i. policy persons/departments ... - health essentials...
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Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 1
I. POLICY All licensed practitioners and providers who practice independently and who desire to
become a participating practitioner or provider in the network will undergo the
credentialing process prior to contracting.
II. PERSONS/DEPARTMENTS AFFECTED A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Quality Improvement
E. Provider Network Management
F. Administration
G. Utilization and Case Management
III. PURPOSE
A. To make certain that practitioners and providers meet initial credentialing standards
prior to network participation.
B. To develop and adopt health plan specific credentialing and recredentialing standards
based on the National Committee for Quality Assurance (NCQA), the Centers for
Medicare and Medicaid Services (CMS) and applicable state regulations. These
standards provide a standardized methodology for admission to the network.
C. To describe the process for “provisional” credentialing whereby a physician can
practice as a health care provider with while his/her application for standard
credentialing is reviewed. A practitioner may be provisionally credentialed during
the initial credentialing process and only under certain circumstances.
1. Provisional credentialing is granted on an occasional basis when it is in
the best interest of members to make a practitioner available prior to
completion of the entire initial credentialing process;
2. A practitioner may be provisionally credentialed only once;
3. Practitioners who were previously in a delegated entity are not eligible
for provisional credentialing;
4. Provisional credentialing may not exceed a period of 60 days.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 2
D. The Credentialing Committee will review all credentialing policies and procedures
annually and revise such standards as necessary in the first quarter of each calendar
year.
Scope of Practitioners:
A. All practitioners and providers who practice independently shall be initially
credentialed and recredentialed at least every 36 months, including the following:
1. Medical Doctor (MD)
2. Doctor of Osteopathic Medicine (DO)
3. Podiatrist (DPM)
4. Chiropractor (DC)
5. Dentist (DDS/Oral Surgeons who provide care under the organization’s
medical benefits and DMD only)
6. Behavioral Health practitioners to include
1. Doctoral or master’s-level psychologists who are state certified or state
licensed
2. Master’s-level clinical nurse specialists or psychiatric nurse practitioners
who are nationally or state certified or state licensed
B. Please refer to Policy and Procedure number CR 02, Allied Health Practitioners
Exceptions:
Practitioners who do not need to be credentialed by HealthEssentials, LLC or its
delegated entity or its affiliates (collectively, “Health Essentials”) includes the following:
A. Practitioners who do not have an independent relationship with Health
Essentials
B. Practice exclusively within the inpatient setting and who provide care to plan
members only as a result of members being directed to the inpatient setting,
such as
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 3
1. Pathologists
2. Radiologists
3. Anesthesiologist
4. Neonatologists
5. Emergency department physicians
6. Telemedicine consultants
C. Practice exclusively within freestanding facilities and who provide care to
plan members only as a result of members being directed to the facility such
as
1. Mammography centers
2. Urgent-care centers
3. Surgicenters
4. Ambulatory behavioral health care facilities
5. Psychiatric and addiction disorder clinics
D. Dentists who provide primary dental care only
1. Endodontists
2. Oral surgeons
3. Periodontists
E. Covering practitioners (i.e.: locum tenens)
F. Practitioners who do not provide care for members in a treatment center such
as University faculty who are hospital based
IV. PROCEDURE
Procedure for Initial Credentialing
A. All applicants shall have identified documents verified at the primary source.
Verification sources that are acceptable include the following:
1. A primary source or entity that originally conferred or issued the license or
credential;
2. A contracted agent of the primary source;
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 4
3. Should a contracted agent of the primary source be used, a letter will be obtained
from the primary source which validates and indicates the contractual relationship
4. Other sources that are accepted by the National Committee for Quality Assurance
(NCQA) or the Centers for Medicare and Medicaid Services (CMS);
5. The National Student Clearinghouse (NSC) is not recognized as a source for
verification of education and training;
a. The NSC would be considered an agent of the medical or professional school
if the school has a contract with the Clearinghouse to provide verification
services. Should an occasion arise for the need of the NSC, documentation
that the specific school has a contract with the Clearinghouse would be
obtained.
B. The organization may or may not choose to delegate specific activities of the
credentialing and recredentialing process.
1. In the event any credentialing or recredentialing activity is delegated to another
source, a written delegation agreement shall be established
a. Will be mutually agreed upon
b. Will define activities to be delegated
c. Will describe responsibilities of the organization and those of the
delegated entity
d. Will define required reporting to the organization, at least on a semi-
annual basis
e. Will describe remedies in the event the delegated entity does not fulfill its
obligations, which shall include terms of revocation of the delegation
agreement
f. Will outline the process by which the organization evaluates the
performance of the delegated entity
g. In the event that a Credentials Verification Organization (CVO) is
delegated for primary source verification, the CVO shall be accredited by
NCQA and shall maintain active accreditation status throughout the
delegation agreement
h. No delegated entity may sub-delegate activities without the written
approval of the organization
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 5
i. The delegation arrangement shall address and include the handling and use
of protected health information (PHI) by the delegate, to include
safeguards, use, handling, informing the organization of inappropriate use
and destruction of PHI
j. The organization shall retain the right to approve, suspend and/or
terminate individual practitioners when and if delegated decision making
is made to another party
k. In the event that delegation is to be granted, a pre-delegation review shall
be conducted by the organization to assess compliance of programs and
policies and procedures before delegation may begin
l. At least every 12 months, the organization shall audit the delegate based
on NCQA standards, CMS regulations, state requirements and
requirements specific to the organization for compliance
m. In the case where the delegate is NCQA accredited, such as a CVO or
NCQA certified for Credentialing, such as an IPA or Medical Group, the
pre-delegation review and the annual audit may be waived at the
discretion of the organization
n. At least every six (6) months, the delegated entity shall submit a report of
the outcomes of delegated activities. Reports shall include progress in
conducting the delegated activities and progress on performance
improvement activities if applicable
B. For those delegates not NCQA accredited or certified, in the event that delegate does
not pass the pre-delegation audit or annual audit, opportunities for improvement
will be identified and documented in a corrective action plan for the delegated
entity
C. Each practitioner shall have a separate and distinct file, which may be maintained in
hard copy or in electronic copy. Documentation in the file shall include, but will not
be limited to the following:
1. When verbal verification is received by Health Essentials or designee, Health
Essentials or designee staff who verified the credentials will date, sign or initial
and note the credentials that were verified.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 6
2. When written verification in the form of a letter or report is received by Health
Essentials or designee, the date of the letter or report, not the receipt date, will be
used in the credentialing or recredentialing process. Health Essentials or designee
staff person who verified the credentials shall sign or initial the verification. The
document must be date stamped as to the date received.
3. When internet or other electronic verification is received by Health Essentials or
designee the date generated by the source when the information is retrieved. If
the source report does not generate a date, the date stamp that is documented by
the staff person who verified the credentials shall be used. The staff who verified
the credentials must sign or initial the verification
4. When applications and supporting documentation are received via the Council for
Affordable Quality Healthcare’s (CAQH’s) Universal Provider Datasource, the
date of the electronic reattestation signature will be used in the credentialing or
recredentialing process. This applies to the date of the attestation as well as any
information such a malpractice insurance that is verified through the application
attestation.
5. If Health Essentials or designee may choose to use an automated credentialing
system, there will be a distinct process for the use of electronic signatures or
unique electronic identifiers.
6. If applicable, will maintain a copy of date stamped, valid DEA or DCS certificate
D. In order to make credentialing decisions, Health Essentials or designee uses a
Credentialing Committee to review the credentials of practitioners, using the
following criteria:
1. When practitioners have a “clean record”, being no adverse findings such as
malpractice cases, licensing issues, quality of care or service concerns, etc., the
committee shall approve at the recommendation of the Medical Director.
2. The Credentialing Committee shall review and make a determination to approve,
deny or terminate practitioners based on peer review of any applicant who does
not have a completely “clean” practice history. The Credentialing Committee
shall be guided by the attached Credentialing Committee Grid (Annex “1”) in
discussing any issues of credentialing or recredentialing applicants.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 7
E. A Medical Director from Health Essentials shall be responsible for oversight of the
credentialing process
F. Credentialing considerations submitted to the Credentials Committee include time
sensitive information. Various time-constraints include the following:
1. Validation of licensure – verify within 180 calendar days of the decision
2. DEA/CDS – no time limit for verification prior to decision
3. Education and Training – no time limit for verification prior to decision
4. Board Certification – verify within 180 calendar days of the decision
5. Malpractice History – verify within 180 calendar days of the decision
6. Work History – verify within 180 calendar days of the decision
7. Attestation – verify within 365 calendar days of the decision, however specific to
CMS Medicare, the attestation time limit is 180 days
G. Should information received from the applicant practitioner vary from the
information obtained during Health Essentials credentialing process, the practitioner
shall be notified and given the opportunity to correct his or her self-submitted
information.
H. Health Essentials does not make credentialing or recredentialing decisions based on
an applicant’s race, ethnic or national identity, gender, age, sexual orientation, or
members in which the practitioner specializes.
I. Health Essentials shall monitor compliance with their nondiscriminatory credentialing
requirements through regular review of reasons for all denied or terminated
applicants.
J. Upon written request, Health Essentials shall disclose relevant credentialing criteria
and procedures to health care practitioners that apply to become participating
practitioners or who are already participating.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 8
K. Health Essentials shall notify applicants of credentialing decisions within 60 calendar
dates from the committee’s decision. The notification shall contain a clear rationale
for the decision.
L. Health Essentials or designee follows strict confidentiality practices with the handling
and storage of credentialing and recredentialing information.
1. All information is shared only on a need to know basis with the staff of Health
Essentials.
2. The Confidentiality and Privacy policy and procedure for HealthEssentials is
strictly followed.
3. All files are maintained in a securely locked area.
4. Fax machines which may receive confidential information is not in a public
accessible area.
5. Staff and committee members sign conflict of interests and confidentiality
statements.
6. When files are used at a work station, they are not in the view of others and are
secured when not directly attended.
7. Information stored electronically are password protected.
M. The Credentials Committee shall use a peer review process to make recommendations
regarding credentialing and recredentialing decisions.
1. Voting members shall represent a range of participating practitioners.
2. Specialists shall be available (non-voting) for consultation and peer review
decisions when necessary.
N. Processes are maintained in collaboration with Network and Provider Services to
make certain that listings in the practitioner or provider directors and other materials
for members are consistent with credentialing dates, including education, training,
certification and specialty.
O. Health Essentials shall make certain that members have access, through Health
Essentials, to only those practitioners who have been properly credentialed
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 9
P. Each applicant will complete the appropriate Provider Application and Conditions of
Application, Release and Immunity (Attestation). The dates that the attestation and
application are signed by the applicant must be within the 180 day period prior to
presentation to the Credentialing Committee for action. Providers that utilize CAQH
must have either initially attested or re-attested electronically, as identified on the
provider report, within the 180 day period prior to presentation to the Credentialing
Committee for action.
Q. The application will contain statements regarding:
1. reasons for any inability to perform the essential functions of the position with or
without accommodation;
2. lack of present illegal drug use or impairment due to chemical
dependency/substance abuse;
3. voluntary or involuntary history of loss of license and/or felony convictions;
4. voluntary or involuntary history of loss or limitation of privileges or disciplinary
activity;
5. work history, education, training, hospital privileges;
6. current malpractice insurance coverage;
7. the correctness and completeness of the application.
R. The Credentialing Department will review all applications, and initiate the
verification process. The Credentialing Department will obtain and review
verification of the following from primary sources within the 180 day period prior to
presentation to the Credentialing Committee:
1. A current valid license to practice in the states where the provider provides
services to Plan members;
A. Licensure is verified mid-cycle should the license expire prior to the
scheduled recredentialing cycle
2. A valid DEA or CDS certificate, if applicable;
3. Written verification of the highest level of training obtained by the provider. If the
provider is Board certified, verification will be obtained from the ABMS or the
AOA;
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 10
4. Medicare, Medicaid and NPI numbers;
5. Query of professional liability claims history;
6. Query of the National Practitioner Data Bank (NPDB) and the Healthcare
Integrity and Protection Data Bank (HIPDB);
7. Query of licensure disciplinary history in the state where the Practitioner most
recently practiced;
8. Query of the Office of Inspector General (OIG) sanction activity;
9. Query of the List of Excluded Individuals and Entities (LEIE);
10. Query of the Federation of State Medical Boards (FSMB) data base;
11. Query of the Medicare Opt-Out list; and
12. Query of Sam.gov.
The Credentialing Department will obtain and review verification of the following from
the application and the corresponding attestation within the 180 day period prior to
presentation to the Credentialing Committee:
1. Clinical/admitting privileges in good standing in at least one
participating hospital; Privileges at other participating facilities may be
considered acceptable in lieu of hospital privileges, if approved by the
Credentialing Committee, based on the proposed scope of care to be
provided. Restrictions on privileges will be considered on an individual
basis.
1. Specialties such as Practitioners working exclusively in a
Skilled Nursing Facility or Long Term Care Facility,
Dermatology, Podiatry or Ophthalmology may or may not have
hospital privileges and this must be documented in the file.
2. Verification of current, adequate malpractice insurance
1. It is acceptable for the insurance face sheet to have a future
effective date if it is on or prior to a start date.
S. Initial Credentialing Site Visits are conducted when the PCP practices in a designated
office setting. All primary care practitioners shall meet office site visit standards at
the time of initial credentialing.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 11
1. The quality, safety, record keeping practices, and accessibility of the
office site were care is delivered shall be included in the site visit.
2. Final site visit scores are assessed.
3. When applicable, corrective action plans will be initiated when scoring
thresholds are not met and compliance is re-assessed at least every six
months until deficiencies has been corrected.
4. Should a site visit score as “reasonable complaint”, a re-visit will take
place every 60 calendar days until the deficiency has been corrected
followed by a follow-up site visit with a full assessment to determine
performance standards.
5. Please refer to P&P CR 15 Practitioner Office Site Visits policy and
procedure.
T. When self-reported as board certified, the Board Certification must be verified within
180 days prior of the committee decision. Acceptable boards are limited to the
following:
1.American Board of Medical Specialties (ABMS)
2.American Osteopathic Association (AOA)
3.Canadian Board Certification
T. Education and Training verification has no time limit in which it must be verified.
Health Essentials or designee shall verify the highest of the three levels of education
and training obtained by the practitioner
1. Graduation from medical school
2. Residency
3. Board Certification
U. Work History – must be verified within 180 days prior of the committee decision
1. If Health Essentials or its designee decides to obtain NCQA accreditation,
work history shall be verified within 180 days prior to the credentialing
committee decision.
2. Primary source verification is not required.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 12
3. A curriculum vitae (CV) is required and will be used to verify work
history and must include the beginning and ending month and year for
each position in the employment experience.
4. A gap exceeding six months must be reviewed and clarified by the
applicant and reviewed by the committee.
5. If any information is received by Health Essentials or its designee’s staff,
that staff member shall initial and date the documented conversation.
V. The Credentialing checklist will be initialed by the Credentialing Department. When
the credentialing file is complete, the file will be reviewed by the Medical Director or
designee. The Medical Director will bring the provider file before the Credentialing
Committee where the provider’s credentialing application is reviewed. Pertinent
concerns cited by the reviewer will be discussed by the Credentialing Committee.
.
W. The Credentialing Committee may approve, deny or request further information. At
the time the Committee makes its final decision on an application, all primary source
verifications and the signed Conditions of Application, Release and Immunity must
comply with required time frames.
X. In the event that a provider’s application and/or attachments are incomplete or
inaccurate the applicant remains responsible for the completion of the application or
correcting inaccuracies. The Credentialing Committee will give the applicant ninety
(90) days to provide the information. If the information is not received within ninety
(90) days, the application will be deemed withdrawn.
Y. All credentialing decisions are conducted in a non-discriminatory manner. Refer to
policy and procedure CR 07.
Z. A notice of the Committee’s final decision shall be provided to each applicant by mail
within sixty (60) days. If the Committee denies a provider, the provider will be given
thirty (30) working days from receipt of notification to notify the Committee if they
wish to appear in person to appeal the decision. The provider is notified in writing of
the appeals procedure and that a like specialist will be present once the hearing is
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 13
scheduled. The provider will have an opportunity to appear before the Committee to
provide information concerning the recommendation to terminate or deny
membership.
Procedure for Provisional Credentialing
Provisional credentialing is used in isolated circumstances, taking place in the interest of
members to make practitioners available prior to completion of the entire initial
credentialing process. The following steps must be followed prior to granting provisional
status:
A. Provisional credentialing is granted under limited circumstance which may include,
but not be limited to the following:
1. The need of a specific practitioner to care for a certain member or groups of
members.
2. The need of a practitioner who is meeting the needs of a rural, underserved
geographic area.
3. A practitioner who has recently graduated and is beginning practice.
B. A practitioner may only be provisionally credentialed once.
C. Practitioners who have been in the network via a delegation arrangement are not
eligible for provisional credentialing by Health Essentials if the delegation
arrangement is terminated or if the practitioner is no longer affiliated with the
delegate.
D. A current and signed application with attestation must be completed by the
practitioner. Electronic reattestation dates will be accepted for those providers
utilizing CAQH.
E. Written confirmation of the past five (5) years of malpractice claims and/or
settlements from the malpractice carrier or the results of the National Practitioner
Data Bank (NPDB) or Healthcare Integrity and Protection Databank (HIPDB) query.
F. Primary-source verification of current, valid unrestricted license to practice.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 14
G. Primary source verification of the past five years of malpractice claims or settlements
from the malpractice carrier, or the results of the National Practitioner Data Bank
(NPDB) or Healthcare Integrity and Protection Databank (HIPDB) query
H. Primary-source verifications must be verified within 180 calendar days of the
credentialing decision and the same process for presenting files to the Credentialing
Committee must be followed.
I. Practitioners cannot be held in provisional status for more than 60 calendar days. In
the event the physician does not meet Health Essentials’s credentialing standard
during this 60 day period, the practitioner must be provided the same appeal process
as any other practitioner applying for participation with Health Essentials.
J. Health Essentials shall follow the same process for presenting files to the
Credentialing Committee or medical director as it does for its regular credentialing
process.
1. If the file meets the definition of a “clean file”, the Medical Director or a
designee has the authority to sign off on it as complete, clean & approved and
this sign-off date is the provisional credentialing decision date.
2. Files having deficiencies/issues are reviewed by the Medical Director and the
Peer Review Committee will make a recommendation on whether to grant
provisional credentialing to a practitioner.
Procedure for Recredentialing:
A. Recredentialing will be performed at a maximum of every thirty-six (36) months.
B. Currently credentialed practitioners shall receive a recredentialing packet six months
prior to the recredentialing date in order to meet the required 36-month time period
C. Health Essentials or delegated entity verifies recredentialing information through
primary sources, unless otherwise indicated.
D. Primary source verification and acceptable time frames shall be adhered to as noted.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 15
E. Health Essentials delegated entity shall assess the practitioners ability to provide
urgent and routine care, and ability to enroll additional patients in accordance with
standards adopted by Health Essentials.
F. When evaluating credentials for specialists who are being requested to serve as
primary care physicians, including standing referral situations, Health Essentials shall
ensure that the specialist can provide access to primary health care services
throughout the arrangement.
G. Validation of licensure must be within 180 days prior to the committee decision for
recredentialing. Verification must come directly from the state licensing agency.
Health Essentials or delegated entity shall verify the practitioner’s license in the
states where the practitioner provides care for members
1.Licensure is verified mid-cycle should the license expire prior to the
scheduled recredentialing cycle
H. DEA/CDS certificate verification has no time limit. The DEA/CDS certificate must
be effective at the time of the recredentialing decision
I. Board Certification must be within 180 days prior to the committee decision.
Acceptable boards are limited to the following:
1. American Board of Medical Specialties (ABMS)
2. American Osteopathic Association (AOA)
3. Canadian Board Certification
J. Malpractice History must be within 180 days prior to the committee decision.
K. Query to the National Practitioner Data Bank (NPDB) is required.
L. Self-disclosure statement from the practitioner is required should there be a history of
malpractice liability claims, whether dropped or closed with or without settlement.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 16
M. History of the past five years includes cases filed within the past five years or had any
activity within the past five years, regardless of when the case was filed.
N. The application and attestation requirements are the same for recredentialing as noted
above for initial credentialing.
O. The Sanction Information requirements are the same for recredentialing as noted
above for initial credentialing.
P. At the time of recredentialing, Health Essentials or its designee shall consider
findings from quality improvement monitoring, member complaints and grievances,
and member satisfaction results
Q. Subsequently, the Credentialing Department re-sends applications on a monthly basis
to those providers who have not returned the application. If the provider is less than
sixty (60) days to their recredentialing due date, and the recredentialing application
has not been returned, the provider will be presented to the Committee for termination
action. At this time, the Credentialing Department will send a certified notice to the
applicant, notifying them of the pending termination. If the required documents are
not received within the next thirty (30) days, the practitioner will be presented at the
next scheduled Credentialing Committee meeting and the application will be
withdrawn. The Credentialing Department will mail a certified letter notifying
him/her that their application has been withdrawn and this action has resulted in
termination of participation with the network.
R. The Recredentialing application (including signed Conditions of Application, Release
and Immunity) must be signed and dated by the applicant. Electronic signature and
re-attestation dates will be accepted for those providers utilizing CAQH.
1. The Conditions of Application, Release and Immunity states that the
information submitted on the application is correct and complete.
2. The date on the recredentialing application and Conditions of Application,
Release and Immunity must be within the 180 day period prior to
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 17
presentation of the provider’s chart to the Credentialing Committee for
action
S. The application will contain statements from the applicant regarding:
1. Reasons for any inability to perform the essential functions of the position
with or without accommodation;
2. lack of present illegal drug use or impairment due to chemical
dependency/substance abuse;
3. history of loss of license and/or felony convictions;
4. voluntary or involuntary history of loss or limitation of privileges or
disciplinary activity;
5. hospital privileges;
6. current malpractice coverage; and
7. the correctness and completeness of the application.
T. The Credentialing Department will verify the following information from primary
sources within the 180 day period prior to presentation to the Credentialing
Committee:
1. A current valid license to practice in the state(s) where the practitioner
provides services to members;
2. A valid DEA or CDS certificate;
3. Verification of board certification, as applicable;
4. Medicare, Medicaid and NPI Numbers;
5. Query of professional liability claims history;
6. Query of the National Practitioner Data Bank (NPDB) and the Healthcare
Integrity and Protection Data Bank (HIPDB);
7. Query of the List of Excluded Individuals and Entities (LEIE);
8. Query of the Office of Inspector General (OIG) sanction activity;
9. Query of licensure disciplinary history in the state(s) where the practitioner
provides services to members;
10. Query of the Federation of State Medical Boards (FSMB) data base;
11. Query of the Medicare Opt-Out List; and
12. Query of Sam.gov.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 18
U. At the time of recredentialing, quality of care or service findings will be assessed. A
performance monitoring form will be distributed to the Quality Improvement
Department 3 months prior to recredentialing of a practitioner in order to document
any trends or quality concerns. On an ongoing basis, the QI Department would
report to the Credentialing Department any significant sentinel event, not waiting for
the recredentialing cycle
V. The Recredentialing checklist will be initialed by the Credentialing Department.
When the recredentialing file is complete, the file will be reviewed by the Medical
Director or designee. The Medical Director will bring the provider file before the
Credentialing Committee where the provider’s recredentialing application is
reviewed. Pertinent concerns cited by the reviewer will be discussed by the
Credentialing Committee.
W. The Credentialing Committee will approve or deny recredentialing, or may pend
further action on the application until additional information is received.
1. If the initial or subsequent Credentialing Committee review results in
pending further action on the application, there must be a defined time
limit that the application is conditionally approved in order to keep the
applicant’s recredentialing status active.
2. At the time of the final review by the Credentialing Committee all
primary source verifications and the signed Conditions of Application,
Release and Immunity must comply with required time frames.
3. All recredentialing decisions are conducted in a non-discriminatory
manner. Please refer to policy and procedure CREDE 251.
X. A notice of the Committee’s final decision shall be provided to each applicant by mail
within sixty (60) days. If the Committee denies a provider, the provider will be given
thirty (30) working days from receipt of notification to notify the Committee if they
wish to appear in person before the Committee to appeal their decision. The provider
is notified in writing of the appeals procedure and that a like specialist will be present
once the hearing is scheduled. The provider will have an opportunity to appear
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 19
before the Committee to provide information concerning the recommendation to
terminate or deny membership.
FOR ALL APPLICANTS AND CONTRACTED NETWORK PRACTITIONERS
A. Annual screening must be completed within 12 months of last screening/survey for
each practitioner
B. Distribution must be completed within 30 days of completing the annual
screening/survey assessment
FOR ALL APPLICANTS - INITIAL SANCTION INFORMATION
A. Health Essentials shall receive information on practitioner sanctions before making a
credentialing or recredentialing decision.
B. Verification of sanctions must be made within 180 days of the committee decision.
C. Health Essentials shall verify sanction information for the following:
1. State sanctions or restrictions on licensure and or limitations on scope of
practice.
2. Medicare and Medicaid sanctions
D. Review on information on sanctions, restrictions on licensure and limitations on
scope of practice must cover the most recent five-year period available through the
data source.
E. If the practitioner was licensed in more than one state in the most recent five-year
period, the query shall include all states in which they worked.
1. Verification sources for physicians
a) National Practitioner Data Bank (NPDB)
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 20
b) Healthcare Integrity and Protection Databank (HIPDB)
c) Federation of State Medical Boards (FSMB)
d) Appropriate state agencies
2. Verification sources for Chiropractors
a) State Board of Chiropractic Examiners
b) HIDB
c) Federation of Chiropractic Licensing Boards’ Chiropractic
Information Network-Board Action Databank (CIN-BAD)
3. Verification sources for Dentists
a) State Board of Dental Examiners
b) HIPDB
c) NPDB
4. Verification sources for Podiatrists
a) State Board of Podiatric Examiners
b) HIPDB
c) Federation of Podiatric Medical Boards
5. Verification sources for non-physician behavioral health care practitioners
a) Appropriate state agency
b) HIPDB
c) State licensure or certification board
F. Acceptable sources for Medicare and Medicaid Sanctions include the following:
1. NPDB
2. HIPDB
3. FSMB
4. List of Excluded Individuals and Entities (maintained by the OIG) available
over the Internet
5. Medicare and Medicaid Sanctions and Reinstatement Report
6. Federal Employees Health Benefits Plan (FEHB) Program department record,
published by the Office of Personnel Management, Office of the Inspector
General
7. AMA Physician Master File entry
8. State Medicaid agency or intermediary and the Medicare intermediary
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 21
G. A practitioner self-query does not satisfy the requirement to review for sanctions.
Provider Responsibilities & Rights:
During the credentialing/recredentialing process, the practitioner or provider will be
given, but may not be limited to, the following rights:
A. The practitioner or provider may review the information they have submitted, or that
the Credentialing Department has obtained through their direct source verification, in
support of their application by requesting so in writing.
B. The practitioner or provider has the right to be notified by the Credentialing
Department by certified mail if any information obtained during the credentialing
process varies substantially from the information they originally submitted. The
provider shall have ten (10) business days to respond to the Department’s notification
to ensure continued processing of their application. All correspondence will be kept
in the provider’s file.
C. The practitioner or provider has the right to correct any erroneous information
submitted by another party. The provider shall be notified by certified mail of any
erroneous information submitted by another party. The provider shall have ten (10)
business days to correct any erroneous information and submit corrections to the
Credentialing Manager in writing. All corrections received from the provider will be
kept in the provider folder and tracked in the credentialing system.
D. The practitioner or provider has the right, upon request, to be informed of the status
of their applications. Requests can be made either in writing or verbally by contacting
the Credentialing Department. The Credentialing Department will return the
information to the provider in the same manner (in writing or verbally). They will
share the following information: missing or incomplete application information,
primary source verifications that have been obtained, and expected date the provider
will go to committee. The Credentialing Department is not required to share
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 22
information concerning references or recommendations, or other information that is
peer-review protected.
E. Practitioners and providers will be notified of these rights at the time when the
credentialing application is sent to the applicant.
Reasons for Denial of Participation
The Committee may rule to deny or terminate a provider. The provider will receive a
written notice of denial, including reason, sent via certified mail by the Credentialing
Department. Reasons for denial or termination include, but are not limited to, the
following:
A. A provider fails to meet the Minimum Requirements for
Credentialing/Recredentialing;
B. Administrative concerns are voiced;
C. Inconsistent information on the provider’s application develops which is not corrected
by the provider upon notice given as discussed in the Provider Rights &
Responsibilities section of this policy;
D. The provider or direct resource fails to respond to requests for information necessary
to complete the file;
E. Evidence develops whereby in the Committee’s, or in its designated peer-review
committee’s opinion, the applicant demonstrates a style of practice inconsistent with
appropriate standards of quality medical care.
NOTIFICATION TO AUTHORITIES, TERMINATION, AND PRACTITIONER APPEAL RIGHTS
A. Health Essentials or its delegated entity shall use objective evidence and patient-care
considerations to decide on the means of altering its relationship with a practitioner
who does not meet its quality standards.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 23
1. It is the responsibility of the Manager of the Credentialing Department, in
coordination with in-house legal counsel, to submit the filing or reporting to the
appropriate authorities.
B. The requirements of 805 report and hearing required by Section 809.1 of the
California Business and Professions Code or the Health Care Quality Improvement
Act of 1986 will be followed.
1. When 805 reporting is required, practitioners involved are defined as Medical
Doctors (MD), Dentists (DDS), Osteopaths (DO), Podiatrists (DPM), Marriage
Family Therapist (MFT), Licensed Clinical Social Workers (LCSW),
Psychologists (PsyD, PhD) and Physician Assistants (PA).
C. Health Essentials or its delegated entity defines the following:
1. The range of actions available to Health Essentials may include the following:
a) More frequent monitoring such as site visits or medical record reviews.
b) A request of explanation or further information.
c) Shorter recredentialing cycle.
d) Conditions or limitations of practice.
e) Termination of existing practitioners.
f) Denial of new applicants.
2. Reporting to authorities
a) Reporting adverse actions to the state licensure board shall be done
according to the state statutes.
b) Reporting to the National Practitioner Data Bank will be conducted
based on criteria and time frames set forth by the NPDB.
3. Appeal processes are afforded to practitioners under certain circumstances and
shall include the following:
a) Shall allow at least 30 calendar days after the notification for
practitioners to request a hearing.
b) Shall allow practitioners to be represented by an attorney or another
person of their choice.
c) Appoint a hearing officer or a panel of individuals appointed by Health
Essentials or designee to review the appeal.
d) Provide written notification of the appeal decision that contains the
specific reason for the decision
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 24
e) Shall follow all state requirements specific to the state of practice
4. There are no appeal processes when a practitioner is terminated or denied based
on administrative reasons, for example
a) Network need
b) Failure to cooperate with the credentialing or recredentialing process
c) Failure to meet the terms of minimum requirements (i.e.: licensure)
5. If a practitioner is termed for administrative reasons (i.e.: failure to complete
recredentialing application)
a) Applicant may be recredentialed and reinstated within 30 days of
recredentialing date.
b) Documentation will be made in the file that the termination of less
than 30 days was beyond control of the Credentialing Department.
c) If the applicant fails to complete the recredentialing process within 30
days after the administrative termination, the applicant must re-apply
as a new applicant and complete initial credentialing.
6. Making the appeal process known to practitioners, which include the following:
a) Written notification will be given when a professional review action has
been brought against a practitioner, reasons for the action and a
summary of the appeal rights and process.
b) Notification will include an outline of the appeal process.
c) Allow practitioners to request a hearing and the specific time period for
submitting the request.
Provider Reporting and Credentialing Files:
Provider records are maintained in hard copy within locked files, with access limited to
specific personnel. File maintenance is supervised by the Credentialing Manager.
Access to the provider database and files are limited. The database is automatically
updated nightly and has a back-up file. All reporting of provider information is centrally
distributed from the Credentialing Department. Upon initial credentialing and
recredentialing, the Credentialing Department is also responsible for maintaining current
copies of the provider’s license, DPS certificate, DEA registration, and malpractice
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 25
insurance facesheet. Any issues such as sanctioning by the state licensing board,
Medicare, or Medicaid will be reported immediately to the Credentialing Committee.
ONGOING MONITORING
A. Health Essentials or delegated entity shall monitor practitioners on an ongoing basis
for the following:
1. Sanctions
2. Complaints
3. Quality of Care or Service
4. Current Licensure
B. When a significant event is identified, the Credentialing Committee for Health
Essentials or its delegated entity shall review the practitioner mid-cycle and shall not
wait for the next 36 month scheduled recredentialing cycle.
C. As information is received from reporting agencies, Health Essentials or its delegated
entity shall review the information within 30 calendar days of a new alert.
D. Entities reporting sanction information may have different schedules, and Health
Essentials or its delegated entity shall review information within 30 calendar days of
its release.
E. In states where reporting entities do not publish sanction information on a set
schedule, Health Essentials or its delegated entity shall query for sanction information
at least every six (6) months.
F. When the reporting entity does not release sanction information reports, Health
Essentials or its delegated entity shall conduct individual queries for any affected
practitioner within 18 months after the last credentialing cycle.
G. Health Essentials or delegated entity shall implement ongoing monitoring and
conduct appropriate peer review with interventions by the following:
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 26
1. Collecting and reviewing Medicare and Medicaid sanctions
a) NPDB
b) HIPDB
c) FSMB
d) List of Excluded Individuals and Entities (maintained by the OIG)
available over the Internet
e) Medicare and Medicaid Sanctions and Reinstatement Report
f) Federal Employees Health Benefits Plan (FEHB) Program department
record, published by the Office of Personnel Management, Office of the
Inspector General
g) AMA Physician Master File entry
h) State Medicaid agency or intermediary and the Medicare intermediary
i) Sam.gov
2. Collecting and reviewing sanctions or limitations on licensure
a) Physicians, podiatrists and chiropractors
I. NPDB
II. HIPDB
III. FSMB
IV. The appropriate state agencies
V. Non-physician behavioral health care professionals
b) Allied Health Practitioners
I. The appropriate state agencies
II. HIPDB
III. State licensure or certification board
3. Collecting and reviewing complaints
a) Shall evaluate both specific complaints and the practitioner’s history of
issues.
b) Significant specific complaints or trends shall be monitored at least
every six (6) months.
4. Collecting and reviewing information from identified adverse events.
a) Health Essentials or delegated entity shall monitor adverse events
involving an injury that occurs while the member is receiving health care
services from the practitioner.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 27
5. Implementing appropriate interventions when Health Essentials or designee
identifies instances of poor quality.
a) When appropriate, the practitioner shall be reviewed mid-cycle.
V. DEFINITIONS
A. Credentialing - Refers to the process by which Health Essentials reviews and
evaluates qualifications of licensed independent practitioners and its provider
employees to provide services to members. Eligibility is determined by the extent to
which applicants meet defined requirements for education, licensure, professional
standing, service availability and accessibility, as well as for conformity to Health
Essentials’ utilization and quality management requirements.
B. Provisional Credentialing – Refers to a type of credentialing that enables someone to
practice as a health care provider with certain restrictions imposed, while his/her
application for standard credentialing is being reviewed.
C. Recredentialing - Refers to the process of evaluating and approving providers
originally credentialed within the network.
D. Delegation - Refers to the agreement between the organization and other entities
which allows such entities to perform the verification function while adhering to the
organization’s credentialing and recredentialing standards.
E. Primary Care - Refers to health care practitioner who, within the scope of the
practitioner's practice, supervises, coordinates, prescribes or otherwise providers or
proposes to provide health care services to a member; initiates member referral for
specialist care; and maintains continuity of member care.
F. Provider – A practitioner, institution, or organization that provides services for Health
Essentials or its designee.
G. Practitioner – A clinical professional who provides health care services. Practitioners
are usually required to be licensed as required by law.
H. Board Certification - The process by which a practitioner is board certified by a
recognized board of the American Board of Medical Specialties (ABMS) or the
American Osteopathic Association (AOA). Canadian Board Certification is also
acceptable.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 28
I. Credentialing Verification Organization (CVO) - An independent contractor who
performs primary source verification for the Credentialing process on a delegated
basis.
J. NCQA – National Committee of Quality Assurance – A private, not for profit
organization dedicated to improving healthcare quality.
K. CMS – The Center for Medicare and Medicaid Services.
L. NPDB - National Practitioner Data Bank. http://www.npdb-
hipdb.hrsa.gov/welcomesq.html
M. HIPDB - Healthcare Integrity and Protection Data Bank. http://www.npdb-
hipdb.hrsa.gov/hipdb.html
N. FSMB - Federation of State Medical Boards. http://www.fsmb.org/fcvs.html
O. Medicare Opt-Out – Meridian Healthcare Solutions
https://med.noridianmedicare.com/web/jea/provider-types
P. OIG - Office of Inspector General, List of Excluded Individuals and Entities (LEIE)
http://oig.hhs.gov/fraud/exclusions/listofexcluded.html.
Q. Sam.gov – System for Award Management
VI. SOURCES
A. Standards set by NCQA effective July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
VII.ATTACHMENTS
A. Credentialing application
B. Recredentialing application
C. Credentialing file worksheet
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 29
Addendum to Credentialing and Recredentialing policy and procedure for the Credentialing of
Physician Executives
Policy
It is the policy of Health Essentials that each physician executive, working for Health Essentials
or another health care organization in an administrative manner will be initially credentialed and
recredentialed on a triennial basis.
Purpose:
To define the credentialing process for physician executives who are serve in administrative
capacities for Health Essentials or other health care organizations
Procedure:
1. All physicians and physician executives who make decisions regarding Utilization
Management, Care Management, Case Management, Quality Improvement, Member
Satisfaction, Peer Review, Pharmacy & Therapeutics, or other decisions touching the
medical or clinical aspect of care or service shall be credentialed according to the
procedures of Health Essentials.
2. All credentialing and recredentialing procedures are applicable to physician executives
outside of Health Essentials, as well as those employed by Health Essentials.
3. In the case where the physician executive is employed by an acute care facility that is
accredited by The Joint Commission, credentialing is considered in the same standards as
Organizational Practitioners or Providers and is not applicable to this policy.
Subject:
Credentialing and Recredentialing
Policy and Procedure
Manual: Credentialing
Policy Number: CR 01
Number of Pages: 30 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, August 22, 2014, October 10,
2014
Confidential Credentialing and Recredentialing Policy and Procedure Page 30
4. All applicable credentialing and recredentialing policies and procedures shall be enforced
for physician executives with the following exceptions:
a. Current certification from a recognized board of the ABMS is mandated.
b. A facility site review audit is not applicable.
c. Medical record review and medical record keeping practices are not applicable.
d. Malpractice insurance may be demonstrated through corporate coverage.
e. Review and ongoing monitoring of quality issues and complaints is not applicable
(note: this does not include the ongoing monitoring of sanctions and licensure,
which remains applicable).
f. Current DEA/CDS certification is not mandatory.
5. Should a health care entity (i.e.: Medical Group, IPA, LPO, etc.) be delegated for
credentialing and recredentialing, the file review will include the physician executives of
that organization
6. This policy addendum is attached to the credentialing and recredentialing policies and
procedures and is applicable to annual review and approval by the Credentialing
Committee
ANNEX “1” TO CR01
CREDENTIALING COMMITTEE GRID
In order to make credentialing decisions, GNMA/HEPN uses a Credentialing Committee to
review the credentials of practitioners (as approved by the Credentialing Committee), using the
following guidelines:
Category of Applicant History of Applicant
Type 1 – Clean Record No licensing issue. No past claims within the past 10 years
(including dismissed matters)
Type 2 – Reviewed by
Committee through summary of
issues
Applicant has two (2) or less claims filed within the past
seven (7) years
Has two (2) or less claims or settlements within the past
7 years under $250,000 each
Has no more than a single settlement within the past
seven (7) years over $500,000
Type 3 – Reviewed by
Committee with individual
documentation of discussion
and consideration
Any licensing issue within the past seven (7) years
o Citation
o Open or closed Accusation
o Probation with license revoked and stayed
Any single settlement within the past seven (7) years
over $500,000
Any applicant with over three (3) claims or settlements
within the past seven (7) years over $250,001
Any applicant with over three (3) grievances within a
calendar year
Any federal or state sanctions
New applicants Are not accepted if there is an open accusation by their
licensing board
Current network providers Any current network practitioner which has a report or
action from a licensing board is to be reviewed within
30 days of the notice of action
*** At the discretion of the Medical Director, any “clean” applicant can be referred to the
Credentialing Committee for further review.
***At the discretion of the Credentialing Committee a “Type 2” provider can be moved to “Type
3” for further investigation and discussion.
Subject:
Credentialing of Allied Health Practitioners
Policy and Procedure
Manual: Credentialing
Policy Number: CR 02
Number of Pages: 4 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing of Allied Health Practitioners Page 1
1. POLICY
1. This policy establishes the criteria for the initial credentialing and recredentialing of allied
health practitioners (mid-level practitioners)
2. This is applicable to mid-level practitioners which may include Nurse Practitioners and
Physician Assistants employed or contracted, either practicing independently or under
the supervision of a physician.
3. Allied Health Practitioners may include the following
1. Nurse Practitioner (NP)
2. Certified Nurse Mid-wife (CNM)
3. Physician Assistant (PA)
4. Certified Registered Nurse Anesthetist (CRNA)
5. Optometrist (OD)
6. Physical Therapist
7. Occupational Therapist
8. Speech Therapist
9. Audiologist
10. Registered Dietician
2. PERSONS/DEPARTMENTS AFFECTED
1. Employed Practitioners
2. Network Practitioners
3. Credentialing
4. Quality Improvement
5. Provider Network Management
6. Administration
7. Clinical Operations
3. PURPOSE To make certain that all allied health professionals who assess the health care needs of members
do so with the proper certification and licensure, following standards set by the National
Subject:
Credentialing of Allied Health Practitioners
Policy and Procedure
Manual: Credentialing
Policy Number: CR 02
Number of Pages: 3 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing of Allied Health Practitioners Page 2
Committee for Quality Assurance (NCQA) and regulations of the Centers for Medicare and
Medicaid Services (CMS) requirements, State of California Department of Managed Care
(DMHC) and Department of Health Care Services (DHCS), and organizational standards.
4. PROCEDURE
1. All allied health practitioners will complete credentialing and recredentialing every 36
months.
2. In cases of Physicians who employ allied health professionals who do not practice
independently, the physicians are required to have a written agreement which includes a
description of the manner in which the non-physician provider will assist the supervising
physician, including a list of delegated functions delegated; policies and procedures that
detail the responsibilities of the providers to ensure that they do not practice outside the scope
of their licensure; and a statement that the supervising physician assumes full legal and
professional responsibility for the performance of the non-physician provider and the care
and treatment of his patients. If changes are made to the written agreement, the new
agreement must be provided to the organization within 30 days.
A. Note these non-independent practitioners are not credentialed through the process.
B. Physician Assistants and Nurse Practitioners providing services for contracted
Primary Care Physicians will not have members assigned to them. Members will
only be assigned to contracted Primary Care Physicians.
3. The recredentialing process for participating allied health practitioners is completed every
thirty-six (36) months. In addition to the items required for initial credentialing, the
following information will be reviewed and considered: Member complaints; results of
quality review activities; utilization management activities; member satisfaction surveys and
current written agreement with supervising physicians.
4. Primary source verification will be conducted at the time of initial credentialing with on-
going review of current status for:
A. Nurse Practitioners and Nurse Midwives
a. California Registered Nursing License
b. DEA-CDS Certificate, NTIS, as applicable
Subject:
Credentialing of Allied Health Practitioners
Policy and Procedure
Manual: Credentialing
Policy Number: CR 02
Number of Pages: 4 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing of Allied Health Practitioners Page 3
c. Nurse Practitioner from the CA Board of Registered Nursing (BRN)
B. Clinical Nurse Specialists
a. CA Registered Nursing license
b. CNS Certification number from the CA BRN
C. Physician Assistants
a. License from MBoC
b. DEA Number
5. All other credentialing and recredentialing criteria as stated in policy and procedure number
CR 01 is applicable with the following exceptions:
1. No hospital privileges required.
2. DEA/CDS may not be applicable.
3. Malpractice coverage may be reduced to $100,000/$300,000.
5. DEFINITIONS 1. Licensed Independent Practitioner:
An individual permitted by law to provide individual or patient care services without
direction or supervision within the scope of the individual’s licensure or certification and
in accordance with individually granted clinical privileges.
1. CMS
The Center for Medicare and Medicaid Services
3. NCQA
National Committee of Quality Assurance – A private, not for profit organization
dedicated to improving healthcare quality.
4. Practitioner
A clinical professional who provides health care services. Practitioners are usually
required to be licensed as required by law.
5. Provider
A practitioner, institution, or organization that provides services for the organization.
6. SOURCES
1. Standards set by NCQA, July 2014
2. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
Subject:
Credentialing of Allied Health Practitioners
Policy and Procedure
Manual: Credentialing
Policy Number: CR 02
Number of Pages: 3 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing of Allied Health Practitioners Page 4
7.RELATED POLICY/PROCEDURE
1. CR 01 Credentialing and Recredentialing
8.SUPPORTING DOCUMENTS
1. Credentialing application for allied health professionals (CPPA)
2. Recredentialing application for allied health professionals
Subject:
Ongoing Monitoring
Sanctions, Licensing, Boards, Agencies,
Complaints and Quality of Care Issues
Manual: Credentialing
Policy Number: CR 03
Number of Pages: 5 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates: May 6, 2014
May 21, 2014
Confidential Ongoing Monitoring Sanctions, Licensing, Boards, Agencies, Complaints and Quality of Care Issues Page 1
I. POLICY
A. It is the policy of Health Essentials to make certain that all Practitioners and Providers that
practice independently are credentialed on a continuous basis and shall review for licensure
sanctions, boards, licensing issues, current licensure and significant complaints or quality
concerns on an ongoing basis.
B. The Credentialing Department shall review the Medicare and Medicaid Sanctions and
Reinstatement reports published by the Office of the Inspector General (“OIG”), the applicable
State Board of licensure sanction report, and the Federal Employee Health Benefits Program
(“FEHBP”) debarment report (procurement and non-procurement) on a monthly basis or as
issued. Participating practitioners that are listed on the Medicare and Medicaid Sanction Reports
are subject to immediate termination and shall be reported immediately, within 30 days, to the
Credentialing Committee.
C. In addition to the ongoing monitoring, the Credentialing Department shall also verify at the time
of original credentialing and recredentialing the above listed items to ensure no sanctions have
been placed against the provider.
II. PERSONS/DEPARTMENTS AFFECTED A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Quality Improvement
E. Provider Network Management
F. Clinical Operations
III. PURPOSE
A. To outline the procedure to monitor practitioners and providers who
B. Have been sanctioned or are sanctioned during their participation by a state or federal
licensing agency
C. Are no longer eligible to participate in the Medicare program according to CMS
guidelines
D. Have complaints made against them by members
Subject:
Ongoing Monitoring
Sanctions, Licensing, Boards, Agencies,
Complaints and Quality of Care Issues
Manual: Credentialing
Policy Number: CR 03
Number of Pages: 5 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates: May 6, 2014
May 21, 2014
Confidential Ongoing Monitoring Sanctions, Licensing, Boards, Agencies, Complaints and Quality of Care Issues Page 2
IV. PROCEDURE
A. The Group shall monitor practitioners on an ongoing basis for the following:
1. Sanctions
2. Complaints
3. Quality of Care or Service issues
4. Current Licensure
B. When a significant event is identified, the Credentials Committee for Health Essentials or
its delegated entity shall review the practitioner mid-cycle and shall not wait for the next
36 month scheduled recredentialing cycle
C. Health Essentials or designee shall implement ongoing monitoring and conduct
appropriate peer review with interventions by the following:
1. Collecting and reviewing Medicare and Medicaid sanctions
i. NPDB
ii. HIPDB
iii. FSMB
iv. List of Excluded Individuals and Entities (maintained by the OIG)
available over the Internet
v. Medicare and Medicaid Sanctions and Reinstatement Report
vi. Federal Employees Health Benefits Plan (FEHB) Program department
record, published by the Office of Personnel Management, office of the
Inspector General
vii. State Medicaid agency or intermediary and the Medicare
intermediary to include the Medi-Cal Suspended and Ineligible Report
on a monthly basis
2. Collecting and reviewing sanctions or limitations on licensure
i. Physicians
1. NPDB
2. HIPDB
3. FSMB
Subject:
Ongoing Monitoring
Sanctions, Licensing, Boards, Agencies,
Complaints and Quality of Care Issues
Manual: Credentialing
Policy Number: CR 03
Number of Pages: 5 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates: May 6, 2014
May 21, 2014
Confidential Ongoing Monitoring Sanctions, Licensing, Boards, Agencies, Complaints and Quality of Care Issues Page 3
4. The appropriate state agencies
ii. Non-physician behavioral health care professionals
1. The appropriate state agencies
2. HIPDB
3. State licensure or certification board
3. Collecting and reviewing complaints
i. Shall evaluate both specific complaints and the practitioner’s history of
issues
ii. Significant specific complaints or trends shall be monitored at least every
six (6) months
4. Collecting and reviewing information from identified adverse events
i. The Health Essentials or designee shall monitor adverse events involving
an injury that occurs while the member is receiving health care services
from the practitioner
5. Implementing appropriate interventions when the Health Essentials or designee
identifies instances of poor quality
i. When appropriate, the practitioner shall be reviewed mid-cycle
D. As information is received from reporting agencies, Health Essentials or its designee
shall review the information within 30 calendar days of a new alert
E. Entities reporting sanction information may have different schedules, and Health
Essentials or its designee shall review information within 30 calendar days of its release
F. In states where reporting entities do not publish sanction information on a set schedule,
the Group or its designee shall query for sanction information at least every six (6)
months
G. When the reporting entity does not release sanction information reports, Health Essentials
or its designee shall conduct individual queries for any affected practitioner within 18
months after the last credentialing cycle
Subject:
Ongoing Monitoring
Sanctions, Licensing, Boards, Agencies,
Complaints and Quality of Care Issues
Manual: Credentialing
Policy Number: CR 03
Number of Pages: 5 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates: May 6, 2014
May 21, 2014
Confidential Ongoing Monitoring Sanctions, Licensing, Boards, Agencies, Complaints and Quality of Care Issues Page 4
H. When processing applications for initial credentialing, applications for re-credentialing,
upon notification from the provider of a change in his/her Medicare status, or when
reviewing the monthly OIG reports, applicable state license board, or FEHBP reports, the
Credentialing Department shall document the date of report, names of practitioners listed
on report, name of employee that reviewed the report and the date the report was
reviewed. It shall also document if no practitioners were listed on the report.
I. When a participating provider is identified with sanctions, the Credentialing Department
shall notify the Credentialing Committee Chairman immediately. If the sanction is by the
Medicare or Medicaid program, the Credentialing Committee Chairman shall terminate
the practitioner’s participation effective immediately.
J. When a practitioner or provider is administratively terminated immediately based on a
licensing or sanction issue, the following notifications will be made within three (3)
business days of the action:
1. Providers will be notified via certified mail.
2. Internal departments will be notified via e-mail to make adjustments in their
respective systems and to coordinate/transition any patient care.
3. There shall be no fair hearing or appeal rights afforded to a practitioner who is
administratively terminated due to licensing issues.
K. If the provider re-obtains eligibility to participate in the Medicare/Medicaid or FEHBP
program(s), it is the provider’s responsibility to contact the Credentialing Department to
begin the initial application process
L. The attached worksheet shall be utilized to document when each licensing board or
reporting list is reviewed, including the name and date of review and outcome of the
review
Subject:
Ongoing Monitoring
Sanctions, Licensing, Boards, Agencies,
Complaints and Quality of Care Issues
Manual: Credentialing
Policy Number: CR 03
Number of Pages: 5 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates: May 6, 2014
May 21, 2014
Confidential Ongoing Monitoring Sanctions, Licensing, Boards, Agencies, Complaints and Quality of Care Issues Page 5
V. DEFINITIONS
A. CMS
The Center for Medicare and Medicaid Services
B. FSMB
Federation of State Medical Boards. http://www.fsmb.org/fcvs.html
C. NCQA
National Committee of Quality Assurance – A private, not for profit organization
dedicated to improving healthcare quality
D. NPDB
National Practitioner Data Bank. http://www.npdb-hipdb.hrsa.gov/welcomesq.html
E. OIG
Office of Inspector General, List of Excluded Individuals and Entities (LEIE)
http://oig.hhs.gov/fraud/exclusions/listofexcluded.html
F. Practitioner
A clinical professional who provides health care services. Practitioners are usually
required to be licensed as required by law
G. Provider
A practitioner, institution, or organization that provides services for the Group or its
designee
VI. SOURCES A. Standards set by NCQA, July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines Chapter 11
VII. RELATED POLICY/PROCEDURE
A. CR 01 Credentialing and Recredentialing
VIII.ATTACHMENTS
A. Complaints and Grievances Monitoring Worksheet
B. Worksheet addendum noting process to document review and outcome
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
Licensing Board, Address and
Phone Numbers
Practitioner Types Website/links Instructions and Comments Report Frequency
Medical Board of California
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815
PH:(916) 263-2382 or (800) 633-
2322
Enforcement Central File Room
PH: (916) 263-2525
FAX: (916) 263-3435
805’s Discipline Coord.
(916) 263-2449
MD
http://www.mbc.ca.gov/
All communications for
disciplinary actions will be done
by e-mail to subscribers.
Link to subscribe for actions:
http://www.mbc.ca.gov/subscribers
.html
Link for all Disciplinary
Actions/License Alerts distributed
http://www.mbc.ca.gov/Publicatio
ns/Disciplinary_Actions/
You must signup to subscribe for
E-mail notifications of accusations,
license suspensions, restrictions,
revocations, or surrenders for physicians
and surgeons licensed by the MBOC.
Disciplinary action documents are
obtainable via the web-site by:
Link to Enforcement Public
Document Search (on the left side of
page under check your doctor online)
or in the
License verification section; Under
Public Documents – Top Right
Bi-Monthly subscribers
will be sent information
regarding Accusations.
Decisions will be sent
on a daily basis as the
decisions become final
Osteopathic Medical Board of CA
1300 National Drive, Suite #150
Sacramento, CA 95834-1991
(916) 928-8390 Office
(916) 928-8392 Fax
E-mail: [email protected]
DO http://www.ombc.ca.gov/
Direct Link To Enforcement
Actions:
http://www.ombc.ca.gov/consumer
s/enforce_action.shtml
Link to Consumers Tab at the top
Link to Enforcement Action
Recommend reviewing after the 2nd
week
after the quarter ends.
To obtain documents must call the board
to obtain price of documents and send a
check with your request.
Quarterly
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
American Board of Medical
Specialties (ABMS)
222 North LaSalle Street, Suite
1500
Chicago, IL 60601-1117
(312) 436-2600
www.abms.org
http://www.abms.org/Who_We_H
elp/Professional_Organizations/pdf
/DisplayAgentList.pdf
ABMS data comes directly from the
24 Member Boards. It is considered
Primary Source Verified (PSV) only
if sourced from specific products and
services designated as an ABMS
Official Display Agent or directly
from ABMS or an ABMS Member
Board
The Official Display Agent list is
subject to change. Please check
www.abms.org or call (312) 436-
2600 and select option 5 for the most
current list.
Medical Board of California Board
of Podiatric Medicine
2005 Evergreen Street, Ste. 1300
Sacramento, CA 95815-3831
PH: (916) 263-2647
Fax:(916) 263-2651
Email: [email protected]
Enforcement Program
Central File Room
Medical Board of California
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815
DPM www.bpm.ca.govhttp://www.bpm.
ca.gov/
Direct Link to Disciplinary
Actions:
http://www.bpm.ca.gov/enforce/dis
psumm.shtml
Link to Enforcement Tab at the top
Link to Disciplinary Actions
Listed alphabetically by category:
Decision, Accusation, etc.
NOTE: No longer reported by the
MBOC, must obtain directly from this
board as of 7/1/08.
Monthly
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
Board of Behavioral Sciences
1625 N Market Blvd., Suite S-200
Sacramento, CA 95834
PH: (916) 574-7830
Fax: (916) 574-8625
E-Mail:
Licensed Marriage and
Family Therapists
(LMFT), Licensed
Clinical Social Workers
(LCSW), Associate
Clinical Social Workers
(ASW), Licensed
Educational Psychologists
(LEP), Licensed
Professional Clinical
Counselors (LPCC) and
Professional Clinical
Counselors Interns
(PCCI)
www.bbs.ca.gov
Sign up for subscribers list for
disciplinary actions.
https://www.dca.ca.gov/webapps/b
bs/subscribe.php
You must sign up for Subscriber list to
obtain Enforcement Actions. E-mail will
be sent to you. If you don’t sign up as a
subscriber, the News Letters will provide
disciplinary actions.
Subscriber lists are currently not available
and this is a board that does not provide
disciplinary action reports.
None.
Information may be
obtained via
subscription only.
Board of Psychology
Board of Psychology
1625 North Market Blvd,
Suite N-215
Sacramento, CA 95834
Office Main Line (916)-574-7720
Toll Free Number: 1-866-503-3221.
Ph.D, PsyD www.psychboard.ca.gov
Direct link to enforcement actions:
www.psychboard.ca.gov/consumer
s/actions.shtml
Sign up for subscribers list for
disciplinary actions:
https://www.dca.ca.gov/webapps/p
sychboard/subscribe.php
Link to Consumer
Link to Disciplinary Actions
Link to Board Actions
To order copies documents, send your
written request, including the name and
license number of the licensee, to the
attention of the Enforcement Program at
the Board's offices in Sacramento. A fee
is charged for these documents.
Recommend subscribing, alpha lists
includes all data for many years.
Monthly in alpha order
very long lists will all
history.
For Subscribers:
E-mail reports
If subscriber you must
review the list monthly.
CA Board of Chiropractic
Examiners
Board of Chiropractic Examiners
901 P Street, Suite 142A
Sacramento, CA 95814
PH (916) 263-5355
FAX (916) 327-0039
www.chiro.ca.gov
DC www.chiro.ca.gov
Monthly Reports http://www.chiro.ca.gov
/enforcement/actions.sh
tml
Note monthly disciplinary actions reports
are available since 7/2012.
Link to Consumer
Link to Disciplinary Actions
From 7/09 to 7/12, the board did not
publish monitoring reports, reports were
available by request via fax or e-mail
directly to:
Valerie James: [email protected]
Monthly as of 7/2012
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
Acupuncture Board
1747 N. Market Blvd
Suite 180
Sacramento, CA 95834
PH: (916) 515-5200
Fax: (916) 928-2204
Email: [email protected]
To order copies of actions sent to
attn of Consumer Protection
Program
LAC/AC www.acupuncture.ca.gov
Direct Link:
www.acupuncture.ca.gov/consume
rs/board_actions.shtml
Sign up for subscribers list for
disciplinary actions:
https://www.dca.ca.gov/webapps/a
cupuncture/subscribe.php
Link to Consumer at the top
Link to Disciplinary Action
Board will be updating monthly as of Jan
2013. Prior to 1/13, lists have not been
updated since 6/12
Monthly running report
listed Alpha
Newer actions
highlighted with date in
blue.
Note: Board meetings
are held quarterly.
Dental Board of California
2005 Evergreen Street, Suite 1550
Sacramento, CA 95815
PH: (916) 263-2300
PH: (877)729-7789 Toll Free
Fax #: (916) 263-2140
Email: [email protected]
Enforcement Unit PH: 916-274-
6326
DDS, DMD www.dbc.ca.gov
Direct Link to Disciplinary
Actions:
http://www.dbc.ca.gov/consumers/
hotsheets.shtml
Link Home Page
Under Highlights -Link to Hot Sheets
Bottom of the page link to Hot
Sheets Disciplinary action.
Note: At the end of the list it provides a
date posted.
Reporting Periods:
Oct 2009 –Dec 2010
Jan 2011 to Jun 2011
Monthly after July 2011
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
Board of Occupational Therapy
2005 Evergreen St.
Suite 2050
Sacramento, CA 95815
PH: (916) 263-2294
Fax: (916) 263-2701
email: [email protected]
OT, OTA www.bot.ca.gov
Direct Link To Enforcement
Actions:
http://www.bot.ca.gov/consumers/
disciplinary_action.shtml
Sign up for subscribers list for
disciplinary actions:
https://www.dca.ca.gov/webapps/b
ot/subscribe.php
Link to Consumer at the top
Link to Disciplinary Action
Practitioners are listed in categories.
Practitioners Currently on Probation and
Revoked, Voluntary Surrender,
Suspensions A – L and M – Z.
Sign up to receive a monthly Hot Sheet
List of disciplinary actions via e-mail to:
Update as needed
(whenever they have an
update). Depends on
when there is an OT
placed on probation or
revoked. Listed Alpha
by type of action. Or
Sign up to receive a
monthly a Hot Sheet
List via e-mail
Will need to send a
written request to
obtain the information,
which may be sent back
to you via e-mail.
California Board of Optometry
2450 Del Paso Road, Suite 105
Sacramento, CA 95834
PH:(916) 575-7292
Consumer toll-free
(866) 585-2666
Fax (916) 575-7292
Email: [email protected]
OD www.optometry.ca.gov
Direct Link To Enforcement
Actions:
http://www.optometry.ca.gov/cons
umers/disciplinary.shtml
Link to Consumer at the top
Link to Citations and Disciplinary
Actions
Bottom of page actions are posted by
year
Practitioners are listed by year, type of
action and then alphabetically
Note: Report provides a Last Updated
date at the top of the report.
Listed by year, in Alpha
Order by type of Action
Website will be updated
as actions are adopted.
Recommend monthly
review.
The Board typically
adopts formal
disciplinary actions
during regularly
scheduled quarterly
meetings.
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
Physical Therapy Board of
California
2005 Evergreen St.
Suite 1350
Sacramento, CA 95815
PH: (916) 561-8200
Fax: (916) 263-2560
PT www.ptb.ca.gov
Direct Link To Enforcement
Actions:
www.ptbc.ca.gov/consumers/enfor
cement/index.shtml
Sign up for subscribers list for
disciplinary actions:
https://www.dca.ca.gov/webapps/p
tbc/interested_parties.php
Link to Consumers Tab at the top
Link to Citations & Disciplinary
Actions
Practitioners are listed Alpha order under
Citation and in Alpha order under
Disciplinary Actions
Note: Report provides a Last Updated
date at the top of the report
Monthly
Physician Assistant Committee
2005 Evergreen Street
Suite 1100
Sacramento, CA 95815
PH: (916) 561-8780
FAX(916) 263-2671
Email: [email protected]
PA/PAC www.pac.ca.gov
Direct Link To Enforcement
Actions:
www.pac.ca.gov/forms_pubs/disci
plinaryactions.shtml
Link to Consumers
Link to Disciplinary Action
Link to Month within the year at
bottom of the page
Practitioners listed via month, then Alpha
Monthly
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
CA Board of Registered Nursing
1747 North Market Blvd,
Suite 150
Sacramento, CA 95834
Mailing Address:
Board of Registered Nursing
P.O. Box 944210
Sacramento, CA 94244-2100
Phone: (916) 322-3350
FAX (916) 574-7693.
Email:
Certified Nurse Midwife
(CNM),
Certified Nurse
Anesthetist (CRNA),
Clinical Nurse Spec.
(CNS),
Critical Care Nurse
(CCRN),
Nurse Practitioner (NP),
Public Health Nurse
(PHN)
www.rn.ca.gov
Direct Link To Enforcement
Actions:
www.rn.ca.gov/enforcement/dispa
ction.shtml#actions
Link to Enforcements at the top
Link to Disciplinary Actions and
Reinstatements
Listed in alpha order by type of action
Disciplinary action and license
reinstatement information may be
obtained by checking the Board's online
license verification system or by calling
the toll-free license verification number at
1-800-838-6828.
Photocopies of this information may be
requested by faxing the Board's
Enforcement Program at (916) 574-7693.
Monthly
Speech-Language Pathology &
Audiology Board
2005 Evergreen Street, Suite 2100
Sacramento, CA 95815
Email:
Main Phone Line: (916) 263-2666
Main Fax Line: (916) 263-2668
SP, AU http://www.speechandhearing.ca.g
ov/
Direct Link to Accusations
Pending and Disciplinary Actions:
http://www.speechandhearing.ca.g
ov/consumers/enforcement.shtml
As of 3/15/13 the information
represents disciplinary action taken
by the Board from 2007 – 2012
As of 7/09/13 the information
represents disciplinary action taken
by the Board from 7/1/07 –
3/31/13
Link to Consumer
Link to Enforcements
For Board decisions select
"Disciplinary Actions”.
For actions pending Board
decisions select "SP/AU” For
Speech-Language Pathology &
Audiology
Quarterly
Disciplinary Actions
are listed by fiscal year.
Pending Actions are
listed alphabetically by
first name.
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
DEA Office of Diversion Control
800-882-9539
DEA Verification www.deadiversion.usdoj.gov/
Direct Link to Validation Form
https://www.deadiversion.usdoj.go
v/webforms/validateLogin.jsp
On the right side under Links: Link to
Registration Validation Need DEA #,
Name as it appears on your registration
and SSN or TIN provided on application.
Note: Please does not use the Duplicate
Certification Link as it is for Physicians,
use the Registration Validation Link.
DEA Office of
Diversion Control
800-882-9539
deadiversionwebmaster
@usdoj.gov
National Council of State Board of
Nursing (BCSBN)
111 East Wacker Drive, Suite 2900
Chicago, IL 60601-4277
Phone: (312) 525-3600
Fax: (312) 279-1032
Email: [email protected]
.
Additional information
for RN/LVN/VH
www.nursys.com
To subscribe for daily, weekly or
monthly (depending on how often
you want to be updated) updates on
license status, expirations and
disciplinary actions.
https://www.nursys.com/EN/ENDe
fault.aspx
Nursys e-Notify informs you if your
employed RNs or LPN/VNs receive
public discipline or alerts from their
licensing jurisdiction(s). It also notifies
you if licenses are expiring. e-Notify is
your simple one-stop shop for monitoring
the status of nurses
National Council of
State Board of Nursing
(BCSBN)
111 East Wacker Drive,
Suite 2900
Chicago, IL 60601-
4277
Phone: (312) 525-3600
Fax: (312) 279-1032
Email: [email protected]
.
HHS Officer of Inspector General
Office of Investigations
Health Care Administrative
Sanctions
Room N2-01-26
7500 Security Blvd.
Baltimore, MD 21244-1850
OIG - List of Excluded
Individuals and Entities
(LEIE) excluded from
Federal Health Care
Programs: Medicare
/Medicaid sanction &
exclusions
www.oig.hhs.gov
Direct Link for individuals:
http://exclusions.oig.hhs.gov/
Direct Link to exclusion database
http://www.oig.hhs.gov/fraud/excl
usions/exclusions_list.asp
Link to Exclusion Program
Link to LEIE Downloadable
Databases under the Exclusion
Program tab
Link to the various reports,
exclusions, reinstatements or
databases.
To subscribe for notifications select the
following at the top of the page of this
link:
E-mail me when this page is updated
and subscribe by entering your e-mail
address.
Monthly
(see note under
instructions regarding
subscribing
notifications)
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
Medicare Opt-Out Physicians
Noridian Healthcare Solutions
1-855-609-9960
Hours of availability are Monday -
Friday, 6 a.m. - 5 p.m. PT
Noridian JE Part A
P.O. Box 6770
Fargo, ND 58108-6770
Or via Certified/Courier Mailings
900 42nd St S
PO Box 6770
Fargo, ND 58103
Medicare Opt-Out
Direct Link to Opt-Out Reports:
Part A: https://med.noridianmedicare.com/
web/jea
Part B: https://med.noridianmedicare.com/
web/jeb
Search by Provider Type
https://med.noridianmedicare.com/
web/jea/provider-types
For additional contact information
https://med.noridianmedicare.com/
web/jea/contact/mailing-addresses
Medicare Part A Part A claims processing covers services
provided through hospitals and post-
hospital care. Noridian administers Part A
for Jurisdiction F and Jurisdiction E.
Medicare Part B Part B claims processing covers doctor
visits, lab tests, and certain prescribed
outpatient services. Noridian administers
Part B
Durable Medical Equipment DME claims processing covers Durable
Medical Equipment, Prosthetics,
Orthotics, and Supplies Jurisdiction D.
Pricing, Data Analysis & Coding -
DME PDAC provides pricing functions, coding
advice and guidance for the DME
industry nationwide.
Quarterly
SAM (System for Award
Management) formerly known as
Excluded Parties List System
(EPLS)
Individuals and
Organizations debarred
from participating in
government contracts or
receiving government
benefits or financial
assistance
http://www.sam.gov/
Note: The SAM website has a user
guide:
Link to SAM User Guide- v1.8.3
of 350:
Link to Data Access
Click on “Open” to open the report
or “Save” to save the report. Report
will begin extracting if you click on
“Open”
Double click to open the file.
System will begin extraction. Click
to open once extraction is completed.
Monthly
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
Medi-Cal Provider Suspended and
Ineligible List
Office of Investigations
Health Care Administrative
Sanctions
Room N2-01-26
7500 Security Blvd.
Baltimore, MD 21244-1850
Medi-Cal
Reports exclusions and
reinstatements from the
State Medi-Cal Program
www.medi-cal.ca.gov
Direct Link to Provider Bulletins:
http://files.medi-
cal.ca.gov/pubsdoco/bulletins_men
u.asp
Direct Link to Part 1-Medi-Cal
Program & Eligibility:
http://files.medi-
cal.ca.gov/pubsdoco/bulletins_men
u.asp
Under Provider Bulletins
Link to Part 1-Medi-Cal Program &
Eligibility
Item 4. Link to current month update
for the list of providers added or
removed from the S&I List
OR
Link to “Medi-Cal Suspended and
Ineligible Provider List to obtain by
various types (susp A, susp C)
– The April Update is a list of
providers who have been added
to or removed from, or whose
information has been updated
and/or corrected in the Medi-Cal
Suspended and Ineligible
Provider List (S&I List) for the
month of April.
OR
Link to the actual type below:
New providers have been added in bold
and reinstated providers were removed
from the following lists: susp A, susp C,
susp F, susp O, susp P, susp R, susp S,
susp T and susp U. Always refer to the
S&I List when verifying provider
ineligibility.
Monthly
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
The Licensed Facility Information
system (LFIS)
The Automated Licensing
Information and Report Tracking
System (ALIRTS) contains license
and utilization data information of
healthcare facilities in California.
The Licensed Facility Information
system (LFIS) is maintained by the
Office of Statewide Health Planning
and Development to collect and
display licensing and other basic
information about California's
hospitals, long-term care facilities,
primary care and specialty clinics,
home health agencies and hospices.
Organizational Providers
License Verification:
Hospitals
Surgery Centers
Home Health Agencies
Hospices
Dialysis Centers
Others
www.alirts.oshpd.ca.gov/Default.a
spx
Direct Link:
www.alirts.oshpd.ca.gov/LFIS/LFI
SHome.aspx
The main source of the information in
LFIS is the licenses issued by the
Department of Health Services (DHS)
Licensing and Certification District
Offices. Contact information for these
District Offices is available at:
www.dhs.ca.gov/LNC/default.htm
To search for a facility
Enter name in box that is found in
top right corner
Search
or
Link to Advance Search on the left
under Login.
LFIS Home
Alirts Home
Advanced Search
You may search by using the following
four search categories, Facility Name,
Facility Number, License and Legal
Entity. Enter your search parameters
within the one category you selected and
click the Search button to the right.
The Licensed Facility
Information system
(LFIS)
The Automated
Licensing Information
and Report Tracking
System (ALIRTS)
contains license and
utilization data
information of
healthcare facilities in
California.
The Licensed Facility
Information system
(LFIS) is maintained by
the Office of Statewide
Health Planning and
Development to collect
and display licensing
and other basic
information about
California's hospitals,
long-term care
facilities, primary care
and specialty clinics,
home health agencies
and hospices.
Ongoing Monitoring Website Information February 2014 ATTACHMENT TO POLICY AND PROCEDURE CR 03, ONGOING MONITORING
The information contained in this document has been compiled for informational purposes only and is subject to change.
Please visit the individual websites listed for the most up-to-date information.
National Plan and Provider
Enumeration System (NPPES)
NPI Enumerator
PO Box 6059
Fargo, ND 58108-6059
800-465-3203
m
The Centers for Medicare &
Medicaid Services (CMS) has
developed the National Plan and
Provider Enumeration System
(NPPES) to assign these unique
identifiers.
The NPI Registry enables you to
search for a provider's NPPES
information. All information
produced by the NPI Registry is
provided in accordance with the
NPPES Data Dissemination Notice.
Information in the NPI Registry is
updated daily. You may run simple
queries to retrieve this read-only
data.
Organizational Providers
and Practitioners
Numbers for the
following:
NPI
Medicare
Medi-Cal
https://nppes.cms.hhs.gov/NPPES/
NPIRegistryHome.do
Search the NPI Registry
Search for an Individual
Provider
Search for an Organizational
Provider
Source for obtaining Medicare Numbers
to verify Medicare Certification
Select Organizational Provider and fill in
search information:
Please enter data for at least one of the
following fields. If searching on Practice
Address State, you must enter data for at
least one other field. To perform a wild
card search, at least two characters must
be entered before the "*". For example, to
search for data beginning with "Ch", enter
"Ch*". Wild card searches are only
available on the Organization Name,
Doing Business As (DBA) and Practice
Address City fields
National Plan and
Provider Enumeration
System (NPPES)
NPI Enumerator
PO Box 6059
Fargo, ND 58108-6059
800-465-3203
customerservice@npien
umerator.com
The Centers for
Medicare & Medicaid
Services (CMS) has
developed the National
Plan and Provider
Enumeration System
(NPPES) to assign
these unique identifiers.
The NPI Registry
enables you to search
for a provider's NPPES
information. All
information produced
by the NPI Registry is
provided in accordance
with the NPPES Data
Dissemination Notice.
Information in the NPI
Registry is updated
daily. You may run
simple queries to
retrieve this read-only
data.
files updated: 05-09-2014
Current Monthly Supplements
• 04-2014 Exclusions: EXE | ZIP • 04-2014 Reinstatements: EXE | ZIP
• Monthly Supplement Archive
Name of Reviewer and Date
No active HealthEssentials (or
GeriNet) practitioner or provider
found. One termed provider
found.
dt - 5/15/12
http://www.oig.hhs.gov/exclusions/exclusions_list.asp
LEIE Downloadable Databases | Exclusions | Office of Inspector General | U.S. Department ... Page 1 of 2
Attachment to CR 06, Medicare Opt Out and CR 03 Ongoing Monitoring Policies and Procedures
• Exclusions • Fraud
• Compliance • Newsroom
• Reports/Pubs
• Recovery
• About OIG
HealthEssentials Evidence of Ongoing Monitoring
LEIE Downloadable Databases
Search the Online LEIE Database
E-mail me when this page is updated.
DATE OF RELEASE
Download the LEIE Database
Below
LEIE Database
• 04-2012 Updated LEIE Database: EXE | ZIP
DOCUMENTATION OF FINDINGS & STAFF REVIEWING
Updated LEIE Information • 04-2012 Updated Information
Record Layout • Current Database Record Layout
Instructions
MONTH REVIEWING
The List of Excluded Individuals/Entities (LEIE) is available in different versions, and all are .dbf files zipped into
self-extracting executable (exe) files.
Save this .exe file to your computer, then extract the.dbf file into either a database program such as Microsoft access or a spreadsheet program such as Microsoft Excel. Please refer to your software's help file for instructions on using .dbf
files.
Versions About the Updated LEIE:
The updated LEIE is a complete database containing all exclusions currently in effect.
Individuals and entities who have been reinstated are not included in this file.
This file is replaced with an updated version each month.
This file is complete and should not be used in conjunction with the monthly exclusion and reinstatement
supplements. Reviewer and date of review Source
(Updated March 7, 2013)
No HealthEssentials or
GeriNet practitioners or
providers found.
Name of Reviewer & Date
Name of Reviewer and
Date
http://www.rn.ca.gov/enforcement/enf-actions-fed.shtml
Board of Registered Nursing - Disciplinary Actions - February 2013 Documentation of Review Page 1 of 5
Release date
(add date) Month reviewing
The information provided below is current as of the date this list was created and may be subject to change. To verify the most recent
information available regarding an RN license, please check the individual's license status through the Online License Verification Sv stem or
by contacting the Board directly.
Accusation Filed
Accusation & Petition to Revoke Probation
Filed Amended Accusation Filed
License Denied by Decision/Order
Order to Issue License -
Conditional Petition to Revoke
Probation Filed Public Reproval
Revocation
Revocation Stay ed License Probation
Only Statement of Issues Filed
Suspension
Voluntarv Surrender
DISCLAIMER: All information provided by the Board of Registered Nursing (BRN) on this web page, is made available to provide immediate
access for the convenience of interested persons. While the Board believes the information to be reliable, human or mechanical error remains
a possibility, as does delay in the posting or updating of information. Therefore, the Board makes no guarantee as to the accuracy,
completeness, timeliness, currency, or correct sequencing of the information. Neither the Board, nor any of the sources of the information,
shall be responsible for any errors or omissions, or for the use or results obtained from the use of this information.
Accusation Filed
ACTION DATE RESPONDENT NAME RN NUMBER
21-FEB-2013 ALLCROFT, NANACY RN 270802
20-FEB-2013 BABCOCK, CAROL JEANNE RN 442853
20-FEB-2013 BAGUE, CARLOS GUITGUITEN RN 728667
21-FEB-2013 BARSNESS, MARLA MICHELLE RN 586101
22-FEB-2013 BAYMA, KARA MARET RN 516844
19-FEB-2013 BECERRA, ANDREW RN 705386
19-FEB-2013 BEHRENS, TINA MARIE RN 766111
Source Reviewer and date of review
Medi-Cal Update
Part 1 - Program and Eligibility I April 2013
The April Update is
1 active, 2 termed, 2
ONWA providers found.
Reviewer and date
Source
Medi-Cal: Medi-Cal Update - Part 1 - Program and Eligibility I April 2013 Page 1 of 2
1.
2. Medi-Cal Suspended and Ineligile Provider List: (Month/Yr) Update
3. Medi-Cal Hotlines
4.
A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status
codes submitted by providers. Erroneous "from-through" dates or patient status billed by one provider and paid by Medi-Cal can result in
the denial of correct claims billed by another provider. This often occurs between hospitals and nursing homes during the transfer of the
recipient. Providers see this on their Remittance Advice Details (RADs) as a claim denied by RAD code 010.
Should the denied provider choose to dispute the claim and there is no resolution between the two providers regarding the dates in
question, Medi-Cal could recoup the full reimbursement of the original erroneously paid claim, and will not make an adjustment without a
correction request from that provider.
Incorrectly paid and denied claims can also create incorrect provider reimbursement data and inaccuracies in the health service records
that may impact beneficiary share of cost, access to services and estate recovery.
For assistance in resolving these issues, providers are advised to write to the Correspondence Specialist Unit at:
Correspondence Specialist Unit
P.O. Box 13029 Sacramento, CA 95813-4029
For information about proper claim form completion, refer to the claim completion section in the appropriate Part 2 manual.
Month reviewing
a list of providers who have been added to or removed from, or whose information has been updated and/or
corrected in the Medi-Cal Suspended and Ineligible Provider List (S&I List) for the month of April.
were removed from the following lists:
Always refer to the S&I List when
Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Office of Inspector General (OIG) List of
Excluded Individuals/Entities.
Suspension of Entities Submitting Claims for Suspended Providers
Entities submitting claims for services rendered by a health care provider suspended from Medi-Cal or excluded from Medicare or Medicaid by the Federal Office of Inspector General are subject to Medi-Cal suspension.
Welfare and Institutions Code (W&I Code), Section 14043.61(a), states, in relevant part, that "a provider shall be subject to suspension if
claims for payment are submitted under any provider number used by the provider to obtain reimbursement from Medi-Cal for the
services, goods, supplies or merchandise provided, directly or indirectly, to a Medi-Cal recipient by an individual or entity that is
suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from Medi-Cal and
the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List or any list published by the Federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the Federal Medicare and Medicaid programs,
to identify suspended, excluded, or otherwise ineligible providers."
Medi-Cal Update Part 1 – Program and Eligibility Month/Yr
2. Medi-Cal Suspended and Ineligible Provider List: Month/Yr Update
Reviewer and date http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/partl201304.asp
No HealthEssentials or GeriNet practitioners or providers found.
Reviewer and date
Medi-Cal Hotlines
Border Providers (916) 636-1200
Source
Reviewer and date of review
Recipient of notice
Med Board actions relating to the license or practice of physicians and surgeons [MBC
[email protected]] on behalf of Do Not Reply
Wednesday, May 01, 2013 5:05 PM
No HealthEssentials or GeriNet practitioners or providers found.
Reviewer and date
From:
Sent: To: Subject:
[email protected] MBC Subscribers' List - Actions relating to the license or practice of physicians and surgeons
This email is to notify recipients that:
Effective May 1, 2013, at 5 p.m., the license of YESSENNIA CANDELARIA, M.D. (C 52575), with an
address of record in Rocklin, CA, was immediately suspended via an Interim Order of Suspension.
Respondent waived the time deadline set forth in Government Code section 11529(c) for conducting the
notice hearing.
Respondent shall, within 15 days of service, provide the Medical Board of California with proof of
services of a true copy of this interim suspension order on the Chief of Staff or Chief Executive Officer at
every medical office or clinic or hospital or other institution or location where Respondent has practice
privileges or is employed in the practice of medicine, and on the Chief Executive Officer at every
insurance carrier where malpractice insurance coverage is extended to Respondent, if any.
Respondent shall not: practice or attempt to practice any aspect of medicine in the state of California
until a decision of the Medical Board of California following an administrative hearing; Advertise, by
any means, or hold herself out as practicing or available to practice medicine as a physician, or in any
other capacity; Be present in any location or office which is maintained for the practice of medicine, or
at which medicine is practiced for any purpose, except as a patient or as a visitor of family or friends;
and shall not: possess, order purchase, receive, furnish, administer, or otherwise distribute controlled
substances or dangerous drugs as defined by federal or state law.
Respondent shall: Immediately deliver to the Medical Board of California pending a final administrative
order of the Board in this matter, all indicia of his licensure as a physician and surgeon.
To view the doctor's profile and obtain a copy of the action(s), please go to http://www.mbc.ca.
gov/lookup.html.
Ifassistance is required, call (800) 633-2322.
Attention: It is the recipient's responsibility to review the Board's Web site periodically for status updates
on this physician's license. We will not send a follow-up e-mail.
Thank you for your interest in the activities of the Medical Board of California.
March 2013
http://www. dbc.ca.gov/consumers/hotsheets. shtml
Information for Consumers - Dental Board of California Page 1 of 2
Home About Us Consumers Licensees Applicants License Verification Forms and Publications Contact Us
Hot Sheets - Summaries of Administrative Actions
Month reviewing
February 2013
January 2013
December 2012
November 2012
October 2012
September
2012 August
2012
June 2012
April 2012
March 2012
February 2012
January 2012
December 2011
November 2011
October 2011
September
2011 August
2011
January 2011 through June 2011
October 2009 throu gh December
2010 July through September 2009
April through June 2009
January through March 2009
May through December
2008
Back to Top I Technical Support I Disclaimer
This web site contains PDF documents that require the most current version of Adobe Reader to view. To download click on the icon below.
Source Reviewer and date of review
[search •
STATE AND CONSUMER AGENCY- Department of Consumer Affairs EDMUND G. BROWN, JR., Governer
THE HOT–ADMINISTRATIVE ACTIONS TAKEN BY THE
Alvarez, Alan Michael, DDS 43677
PC23 Restriction effective 3-15-13
Bishay, Peter, DDS 51230
Probation-3 years effective 3-28-13
Bodek, Edward Joseph, 33008
PC23 Suspension effective 3-26-13
Cornejo, Ana Maria, RDA 76865
Aka Ana Maria F. Cornejo De Verduzco Aka Ana Maria Lopez
Surrendered license effective 3-28-13
Flanzer, Jeffrey Marc,
Petition for Reinstatement of cancelled
license (DDS 37821) denied
Effective 3-28-13
Golgolab, John S, DDS 37110
Accusation filed 2-26-13
Javahery, Simin, 47104
Probation-3 years effective 3-29-13
Kim, Geehong, DDS 35510, OCS 1906 3rd Amended Accusation filed 3-5-13
1
This page and pages that follow, display an alphabetical listing of actions taken by the Board during the specified period. To verify the license or permit of any one of the board's licensees,
and view disciplinary documents if applicable, the following steps may be helpfuL
1.
2. 3. 4.
From the homepage, displayed across the top of the page. Select "License Verification" (again). Select the license or permit type.
select "License VerificationH from the subject tabs
5.
6.
On the "License Search" page, enter either the LAST NAME ONLY 2! the LICENSE NUMBER ONLY (no letter prefix). If your search was by license number, when you hit enter, the desired licensee's name should be displayed. If by last name, there may be a list from which you will select the desired name. Do a left-click over the name of your licensee, and on the next page, scroll down and
select the document you want to view and/or print
If you use the following link, begin at step 3, above.
Insert Month and Year
No HealthEssentials or
GeriNet practitioner or
provider found.
Add date and reviewer
Insert Date Posted
Leiva, Tomas, RDA 75184 1st Amended Accusation and Petition
Revoke Probation filed 3-5-13
Theodore, Carolyn Marie, RDA 56832
Revoked effective 3-13-13
Tiffany Dawn, RDA 48418
Probation-3 years effective 3-29-13
Visoutsri, Mangkone, RDA 73905
Revoked Default effective 3-29-13
Martinez, Zebry Marylou, RDA 66083 Aka Zamarron
Revoked by effective 3-29-13
Meza Olivera, Luis, 74352
Aka Mesa
Stipulated Surrender of License
Effective 3-28-13
Pendergast, Michelle Ann, 69085
Accusation filed 2-26-13
Rubinoff, Craig Henry, DDS 35327
Accusation filed 3-13-13
Sandarg, Scott WiHiam
Petition for Reinstatement previously
revoked(DDS 45006) denied Effective
13
Suelflohn, Leroy, DDS 39480
Voluntary Surrender of License
Effective 3-28-13
Tash, Edmond Madjidian, DDS 47422 1st Amended Accusation filed 3-13-13
2
Subject:
Credentialing Committee
Policy and Procedure
Manual: Credentialing
Policy Number: CR 04
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Committee Policy and Procedure Page 1
I. POLICY
It is the policy of Health Essentials to have a designated Credentialing Committee that
conducts reviews and makes decisions regarding credentialing, recredentialing and mid-
cycle review decisions using a confidential peer review process and to define the
composition and responsibilities of the Credentialing Committee.
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Practitioner Network
C. Credentialing
D. Quality Improvement
E. Provider Services/Network Management
F. Administration
G. Utilization Management
H. Case Management
III. PURPOSE
A. To make certain that credentialing and recredentialing decisions are non-
discriminatory, not based on an applicant’s race, ethnicity nationality, gender, age,
religion or sexual orientation, and not be based solely on the types of procedures
performed (e.g. abortions) or types of patients (i.e.: Medi-Cal or Medicaid) the
provider treats.
B. To make certain that providers contracted by Health Essentials and designee meet
certain minimum quality standards developed with regulations and standards from the
California Department of Health Care Services (DHCS), the California Department of
Managed Health Care (DMHC), the Centers for Medicare and Medicaid Services
(CMS) and the National Committee for Quality Assurance (NCQA) to provide a
valid, standardized methodology for admission to, and retention in, the network
C. To support the processes used to obtain meaningful advice and expertise from
participating practitioners in making credentialing decisions
Subject:
Credentialing Committee
Policy and Procedure
Manual: Credentialing
Policy Number: CR 04
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Committee Policy and Procedure Page 2
IV. PROCEDURE
A. No practitioner or provider shall participate in the network or on behalf of Health
Essentials or designee prior to the final credentialing decision.
B. Credentialing policies and procedures shall be maintained and shall describe the
process used to determine clean files and shall identify the Medical Director, who is
the committee chairperson, as the individual with the authority to determine that the
file is “clean”
1. An applicant for initial credentialing or recredentialing may be approved
by the designated Medical Director when the applicant is considered to
have a clean file.
2. The Credentialing Committee shall receive a list of all applicants
approved outside of the Committee review process at least quarterly.
C. The Credentialing policies and procedures shall define the review processes for the
Committee to apply and make certain that an equitable decision making process is
maintained.
D. Voting membership shall be limited to licensed practitioners who represent the
practitioner network (i.e.: MD, DO, DPM, NP, PhD, etc.).
E. Quorum shall be defined as 50% +1 of the voting membership.
F. Each Committee member shall be required to attend no less than seventy-five percent
(75%) of the meetings to be considered a member in good standing
Membership:
A. The Credentialing Committee consists of practitioners representing primary care
practitioners and diverse specialties and one designated member of the Board of
Directors (Board) of GN Medical Associates, Inc. Members of the Committee shall
have the following qualifications:
1. Board certification in their specialty or at least five years of clinical practice in
their field of specialty and training;
2. Objectivity with respect for confidentiality;
3. Impeccable professional credentials;
4. Credibility with their peers;
5. Experience in hospital/managed care organization credentialing preferred; and
Subject:
Credentialing Committee
Policy and Procedure
Manual: Credentialing
Policy Number: CR 04
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Committee Policy and Procedure Page 3
6. Understanding and support the concept of managed care.
B. The members of the Committee shall elect a Chairperson. The Committee
Chairperson is the individual directly responsible for the Credentialing Program.
Responsibilities of the Chairperson include, but are not limited to, the following
activities:
1. Signature on all official credentialing documents, including provider
acceptance/rejection letters, termination letters, and monthly credentialing
minutes;
2. Review of all new and revised Credentialing Policy and Procedures prior to
committee review and approval;
3. Determination that a file is “clean” i.e. meets established criteria for provider
participation, see CR 01 Credentialing and Recredentialing policy and procedure
4. Pre-processing review of all new applicants;
5. Final review of all recredentialing applicants;
6. Providing additional information as needed concerning utilization issues;
7. Conducting applicant interviews, if necessary;
8. Calls to order and adjourns the credentialing meeting.
The Credentialing Committee shall:
A. Maintain documentation that the Governing Board has delegated to the Credentialing
Committee decision making authority for credentialing and recredentialing decisions
B. Document designation of authority to the Chairperson to approve “clean” files.
C. Approve minutes from each meeting.
a. Signature and date of Chair
b. Signature of recorder
c. Place and date of meeting
d. Start and end time of meeting
D. The Committee shall review the application material of all practitioners being
credentialed or recredentialed who do not meet Health Essentials or designee
established criteria
E. Review all credentialing and recredentialing policies and procedures, at least
annually, and recommend and approve revisions as necessary;
Subject:
Credentialing Committee
Policy and Procedure
Manual: Credentialing
Policy Number: CR 04
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Committee Policy and Procedure Page 4
F. Review, discuss and make recommendations regarding practitioner’s applications for
initial acceptance into the network and participating practitioner’s credentialing and
recredentialing applications;
G. If the initial committee review results in a “pending” status for a practitioner, there
shall be a final review and decision when the committee evaluates all credentials at
the same time.
H. If the result of a delayed decision is that some information in the practitioner file no
longer meets timeliness requirements, Health Essentials or designee shall re-verify
the noncompliance information before presenting it to the Committee for a final
decision
I. Shall provide oversight of entities delegated for credentialing functions and maintains
ultimate accountability and authority for credentialing and recredentialing decisions
J. Review and make recommendations regarding initial and annual delegation of
credentialing and recredentialing to Provider Organizations in accordance with the
organization’s delegation policies and procedures;
K. Maintain confidentiality of all information presented to, or discussed at the
Committee meetings;
L. Annually the Credentialing Committee shall evaluate the effectiveness of the
Credentialing and Recredentialing Committee and process;
M. Shall administer the credentialing fair hearing process for quality of care terminations
or denials as described in CR 14 Termination or Denial with Cause policy and
procedure; and
N. Engage in other functions as determined by the Board of Directors.
Meetings:
A. The Committee will meet as often as necessary to process new applicants in a timely
manner and to review the recredentialing applications of participating providers. At a
minimum, the Committee will on a quarterly basis.
B. The Credentialing Department will present a report of applications to the Committee
together with all necessary information on applicants. The report will be divided into
“clean” files and files that will require review. A “clean” file is one which meets the
“ Credentialing and Recredentialing” (P&P CR 01)
Subject:
Credentialing Committee
Policy and Procedure
Manual: Credentialing
Policy Number: CR 04
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Committee Policy and Procedure Page 5
C. The Committee Chairman has the authority to make the final determination of a clean
file and to approve it. All other files will be discussed by the Committee and a final
determination concerning participation will be made.
D. Review of all terminations, denials, deferrals, and approvals will take place within
one month of assimilation of the required information.
V. DEFINITIONS
B. Board Certification
The process by which a practitioner is board certified by a recognized board of the
American Board of Medical Specialties (ABMS) or the American Osteopathic
Association (AOA). Canadian Board Certification is also acceptable.
C. Clean file
An applicant with no licensing, privileging, or liability claims activity or any
other issue identified through attestation questions.
D. CMS
The Center for Medicare and Medicaid Services
E. Credentialing Verification Organization (CVO)
An independent contractor who performs primary source verification for the
Credentialing process on a delegated basis
F. NCQA
National Committee of Quality Assurance – A private, not for profit organization
dedicated to improving healthcare quality
G. Practitioner
A clinical professional who provides health care services. Practitioners are
usually required to be licensed as required by law
H. Primary Care Physician
A health care practitioner who, within the scope of the practitioner's practice,
supervises, coordinates, prescribes or otherwise providers or proposes to provide
health care services to a member; initiates member referral for specialist care; and
maintains continuity of member care
I. Provider
Subject:
Credentialing Committee
Policy and Procedure
Manual: Credentialing
Policy Number: CR 04
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Committee Policy and Procedure Page 6
A practitioner, institution, or organization that provides services for
HealthEssentials or its designee
VI. SOURCES
A. Standards set by NCQA effective July 1, 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
VII. RELATED POLICY/PROCEDURE
A. Credentialing Committee Charter
B. CR 01 Credentialing and Recredentialing policy and procedure
C. CR 07 Credentialing Non-Discrimination policy and procedure
D. CR 12 Practitioner Confidentiality
E. CR 13 Sanctions, Complaints and Quality Issues Monitoring policy and procedure
F. CR 14 Termination or Denial with Cause policy and procedure
VIII. ATTACHMENTS
A. Conflict of Interest Statement
B. Confidentiality Statement
Health Essentials
2014 Quality Improvement Program
Credentialing Committee Charter
Name of Committee: Credentialing Committee
Chairperson: Iyad Houshan, M.D., Chief Medical Officer/
Medical Director
Committee Members:
Voting Members (4):
Iyad Houshan, M.D.
Christine Mlot, MD
Thuy Nguyen, MD
Estelei Penuliar, NP
Support Staff (Non-Voting Members):
Amina Silan, Credentialing Coordinator
Allen Bauzon, Director of Legal and Contracting (Credentialing Manager)
Meeting Frequency:
At least quarterly
2014 Meeting Dates:
February May
August November
Quorum:
A simple majority of 50% +1 of voting members is required (3 voting practitioners)
Reports to Committee:
Board of Directors on a quarterly basis
Responsibilities:
1. The Health Essentials Credentialing Committee is responsible for administering
the Credentialing Program.
2. The Committee reviews and recommends approval of practitioners and providers
that have completed the credentialing process and have been found to meet the
credentialing requirements of Health Essentials.
Health Essentials
2014 Quality Improvement Program
Credentialing Committee Charter
3. The Credentialing Department will present a report of applications to the
Committee together with all necessary information on applicants. The report will
be divided into “clean” files and files that will require review. A “clean” file is
one which meets Credentialing and Recredentialing policy and procedures CR 01.
4. The Committee Chairman has the authority to make the final determination of a
clean file and to approve it. All other files will be discussed by the Committee and
a final determination concerning participation will be made.
5. If the result of a delayed decision is that some information in the practitioner file
no longer meets timeliness requirements, Health Essentials shall re-verify the
noncompliance information before presenting it to the committee for a final
decision.
6. The Committee reviews and discusses any provider or facility file which, after
completing credential review, is found to have exceptions to the standard
credentialing requirements. The Credentialing Committee has the authority to
recommend action to the Board of Directors, including acceptance of applications
with or without restrictions, or rejection/termination of an application. The
Credentialing Committee may base its recommendations on factors it deems
appropriate.
7. Conducts an annual review of Credentialing Policies and Procedures and for
revisions and approval.
8. Oversees, reviews and approves any delegation of credentialing or recredentialing
functions, including the use of a Certified Verification Organization (CVO), as
applicable.
9. Reviews of all terminations, denials, deferrals, and approvals will take place
within one month of assimilation of the required information.
10. Reviews Quality of Care and Quality of Service issues on an ongoing basis.
11. Reviews all sanctions and licensure matters (i.e.; accusations, citations) within 30
days of notification Takes action at any time, including mid-cycle
recredentialing as needed. Maintain documentation that the Governing Body has
delegated for credentialing and recredentialing decision making authority.
12. The Credentialing Department shall notify the applicant within 60 days of the
Credentialing decision on behalf of the Credentialing Committee.
Health Essentials
2014 Quality Improvement Program
Credentialing Committee Charter
13. Maintain confidentiality of all information presented to, or discussed at the
Committee meetings.
14. Approve minutes from each meeting, including signature of chair, recorder and
dates.
15. Annually, the Credentialing Committee shall evaluate the effectiveness of the
Credentialing and Recredentialing Committee and process.
16. Shall administer the credentialing fair hearing process for quality of care
terminations or denials as described in CR 14 Termination or Denial with Cause
policy and procedure.
17. Please refer to CR 04 Credentialing Committee policy and procedure for
additional details.
Subject:
Credentialing Medicare Opt-Out
Policy and Procedure
Manual: Credentialing
Policy Number: CR 06
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014
Confidential Credentialing Medicare Opt-Out Policy and Procedure Page 1
I. POLICY
It is the policy of Health Essentials and their entities to not hire or contract with practitioners
who have elected to “Opt-Out” of Medicare or are excluded or sanctioned from participation
in Medicare or Medi-Cal programs.
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Provider Network Management
III. PURPOSE
A. To make certain that no practitioner is identified as having opted-out of participation
with the Medicare Program.
B. To define the process that is used to document that each practitioner is eligible to
participate in Medicare.
IV. PROCEDURE
A. The Medicare Opt-out report must be evident for each initial and recredentialing file.
B. The Credentialing Department will review the information from the most recently
issued Medicare Opt-out List.
C. Review will be documented by maintaining a file containing the most recent complete
listing of California providers that have opted out.
1. Evidence of review
2. Documented on the internal file checklist of query and report reviewed
3. Copy of the page, from the complete listing report, showing where the
providers name would have been listed in alphabetical order
D. The complete listing report and/ or quarterly report will be downloaded from the
following site
Noridian Healthcare Solutions
https://med.noridianmedicare.com/web/jeb/enrollment/opt-out/opt-out-
listing;jsessionid=078F02847E21225DDB41EBEAB6CD7FA0
E. The only exception for opting-out of the Medicare program is Registered Dietitians
per the Medicare Benefits Improvement and Protection Act of 2000, section 1802
Subject:
Credentialing Medicare Opt-Out
Policy and Procedure
Manual: Credentialing
Policy Number: CR 06
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates: May 6, 2014
May 21, 2014
Confidential Credentialing Medicare Opt-Out Policy and Procedure Page 2
F. In the event that a currently credentialed hired or contracted practitioner be identified
as opted-out of Medicare, that practitioner shall be immediately terminated with no
appeal rights
G. The attached worksheet shall be utilized to document when each Opt Out list was
reviewed, including the name and date of review and outcome of the review
V. DEFINITIONS
A. CMS
The Center for Medicare and Medicaid Services
B. Credentialing Verification Organization (CVO)
An independent contractor who performs primary source verification for the
Credentialing process on a delegated basis
C. NCQA
National Committee of Quality Assurance – A private, not for profit organization
dedicated to improving healthcare quality
D. Opt-Out
Participating physicians and practitioners who chose to opt-out by filing an
affidavit that meets the established criteria and which is received by the Carrier at
least 30 days before the first day of the next calendar quarter showing an effective
date of the first day in that quarter (i.e. 1/1. 4/1. 7/1. 10/1). Their participation
agreement will terminate at that time. They may not provide services under
private contracts with beneficiaries earlier than the effective date of the affidavit.
Non-participating physicians and practitioners may opt-out at any time. The Opt-
Out contract lasts for a two-year period beginning the date the physician or
practitioner files and signs an affidavit that he or she has opted out of Medicare.
Then the physician or practitioner could decide to return to Medicare or to “opt
out” again
E. Practitioner
A clinical professional who provides health care services. Practitioners are
usually required to be licensed as required by law
F. Provider
A practitioner, institution, or organization that provides services for Health
Essentials or its designee
Subject:
Credentialing Medicare Opt-Out
Policy and Procedure
Manual: Credentialing
Policy Number: CR 06
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014
Confidential Credentialing Medicare Opt-Out Policy and Procedure Page 3
VI. SOURCES
A. Standards set by NCQA effective July 1, 2014
B. CMS Manual System; Medicare Benefit Policy dated Dec. 22, 2006
VII.RELATED POLICY/PROCEDURE
A. CR 01 Credentialing and Recredentialing policy and procedure
B. CR 03 Ongoing Monitoring of Required Board and Agencies policy and procedure
C. CR 03 Attachment, Worksheet of Website Information
D. CR 12 Practitioner Confidentiality
E. CR 13 Sanctions, Complaints and Quality Issues Monitoring policy and procedure
F. CR 14 Termination or Denial with Cause policy and procedure
VIII.ATTACHMENTS
Worksheet addendum noting process to document review and outcome
files updated: 05-09-2014
Current Monthly Supplements
• 04-2014 Exclusions: EXE | ZIP • 04-2014 Reinstatements: EXE | ZIP
• Monthly Supplement Archive
Name of Reviewer and Date
No active HealthEssentials (or
GeriNet) practitioner or provider
found. One termed provider
found.
dt - 5/15/12
http://www.oig.hhs.gov/exclusions/exclusions_list.asp
LEIE Downloadable Databases | Exclusions | Office of Inspector General | U.S. Department ... Page 1 of 2
Attachment to CR 06, Medicare Opt Out and CR 03 Ongoing Monitoring Policies and Procedures
• Exclusions • Fraud
• Compliance • Newsroom
• Reports/Pubs
• Recovery
• About OIG
HealthEssentials Evidence of Ongoing Monitoring
LEIE Downloadable Databases
Search the Online LEIE Database
E-mail me when this page is updated.
DATE OF RELEASE
Download the LEIE Database
Below
LEIE Database
• 04-2012 Updated LEIE Database: EXE | ZIP
DOCUMENTATION OF FINDINGS & STAFF REVIEWING
Updated LEIE Information • 04-2012 Updated Information
Record Layout • Current Database Record Layout
Instructions
MONTH REVIEWING
The List of Excluded Individuals/Entities (LEIE) is available in different versions, and all are .dbf files zipped into
self-extracting executable (exe) files.
Save this .exe file to your computer, then extract the.dbf file into either a database program such as Microsoft access or a spreadsheet program such as Microsoft Excel. Please refer to your software's help file for instructions on using .dbf
files.
Versions About the Updated LEIE:
The updated LEIE is a complete database containing all exclusions currently in effect.
Individuals and entities who have been reinstated are not included in this file.
This file is replaced with an updated version each month.
This file is complete and should not be used in conjunction with the monthly exclusion and reinstatement
supplements. Reviewer and date of review Source
(Updated March 7, 2013)
No HealthEssentials or
GeriNet practitioners or
providers found.
Name of Reviewer & Date
Name of Reviewer and
Date
http://www.rn.ca.gov/enforcement/enf-actions-fed.shtml
Board of Registered Nursing - Disciplinary Actions - February 2013 Documentation of Review Page 1 of 5
Release date
(add date) Month reviewing
The information provided below is current as of the date this list was created and may be subject to change. To verify the most recent
information available regarding an RN license, please check the individual's license status through the Online License Verification Sv stem or
by contacting the Board directly.
Accusation Filed
Accusation & Petition to Revoke Probation
Filed Amended Accusation Filed
License Denied by Decision/Order
Order to Issue License -
Conditional Petition to Revoke
Probation Filed Public Reproval
Revocation
Revocation Stay ed License Probation
Only Statement of Issues Filed
Suspension
Voluntarv Surrender
DISCLAIMER: All information provided by the Board of Registered Nursing (BRN) on this web page, is made available to provide immediate
access for the convenience of interested persons. While the Board believes the information to be reliable, human or mechanical error remains
a possibility, as does delay in the posting or updating of information. Therefore, the Board makes no guarantee as to the accuracy,
completeness, timeliness, currency, or correct sequencing of the information. Neither the Board, nor any of the sources of the information,
shall be responsible for any errors or omissions, or for the use or results obtained from the use of this information.
Accusation Filed
ACTION DATE RESPONDENT NAME RN NUMBER
21-FEB-2013 ALLCROFT, NANACY RN 270802
20-FEB-2013 BABCOCK, CAROL JEANNE RN 442853
20-FEB-2013 BAGUE, CARLOS GUITGUITEN RN 728667
21-FEB-2013 BARSNESS, MARLA MICHELLE RN 586101
22-FEB-2013 BAYMA, KARA MARET RN 516844
19-FEB-2013 BECERRA, ANDREW RN 705386
19-FEB-2013 BEHRENS, TINA MARIE RN 766111
Source Reviewer and date of review
Medi-Cal Update
Part 1 - Program and Eligibility I April 2013
The April Update is
1 active, 2 termed, 2
ONWA providers found.
Reviewer and date
Source
Medi-Cal: Medi-Cal Update - Part 1 - Program and Eligibility I April 2013 Page 1 of 2
1.
2. Medi-Cal Suspended and Ineligile Provider List: (Month/Yr) Update
3. Medi-Cal Hotlines
4.
A frequent cause of claim denials by Medi-Cal is due to incorrect recipient admission and discharge dates and/or incorrect patient status
codes submitted by providers. Erroneous "from-through" dates or patient status billed by one provider and paid by Medi-Cal can result in
the denial of correct claims billed by another provider. This often occurs between hospitals and nursing homes during the transfer of the
recipient. Providers see this on their Remittance Advice Details (RADs) as a claim denied by RAD code 010.
Should the denied provider choose to dispute the claim and there is no resolution between the two providers regarding the dates in
question, Medi-Cal could recoup the full reimbursement of the original erroneously paid claim, and will not make an adjustment without a
correction request from that provider.
Incorrectly paid and denied claims can also create incorrect provider reimbursement data and inaccuracies in the health service records
that may impact beneficiary share of cost, access to services and estate recovery.
For assistance in resolving these issues, providers are advised to write to the Correspondence Specialist Unit at:
Correspondence Specialist Unit
P.O. Box 13029 Sacramento, CA 95813-4029
For information about proper claim form completion, refer to the claim completion section in the appropriate Part 2 manual.
Month reviewing
a list of providers who have been added to or removed from, or whose information has been updated and/or
corrected in the Medi-Cal Suspended and Ineligible Provider List (S&I List) for the month of April.
were removed from the following lists:
Always refer to the S&I List when
Eligibility or ineligibility must also be verified through the Health and Human Services (HHS) Office of Inspector General (OIG) List of
Excluded Individuals/Entities.
Suspension of Entities Submitting Claims for Suspended Providers
Entities submitting claims for services rendered by a health care provider suspended from Medi-Cal or excluded from Medicare or Medicaid by the Federal Office of Inspector General are subject to Medi-Cal suspension.
Welfare and Institutions Code (W&I Code), Section 14043.61(a), states, in relevant part, that "a provider shall be subject to suspension if
claims for payment are submitted under any provider number used by the provider to obtain reimbursement from Medi-Cal for the
services, goods, supplies or merchandise provided, directly or indirectly, to a Medi-Cal recipient by an individual or entity that is
suspended, excluded, or otherwise ineligible because of a sanction to receive, directly or indirectly, reimbursement from Medi-Cal and
the individual or entity is listed on either the Medi-Cal Suspended and Ineligible Provider List or any list published by the Federal Office of Inspector General regarding the suspension or exclusion of individuals or entities from the Federal Medicare and Medicaid programs,
to identify suspended, excluded, or otherwise ineligible providers."
Medi-Cal Update Part 1 – Program and Eligibility Month/Yr
2. Medi-Cal Suspended and Ineligible Provider List: Month/Yr Update
Reviewer and date http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/partl201304.asp
No HealthEssentials or GeriNet practitioners or providers found.
Reviewer and date
Medi-Cal Hotlines
Border Providers (916) 636-1200
Source
Reviewer and date of review
Recipient of notice
Med Board actions relating to the license or practice of physicians and surgeons [MBC
[email protected]] on behalf of Do Not Reply
Wednesday, May 01, 2013 5:05 PM
No HealthEssentials or GeriNet practitioners or providers found.
Reviewer and date
From:
Sent: To: Subject:
[email protected] MBC Subscribers' List - Actions relating to the license or practice of physicians and surgeons
This email is to notify recipients that:
Effective May 1, 2013, at 5 p.m., the license of YESSENNIA CANDELARIA, M.D. (C 52575), with an
address of record in Rocklin, CA, was immediately suspended via an Interim Order of Suspension.
Respondent waived the time deadline set forth in Government Code section 11529(c) for conducting the
notice hearing.
Respondent shall, within 15 days of service, provide the Medical Board of California with proof of
services of a true copy of this interim suspension order on the Chief of Staff or Chief Executive Officer at
every medical office or clinic or hospital or other institution or location where Respondent has practice
privileges or is employed in the practice of medicine, and on the Chief Executive Officer at every
insurance carrier where malpractice insurance coverage is extended to Respondent, if any.
Respondent shall not: practice or attempt to practice any aspect of medicine in the state of California
until a decision of the Medical Board of California following an administrative hearing; Advertise, by
any means, or hold herself out as practicing or available to practice medicine as a physician, or in any
other capacity; Be present in any location or office which is maintained for the practice of medicine, or
at which medicine is practiced for any purpose, except as a patient or as a visitor of family or friends;
and shall not: possess, order purchase, receive, furnish, administer, or otherwise distribute controlled
substances or dangerous drugs as defined by federal or state law.
Respondent shall: Immediately deliver to the Medical Board of California pending a final administrative
order of the Board in this matter, all indicia of his licensure as a physician and surgeon.
To view the doctor's profile and obtain a copy of the action(s), please go to http://www.mbc.ca.
gov/lookup.html.
Ifassistance is required, call (800) 633-2322.
Attention: It is the recipient's responsibility to review the Board's Web site periodically for status updates
on this physician's license. We will not send a follow-up e-mail.
Thank you for your interest in the activities of the Medical Board of California.
March 2013
http://www. dbc.ca.gov/consumers/hotsheets. shtml
Information for Consumers - Dental Board of California Page 1 of 2
Home About Us Consumers Licensees Applicants License Verification Forms and Publications Contact Us
Hot Sheets - Summaries of Administrative Actions
Month reviewing
February 2013
January 2013
December 2012
November 2012
October 2012
September
2012 August
2012
June 2012
April 2012
March 2012
February 2012
January 2012
December 2011
November 2011
October 2011
September
2011 August
2011
January 2011 through June 2011
October 2009 throu gh December
2010 July through September 2009
April through June 2009
January through March 2009
May through December
2008
Back to Top I Technical Support I Disclaimer
This web site contains PDF documents that require the most current version of Adobe Reader to view. To download click on the icon below.
Source Reviewer and date of review
[search •
STATE AND CONSUMER AGENCY- Department of Consumer Affairs EDMUND G. BROWN, JR., Governer
THE HOT–ADMINISTRATIVE ACTIONS TAKEN BY THE
Alvarez, Alan Michael, DDS 43677
PC23 Restriction effective 3-15-13
Bishay, Peter, DDS 51230
Probation-3 years effective 3-28-13
Bodek, Edward Joseph, 33008
PC23 Suspension effective 3-26-13
Cornejo, Ana Maria, RDA 76865
Aka Ana Maria F. Cornejo De Verduzco Aka Ana Maria Lopez
Surrendered license effective 3-28-13
Flanzer, Jeffrey Marc,
Petition for Reinstatement of cancelled
license (DDS 37821) denied
Effective 3-28-13
Golgolab, John S, DDS 37110
Accusation filed 2-26-13
Javahery, Simin, 47104
Probation-3 years effective 3-29-13
Kim, Geehong, DDS 35510, OCS 1906 3rd Amended Accusation filed 3-5-13
1
This page and pages that follow, display an alphabetical listing of actions taken by the Board during the specified period. To verify the license or permit of any one of the board's licensees,
and view disciplinary documents if applicable, the following steps may be helpfuL
1.
2. 3. 4.
From the homepage, displayed across the top of the page. Select "License Verification" (again). Select the license or permit type.
select "License VerificationH from the subject tabs
5.
6.
On the "License Search" page, enter either the LAST NAME ONLY 2! the LICENSE NUMBER ONLY (no letter prefix). If your search was by license number, when you hit enter, the desired licensee's name should be displayed. If by last name, there may be a list from which you will select the desired name. Do a left-click over the name of your licensee, and on the next page, scroll down and
select the document you want to view and/or print
If you use the following link, begin at step 3, above.
Insert Month and Year
No HealthEssentials or
GeriNet practitioner or
provider found.
Add date and reviewer
Insert Date Posted
Leiva, Tomas, RDA 75184 1st Amended Accusation and Petition
Revoke Probation filed 3-5-13
Theodore, Carolyn Marie, RDA 56832
Revoked effective 3-13-13
Tiffany Dawn, RDA 48418
Probation-3 years effective 3-29-13
Visoutsri, Mangkone, RDA 73905
Revoked Default effective 3-29-13
Martinez, Zebry Marylou, RDA 66083 Aka Zamarron
Revoked by effective 3-29-13
Meza Olivera, Luis, 74352
Aka Mesa
Stipulated Surrender of License
Effective 3-28-13
Pendergast, Michelle Ann, 69085
Accusation filed 2-26-13
Rubinoff, Craig Henry, DDS 35327
Accusation filed 3-13-13
Sandarg, Scott WiHiam
Petition for Reinstatement previously
revoked(DDS 45006) denied Effective
13
Suelflohn, Leroy, DDS 39480
Voluntary Surrender of License
Effective 3-28-13
Tash, Edmond Madjidian, DDS 47422 1st Amended Accusation filed 3-13-13
2
Subject:
Credentialing Non-Discrimination
Manual: Credentialing
Policy Number: CR 07
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
Confidential Credentialing Non-Discrimination Page 1
I. POLICY
A. The organization, its staff, committees and Board of Directors or delegated entities as
applicable, will not make credentialing and recredentialing decisions based solely on
the following:
1. An applicant’s race, creed, color, ancestry, national origin or ethnicity
nationality
2. Gender, age or religion
3. Non-job related handicap or disability
4. Any other protected class or sexual orientation
B. Credentialing or recredentialing decision may not be based solely on the following:
1. Types of procedures performed (e.g. abortions)
2. Types of patients (e.g. Medicaid) the provider treats
3. How the practitioner advocates on behalf of the member
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing Department
D. Quality Improvement
E. Provider Network Management
F. Administration
G. Member Services
III. PURPOSE
A. To describe the steps that the organization takes to monitor for and prevent
discriminatory practices during the credentialing and recredentialing processes
B. The non-discrimination practice does not preclude the organization from including in
its hired or contracted network practitioners who meet certain demographic or
specialty needs to meet the cultural needs of the membership
Subject:
Credentialing Non-Discrimination
Manual: Credentialing
Policy Number: CR 07
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Non-Discrimination Page 2
IV. PROCEDURE
The organization shall monitor for and prevent discriminatory practices on an ongoing
basis by:
A. Having all Credentialing Committee members sign an affirmative statement to make
decisions in a non-discriminatory manner.
B. Conducting periodic audits of in-process applicants, applicants denied for
administrative reasons, and those applicant approved, denied or terminated by
Committee decision files and termination decisions.
C. Should a significant sentinel event be identified, that applicant shall be re-evaluated
by the Committee within 30 days of identification.
a. An ad hoc Credentialing Committee may be convened to meet the
prescribed timeframe of 30 days for a review to be conducted.
b. If a trend is identified, a focus review will be done by the Credentials
Committee.
D. Ongoing review of member and practitioner complaints to determine if there are
complaints alleging discrimination by participating providers.
E. A semi-annual report of any negative trends or patterns shall be reported to the
Credentialing Committee monitoring and evaluation process and who, when
necessary, shall document corrective actions.
V. DEFINITIONS
A. Board Certification The process by which a practitioner is board certified by a
recognized board of the American Board of Medical
Specialties (ABMS) or the American Osteopathic
Association (AOA). Canadian Board Certification is also
acceptable
Subject:
Credentialing Non-Discrimination
Manual: Credentialing
Policy Number: CR 07
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
Confidential Credentialing Non-Discrimination Page 3
B. CMS The Center for Medicare and Medicaid Services
C. Credentialing Verification Organization (CVO)
An independent contractor who performs primary source
verification for the Credentialing process on a delegated
basis
D. NCQA National Committee of Quality Assurance – A private, not
for profit organization dedicated to improving healthcare
quality
E. Practitioner A clinical professional who provides health care services.
Practitioners are usually required to be licensed as required
by law
F. Primary Care Physician A health care practitioner who, within the scope of the
practitioner's practice, supervises, coordinates, prescribes
or otherwise providers or proposes to provide health care
services to a member; initiates member referral for
specialist care; and maintains continuity of member care
G. Provider A practitioner, institution, or organization that provides
services for the Health Plan or its designee
VI. SOURCES
A. Standards set by NCQA effective July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
C. Title VI of the Civil Rights Act
D. Section 504 of the Rehabilitation Act of 1973
E. The Age Discrimination Act of 1975
F. Title III of the Americans with Disabilities Act (ADA)
G. California Department of Health Care Services
VII.RELATED POLICY/PROCEDURE
A. CR 01 Credentialing and Recredentialing policy and procedure
VIII.ATTACHMENTS
None
Subject:
Credentialing Administrative Terminations
Policy and Procedure
Manual: Credentialing
Policy Number: CR 08
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Administrative Terminations Policy and Procedure Page 1
I. POLICY
A. The Credentialing Department staff for the organization shall utilize established
procedures for processing the administrative termination of contracted or hired
practitioners or providers from the network.
B. Administrative Terminations will be imposed as an immediate summary suspension
for;
1. Loss of license to practice;
2. Participation as a Medicare Opt-Out Practitioner;
3. State or Federal Sanction;
4. Identified in the List of Excluded Individuals and Entities (LEIE).
C. This is not applicable to termination or denial decisions based on quality of care,
quality of service, adverse practice patterns or licensing issues as determined by the
Credentialing Committee.
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Provider Services and Contracting
E. Administration
III. PURPOSE
To make certain that administrative termination of practitioners and providers is
completed in a consistent and accurate manner and that continuity of care is provided for
members affected by such termination.
IV. PROCEDURE
Termination by Provider: Upon receipt of a practitioner’s notice of administrative termination from the network, the
following procedure will be followed:
A. Reasons for administrative terminations may include, but would not be limited to the
following:
Subject:
Credentialing Administrative Terminations
Policy and Procedure
Manual: Credentialing
Policy Number: CR 08
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Administrative Terminations Policy and Procedure Page 2
1. Breach of contract, not related to a validated quality of care or service matter;
2. Practitioner refusal to cooperate with the credentialing or recredentialing process;
3. Practitioner voluntarily resigns from the network with no pending quality
investigation;
4. Listing on the LEIE;
5. Listing as an Opt-Out practitioner;
6. Loss of License;
7. See section below on “network termination”
B. There are no fair hearing or appeal rights for practitioners or providers who are
terminated for administrative reasons.
C. The notification of administrative termination will be sent directly to the practitioner
signed by the Chairperson of the Credentialing Committee via registered mail. The
Provider Network Management Department will be informed of the termination per the
add, change and delete process.
D. If terminating provider is a Primary Care Physician with an active panel of members, the
Customer Care Managers shall identify, and obtain written acceptance from, another
Primary Care Physician to accept the terminating provider’s members.
E. The Credentialing Department is responsible for loading the termination information into
the credentialing database and presenting such documentation to the Credentialing
Committee for information purposes.
Network Termination:
The organization may terminate a practitioner or provider without cause, as outlined in the
relevant Professional Service Agreement or Physician Employment Agreement by giving the
required prior written notice to the provider. If a provider is terminated with cause, including
immediate termination or summary suspension, please refer to the Credentialing and
Recredentialing policy and procedure CR 01.
A. If the practitioner is terminated for administrative reasons based on Credentialing
functions (i.e.: Practitioner refused to complete the application process), the
Subject:
Credentialing Administrative Terminations
Policy and Procedure
Manual: Credentialing
Policy Number: CR 08
Number of Pages: 3 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Administrative Terminations Policy and Procedure Page 3
Credentialing Department is responsible for notifying the practitioner or provider in
writing of the termination notice and effective date. The Credentialing Department is
responsible for loading the termination information into the credentialing database as
provided in the documentation described above.
B. The Credentialing Department will notify applicable internal departments (i.e. Customer
Care Center, Utilization Department, Billing Department, , and Contract Department) by
providing a list on a monthly basis of providers terminating from the network.
C. The Contract Services Department will load the termination date in the claims system.
D. The Credentialing Department will send the provider’s credentialing file to secured off-
site storage six (6) months after the termination effective date.
V. DEFINITIONS
A. LEIE List of Excluded Individuals and Entities
B. Opt Out Voluntary participation to Opt Out of the Medicare program by a
practitioner or provider
C. Practitioner A clinical professional who provides health care services.
Practitioners are usually required to be licensed as required by law
D. Provider A practitioner, institution, or organization that provides services
for the organization or its designee
VI.RELATED POLICY/PROCEDURE
A. CR 01 Credentialing and Recredentialing policy and procedure
B. CR 02 Credentialing Allied Health policy and procedure
C. CR 06 Medicare Opt Out policy and procedure
D. CR 11 Practitioner and Provider Changes policy and procedure
E. CR 13 Sanctions, Complaints and Quality Issues Monitoring policy and procedure
VII.ATTACHMENTS
None
Subject:
Credentialing Quality Improvement (QI) File
Audit Policy and Procedure
Manual: Credentialing
Policy Number: CR 09
Number of Pages: 2 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Quality Improvement (QI) File Audit Policy and Procedure Page 1
I. POLICY
At least quarterly, internal file evaluations shall be conducted to determine if the
Credentialing policies and procedures are being accurately and consistently applied in the
initial credentialing and recredentialing of providers and to monitor files for
recredentialing within the 36-month required time period.
II. PERSONS/DEPARTMENTS AFFECTED
A. Credentialing
B. Quality Improvement
C. Clinical Operations
III. PURPOSE
To promote accuracy in timelines, data entry and file preparation as outlined in
Credentialing policies and procedures
IV. PROCEDURE
A. A file review shall be conducted prior to each of the credentialing committee
meetings to assess completeness and accuracy of review requirements.
B. The Credentialing Coordinator or designee shall audit the files.
C. The audit will consist of 50% of the files to be presented to each Credentialing
Committee or a minimum of 15 files, whichever is greater.
D. The Credentialing File Evaluation form shall be used to record audit findings (see
attached).
E. The auditor shall use and apply Credentialing policies and procedures when
reviewing the selected files.
Subject:
Credentialing Quality Improvement (QI) File
Audit Policy and Procedure
Manual: Credentialing
Policy Number: CR 09
Number of Pages: 2 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
XXXX XXXXX, MD Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Quality Improvement (QI) File Audit Policy and Procedure Page 2
F. Files scoring less than 100% shall be reviewed with the Credentialing Coordinator
responsible for the file. The Credentialing Coordinator shall correct the file before
being presented to the Credentialing Committee.
G. Overall results will be conveyed on a quarterly basis and on each Credentialing
Coordinator’s annual job performance evaluation.
H. Recredentialing files are reviewed the same as credentialing files with the addition of
monitoring the required 36 month time frame.
.
I. DEFINITIONS
J. SOURCES
A. Standards set by NCQA, July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
K.RELATED POLICY/PROCEDURE
L.ATTACHMENTS
A. CR 09 Attachment A Performance Improvement work sheet
(Credentialing Record Evaluation Form)
Credentialing Checklist - CR 09 Attachment A QI of Credentialing File
This document is for informational purposes only.
INITIAL CREDENTIALING □ RECREDENTIALING □ PRIOR CRED DATE:
____________
NAME : SPECIALTY (S): ROLE:
Please identify the source used to validate the elements as listed below. VERIFIED/REVIEWED
BY DATE
STATE LICENSE Source: Expiration Date:
___________
DEA CERTIFICATE
(for each state the provider is
practicing in)
Source: □ Copy □ NTIS □ Other:__________________
State(s) listed on DEA(s): _____________ Expiration Date:
___________
EDUCATION/TRAINING
(Highest level of education is
required)
Source: □ AMA/AOA □ Letter □ Phone □
Other:_________________
Medical/Professional School:__________________________________
Internship/Residency:________________________________________
Fellowship: ________________________________________________
BOARD CERTIFICATION
Source: □ ABMS □ AOA Board □ AMA/AOA Master □
Other:_________
Specialty: __________________________________ Expiration Date:
___________
Specialty: __________________________________ Expiration Date:
___________
Specialty: __________________________________ Expiration Date:
___________
WORK HISTORY
N/A for Recredentialing Source: □ Application □ CV □ Other:____________
Explanation of gaps of 6 months or longer: □ Yes □ No
MALPRACTICE CLAIMS
HISTORY
Source: □ NPDB □ Insurance Carrier □ Other:_____________
ATTESTATION
QUESTIONS
Check each applicable box
answering the corresponding
question.
□ Reasons for Inability □ Lack of Drug Use □ Loss of License
□ Felony Convictions □ Loss or limits of Privileges
Attestation Signature Date: _______________
LIABILITY INSURANCE
Source: □ Face Sheet □ Letter from Carrier □ Attestation
Limits of Liability: $_____/$______ Expiration Date:
___________
STATE SANCTIONS OR
RESTRICTIONS ON
LICENSURE
Source: □ NPDB □ FSMB □ Continuous Query □
Other:_______________
MEDICARE/MEDICAID
SANCTIONS Source: □ NPDB □ OIG □ Continuous Query
□ Medi-Cal Suspended and Ineligible List □
Other:________________________
HOSPITAL ADMITTING
PRIVILEGES Source: □ Letter □ Phone □ Roster □ Application
Hospital(s) ______________________ Coverage Plan if
applicable_____________
MEDICARE OPT-OUT
If Provider Opts Out immediate
summary suspension is applied
and all parties notified
Source: Noridian Healthcare Solutions
Report/Run Date____________
Findings: Practitioner on Opt-Out List □ Yes □ No
Credentialing Checklist - CR 09 Attachment A QI of Credentialing File
This document is for informational purposes only.
QUALITY ISSUES/
COMPLAINTS
Since last cred cycle file contains
evidence that:
Quality Issues reviewed: □ Yes #_____ □ None
Complaints reviewed: □ Yes #______ □ None
SITE VISIT (if applicable) Date of Visit: ________ Compliant □ Yes □ No
A copy of the completed Site Visit tool must be kept with the file.
Unless otherwise indicated all
elements above were reviewed
by:
NAME: DATE:
COMMITTEE DATE:____________ COMMITTEE DECISION: □ Approve □ Deny □ Terminate □ Pend
MEDICAL DIRECTOR SIGNATURE:____________________________________________________
Subject:
Credentialing Practitioner, Provider and Member
Confidentiality Specific to Credentialing Activities Policy and Procedure
Manual: Credentialing
Policy Number: CR 10
Number of Pages: 4 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Confidentiality Policy and Procedure Page 1
I. POLICY
A. It is the policy of the organization to protect the privacy of all practitioner and
provider credentialing records that may be obtained as a result of applying for
participation in the network and to comply with applicable laws and regulations.
B. It is the policy of the organization to protect the privacy of all members’ health and
medical records, and identifying information, that may be obtained as a result of
credentialing and related peer review activities and to comply with applicable laws
and regulations.
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Provider Network Management
E. Quality Improvement
III. PURPOSE
A. To define the responsibility of Health Essentials employees to protect the integrity of all
practitioners’, providers’ and members’ confidential information and to eliminate the
possibility of information being disseminated to unauthorized individuals.
B. To define the process where the organization follows strict confidentiality practices with
the handling and storage of credentialing and recredentialing information.
1. All information is shared only on a need to know basis with the staff of the
organization or designee.
2. The Confidentiality and Privacy policy and procedure for the organization or
designee is strictly followed.
3. All files are maintained in a secured area
i. When maintained in hard copy, the area shall be locked when not attended
by the Credentialing staff
ii. When maintained electronically, the files are password protected
4. Fax machines which may receive confidential information is not in an area
accessible to the public or staff not involved in the credentialing process
Subject:
Credentialing Practitioner, Provider and Member
Confidentiality Specific to Credentialing Activities Policy and Procedure
Manual: Credentialing
Policy Number: CR 10
Number of Pages: 5 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Confidentiality Policy and Procedure Page 2
5. Staff and committee members sign conflict of interests and confidentiality
statements annually.
6. When files are used at a work station, they are not in the view of others and are
secured when not directly attended.
7. Information stored electronically are password protected.
IV. PROCEDURE
A. All credentialing personnel, current and new, are responsible to protect the
confidentiality of (a) medical records and any information that discloses medical
conditions or the use of services, claims, the Health Questionnaire, or information
obtained in the service authorization or care management process and (b) provider
credentialing documents that disclose provider specific information.
B. All credentialing personnel are required to maintain provider and member
information in strict professional confidence. Unauthorized disclosure of information
to individuals outside the organization is not permitted, and may result in termination
of employment.
C. Individually identifiable credentialing or health information will be disclosed only
with the written consent and authorization of the individual. Only information within
the scope of the authorization will be released to the party or entity noted as the
receiving party on the authorization. An authorization may be valid for a year in
some states and for a longer period of time in other states.
D. Under certain circumstances, individually identifiable credentialing or health
information can be released under a legal exception without an authorization. When
questions arise about whether an exception applies in a particular case, the Legal
Department will be consulted. Common exceptions are:
1. For customer claims experience reports, audits or other administrative
data when the identifiable information is given to a Company affiliate
(aggregate information is provided to the customer unless individually
identifiable information is reasonably necessary and legally allowed);
2. For internal disease management and health promotion programs;
3. For quality of care reviews;
4. For review of a provider’s services by a professional peer review
organization;
Subject:
Credentialing Practitioner, Provider and Member
Confidentiality Specific to Credentialing Activities Policy and Procedure
Manual: Credentialing
Policy Number: CR 10
Number of Pages: 4 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Confidentiality Policy and Procedure Page 3
5. For certain medical or health care research activities;
6. To investigate or report fraudulent claims;
7. For a regulatory purpose or audit by state or federal government;
8. In professional liability actions;
9. When there is a requirement to report professional misconduct;
10. In response to a court order or search warrant;
11. For treatment of a bona fide emergency;
12. To protect a third party from an imminent risk of harm (“Duty to
Warn”);
13. Where there is a risk of harm by an individual who could endanger
others (e.g. a bus driver with active substance abuse use or an individual
with safety issues who works in a nuclear plant);
14. In a good faith action for involuntary commitment;
15. For good faith vulnerable adult reports;
16. For good faith reports of child abuse;
17. In certain criminal investigations under certain circumstances; and
18. For public health reporting
F. All electronic transmissions and claims data are protected from outside
intervention by company standard software. Access to electronic data is limited
by level of employment and a documented need for access.
G. Internal electronic mail distribution is linked to each authorized user by a unique
employee identifier. External electronic mail communication is similarly linked,
and is monitored by the Information Technology Department.
H. Documents sent by fax to external sources include a cover sheet identifying the
confidentiality of the information, and are sent to a single, verified fax number
I. Paper records are maintained in secured files on company property. Records no
longer needed on-site are maintained off-site per the company record retention
policy.
Subject:
Credentialing Practitioner, Provider and Member
Confidentiality Specific to Credentialing Activities Policy and Procedure
Manual: Credentialing
Policy Number: CR 10
Number of Pages: 5 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Confidentiality Policy and Procedure Page 4
V. DEFINITIONS
A. CMS The Center for Medicare and Medicaid Services
B. NCQA National Committee of Quality Assurance – A private, not for
profit organization dedicated to improving healthcare quality
C. Practitioner A clinical professional who provides health care services.
Practitioners are usually required to be licensed as required by law care
D. Provider A practitioner, institution, or organization that provides services
for the Health Plan or its designee
E. HIPAA The Health Insurance Portability and Accountability Act of 1996
F. Identifying information includes, but is not limited to name, address, social security
number, member number, photograph, significant medical claim dollars in
combination with employer group identity, hospitalization dates in combination with
employer group identity, or other information through which an individual can be
identified as receiving or having received health care services
G. Individually identifiable health information includes, but is not limited to any records,
documents, verbal or written information that could identify an individual with a
medical diagnosis or medical treatment. Confidential health information also
includes information about whether an individual may receive, is receiving or has
received health services
VI. SOURCES
A. Standards set by NCQA, effective July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
C. HIPAA 1996
VII.RELATED POLICY/PROCEDURE
VIII.ATTACHMENTS
A. Conflict of Interest Statement
B. Confidentiality Statement
Subject:
Credentialing Practitioner Changes
Policy and Procedure
Manual: Credentialing
Policy Number: CR 11
Number of Pages: 2 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Practitioner Changes Policy and Procedure Page 1
I. POLICY
It is the policy of Health Essentials and designated entities to maintain current and
accurate records of the practitioner and provider network.
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Provider Network Management
E. Administration
F. Clinical Operations
III. PURPOSE
A. To establish the processes that allow for the smooth transition of a practitioner’s or
provider’s change of information.
B. To make certain timely and effective management and coordination related to a
practitioner’s or provider’s change of information is done. This applies to all
practitioner and provider changes including, but not limited to additions,
terminations, demographics, and participation within the organization’s network.
C. PROCEDURE
A. It is the responsibility of each employed or contracted practitioner or provider to notify
the Credentialing Department to change their profile information which may include a
change of address, name change, population served, etc.
B. The Credentialing Department will process the information changed and forward it to the
Credentialing Department for loading in the provider database.
C. Provider change forms received by the Credentialing Department, for an employed or
contracted practitioner or contracted provider, will be processed by the Credentialing
Department on a weekly basis.
Subject:
Credentialing Practitioner Changes
Policy and Procedure
Manual: Credentialing
Policy Number: CR 11
Number of Pages: 2 pages
Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Practitioner Changes Policy and Procedure Page 2
D. Once all database changes are completed, the Credentialing Coordinator shall verify that
all changes were entered correctly.
E. The completed Provider Database Change Forms are filed in the correspondence section
of each provider’s credentialing file.
F. On a monthly basis, the Credentialing Department reports all completed changes to the
necessary internal departments or functions for their respective processing.
G. The organization’s web site is updated monthly and the printed Provider Directory at
least annually.
H. DEFINITIONS
A. Practitioner A clinical professional who provides health care services. Practitioners
are usually required to be licensed as required by law
B. Provider A practitioner, institution, or organization that provides services for the
Organization or its designee
I. SOURCES
J.RELATED POLICY/PROCEDURE CR 01 Credentialing and Recredentialing
K.ATTACHMENTS
A. Change of Information Form
Subject:
Credentialing Sanctions, Complaints, and
Quality Issues Monitoring
Policy and Procedure
Manual: Credentialing
Policy Number: CR 12
Number of Pages: 6 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Sanctions, Complaints and QI Monitoring Policy and Procedure Page 1
I. POLICY
A. It is the policy of Health Essentials and its affiliates to make certain that all
Practitioners and Providers that practice independently are credentialed on a
continuous basis and shall review for licensure sanctions, licensing issues and
significant complaints on an ongoing basis.
B. The Credentialing Department shall review the Medicare and Medicaid Sanctions and
Reinstatement reports published by the Office of the Inspector General (“OIG”), the
applicable State Board of licensure sanction report, and the Federal Employee Health
Benefits Program (“FEHBP”) debarment report (procurement and non-procurement)
on a monthly basis or as issued. Participating providers that are listed on the
Medicare and Medicaid Sanction Reports are subject to immediate termination and
shall be reported immediately, within 30 days, to the Credentialing Committee.
C. The Credentialing Department shall also verify at the time of original credentialing
and re-credentialing the above listed items to ensure no sanctions have been placed
against the provider.
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Quality Improvement
E. Provider Network Management
F. Clinical Operations
III. PURPOSE
To outline the procedure to monitor practitioners and providers who
A. Have been sanctioned or are sanctioned during their participation by a state
or federal licensing agency
B. Are no longer eligible to participate in the Medicare program according to
CMS guidelines
Subject:
Credentialing Sanctions, Complaints, and
Quality Issues Monitoring
Policy and Procedure
Manual: Credentialing
Policy Number: CR 12
Number of Pages: 6 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Sanctions, Complaints and QI Monitoring Policy and Procedure Page 2
C. Have complaints made against them by members
D. Have validated and significant quality of care or service findings
IV. PROCEDURE
A. The organization or delegated entity shall monitor practitioners on an ongoing basis
for the following:
1. Sanctions
2. Complaints
3. Quality of Care or Service issues
B. When a significant event is identified, the Credentialing Committee for the
organization or its delegated entity shall review the practitioner mid-cycle and shall
not wait for the next 36-month scheduled recredentialing cycle
C. The organization or designee shall implement ongoing monitoring and conduct
appropriate peer review with interventions by the following:
1. Collecting and reviewing Medicare and Medicaid sanctions
i. NPDB
ii. HIPDB
iii. FSMB
iv. List of Excluded Individuals and Entities (maintained by the OIG)
available over the Internet
v. Medicare and Medicaid Sanctions and Reinstatement Report
vi. Federal Employees Health Benefits Plan (FEHB) Program department
record, published by the Office of Personnel Management, Office of
the Inspector General
vii. AMA Physician Master File entry
viii. State Medicaid agency or intermediary and the Medicare
intermediary
2. Collecting and reviewing sanctions or limitations on licensure
i. Physicians
1. NPDB
Subject:
Credentialing Sanctions, Complaints, and
Quality Issues Monitoring
Policy and Procedure
Manual: Credentialing
Policy Number: CR 12
Number of Pages: 6 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Sanctions, Complaints and QI Monitoring Policy and Procedure Page 3
2. HIPDB
3. FSMB
4. The appropriate state agencies
ii. Non-physician behavioral health care professionals
1. The appropriate state agencies
2. HIPDB
3. State licensure or certification board
3. Collecting and reviewing complaints
i. Shall evaluate both specific complaints and the practitioner’s history
of issues.
ii. Significant specific complaints or trends shall be monitored at least
every six (6) months.
4. Collecting and reviewing information from identified adverse events and
quality of care or quality of service reviews
i. The organization or designee shall monitor adverse events involving
an injury that occurs while the member is receiving health care
services from the practitioner.
ii. Peer review findings with potential or actual member harm will be
immediately reported to the Credentialing Department for review by
the Credentials Committee within 30 days of identification.
5. Implementing appropriate interventions when the organization or designee
identifies instances of poor quality
i. When appropriate, the practitioner shall be reviewed mid-cycle
D. As information is received from reporting agencies, the organization or its designee
shall review the information within 30 calendar days of a new alert.
E. Entities reporting sanction information may have different schedules, and the
organization or its designee shall review information within 30 calendar days of its
release
Subject:
Credentialing Sanctions, Complaints, and
Quality Issues Monitoring
Policy and Procedure
Manual: Credentialing
Policy Number: CR 12
Number of Pages: 6 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Sanctions, Complaints and QI Monitoring Policy and Procedure Page 4
F. In states where reporting entities do not publish sanction information on a set
schedule, the organization or its designee shall query for sanction information at least
every six (6) months.
G. When the reporting entity does not release sanction information reports, the
organization or its designee shall conduct individual queries for any affected
practitioner within 18 months after the last credentialing cycle.
H. When processing applications for initial credentialing, applications for re-
credentialing, upon notification from the provider of a change in his/her Medicare
status, or when reviewing the monthly, or as issued, OIG, applicable state license
board, or FEHBP reports, the Credentialing Department shall document the date of
report, names of practitioners listed on report, name of employee that reviewed the
report and the date the report was reviewed. It shall also document if no practitioners
were listed on the report.
I. When a participating practitioner or provider is identified with sanctions, the
Credentialing Department shall notify the Credentialing Committee Chairman
immediately. If the sanction is by the Medicare or Medicaid program, the practitioner
shall be immediately administratively terminated. Please refer to CR 08,
Administrative Termination policy and procedure.
1. Applicable departments shall be notified by the Credentialing Department so
they may have an opportunity to participate in notification of the involved
practitioner
J. When a practitioner or provider is administratively terminated immediately based on
a licensing or sanction issue, the following notifications will be made within three (3)
business days of the action:
Subject:
Credentialing Sanctions, Complaints, and
Quality Issues Monitoring
Policy and Procedure
Manual: Credentialing
Policy Number: CR 12
Number of Pages: 6 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential Credentialing Sanctions, Complaints and QI Monitoring Policy and Procedure Page 5
1. Practitioners and Providers will be notified via certified mail.
2. Internal departments will be notified via e-mail to make adjustments in their
respective systems and to coordinate/transition any patient care.
3. There shall be no fair hearing or appeal rights afforded to a practitioner who is
administratively terminated due to licensing issues, in accordance with CR 16,
Fair Hearing policy and procedure.
K. If the provider re-obtains eligibility to participate in the Medicare/Medicaid or
FEHBP program(s), it is the provider’s responsibility to contact the Credentialing
Department to begin the initial application process.
V. DEFINITIONS
A. NPDB
National Practitioner Data Bank. http://www.npdb-hipdb.hrsa.gov/welcomesq.html
B. HIPDB
Healthcare Integrity and Protection Data Bank. http://www.npdb-
hipdb.hrsa.gov/hipdb.html
C. FSMB
Federation of State Medical Boards. http://www.fsmb.org/fcvs.html
D. OIG
Office of Inspector General, List of Excluded Individuals and Entities (LEIE)
http://oig.hhs.gov/fraud/exclusions/listofexcluded.html
E. CMS
The Center for Medicare and Medicaid Services
F. NCQA
National Committee of Quality Assurance – A private, not for profit organization
dedicated to improving healthcare quality
G. Practitioner
A clinical professional who provides health care services. Practitioners are usually
required to be licensed as required by law
H. Provider
A practitioner, institution, or organization that provides services for the organization
or its designee
Subject:
Credentialing Sanctions, Complaints, and
Quality Issues Monitoring
Policy and Procedure
Manual: Credentialing
Policy Number: CR 12
Number of Pages: 6 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential Credentialing Sanctions, Complaints and QI Monitoring Policy and Procedure Page 6
VI. SOURCES
A. Standards set by NCQA effective July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
VII.RELATED POLICY/PROCEDURE
A. CR 01 Credentialing and Recredentialing policy and procedure
B. CR 08 Administrative Terminations policy and procedure
C. CR 13 Termination or Denial with Cause policy and procedure
D. CR 16 Fair Hearing policy and procedure
VIII.ATTACHMENTS
A. Quality Documentation Worksheet
B. Sanctions Monitoring Worksheet
C. Complaints and Grievances Monitoring Worksheet
Subject:
Credentialing Termination or Denial of
Applicant with Cause Policy and Procedure
Manual: Credentialing
Policy Number: CR 13
Number of Pages: 4 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential
Credentialing Termination or Denial of Applicant with Cause Policy and Procedure
Page 1
I. POLICY
A. It is the policy of Health Essentials and affiliates that the Credentialing Committee is
the authorized peer review body that makes any termination of existing network
practitioners or denial of new applicant’s decisions of all practitioners or providers
when terminated or denied due to quality of care or quality of service issues. The
quality of care termination or denial affords certain practitioners fair hearing and
appeal rights.
B. If the practitioner or provider is terminated or denied for cause due to administrative
breach of contract, the Credentials Committee is not involved and subsequently there
are no fair hearing or appeal rights. Please refer to CR 08 Administrative
Terminations policy and procedure.
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Credentialing
D. Quality Improvement
E. Provider Network Management
III. PURPOSE
To provide an equitable process for termination of practitioners and providers who fail to
meet the criteria or standards set forth by the Credentialing Committee.
IV. PROCEDURE
A. The recommendation to deselect a provider may originate from one of several sources
including, but not limited to, the Provider Network Management staff, Quality
Improvement/Peer Review Committee or Utilization Management Committee. A
Subject:
Credentialing Termination or Denial of
Applicant with Cause Policy and Procedure
Manual: Credentialing
Policy Number: CR 13
Number of Pages: 5 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential
Credentialing Termination or Denial of Applicant with Cause Policy and Procedure
Page 2
recommendation to deselect a provider may be as a result of, but is not limited to, the
following:
1. Negative practice history with demonstrated deviation from the standard of
care or practice;
2. A threat to member health, safety or welfare;
3. Serious non-ethical behavior;
4. A practitioner who refuses to seek or adhere to treatment for chemical abuse
or psychological disorders;
A. The Credentialing Committee may initiate immediate summary suspension of new
applicants or termination of current practitioners if it is deemed that Member care
would be in imminent danger.
B. The Credentialing Committee will send written notification to the practitioner or
provider of their decision for denial or termination within 30 business days following
the meeting, which will include the fair hearing rights applicable to their individual
case. Please refer to CR 16 Fair Hearing policy and procedure.
C. Reports made to the National Practitioner Data Bank and respective State Licensing
Board and other applicable agencies when required by contractual obligation or rule of
law. The Medical Director will also be notified.
D. All correspondence will be sent registered mail, identified as personal/confidential
Summary Suspension A summary suspension may be imposed under certain circumstances which would mandate
that the practitioner immediately be removed from the practitioner and provider network.
Should the practitioner qualify for a fair hearing, the summary suspension will be enforced
during the fair hearing process and until the determination of the fair hearing officer.
It is impossible to specifically enumerate all the different forms of disruptive or inappropriate
conduct that would be deemed to fall below acceptable standards of conduct, which might
Subject:
Credentialing Termination or Denial of
Applicant with Cause Policy and Procedure
Manual: Credentialing
Policy Number: CR 13
Number of Pages: 4 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates:
Confidential
Credentialing Termination or Denial of Applicant with Cause Policy and Procedure
Page 3
lead to an instant summary suspension. Examples of conduct warranting a summary
suspension might include, but not limited to, documentation of the following:
A. Repeated use of vile, loud, intemperate, offensive or abusive language to members or
staff;
B. Repeatedly acting in a rude, insolent, demeaning or disrespectful manner;
C. Verbal or physical threats, intimidation or coercion;
D. Actual physical abuse, or unwanted touching;
E. Illegal discrimination against persons, or refusal to provide patient care;
F. Services based upon unlawful criteria;
G. Lack of cooperation or unavailability to other practitioners for exchange of pertinent
patient care information or resolution of patient care issues;
H. Sexual or other forms of harassment, including unwelcome sexual advances, requests
for sexual favors, or other verbal or physical conduct of a sexual nature which has the
purpose or effect of substantially interfering with the individual’s work performance or
creating an intimidating, hostile or offensive work environment;
I. Overt Breach of confidentiality;
J. Inappropriate entries in patient medical records which have the primary purpose or
effect of attacking or belittling other providers, imputing stupidity or incompetence of
other providers, or impugning the quality of care of other providers;
V. DEFINITIONS
A. The terms used in this Policy and not defined herein shall have the same meanings as
those set forth in the Professional Services Agreement or Physician Employment
Agreements.
B. CA B&P 805 California Business and Professional Code. Dictates the
process in which a peer review body reviews the basic
qualifications, staff privileges, employment, medical
outcomes, or professional conduct of licentiates to make
recommendations for quality improvement and education
C. CA B&P 809 To protect the health and welfare of the people of
California, it is the policy of the State of California to
exclude, through the peer review mechanism as provided for by
California law, those healing arts practitioners who provide
Subject:
Credentialing Termination or Denial of
Applicant with Cause Policy and Procedure
Manual: Credentialing
Policy Number: CR 13
Number of Pages: 5 pages
Supporting Documents: Y N X
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD
Credentialing Committee Chair
Revision Dates:
Confidential
Credentialing Termination or Denial of Applicant with Cause Policy and Procedure
Page 4
substandard care or who engage in professional misconduct,
regardless of the effect of that exclusion on competition
D. NCQA National Committee of Quality Assurance – A private, not
for profit organization dedicated to improving healthcare
quality
E. Peer Review Evaluation or review of colleague performance by
professionals with similar types and degrees of expertise; the
evaluation of one practitioners practice by another practitioner
F. Practitioner A clinical professional who provides health care services.
Practitioners are usually required to be licensed as required
by law
G. Provider A practitioner, institution, or organization that provides
services for the organization or its designee
H. Summary suspension The immediate removal of a practitioner or provider based
on imminent danger to the health, safety or welfare of a
member
I. “With Cause” Refers to an aspect of a practitioner’s competence or
professional conduct which is reasonably likely to be
detrimental to member safety, health or welfare
VI. SOURCES
A. Standards set by NCQA effective July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
C. California Business and Professional Codes 805 and 809
VII.RELATED POLICY/PROCEDURE
A. CR 01 Credentialing and Recredentialing policy and procedure
B. CR 02 Credentialing Allied Health policy and procedure
C. CR 06 Medicare Opt Out policy and procedure
D. CR 08 Administrative Terminations policy and procedure
E. CR 12 Sanctions, Complaints and Quality Issues Monitoring policy and procedure
F. CR 17 Fair Hearing policy and procedure
Subject:
Credentialing Office (or facility) Site Visit Policy and Procedure
Manual: Credentialing
Policy Number: CR 14
Number of Pages: 5 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: NOTE: AT THIS TIME, OFFICE SITE
REVIEWS ARE NOT APPLICABLE TO
HEALTHESSENTIALS OR THEIR
AFFILIATES AS PRIMARY CARE IS NOT
PROVIDED AT THE OUTPATIENT,
ABMULATORY SETTING
Confidential Credentialing Office Site Visit Policy and Procedure Page 1
I. POLICY
A. It is the policy of Health Essentials or affiliates (the Organization) to make certain to
comply with all applicable state and federal laws and regulations, including, but not
limited to, those pertaining to the Medi-Cal and Medicaid programs
B. The organization maintains standards for practitioner offices and for medical record-
keeping practices which are shared with applicable practitioners during the initial
credentialing process and on an ongoing basis through inclusion of the standards of
the organization
C. It is the policy of the organization to assess and evaluate the quality, safety, and
accessibility of practitioner office sites through compliance with office site standards
II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners
B. Contracted Network Practitioners
C. Practitioner Applicants
D. Credentialing
E. Quality Improvement
F. Provider Network Management
III. PURPOSE
A. To define when an office site visit would be applicable
B. Site Review Guidelines provide the standards, directions, instructions, rules,
regulations, perimeters, or indicators for the site review survey
C. To provide guidelines that shall be used as a gauge or touchstone for measuring,
evaluating, assessing, and making decisions
IV. PROCEDURE
A. Office site reviews shall be conducted at the time of initial credentialing, as
applicable, for all Primary Care Physicians (PCPs) and at least every three years
Subject:
Credentialing Office (or facility) Site Visit Policy and Procedure
Manual: Credentialing
Policy Number: CR 14
Number of Pages: 5 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD Credentialing Committee Chair
Revision Dates: NOTE: AT THIS TIME, OFFICE SITE
REVIEWS ARE NOT APPLICABLE TO
HEALTHESSENTIALS OR THEIR
AFFILIATES AS PRIMARY CARE IS NOT
PROVIDED AT THE OUTPATIENT,
ABMULATORY SETTING
Confidential Credentialing Office Site Visit Policy and Procedure Page 2
B. Should an applicant or currently credentialed practitioner be due for a site review and
should that site have been completed with a successful review in the previous 12
months, the site review may be used for the current applicant or practitioner
C. In the event that any practitioner site, regardless of the number of practitioners
located at each site, receives in excess of three complaints or grievances in the same
category within a 12 month rolling period, a full site visit will be conducted with
appropriate follow up documented
1. The review shall be conducted within 60 days of identification of a trend
D. In the event of a significant peer review finding or compliant being filed that results
in potential or actual harm to a member, a full site review will be conducted within 60
days of receipt of the findings
E. The standards for office site reviews are communicated to Practitioners in Practitioner
newsletters and through the credentialing policies and procedures
F. Site review guidelines shall be followed as defined by the California Department of
Health Care Services (DHCS), see Attachment B
G. Upon receipt of the initial credentialing application, those practitioners who will serve
as a PCP shall undergo an office site visit utilizing the California DHCS office site
review tool. Please refer to attachment A
H. Component of the office site review shall include, but may not be limited to the
following as applicable:
1. Accessibility
2. Site Personnel
3. Safety
4. Office Management
5. Handling of Pharmaceuticals
6. Laboratory Services
7. Radiology Services
8. Preventive Services
9. Infection Control Practices
I. When applicable, the office site review shall include review and scoring of physical
accessibility. Attachment E – Physical Accessibility Review Survey
Subject:
Credentialing Office (or facility) Site Visit Policy and Procedure
Manual: Credentialing
Policy Number: CR 14
Number of Pages: 5 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: NOTE: AT THIS TIME, OFFICE SITE
REVIEWS ARE NOT APPLICABLE TO
HEALTHESSENTIALS OR THEIR
AFFILIATES AS PRIMARY CARE IS NOT
PROVIDED AT THE OUTPATIENT,
ABMULATORY SETTING
Confidential Credentialing Office Site Visit Policy and Procedure Page 3
J. Findings and outcomes of the site review shall be scored using objective criteria and
the final score shall include a final score based on findings of review for the site visit,
medical records and accessibility review tools
K. Office site reviews include evaluation and assessment of medical record keeping
practices. When indicated, follow-up audits with practitioners who fail to meet
minimum standards, the medical record portion of the office site review audit shall be
conducted until which time, a passing score is reached. Included will be the
following:
1. Scoring process and follow up re-assessments with scoring thresholds
2. Secure and confidential filing systems
3. Legible file markers
4. Records to be easily located and retrievable
L. Findings from the Medical Record keeping practices shall be discussed with the
practitioner or office manager at the time of the audit which will include methods
used to keep consistent information and how the practice supports maintaining
confidentiality of records
M. A California licensed Registered Nurse shall conduct the site visit staff will make
arrangements with the practitioner or provider group to schedule a date and time for
the on-site visit
1. Every effort will be made to provide at least a seven-day notice of an on-site
visit
2. The site visit staff will conduct the on-site survey and complete the
appropriate sections of the office site visit assessment tools (Attachments A, C
and E)
N. The organization utilizes the National Committee for Quality Assurance
(NCQA) 8/30 rule methodology to review health records. In cases where no member
records are available specific to the membership of the organization, a “blinded”
health or mental health record or a model record will be used to meet the review
Requirement
O. Threshold for compliance
Subject:
Credentialing Office (or facility) Site Visit Policy and Procedure
Manual: Credentialing
Policy Number: CR 14
Number of Pages: 5 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
John Wong, MD Credentialing Committee Chair
Revision Dates: NOTE: AT THIS TIME, OFFICE SITE
REVIEWS ARE NOT APPLICABLE TO
HEALTHESSENTIALS OR THEIR
AFFILIATES AS PRIMARY CARE IS NOT
PROVIDED AT THE OUTPATIENT,
ABMULATORY SETTING
Confidential Credentialing Office Site Visit Policy and Procedure Page 4
1. A score of 85 percent or higher means the organization may provide on-site
education for any noted deficiency. If deemed necessary, the organization may
follow up on specific deficiencies.
2. A score of 84 percent or below requires review by the organization’s Medical
Director and Credentialing Committee to determine whether further action or
monitoring is necessary
3. The Credentialing Committee will require a corrective action plan (CAP)
based on review of the site visit report or investigation of a complaint should
the final score be under 80% compliant. If a CAP is required, the Medical
Director will notify the site in writing and request a CAP
4. The site or facility will develop and submit a CAP to the Credentialing
Department within 30 days of notification
5. A CAP template will be provided
6. A specified time frame for completion of the CAP will be provided
7. An expected date of follow-up will be provided.
P. All CAPs must include the following:
1. Measurable objectives for each action, including the degree of expected
change in people or situations
2. Times frames for corrective action
3. People responsible for implementing corrective action
4. The organization’s Credentialing Department, in collaboration with the
Medical Director, is responsible for monitoring follow-up every six months
5. until standards are met or as determined in any CAP developed upon
completion of the site visit
6. All site visits are tracked in the site visit tracking record and filed in the
practitioner’s credentialing file.
V. DEFINITIONS
The terms used in this Policy and not defined herein shall have the same meanings
as those set forth in the Physician Participation Agreements
DHCS California Department of Health Care Services defines
requirements of Site Review Guidelines to direct the standards,
Subject:
Credentialing Office (or facility) Site Visit Policy and Procedure
Manual: Credentialing
Policy Number: CR 14
Number of Pages: 5 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: NOTE: AT THIS TIME, OFFICE SITE
REVIEWS ARE NOT APPLICABLE TO
HEALTHESSENTIALS OR THEIR
AFFILIATES AS PRIMARY CARE IS NOT
PROVIDED AT THE OUTPATIENT,
ABMULATORY SETTING
Confidential Credentialing Office Site Visit Policy and Procedure Page 5
directions, instructions, rules, regulations, perimeters, or indicators
for the site review survey
CMS The Center for Medicare and Medicaid Services
NCQA National Committee of Quality Assurance – A private, not for
profit organization dedicated to improving healthcare quality
Practitioner A clinical professional who provides health care services.
Practitioners are usually required to be licensed as required by law
care
VI. SOURCES
A. Standards set by NCQA, July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines
C. California Department of Health Care Services
D. California DHCS, policy letter 13-003
VII. ATTACHMENTS
CR 14 Attachment A – Site Review Survey Tool
CR 14 Attachment B – Site Review Survey Guidelines
CR 14 Attachment C – Medical Record Review Tool
CR 14 Attachment D – Office Site Complaint Tracking
CR 14 Attachment E – Physical Accessibility Review Survey Tool
VIII. RELATED POLICY/PROCEDURE and DOCUMENTS A. CR 01 Credentialing and Recredentialing policy and procedure
B. CR 02 Credentialing Allied Health policy and procedure
C. CR 12 Sanctions, Complaints and Quality Issues Monitoring
Subject:
Credentialing Organizational Providers (Facilities)
Policy and Procedure
Manual: Credentialing
Policy Number: CR 15
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Not Applicable
Approved by:
GNMA Credentialing Committee
Revision Dates:
Note: At this time, HealthEssentials and Gerinet do not
contract with Organizational Providers and therefore
standard is not applicable for purpose of audits or
surveys
Confidential Credentialing Organizational Providers Policy and Procedure Page 1
PURPOSE
To describe the criteria and process for the credentialing and recredentialing of Organizational Providers
(Providers) and to make certain those providers are in good standing with regulatory bodies and
accredited by an appropriate body as applicable
POLICY
A. HealthEssentials will make certain that organizational facilities (aka providers) to be contracted with
the organization are approved and hold current accreditation status with a recognized and approved
accrediting agency
B. Should an organization lose their accreditation status or not be accredited for another reason, that
provider shall undergo a facility site review
SCOPE
A. Contracted Organizational Facilities, as applicable
a. Hospitals
b. Home Health Agencies
c. Skilled Nursing Facilities
d. Free-standing Surgical Centers
e. Durable Medical Equipment
f. Behavioral Health (BH) Inpatient
g. BH Residential
h. BH Ambulatory
B. Credentialing
C. Quality Improvement
D. Provider Services and Contracting
PROCEDURE
Prior to contracting with an Organizational Provider, HealthEssential/Gerinet shall confirm the provider
organization meets the following standards for participation:
Subject:
Credentialing Organizational Providers (Facilities)
Policy and Procedure
Manual: Credentialing
Policy Number: CR 15
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Not Applicable
Approved by:
XXXX XXXXX, MD
Credentialing Committee Chair
Revision Dates:
Note: At this time, HealthEssentials and Gerinet do not
contract with Organizational Providers and therefore
standard is not applicable for purpose of audits or
surveys
Confidential Credentialing Organizational Providers Policy and Procedure Page 2
A.The provider is in good standing with state and federal regulatory bodies. The facility shall provide a
copy of current licensure and review of Medicare/Medicaid sanction reports for the last three years
B.Confirm and document that the provider has been reviewed and approved by an acceptable accrediting
body as listed below. The facility shall provide a copy of accreditation approval letter
ORGANIZATIONAL PROVIDER ACCEPTABLE ACCREDITING BODY
Hospital TJC or AOA
Home Health Agency TJC or CHAPS or CMS
Skilled Nursing Home TJC or CCAC or CARF or CMS and state licensure
Free Standing Surgical Center TJC or AAAHC or AAAASF or CMS Certified and
state licensure
Behavioral Health Facilities
Inpatient
Residential
Ambulatory
TJC or CARF
Free Standing Radiology Center TJC or ACR for Mammography
Laboratory TJC or CAP or COLA or CLIA
C.A monthly review of the OIG report shall be done and is considered compliant in the ongoing monitor
activities for federal issues
D.The credentialing staff shall confirm that the provider has been reviewed and approved by an accrediting
body. Confirmation that the organizational provider has been reviewed and approved by an accrediting
body
The Joint Commission (TJC)
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.jointcommission.org
Subject:
Credentialing Organizational Providers (Facilities)
Policy and Procedure
Manual: Credentialing
Policy Number: CR 15
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Not Applicable
Approved by:
GNMA Credentialing Committee
Revision Dates:
Note: At this time, HealthEssentials and Gerinet do not
contract with Organizational Providers and therefore
standard is not applicable for purpose of audits or
surveys
Confidential Credentialing Organizational Providers Policy and Procedure Page 3
American Osteopathic Association (AOA)
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.osteopathic.org/index.cfm?PageID=findado_main
Community Health Accreditation Program (CHAP)
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.chapinc.org
Commission on Accreditation or Rehabilitation Facilities (CARF)
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.carf.org
Continuing Care Accreditation Commission (CCAC) (this is part of CARF)
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.carf.org
Accreditation Association for Ambulatory Health Care (AAAHC)
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.aaahc.org
American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.aaaasf.org
COLA
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.cola.org/search_lab.html
CLIA
Subject:
Credentialing Organizational Providers (Facilities)
Policy and Procedure
Manual: Credentialing
Policy Number: CR 15
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Not Applicable
Approved by:
XXXX XXXXX, MD
Credentialing Committee Chair
Revision Dates:
Note: At this time, HealthEssentials and Gerinet do not
contract with Organizational Providers and therefore
standard is not applicable for purpose of audits or
surveys
Confidential Credentialing Organizational Providers Policy and Procedure Page 4
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://wwwn.cdc.gov/clia/oscar.aspx
CAP
- accreditation report or a letter from the regulatory and accrediting bodies regarding the status
of the provider
- website: http://www.cap.org/apps/cap.portal?_nfpb=true&_pageLabel=accreditation
E.Although a CMS or state review or certification does not serve as accreditation of an institution, in the
case of non-accredited institutions, HealthEssentials/Gerinet or its designee may substitute a CMS or
state review in lieu of the required site visit. In this case, the report form the institution to verify the
review shall be obtained or a letter from CMS which shows that the facility was reviewed and indicates
a passing inspection
F.A site visits of nonaccredited providers is not required if the state of California or CMS has not conducted
a site review of the provider and the provider is in a rural area, as defined by the U.S. Census Bureau.
a. HealthEssentials/Gerinet shall identify excluded providers and provide evidence that the above
conditions are met
G.The Credentialing Committee must approve exceptions for non-accredited facilities. If the provider is not
accredited, the provider shall provide current unrestricted copies of their state license, DEA certification,
DPS certification, CLIA/CAP certification, pharmacy license, and any other certifications held by such
organization to the extent applicable.
H.If a provider is not accredited, and does not meet conditions noted in procedure “E” above,
HealthEssentials/Gerinet shall conduct a site review of the organizational provider. The provider must
obtain a minimum overall passing score of 80% and a minimum of 70% by section to be considered for
participation in the Health Plan network. The on-site assessment shall be conducted by an LVN. or RN
level nurse
Parameters of the assessment will vary according to the type and complexity of the provider
I.HealthEssentials/Gerinet confirms every three years that the Organizational Provider remains in good
standing with state and federal regulatory bodies, and if applicable, is reviewed and approved by an
accrediting body. The three-year assessment follows the same standards of participation as the initial
assessment
Subject:
Credentialing Organizational Providers (Facilities)
Policy and Procedure
Manual: Credentialing
Policy Number: CR 15
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Not Applicable
Approved by:
GNMA Credentialing Committee
Revision Dates:
Note: At this time, HealthEssentials and Gerinet do not
contract with Organizational Providers and therefore
standard is not applicable for purpose of audits or
surveys
Confidential Credentialing Organizational Providers Policy and Procedure Page 5
J.Organizational contracts or agreements will not be executed until all requirements of credentialing are met
K. The Credentialing Department maintains current licensure and Medicare certification in the
Organizational Provider’s credentialing file at all times
L. Documentation of credentialed providers shall be logged and maintained in an electronic file which
provides for an automatic system to notify when recredentialing is due
M. The documentation log shall include the following:
1. Name and type of the provider, facility or organization
2. Accrediting body or applicable completion of a site audit
3. Documentation of licensure
4. Any corrective action plans, if applicable
DEFINITIONS
E. Organizational Providers Include but may not be limited to hospitals, home health agencies,
skilled nursing facilities, free standing surgical centers, mental
health and substance abuse services (typically delegated), free
standing radiology centers and laboratories
F. Provider An institution or organization that provides services for
HealthEssentials/Gerinet or its designee
G. AOA American Osteopathic Association
H. The Joint Commission (TJC) Formerly known as the Joint Commission on Accreditation of
Health Care Organizations
I. CMS The Centers for Medicare and Medicaid Services
J. CARF Commission on Accreditation of Rehabilitation Facilities
K. COLA A nationally recognized not-for-profit healthcare organization and
is a leader in providing an educational approach to laboratory
accreditation
L. CAP: College of American Pathology
M. CLIA Consolidated Laboratory Improvement Act
N. AAAHC Accreditation Association for Ambulatory Health Care
Subject:
Credentialing Organizational Providers (Facilities)
Policy and Procedure
Manual: Credentialing
Policy Number: CR 15
Number of Pages: 6 pages
Supporting Documents: Y X N
Original Date of Issue: Not Applicable
Approved by:
XXXX XXXXX, MD
Credentialing Committee Chair
Revision Dates:
Note: At this time, HealthEssentials and Gerinet do not
contract with Organizational Providers and therefore
standard is not applicable for purpose of audits or
surveys
Confidential Credentialing Organizational Providers Policy and Procedure Page 6
O. ACR American College of Radiology
P. AAAASF American Accreditation Association for Accreditation for
Ambulatory Surgery Facilities
Q. CHAP Community Health Accreditation Program CCAC - Continuing
Care Accreditation Commission
SOURCES
A. Standards set by NCQA effective July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines, Version 5
ATTACHMENTS
A. Organizational Summary Review Worksheet
B. Organizational Tracking Tool
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 1
I. POLICY
A. It is the policy of Health Essentials (the Organization) to afford defined applicants
and current network practitioners a fair hearing and appeal process should the
credentialing committee make a negative initial or recredentialing determination and
deny new participation or terminate existing participation from the network.
B. This policy will apply to defined current network practitioners and providers who are
contracted for the purpose of providing health care services to enrolled members and
to defined practitioners applying for network participation.
C. The defined practitioners and providers will have an opportunity to appear before a
hearing panel to appeal a termination decision if requested. II. PERSONS/DEPARTMENTS AFFECTED
A. Employed Practitioners as defined in Procedure, Section 2, Scope of Policy
B. Network Practitioners as defined in Procedure, Section 2, Scope of Policy
C. Practitioner Applicants
D. Credentialing
E. Quality Improvement
F. Provider Services and Contracting
G. Administration III. PURPOSE
A. To provide a process for allowing defined currently participating practitioners to
appeal adverse actions that result in termination from the organization or contracted
network and the reporting process to the appropriate authorities.
B. To provide a process for allowing defined applying practitioners to appeal adverse
actions that result in denial from network participation and the reporting process to
the appropriate authorities.
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 2
IV. PROCEDURE
Section 1. Definitions
The terms used in this policy and procedure and not defined herein shall have the
same meanings as those set forth in the Physician Participation Agreements.
Section 2. Scope of Policy
2.1.1 Practitioners who are afforded fair hearing appeal rights include the
following:
2.1.2 Medical Doctor (MD)
2.1.3 Doctor of Osteopathic Medicine (DO)
2.1.4 Podiatrists (DPM)
2.1.5 Behavioral Health practitioners that are Doctoral or master’s-level
psychologists who are state certified or state licensed
2.1.6 Nurse Practitioners (Independently Practicing);
2.1.7 Physician Assistants
2.1.8 Rights are based on California Business and Professional Codes 805 and
809
Those practitioners not afforded fair hearing or appeal rights include the
following:
2.1.9 Chiropractor (DC)
2.1.10 Dentist (DDS)
2.1.11 Behavioral Health practitioners that are Master’s-level clinical nurse
specialists or psychiatric nurse practitioners who are nationally or state
certified or state licensed
This Policy governs the rights of a practitioner who is not approved for continued
participation in the Network, who is terminated from the Network, whose scope
of practice is limited based on quality of care or professional competence reasons,
or who is subject to a corrective action that will result in a report to the National
Practitioner Data Bank (NPDB) or Healthcare Integrity and Protection Data Bank
(HIPDB) and the applicable state licensing board.
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 3
2.2 This Policy shall govern the rights of a Practitioner to contest termination
of his/her Agreement when that termination is based on quality of care or
quality of service issues. This is not applicable when termination is based
upon revocation or suspension of the Practitioner’s license to practice or
the Practitioner's failure to maintain the malpractice insurance required by
law or by the Agreement or other administrative reasons. In addition,
unless otherwise required by applicable law or unless the action results in
a report to the NPDB or HIPDB and the applicable state licensing agency,
this Policy shall not apply to the following: warnings; letters of
reprimand; probationary periods; or the reduction or modification of the
Practitioner’s scope of practice or of the rights and duties of a Practitioner
under an Agreement
2.3 This Policy shall be the sole basis by which a Practitioner may contest the
termination of his/her Agreement or a corrective action that will result in a
report to the NPDB or HIPDB and applicable state licensing agency.
2.4 A Practitioner who receives notice of termination of his/her Agreement
shall not be entitled to participate in the Network after the termination date
set forth in such notice.
Section 3.
NOTIFICATION TO PRACTITIONER OF APPEAL RIGHTS
3.1 When the Credentialing Committee decides to terminate a Practitioner’s
Agreement or impose a corrective action that will result in a report to the
NPDB or HIPDB and applicable state licensing agency, the Credentialing
Department shall promptly notify the affected Practitioner by certified
mail, return receipt requested. Such notice shall:
(a) state the specific reason for the termination or corrective action;
(b) inform the Practitioner that she/he has the right to request a hearing;
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 4
(c) contain a summary of the Practitioner's right in the hearing under this
Policy;
(d) inform the Practitioner that she/he has (30) days following receipt of the
notice within which to submit a request for a hearing:
(e) state that failure to request a hearing within the specified time period shall
constitute a waiver of the right to a hearing; and
(f) state that upon receipt of his hearing request, the Practitioner will be
notified of the date, time and place of the hearing
(g) Allow the practitioner to be represented by an attorney or another person
of their choice
.
3.2 A Practitioner shall have thirty (30) days following receipt of notice to file
a written request for a hearing. Requests shall be hand delivered or sent
by certified mail, return receipt requested, to the chairperson of the
Credentials Committee.
3.3 A practitioner who fails to request a hearing within the time and in the
manner specified in this Policy waives any right to such hearing. Such a
waiver shall constitute acceptance of the action, which then becomes the
final, un-appealable decision of the Credentialing Committee.
Section 4. Provider Hearing Prerequisites.
4.1 Notice of Hearing. Promptly upon receipt of a timely request for a hearing
from a Practitioner, the Medical Director shall schedule and arrange for a
hearing and shall notify the Practitioner of the place, time and date of the
hearing, by certified mail, return receipt requested. The hearing date shall
be not less than thirty (30) days from the date of such notice. The notice
of the hearing shall also include a list of the witnesses, if any, expected to
testify at the hearing on behalf of the organization.
4.2 Appointment of Hearing Committee. A hearing requested pursuant to
Section 3.2 of this Policy shall be conducted before a hearing panel
appointed by the Organization’s Chief Medical Officer who are in the
same or similar area of practice
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 5
Section 5. Conduct of Provider Hearing.
5.1 Personal Presence. The practitioner who requested the hearing must be
physically present at the hearing and may be accompanied by an attorney
or representative. A practitioner who fails without good cause to appear
for a hearing shall be deemed to have waived his rights in the same
manner and with the same consequences as provided in Section 3.3 of this
Procedure.
5.2 Presiding Officer and Panel. The Chief Medical Officer of the
Organization shall select from the panel a presiding officer over the
appointed panel for the hearing. The members of the panel shall have a
background similar to the applicant in training and specialty and shall
have not professional or business relationships with the applicant. The
members of the panel shall act to maintain decorum and to assure that all
participants in the hearing have a reasonable opportunity to present
relevant oral and documentary evidence. The Panel appointees will have
not acted as accusers, investigators, fact-finders or decision makers in the
same matter and who have not previously taken an active part in the
matter being appealed. With the advice of counsel, the the panel shall be
entitled to determine the order of procedure during the hearing and shall
make all rulings on matters of law, procedure and the admissibility of
evidence.
5.3 Representation by Attorney or Other Person. The affected practitioner
shall be entitled to representation by an attorney or other person of the
Practitioner's choice. In addition, Health Essentials may have an attorney
or other person present for the purpose of rendering advice or assistance.
In the event that the practitioner does not have attorney representation, the
organization will not use an attorney representative.
5.4 Other Rights of Parties. During a hearing, each of the parties shall have
the following rights: to call, examine and cross-examine witnesses; to
present evidence determined to be relevant by the panel , regardless of its
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 6
admissibility in a court of law; to challenge any witness; to rebut any
evidence and to submit a written statement at the close of the hearing. If
the Practitioner does not testify on his or her own behalf, they may be
called and examined as if under cross-examination.
5.5 Procedure and Evidence. The hearing need not be conducted strictly
according to rules of law relating to the examination of witnesses or
presentation of evidence. Any relevant matter upon which reasonable
persons customarily rely in the conduct of serious affairs shall be
admitted, regardless of the admissibility of such evidence in a court of
law. Each party shall, before and/or at the conclusion of the hearing, be
entitled to submit memoranda concerning any issue of law or fact, and
such memoranda shall become part of the hearing record. The panel may,
but shall not be required to, order that oral evidence be taken only on oath
or affirmation administered by any person designated by him or her.
5.6 Official Notice. In reaching a decision, the panel may take official notice,
either before or after submission of the matter for decision, of any
generally accepted technical or scientific matter relating to the issues
under consideration, and of any facts that may be judicially noticed by the
courts of the state.
5.7 Burden of Proof. The practitioner who requested the hearing shall have
the burden of proof, by clear and convincing evidence, that the
recommendation lacks any substantial factual basis or that such basis or
the conclusions drawn there from are arbitrary, unreasonable or
capricious.
5.8 Record of Hearing. An accurate record of the hearing shall be kept by the
use of a recognized court reporter. The practitioner shall have the right to
obtain copies of the record of the hearing, upon payment of any charges
associated with the preparation thereof.
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 7
5.9 Postponement. Requests for postponement of a hearing shall be granted
by the panel only upon a showing of good cause and only if the request is
made as soon as is reasonably practical.
Section 6. Provider Termination Committee Recommendation: Company Decision.
6.1.1 Within 30 days after final adjournment of the hearing, the panel shall
make a written report of their findings and recommendations in the matter
and shall forward the same to Health Essentials. The affected Practitioner
shall be sent a copy of the panel’s decision by certified mail, return receipt
requested. The hearing record (transcript) will only be provided to the
Practitioner if a copy is requested and the Practitioner agrees to pay his
pro rata share of the reasonable cost of preparing the record.
6.1.2 The decision of the panel will be binding
6.1.3 Practitioners who have been terminated through the Fair Hearing process
are not eligible to apply for network participation for a period of five (5)
years from the date of the final decision
Section 7 Reporting to Authorities
A. Reporting adverse actions to the applicable state licensure board shall be done
according to the state statutes. Specific to California, reporting shall be made
within 15 days of the final adverse decision
B. Reporting to the National Practitioner Data Bank will be conducted based on
criteria and time frames (30 days of the final adverse decision) set forth by the
NPDB
C. Reporting to required entities such as a licensing board that the National
Practitioner Data Bank will be filed at the direction of the Credentialing
Committee and will be done so by in-house counsel of the organization
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 8
D. Outcomes which may require reporting to authorities are based on CA B&P
Code 805.01. The report required under this section shall be in addition to
any report required under Section 805, and may include
1. Incompetence, or gross or repeated deviation from the standard
of care involving death or serious bodily injury to one or more
patients, to the extent or in such a manner as to be dangerous or
injurious to any person or to the public. This paragraph shall not be
construed to affect or require the imposition of immediate
suspension pursuant to Section 809.5.
2. The use of, or prescribing for or administering to himself or
herself, any controlled substance; or the use of any dangerous drug,
as defined in Section 4022, or of alcoholic beverages, to the extent
or in such a manner as to be dangerous or injurious to the
licentiate, any other person, or the public, or to the extent that
such use impairs the ability of the licentiate to practice safely.
3. Repeated acts of clearly excessive prescribing, furnishing, or
administering of controlled substances or repeated acts of
prescribing, dispensing, or furnishing of controlled substances
without a good faith effort prior examination of the patient and
medical reason therefor. However, in no event shall a physician and
surgeon prescribing, furnishing, or administering controlled
substances for intractable pain, consistent with lawful prescribing,
be reported for excessive prescribing and prompt review of the
applicability of these provisions shall be made in any complaint that
may implicate these provisions.
4. Sexual misconduct with one or more patients during a course of
treatment or an examination.
Subject:
Credentialing Fair Hearing Policy and Procedure
Manual: Credentialing Policy Number: CR 16 Number of Pages: 8 pages Supporting Documents: Y X N
Original Date of Issue: Feb 10, 2014
Approved by:
GNMA Credentialing Committee
Revision Dates: May 6, 2014
May 21, 2014, July 18, 2014, October 10, 2014
Confidential Credentialing Fair Hearing Policy and Procedure Page 9
V. DEFINITIONS
A. The terms used in this Policy and not defined herein shall have the same meanings
as those set forth in the Physician Participation Agreements
B. CA B&P 805 California Business and Professional Code. Dictates the process in
which a peer review body reviews the basic qualifications, staff
privileges, employment, medical outcomes, or professional
conduct of licentiates to make recommendations for quality
improvement and education
C. CA B&P 809 To protect the health and welfare of the people of California, it is
the policy of the State of California to exclude, through the peer
review mechanism as provided for by California law, those healing
arts practitioners who provide substandard care or who engage in
professional misconduct, regardless of the effect of that exclusion
on competition
A. CMS The Center for Medicare and Medicaid Services
B. NCQA National Committee of Quality Assurance – A private, not for
profit organization dedicated to improving healthcare quality
C. Practitioner A clinical professional who provides health care services.
Practitioners are usually required to be licensed as required by law
care
D. NPDB National Practitioner Data Bank VI. SOURCES
A. Standards set by NCQA, July 2014
B. CMS Regulations, Medicare Advantage Audit Guidelines
C. California Business and Professional Codes 805 and 809
VII. RELATED POLICY/PROCEDURE A. CR 01 Credentialing and Recredentialing policy and procedure
B. CR 02 Credentialing Allied Health policy and procedure
C. CR 06 Medicare Opt Out policy and procedure
D. CR 08 Administrative Terminations policy and procedure
E. CR 12 Sanctions, Complaints and Quality Issues Monitoring policy and procedure
F. CR 13 Termination or Denial with Cause policy and procedure