Saturday, January 20, 2018       
     
 
Clients
 
     
     
 
Members

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  Credentialing Policies  

Cyan.jpgCredentialing and recredentialing standards are developed by MHNet’s Corporate Credentialing Department and are based on NCQA and URAC guidelines.  MHNet’s policies for verification of the information are detailed below.

Practitioner must supply MHNet with the following information:

  • Practice and billing location addresses
  • Information on practice hours
  • After hours coverage
  • Malpractice insurance coverage
  • Limits and expiration date
  • Licensure information and information regarding education and training
  • Statement regarding physical and mental health status
  • Statement regarding lack of impairment due to chemical dependency/substance abuse
  • History of loss of license and/or felony convictions
  • History of loss or limitation of privileges or disciplinary activity
  • Resume or CV demonstrating a minimum of five years of work history
  • Sub-specialty questionnaire for referrals
  • Release of information form
  • Practitioner agreement and all applicable exhibits and completed W-9

 

MHNet will verify the following information through primary sources:

  • License
  • DEA/CDS
  • Education/Training
  • Board Certification
  • Work History
  • Malpractice claims history

 

MHNet will request the following information from additional organizations:

  • Sanctions, restrictions or limitations on licensure
  • Information on previous sanction activity by Medicare and Medicaid
  Site Visits  

Green.jpgThe Regional Provider Relations or Clinical Director conducts pre-contractual office site visits for all practitioners who are determined to be a potential high volume practitioner.  Potential high volume specialists are selected based on:

  • The practitioner is in a unique geographical location (i.e. rural) and is anticipated to receive a high-volume of referrals.
  • The practitioner has identified him/herself as being able to address a particular member need or preference (e.g. language, cultural background, race, etc.), which is expected to generate a high-volume of referrals.
  • As determined by the Regional Executive Director, the practitioner is anticipated to receive a high-volume of referrals (e.g. new business is anticipated in a particular area).

 

Actual high volume practitioners are identified by a utilization report called the High Volume Report, which represents the top 10% of unique referrals based on claims data.

 

The site visit includes an assessment of the following areas:

  • Physical accessibility
  • Physical appearance
  • Adequacy of waiting and treatment room space
  • Availability of appointments
  • Adequacy of treatment record keeping practices
  • Maintenance of confidentiality of treatment records

 

Site visit results are included in the credentialing decision.

  Recredentialing  

Orange.jpgRecredentialing occurs once every 3 years.  The recredentialing process mirrors the credentialing process in most cases.  Additionally, a site visit will be conducted if the provider has moved or changed office locations.

The recredentialing process for high-volume practitioners differs slightly from the standard credentialing process.  MHNet conducts an examination of utilization reports and complaint information for each practitioner.  If further examination is deemed necessary, MHNet will review information from:

  • Member complaints about the practitioner or his or her office
  • Presence or absence of sentinel events
  • Results from under or over utilization monitoring
  • Administrative concerns related to compliance with contractual obligations
  Suspending, Terminating and Reducing Practitioner Privileges  

Purple.jpgThe following actions must be reported:

  • Professional review action based on a practitioner’s professional competence or professional conduct that adversely effects his/her clinical privileges for a period of more than 30 days
  • Acceptance of the surrender or restriction of clinical privileges while the practitioner is under investigation by the hospital or health care entity relating to possible professional incompetence or improper professional conduct 

Only final actions are reported.  A final, reportable action occurs when the Corporate Credentials Committee makes a final decision on the course of action to be taken after considering all available information including the report of any appeal hearing panel, if such was convened.  MHNet’s legal counsel reviews all action prior to reporting.

 

The information must be reported within seven days of the adverse action being taken.

 

For final, reportable actions, reports are made to:

  • The Health Plan
  • National Practitioner Data Bank
  • Appropriate state licensing or regulatory agencies

A practitioner can appeal any decision and a hearing will be conducted within 30 days.

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