Thursday, July 21, 2016

Check list for provider credentialing and re-credentialing - documents


 Credentialing Criteria

At a minimum, eligible providers must meet the criteria listed below before they can participate in the 1199SEIU Benefit Funds’ network:

1. A valid, current, unencumbered license to practice issued by the state education department within the state of practice.

2. Graduation from an accredited medical school, professional school, college of osteopathy or a foreign medical school recognized by the World Health Organization and completion of a residency program.

3. Foreign medical school graduates must submit an ECFMG certification (if licensed after 1986).

4. Current, active medical staff privileges (if applicable) in good standing at a participating hospital.

5. Evidence of at least five years of work history. (“Work” includes time spent in the past five years – post-fellowship, military service, etc.).

6. Professional liability insurance in the amount of $1 million per incident/$3 million aggregate per annum.

7. Current Drug Enforcement Agency (DEA) registration, where applicable.

8. For MDs and DOs only, board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association. For an applicant who is not board-certified, sufficient work history (the practitioner must be in practice for 20 or
more years) and evidence of significant network need in a local area will be considered. The credentialing committee will make this determination on a case-by-case basis.

9. For MDs only, current and unencumbered participation in the Medicaid and Medicare programs or proof that such non-participation is entirely voluntary and not due to current or past debarment from the programs.

10. Absence of a physical or mental impairment or condition that may impede the provider’s performance of essential functions of his/her clinical responsibility. If the provider does have a physical or mental impairment, he or she must submit adequate evidence that a physical or mental impairment or condition does not render the provider unable to perform the essential functions without threatening the health or safety of others.

11. Absence of a current chemical dependency or substance abuse problem. For an applicant with this history, the provider must submit adequate evidence that a past chemical  dependency or substance abuse problem does not adversely affect the provider’s ability to
competently and safely perform essential functions.

12. Absence of a history of professional disciplinary actions or absence of any other information that may indicate provider is engaged in unprofessional misconduct. Unprofessional misconduct can be defined as, but not limited to, sexual misconduct (e.g., with patients), sexual harassment of his or her patients or fraudulent billing practices.
An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

13. Absence of a history of felony criminal conviction or indictment. An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

14. Absence of falsification of the credentialing application, requested documents or material omission of information requested in the  pplication.

At the Time of Re-Credentialing:

15. Absence of information to indicate a pattern of inappropriate utilization of medical resources.

16. Absence of substantiated member complaints. An applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance.

17. All criteria applicable to original credentialing must still be true.

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