required to be independently credentialed if those Providers only provide services to the providers serve Health Plan Enrollees enrollees only through the Hospitalhospital. (2) . The Health Plan shall establish and verify credentialing and recredentialing criteria for all professional Providers providers that, at a minimum, meet the Agency's Medicaid participation standardsstandards and shall document that such standards are met. The Agency’s criteria includesinclude: (a) a. A copy of each Providerprovider's current medical license pursuant to Section s. 641.495, F.SF.S.; (b) b. No receipt of revocation or suspension of the Providerprovider's State License 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 c. A satisfactory Level II background check with the Florida Department of Law Enforcement (FDLE) pursuant to s. 409.907, F.S., for all treating providers not currently enrolled in Medicaid’s Feefee-for-Service service program.; (i1) Upon Agency notice of implementation of a managed care electronic background screening verification process, the Health Plan shall verify the provider’s Medicaid eligibility through the Agency’s electronic background screening system. If the provider’s fingerprints are not retained in the Care Provider Background Screening Clearinghouse (see s. 435.12, F.S.) and/or eligibility results are not found, the Health Plan shall submit complete sets of the provider’s fingerprints electronically for Medicaid Level II screening following the WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract appropriate process described on the Agency’s background screening website. Until such process is implemented, the Health Plan may, for providers exempt from the criminal background screening requirements, accept a copy of the screen print of the Providerprovider’s current Department of Health licensure status and with the exemption reason must be included.included as documentation; (ii2) The Health Plan shall not contract with any Provider 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 435.03s. 435.04, F.S.; (e3) Individuals already screened as Medicaid providers or screened within the past twelve (12) months by the Agency or another Florida agency or department using the same criteria as Medicaid are not required to submit fingerprints electronically but shall document the results of the previous screening to the Health Plan; (4) Individuals listed in s. 409.907(8)(a), F.S., for whom criminal history background screening cannot be documented must provide fingerprint cards or, upon Agency notice of implementation of a managed care electronic background screening verification process, must provide fingerprints electronically following the Medicaid managed care applicable process described on the Agency’s background screening website. d. Disclosure related to ownership and management (42 CFR 455.104), business transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106); e. Proof of the Providerprovider'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) f. Evidence of specialty board certification, if applicable.; (g) g. Evidence of the Providerprovider's professional liability claims history.; (h) h. Any sanctions imposed on the Provider provider by Medicare or Medicaid; and i. The provider’s Medicaid ID number, Medicaid provider registration number or documentation of submission of the Medicaid provider registration form. (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 provider rendering Behavioral Health Servicesbehavioral health services. (4) . The Health Plan's credentialing and recredentialing policies and procedures shall be in writing and include the following: (a) a. Formal delegations and approvals of the credentialing process.; (b) b. A designated credentialing committee.; (c) c. Identification of Providers providers who fall under its scope of authority.; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (d) d. A process which that provides for the verification of the credentialing and recredentialing criteria required under this Contract.; (e) e. Approval of new Providers providers and imposition of sanctions, termination, suspension and restrictions on existing Providers.providers; and (f) f. Identification of quality deficiencies which that result in the Health Plan's restriction, suspension, termination or sanctioning of a Providerprovider. (5) . The credentialing and recredentialing processes must also include verification of the following additional requirements for physicians and must ensure compliance with 42 CFR 438.214: (a) a. Good standing of privileges at the Hospital hospital designated as the primary admitting facility by the PCP physician or if the PCP physician does not have admitting privileges, good standing of privileges at the Hospital hospital by another Provider provider with whom the PCP provider has entered into an arrangement for Hospital hospital coverage.; (b) b. Valid Drug Enforcement Administration (DEA) certificates, where applicable.; (c) c. Attestation that the total active patient load (all populations with Medicaid FFS, CMS Children’s Medical Services Network, HMO, Health PlanPSN, Medicare and commercial coverage) is no more than 3,000 patients per PCP. An active patient is one that is seen by the Provider provider a minimum of three (3) times per year.; (d) d. A good standing report on a site visit survey. For each PCP and OB/GYN ProviderPCP, documentation in the Health Plan’s credentialing files regarding the site survey shall include the following: i. (1) Evidence that the Health Plan has evaluated the Providerprovider's facilities using the Health Plan's organizational standards.; ii. (2) Evidence that the provider’s office meets criteria for access for persons with disabilities and that adequate space, supplies, proper sanitation, smoke-free facilities, and proper fire and safety procedures are in place; (3) Evidence that the Health Plan has evaluated the Providerprovider's medical record keeping practices at each site to ensure conformity with the Health Plan's organizational standards.; iii. (4) Evidence that the Health Plan has determined that the following documents are posted in the Providerprovider's waiting room/reception area: the Agency’s statewide consumer call center telephone number, including hours of operation operation, and a copy of the summary of Florida’s Patient’s Xxxx Bxxx of Rights and Responsibilities, in accordance with Section s. 381.026, F.S.; the Provider has F.S. The provider must have a complete copy of the Florida Patient’s Xxxx Bxxx of Rights and Responsibilities, available upon request by an Enrolleeenrollee, at each of the Providerprovider's offices.; iv. The Provider's waiting room/reception area has a consumer assistance notice prominently displayed in the reception area in accordance with Section 641.511, F.S. (e) e. Attestation to the correctness/completeness of the Providerprovider's application.; (f) f. Statement regarding any history of loss or limitation of privileges or disciplinary activity as described in Section s. 456.039, F.S.; WellCare of Florida, Inc., Medicaid HMO Non-Reform Contract (g) g. A statement from each Provider provider applicant regarding the following: i. (1) Any physical or mental health problems that may affect the Providerprovider's ability to provide health care; ii. (2) Any history of chemical dependency/substance abuse; iii. (3) Any history of loss of license and/or felony convictions; and iv. (4) The Provider provider is eligible to become a Medicaid provider.; (h) h. Current curriculum vitae, which includes at least five (5) years of work history. (6) . The Health Plan shall recredential its Providers providers at least every three (3) years. (7) . The Health Plan shall develop and implement an appeal procedure for Providers providers against whom the Health Plan has imposed sanctions, restrictions, suspensions and/or terminations. (8) 8. The Health Plan shall submit a Provider Network for initial or expansion review disclosures and notifications to the Agency for approval only when federal Department of Health and Human Services (DHHS) Office of the Health Plan has satisfactorily completed Inspector General (OIG) and to MPI in accordance with s. 1128, s. 1156, and s. 1892, of the minimum standards required Social Security Act, 42 CFR 455.106, 42 CFR 1002.3, and 42 CFR 1001.1, as described in Section VIIX, Provider Network E.,11., Fraud and the minimum credentialing steps required in Section VIII.A.3.h.(2)Abuse Prevention, (3) and (5)of this Contract.