Below is a copy of the Cenpatico Credentialing Program Description. In this document you will find information on our credentialing process, including a description of its authority and responsibilities as well as the Appeal Process. If you have any questions regarding this document, please call provider services at 1.866.495.6738.
The Cenpatico Credentialing Program provides credentialing and re-credentialing services for practitioners, providers and facilities that serve Members managed by Cenpatico. This Credentialing Program provides a broad overview of the credentialing and re-credentialing processes conducted by the organization. Policies and procedures further delineate these processes to ensure that all staff manages the credentialing and re-credentialing processes consistently and appropriately. This Credentialing Program will be reviewed and modified as necessary, at least annually by the Quality Management Committee.
The Credentialing Program includes health care organizations, licensed independent practitioners, and state mandated non-licensed master level practitioners. Applicants are required to comply with the criteria listed in the Credentialing Program and applicable policies and procedures. Practitioners include, at a minimum, MDs, DOs, PhDs, LPCs, LMSWs, LCSWs, LMFTs, LACs, LBSWs, LAMFTs, LSATs, LASACs, LISACs, PsyDs, other licensed, and state mandated non-licensed behavioral health practitioners. Organizational providers include, at a minimum, free standing psychiatric hospitals, psychiatric and addiction disorder units, units in general hospitals, psychiatric and addition disorder residential treatment centers, community mental health centers, ambulatory psychiatric and addiction disorder treatment facilities and clinics. Practitioners employed or contracted by organizational providers and who will not be listed as independent practitioners in the Provider Directory are excluded from the scope of this credentialing program. Review, selection and retention criteria do not discriminate against any practitioner or facility seeking accreditation as a participating provider, including providers who serve high-risk populations or costly conditions.
The Credentialing Committee, a sub-committee of the QMC, does not make credentialing and recredentialing decisions based solely on an applicant”s race, ethnic/national identity, gender, age, sexual orientation or the types of procedures or types of patients (e.g., Medicaid) the practitioner specializes in.
It is the goal of the credentialing program to credential an effective and efficient panel of mental health and substance use treatment practitioners able to provide high quality and integrated services to members. To achieve this goal, the credentialing program uniformly collects and maintains information and documentation regarding the professional experience and qualifications of the practitioners and facilities requesting participation in Cenpatico networks.
The credentialing program conforms to the standards of accrediting organizations such as Utilization Review Accreditation Commission and National Committee for Quality Assurance (Standards for Managed Behavioral Healthcare Organizations) and regulatory agencies, while also conforming to the delegation requirements within each business unit. Specific goals of the credentialing program are to:
- Verify the professional qualifications of all applicants and practitioners who are participating providers and who provide covered health care services to Cenpatico enrollees and members;
- Verify the qualifications of all organization applicants and organizations that are participating providers and that provide covered health care services to Cenpatico enrollees and clients;
- Provide a consistent, clinically appropriate process for approving or disapproving applications by practitioners for participation in the Cenpatico networks, with a focus on meeting members’ needs for adequate network coverage, practitioner specialty availability, and practitioner accessibility;
- Ensure that there is no discrimination against any practitioner seeking qualification as a participating practitioner;
- Ensure the confidentiality of practitioner credentialing data;
- Communicate in an appropriate and timely way about the credentialing process with network practitioners, including requesting any missing information;
- Communicate in an appropriate and timely way to business unit staff, the roster of practitioner and facility applicants credentialed and re-credentialed;
- Ensure that network practitioners remain appropriately qualified to serve enrollees, including review of any data on practitioner performance obtained through the business units’ quality improvement process.
Authority and Responsibilities:
The Board of Directors of Cenpatico has authorized the Credentialing Committee (CC), a sub-committee of the QMC, to make credentialing and recredentialing decisions related to independent contractors, and network practitioners within the scope of the credentialing program. The Credentialing Committee is authorized to review the scope of clinical practice as well as the professional conduct and clinical performance of each practitioner. Informal review of practitioner performance is ongoing and is not limited to the formal process of credentialing and recredentialing. The Credentialing Committee’s findings and actions are reported to the QMC.
Reporting to the business units is performed per the agreements with Cenpatico and usually includes additions and resignation to/from the provider networks. The applicable governing bodies have delegated to the Vice President of Medical Affairs the primary responsibility for reviewing the scope of practice. The Vice President of Medical Affairs is the senior clinical person with overall responsibility for the credentialing program, and is responsible for determining which procedures and treatments are outside the scope of customary medical practice. The Vice President of Medical Affairs has ongoing consultation with the Medical Directors, Chief Medical Officers and/or Administrators at each business unit, periodic consultation with practitioners in the field, consultation through outside practitioners’ participation in the Credentialing Committee and through other means. The Vice President of Medical Affairs and/or their designees, collaborating with the appropriate business unit representatives, are responsible for determining the scope of practice for non-physician practitioners. The Credentialing Committee will comply with the limitations imposed on the professional practices of non-physician practitioners by statute and governmental regulations, as well as those imposed by the community standards and professional society guidelines. The Vice President of Medical Affairs chairs the Credentialing Committee . All recommendations to deny, limit, or restrict clinical privileges are referred to the Credentialing Committee . Credentialing Department staff verifies that all credentialing application information is complete and accurate prior to Credentialing Committee review, and for conducting primary source verification and maintaining credentialing records.
The Credentialing Committee is a sub-committee of the Quality Management Committee. The Credentialing Committee meets minimally ten (10) times per year or as often as is necessary to fulfill its responsibilities. The purpose of the Committee is to review practitioner and facility credentials for recommendation of disposition in the provider panel by:
- Applying established criteria to practitioners” professional information for initial credentialing;
- Reviewing practitioners that exceed the credentialing and recredentialing citeria/standards;
- Exploring practitioner concerns as they relate specifically to credentialing criteria;
- Discuss whether practitioners are meeting reasonable standards of care;
- Accesses appropriate clinical peer input when discussing standards of care for a particular type of practitioner;
- Evaluates and reports to the Quality Management Committee (QMC) the effectiveness of the credentialing program.
- Review and approve Credentialing Policies and Procedures and Program description at least annually
Changes in the credentialing criteria are obligated to reflect changes in federal, state,
professional, and payer guidelines. The Credentialing Committee is also charged with evaluating the effectiveness and timeliness of the credentialing program, and reports this information to the Quality Management Committee.
Applicants who meet the participation criteria, are approved by the Network Advocacy Committee, and have no adverse activity (“clean files”), will be reviewed via the practitioner/provider listings and approved for network participation by the Medical Director or chair of the Credentialing Committee . Applicants who meet the minimum participation criteria with adverse activity (license sanctions, quality of care issues, settled malpractice claims history or pending malpractice claim information) will be brought to the Credentialing Committee as Exceeding the Credentialing Criteria/Standards for further review/ recommendation. Should the applicant be denied participation by the Credentialing Committee as not meeting the minimum participation criteria the Credentialing Manager will notify the applicant in writing.
The CC may utilize an exception process should it be necessary to credential certain practitioners given the needs of its membership. The Credentialing Committee will examine all other criteria based first on the need for the given practitioner”s service in a geographic area. If such a need exists, each criterion for selection will be examined on an individual basis by the Credentialing Committee .
The credentialing process shall not discriminate against any practitioner:
- on the basis of sex, race, religion, age, disability, sexual orientation, or ethnic origin.
- acting within the scope of his/her license or certification under applicable State law,solely on the basis of that license or certification;
- serving high-risk populations or specializing in conditions requiring costly treatment.
The Credentialing Committee has the authority to approve or deny an applicant”s participation in the Cenpatico
network. All decisions shall be shared in writing with applicants within 30 calendar days of the approval decision. In the event that Cenpatico Medical Director or Credentialing Committee decides not to extend participation status to a practitioner, the practitioner will be notified via certified mail of the Credentialing Committee denial decision within 30 calendar days of the Credentialing Committee’s decision. The letter of denial shall include information on the practitioner”s right to request a reconsideration or appeal as appropriate.
To ensure that Cenpatico has a mechanism in place to validate that the Credentialing Committee approval process does not deviate from the standards the following process is in place:
Initial Credentialing: All practitioners and providers who are denied initial credentialing are given the right to ask the Credentialing Committee for reconsideration by submitting additional information to support the initial credentialing application. In addition, the Credentialing Manager/Supervisor will present to the Credentialing Committee on a semi-annual basis, a list of all practitioners who have been denied initial network participation. The Credentialing Committee will review the denied practitioner and provider list for trends and any deviation from the approval process. Should there be any concerns with any practitioner or provider who has been denied participation, the Committee Chair will recommend that a second review of that practitioner or provider be presented to the Credentialing Committee.
Participating Practitioners/Providers: Practitioners and or Providers who are participating and are terminated from the network are presented to the Credentialing Committee on a monthly basis with the reason for the termination. The Credentialing Committee reviews the report with the reason for termination and will provide a final recommendation/approval. Practitioners/Providers are notified of the termination effective date and their right to dispute/appeal process.
In addition, Cenpatico also monitors complaints from practitioners regarding discrimination related to the credentialing process and will report quarterly to the credentialing committee all complaints regarding discrimination.
Reconsideration and Appeals:
New applicants who are declined participation for reasons such as quality of care or liability claims issues have the right to request a reconsideration of the decision in writing within fourteen (14) days of formal notice of denial. All written requests should include additional supporting documentation in favor of the applicant”s reconsideration for Cenpatico. Reconsiderations will be reviewed by the Credentialing Committee at the next regularly scheduled meeting, but in no case later than 60 days from the receipt of the additional documentation, with recommendation of Credentialing Committee for final decision.
The applicant will be sent a written response to his/her request within two (2) weeks of the Credentialing Committee decision. Current Practitioners whose participation is suspended, reduced, or terminated, shall have the right to appeal the decision in writing within 30 days of receipt of the formal notice. The Credentialing Committee Chair Person will appoint an Appeals Committee on an ad hoc basis when the law requires a hearing. This Appeals Committee hears appeals of decisions from the Credentialing Committee or Cenpatico to deny, suspend, or restrict participation or to terminate the participation status of practitioners. The Appeal Hearing will be scheduled no later than thirty (30) days after the receipt of the request. The Appeals Committee may uphold, reject or modify the initial Credentialing Committee recommendation. The Appeals Committee’s recommendation will be based upon the evidence admitted at the hearing and will be by the affirmative vote of the majority of the members of the Appeals Committee.
The Credentialing Committee reviews the recommendation of the Appeals Committee and may approve, reject or modify the recommendation of the Appeals Committee. The action of the Credentialing Committee upon the recommendation of the Appeals Committee regarding any restriction, suspension, or termination matter is final.
Notification to Authorities:
Where the practitioner”s Network participation is to be suspended or terminated for reasons relating to the practitioner”s competence or professional conduct, Cenpatico shall notify the appropriate authorities, including state agencies and NPDB, of the action.
Credentialing Program Activities:
The CC must approve all credentialing applicants before a practitioner or facility is designated as a participating practitioner within the Cenpatico network.
Application Process and Review:
Unless otherwise specified, applicants must first complete an application for participation in the network. When approved by the state, applicants have the option of requesting Cenpatico retrieve their application directly from the Council for Affordable Quality Healthcare (CAQH) universal credentialing data source, or use the Cenpatico application. In certain States, the CAQH application may be retrieved in the form of the State specific application format. The application may be submitted electronically or on paper.
On receipt, each application is reviewed. To be considered, the application must include the following minimum requirements:
- Complete, signed and dated application for participation;
- History of education and professional training including board certification status;
- Work History for the past 5 years or since last credentialed by Cenpatico;
- Current unrestricted license in the state where the practice is located as well as a history of licensure in all jurisdictions;
- Current valid federal DEA certificate and State BNDD (as applicable);
- Current liability insurance in compliance with minimum limits;
- Professional liability claims history including any pending professional liability actions;
- History of Medicare/Medicaid sanctions showing practitioner is currently in good standing;
- Listing of all sanctions or penalties imposed by hospitals, licensing boards and managed behavioral health organizations or managed care organizations within the past 5 years;
- Documentation of any voluntary or involuntary relinquishment of privileges to practice in a facility or jurisdiction;
- Hospital affiliations or privileges, as applicable;
- Attestation of history of loss of license and /or clinical privileges, disciplinary actions, and /or felony convictions; Disclosure of any physical, mental, or substance abuse problems that could, without reasonable accommodation, impede the practitioner”s ability to provide care according to accepted standards of professional performance or pose a threat to the health or safety of patients;
- Attestation to the correctness/completeness of the application;
- Signed and dated Release of Information form.
Applicants and providers submitting incomplete applications or submitting the incorrect application will be contacted in writing and given the opportunity to complete the application process or re-file using the correct application. On identification of erroneous information, the applicant will be notified in writing and given the opportunity to correct the information.
Application Review Criteria:
The Credentialing Committee , using defined criteria, shall consider each applicant for participation. Such criteria may include but not limited to:
- Applicable training (Highest level achieved);
- Work History;
- Competence and professional conduct;
- Acceptance by other MBHOs and/or other payers;
- Recognized geographic needs;
- Malpractice History;
- State license status;
- Medicare/Medicaid Sanction Activity; and
- OIG / EPLS Sanction Activity.
- Medicaid and NPI numbers.
Primary Source Verification:
As part of the credentialing and re-credentialing processes, primary and secondary verification is conducted in a manner consistent with the process required by URAC and by NCQA”s Guidelines for Managed Behavioral Healthcare Organizations.
Application Review Process:
Following completion of the verification process, credentialing staff will review each application for completeness. The names of all those with complete applications will be forwarded to the Vice President of Medical Affairs or designee. The Vice President of Medical Affairs or designee reviews all applications exceeding established thresholds then forward the file to the Credentialing Committee for review. If exceeded, thresholds requiring Vice President of Medical Affairs review include but are not limited to the following:
- Malpractice claims history: greater than three (3) claims in a ten (10) year period;
- History of impairment;
- When applicable, office site visit score less than 85%;
- Office site does not meet appointment availability standards;
- Previous sanction activity within the past 10 years;
- For practitioners being re-credentialed, any elements of the quality improvement report that exceed established thresholds;
- Lack of state licensure when applicable for individual or organizational providers.
The Credentialing Committee utilizes an exception process should it be necessary to credential certain practitioners/providers given the needs of the membership and clients. The Credentialing Committee will examine all other criteria based first on the need for the given providers service in a geographic area. If such a need exists, each criterion for selection will be examined on an individual basis taking into account the following:
- Malpractice claims history: no more than three (3) claims in a ten (10) year period, or claims judged to be of nuisance value. Exceptions will be granted and reviewed on anindividual basis by the Credentialing Committee .
- History of impairment with involvement in a credible program to correct the impairment with concurrent and present monitoring by the medical society or state board, and no evidence of recidivism.
- Previous sanction activity within the past 10 years: the nature of the sanction and remedy.
- Office site visit: a corrective action plan to remedy any deficiencies with provisional approval until the remedy is achieved.
- Additional exceptions will be granted and reviewed on an individual basis by the Credentialing Committee.
When reviewing any opportunity to expand the network, additional criteria are considered, including current patient enrollment, geographic needs, patients” cultural/language/ethnic needs, provider specialties needed, quality of care and quality of service, and accessibility of providers. In addition to the above stated considerations, the applicant”s qualifications, special training/experience, location, ability to meet access standards, number of new referrals a month they can accept, composition of the network serving the population in that area/for that service, community input, etc. are all considered in the decision making process. Special consideration is given to practitioners with special expertise in treating under-served groups, such as: Physicians who are Board Certified in Child Psychiatry, any practitioner who is Bi-Lingual, and any practitioner with sign language ability.
Occasionally, it is in the interest of members to make practitioners available prior to completion of the entire initial credentialing process. Cenpatico may opt to provisionally credential practitioners who are applying to the network for the first time. A practitioner may only be provisionally credentialed once and practitioners may not be held in a provisional credentialing status for more than 60 calendar days. Practitioners who had been in the Cenpatico network via a delegation of credentialing arrangement are not eligible for provisional credentialing if the delegation arrangement is terminated or if the practitioner is no longer affiliated with the delegated entity.
For these practitioners, the following factors must be primary source verified within 180 calendar days of the Credentialing Committee decision.
- Verification of a current, valid license to practice.
- Verification of the past ten years of malpractice claims or settlements from the malpractice carrier or the results of the National Practitioner Data Bank (NPDB) query.
- A current and signed application with attestation.
Cenpatico conducts onsite visits to the provider/practitioner’s office to investigate member complaints for concerns about physical accessibility and appearance or adequacy of exam room/waiting room space. Site visits for facilities that are not accredited are conducted prior to credentialing. If the facility is accredited by a CMS certified accrediting agency (e.g., JCAHO, CARF, or COA), no site visit/on-site quality assessment is required. Standards are determined based on State and/or NCQA guidelines. For sites that do not meet an overall minimum score of eighty (85) %, Cenpatico develops follow-up actions and revisits are scheduled at least every six (6) months until performance standards have been met.
Cenpatico’s Quality Management Department will monitor member complaints for deficiencies related to a practitioner”s office. Upon receipt of a complaint related to quality of practitioner”s office site (physical appearance/accessibility and adequacy of waiting room/exam room), Quality Management will perform an onsite visit within 60 days of receipt of the complaint.
The site evaluation includes but is not limited to:
- Staff information (i.e. provider make interpreter services available)
- Office policies/general information
- Physical/safety information/physical accessibility
- Scheduling/appointments availability/office protocols
- Availability of emergency equipment (as applicable)
- Medication administration/dispensing
- Medical record keeping practices
- Access/24-7 access
Standards for access to care and appointment availability are reviewed in order to assure appointment access for Cenpatico members. Standards are determined based on state law and URAC and/or NCQA standards and are further outlined in the associated Quality Management policy. Ongoing monitoring process between recredentialing cycles:
Monitoring of practitioner Medicare/Medicaid sanctions, limitations or sanctions on state licensure, adverse events and complaints between recredentialing cycles occurs monthly. Reports are provided to the Credentialing Committee on a monthly basis. The Vice President of Medical Affairs/Medical Director working with the Credentialing Committee will take appropriate actions against providers when it identifies occurrences of poor quality. The Credentialing Committee reviews sanctions during its regularly scheduled meetings or via an adjunct-emergency meeting. See separate policy for Ongoing Monitoring of Sanctions. The Credentialing Committee also reviews data and discusses whether providers are meeting reasonable standards of care. The Credentialing Committee accesses appropriate peer input when discussing standards of care for a particular type of practitioner/provider.
Recredentialing is completed every three years except for Celticare which requires recredentialing to be conducted every two years. As part of the recredentialing process, the Credentialing Committee requires an application updating any information subject to change. The Credentialing Committee considers information collected by the business units regarding the provider”s performance, including information collected through the Quality Management programs; such as, complaints and adverse events. The Credentialing Committee will also review any site visit results, chart audit results, complaints, and other information collected through the Quality Management Programs.
If the Credentialing Committee does not approve a practitioner/provider for continued participation in the network, the practitioner/provider is notified in writing. Correspondence is mailed within fourteen (14) days of the decision stating the decision and reason.
Terminating, restricting, limiting, and denying clinical privileges:
The Chairperson of the Credentialing Committee or designee has the authority to notify any practitioner with lapsed licensure/malpractice coverage that the practitioner may not provide services to Cenpatico business unit members or clients until the issue has been corrected and verification received from the licensing/insurance entity. The practitioner/provider is expected to correct the issue within thirty (30) days or further de-credentialing action may be taken by the Credentialing Committee .
Actions that may result in limitation, restriction, denial, and termination of clinical privileges may be referred to the Peer Review via the Credentialing Committee. The Credentialing
Committee Peer Review is responsible for instituting disciplinary actions, where indicated, and monitoring for compliance. The Committee may make recommendations to the as to the appropriate action for the situation. Recommendations resulting in limitation, restriction, denial, and termination of clinical privileges are communicated with appropriate business unit staff to implement actions consistent with the recommendation.
In all Credentialing Committee actions that terminate, restrict, limit, or deny clinical privileges of a practitioner/provider based on issues of quality of care and/or services, the Credentialing Committee shall notify the practitioner of the proposed action prior to action being taken unless there is thought to be imminent harm to the members or clients, along with an explanation of the reasons for the action, and of the practitioner”s right to enter into the Provider Dispute Resolution process. When state regulations regarding the practitioner”s/providers” appeal or hearing process differ from the process outlined, Cenpatico will follow the state required guidelines. The relationship between Cenpatico and the business unit practitioners/providers include contractual language for the immediate and potential termination of the contract for cause and for no cause. The Credentialing Committee may recommend such termination to the Peer Review Committee for follow-up. The Vice President of Medical Affairs and/or designee will communicate the Peer Review Committee”s determination to the Credentialing Committee who will communicate in writing to the practitioner. Notification of termination is given to the practitioner prior to the termination date.
Individual confidential files containing credentialing information for each credentialed practitioner are maintained electronically. Access to those files is limited to authorized personnel only. Electronic records are maintained in a credentialing database on a network drive; access to this drive is limited to appropriate personnel using secure logons in the Windows NT security system. Staff receives appropriate training on protecting the confidentiality of protected information such as credentialing files, and at least annually signs a confidentiality agreement affirming that they will protect confidential data.
Cenpatico maintains an on-line directory and updates the online Provider Directory on a weekly basis. The data is generated from the credentialing data base and is audited by the data analyst against the practitioner /provider”s credentialing data to ensure that the practitioner/provider appearing in the directory have the accurate information regarding the practitioners” names, degree, specialty, locations, office hours, telephone number, and of non-English languages spoken. The directory includes at minimum information relative to Health practitioners and shall also identify practitioners/providers that are not accepting new patients.
Maintenance of Confidentiality:
Practitioner/Provider information reviewed by the CC is considered privileged and confidential, and this information is maintained in a secure area and is accessible only to staff with a direct need to access this information.
Initial Assessment of Health Delivery Organizations:
Prior to contracting with health delivery organizations, Cenpatico verifies that organizations have been reviewed and approved by a recognized accrediting body or meets Cenpatico standards for participation, and are in good standing with state and federal agencies.
Organizational providers include, at a minimum, hospitals, home health agencies, skilled nursing facilities, nursing homes, freestanding surgical centers, and behavioral health facilities providing mental health or substance abuse services in an inpatient, residential or ambulatory care setting.
Cenpatico recognizes the following accrediting bodies:
- AAAASF American Association for Accreditation of Ambulatory Surgery Facilities http://www.aaaasf.org/
- AAAHC Accreditation Association for Ambulatory Health Care. http://www.aaahc.org/eweb/StartPage.aspx
- ACHC The Accreditation Commission for Health Care http://www.achc.org/
- CARF/CCAC Commission on Accreditation of Rehabilitation Facilities / Continuing Care Accreditation Commission http://www.carf.org/
- CHAP Community Health Accreditation Program http://www.chapinc.org/
- JCAHO Joint Commission on Accreditation of Healthcare Organizations http://www.jcaho.org
For those organizations that are not accredited and licensed, the network Provider Relations Specialist schedules an on-site evaluation to determine the scope of services available at the facility, physical plant safety, reviews the health delivery organization”s quality improvement program for adequate mechanisms to credential practitioners delivering care in the facility, identify and manage situations involving risk, and assess the organization”s medical record keeping practices. A current Center for Medicare and Medicaid Services (“CMS”) certificate will be accepted in lieu of a formal site visit, and can be utilized to augment the information required to assess compliance with Plan standards.
The Credentialing Committee reviews and approves all organizational credentialing activities. health delivery organizations are recredentialed every three years to assure that the organization is in good standing with state and federal regulatory bodies, has been reviewed and approved by an accrediting body (as applicable), and continues to meet Plan participation and Quality Management requirements.