Sunday, July 24, 2016

What is Re-credentialing, delegated credentialing and facility credentialing


All providers must be re-credentialed every three years to continue their participation with the 1199SEIU Benefit Funds. Re-credentialing allows us to re-evaluate qualifications and performance and ensure compliance with the 1199SEIU Benefit Funds’ criteria. Providers may be re-credentialed off-cycle for disciplinary actions, a suspended license, cancellation of professional liability coverage, loss of privileges, suspected fraudulent behavior and quality-of-care or member dissatisfaction concerns.

Any fraudulent or erroneous information submitted to the 1199SEIU Benefit Funds, including at the time of the original credentialing, can be cause for a provider to immediately lose his or her participation status with the 1199SEIU Benefit Funds. Providers are obligated  to immediately notify the 1199SEIU Benefit Funds of changes to any information submitted as part of the credentialing and re-credentialing processes.

Delegated Credentialing

In certain instances, providers may be credentialed through “delegated credentialing,” whereby an outside entity authorized by the 1199SEIU Benefit Funds (generally a hospital) will credential the provider. That provider still must sign a contract directly with the 1199SEIU Benefit Funds and pass the 1199SEIU Benefit Funds’ onsite auditing process. However, the 1199SEIU Benefit Funds retain the final authority to approve, terminate or suspend a provider at their sole discretion. The 1199SEIU Benefit Funds may delegate credentialing to contracted facilities, organizations or provider groups who demonstrate the ability, through a pre-delegation assessment, to meet the performance requirements of the 1199SEIU Benefit Funds. Approved delegates may be evaluated annually to monitor continued compliance with the
1199SEIU Benefit Funds’ current credentialing criteria.

 Facility and Ancillary Provider Credentialing

The 1199SEIU Benefit Funds have established facility and ancillary criteria for evaluating and appointing providers to its network. This facility and ancillary application assesses and gathers appropriate certification data and also verifies the extensive list of services provided by our
facilities for areas such as behavioral health, mental health, substance abuse, durable medical equipment, orthotics and prosthetics, home health/hospice, freestanding ambulatory surgery,  and rehabilitation and dialysis.

Please contact the Provider Relations Department to speak to one of our representatives about applying to be a participating Ancillary Provider.

The 1199SEIU Benefit Funds are committed to protecting the confidentiality of all provider information obtained during the credentialing process.

Please note that participating hospitals, treatment centers, ancillary facilities, group and individual providers should notify the Provider

Relations Department of new providers joining  (and leaving) existing practices.

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