Common use of PROVIDER APPLICATION REVIEW PROCESS Clause in Contracts

PROVIDER APPLICATION REVIEW PROCESS. a. All credentialing and re-credentialing applications shall be reviewed by CONTRACTOR. Providers with identified adverse issues shall be asked to provide a written explanation prior to CONTRACTOR review. In addition, CONTRACTOR shall maintain P&Ps for altering the conditions of the practitioner’s participation in the network based on issues of the quality of care and service that may arise after completing the credentialing process. Such P&Ps shall be provided to ADMINISTRATOR, upon request. Decisions to alter or terminate a provider’s participation in the network shall be made by CONTRACTOR. Providers with identified quality of care or service concerns shall be presented to the Peer Review Committee established by CONTRACTOR. Providers shall be advised in advance of the identified problems and shall be invited to respond in writing to the issues to go before the Peer Review Committee. The provider’s response, along with any additional documentation supplied by CONTRACTOR, shall be reviewed by the Peer Review Committee. The Peer Review Committee may recommend that no action be taken, that the provider be issued a Corrective Action Plan, or that the provider be terminated from the network. b. CONTRACTOR shall provide notice and a fair hearing to CONTRACTOR’s Network Providers, as required under applicable state and federal law, or at the discretion of CONTRACTOR’s Medical Director, in any case in which action is proposed to be taken by CONTRACTOR to restrict, suspend or terminate the Network Provider’s ability to provide health care services to Beneficiaries for reasons relating to deficiencies in quality of care, professional competence, or professional conduct which affects or could adversely affect the health, safety or welfare of any Beneficiaries and/or is reasonably likely to be detrimental to the delivery of quality care. If CONTRACTOR takes adverse action against a provider based on a quality-of-care issue, CONTRACTOR shall report as required by state and federal agencies and as required by the NPDB. c. ADMINISTRATOR shall be notified of any providers required to submit a Corrective Action Plan, or terminated as the result of a quality-of-care issue, within fourteen (14) calendar days of such action. The quality-of-care issue shall also be summarized and included with the notification.

PROVIDER APPLICATION REVIEW PROCESS. a. All credentialing and re-credentialing applications shall be reviewed by CONTRACTOR. Providers with identified adverse issues shall be asked to provide a written explanation prior to CONTRACTOR review. In addition, CONTRACTOR shall maintain P&Ps for altering the conditions of the practitioner’s participation in the network based on issues of the quality of care and service that may arise after completing the credentialing process. Such P&Ps shall be provided to ADMINISTRATOR, upon request. Decisions to alter or terminate a provider’s participation in the network shall be made by CONTRACTOR. Providers with identified quality of care or service concerns shall be presented to the Peer Review Committee established by CONTRACTOR. Providers shall be advised in advance of the identified problems and shall be invited to respond in writing to the issues to go before the Peer Review Committee. The provider’s response, along with any additional documentation supplied by CONTRACTOR, shall be reviewed by the Peer Review Committee. The Peer Review Committee may recommend that no action be taken, that the provider be issued a Corrective Action Plan, or that the provider be terminated from the network. b. CONTRACTOR shall provide notice and a fair hearing to CONTRACTOR’s Network Providers, as required under applicable state and federal law, or at the discretion of CONTRACTOR’s Medical Director, in any case in which action is proposed to be taken by CONTRACTOR to restrict, suspend or terminate the Network Provider’s ability to provide health care services to Beneficiaries Clients for reasons relating to deficiencies in quality of care, professional competence, or professional conduct which affects or could adversely affect the health, safety or welfare of any Beneficiaries Client and/or is reasonably likely to be detrimental to the delivery of quality care. If CONTRACTOR takes adverse action against a provider based on a quality-of-care issue, CONTRACTOR shall report as required by state and federal agencies and as required by the NPDB. c. ADMINISTRATOR shall be notified of any providers required to submit a Corrective Action Plan, or terminated as the result of a quality-of-care issue, within fourteen (14) calendar days of such action. The quality-of-care issue shall also be summarized and included with the notification.