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.