Credentialing Program

Credentialing Program

Below is a copy of the Cenpatico of Arizona 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 reconsideration process.
If you have any questions regarding this document, please call the Credentialing Department at 1.866.495.6738

Scope:
Cenpatico of Arizona (CAZ) Credentialing Department & Quality Management Departments

Purpose:
To describe the CAZ Credentialing and Re-credentialing Program.

Policy:
The CAZ Credentialing Department will maintain a Credentialing Program Description, which encompasses the functions of credentialing and re-credentialing of both licensed individual practitioners and organizational providers. The program description will be consistent with applicable State regulations, URAC guidelines and internal guidelines.

Purpose:
CAZ Credentialing Program provides credentialing and re-credentialing services for practitioners, providers and facilities that serve Members managed by CAZ and other contracted cross functional entities. This Credentialing Program Description 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 (QMC).

Program Scope:
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, Physicians (MD ‘sand DO’s), Licensed Psychologist (PHD), Licensed Psychiatrist, Nurse Practitioners that are certified to practice within scope, Physician Assistants, Licensed Clinical Social Workers (LCSW’s), Licensed Marriage and Family Therapists (LMFT’s), Licensed Independent Substance Abuse Counselors(LISAC’s), Licensed Professional Counselor(LPC’s) and state mandated non-licensed behavioral health practitioners. Organizational providers include, at a minimum, Behavioral Health Residential Facilities, Behavioral Health Outpatient Clinics, free standing psychiatric hospitals, psychiatric and addiction disorder units, units in general hospitals, psychiatric and addiction disorder residential treatment centers and community mental health centers. 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.

To ensure the review selection and retention criteria will not discriminate against any practitioner or facility seeking participation in the CAZ network, the following guidelines are adhered to;

  • The Credentialing Committee (CC) does not make credentialing and re-credentialing decisions based on an applicant’s race, ethnic/national identity, gender, age, sexual orientation or the types of services the provider offers.
  • Credentialing determinations also are not based on providers who serve high-risk populations or costly conditions or types of patients (e.g., Medicaid) the practitioner specializes in.

Program Goal:
It is the goal of the CAZ Credentialing Department to credential an effective and efficient panel of mental health and substance abuse practitioners able to provide high quality and integrated services to members. To achieve this goal, the CAZ Credentialing Department uniformly collects and maintains information and documentation regarding the professional experience and qualifications of the practitioners and facilities requesting participation in CAZ’s network.

The CAZ Credentialing Department conforms to the standards referenced in the Arizona Department of Health Services, Division of Behavioral Health Services Provider Manual Section 3.20, Credentialing and Recredentialing and standards as outlined in the Quality Management and Performance Improvement Program Chapter 900, Policy 950 Credentialing and Recredentialing Processes. Specific goals of the Credentialing Department are to:

  • Verify the professional qualifications of all applicants and practitioners who are participating providers and who provide covered behavioral health care services to CAZ enrollees and members;
  • Verify the qualifications of all organizational applicants and organizations that are participating providers and that provide covered behavioral health care services to CAZ enrollees and members;
  • Provide a consistent, clinically appropriate process for approving or disapproving applications;
  • Ensure providers entering in the network 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 participation in CAZ Network;
  • Ensure the confidentiality of practitioner credentialing data;
  • Communicate in an appropriate and timely way about the credentialing process including requests for any missing information;
  • Communicate in an appropriate and timely way to business unit staff the roster of practitioners and facility applicants credentialed and re-credentialed;
  • Ensure that network practitioners remain appropriately qualified to serve members. This includes the continuous review of any data on the practitioner’s performance obtained through the business unit’s quality improvement process or other primary sourced credentialing sources;

Authority and Responsibilities:
The Executive Management Team (EMT) of Cenpatico of Arizona has authorized the Credentialing Committee (CC), a sub-committee of the QMC to make credentialing and re-credentialing decisions related to independent contractors and network practitioners within the scope of the credentialing program. The CC 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 re-credentialing. The CC’s findings and actions are reported to the QMC. The CC is authorized to make delegation decisions based upon criteria and when permitted by the business unit and client. The CC retains responsibility for final approval of all delegated providers.

The EMT has delegated to the Chief Medical Officer (CMO) of Cenpatico of Arizona the primary responsibility for reviewing the scope of practice for the credentialing program. The CMO 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 CMO can appoint a Medical Director to make determinations on provider credentials that could result in continued participation, termination or full credentialing committee review.

The CMO will have ongoing consultation with the Credentialing, Contracting and Network Development departments of CAZ when deemed necessary for expediting the credentialing process.

The CMO or CC has the authority to grant special consideration for practitioners with special expertise in treating under-served groups, such as: physicians who are board certified in child psychiatry, any practitioner who is bilingual, and any practitioner with sign language ability. The CMO or the CC has the authority to allow Internal Medicine, Family Practice or General Practice licensed physician’s access to the CAZ network. These providers are essentially classified as out of scope providers, but some agencies and provider groups contract with these providers to provide behavioral health services to CAZ members.

Credentialing Committee:
The Credentialing Committee is a sub-committee of the QMC. The CC meets minimally ten (10) times per year or as often as is necessary to fulfill its responsibilities. The purpose of the Credentialing Committee is to review practitioner and facility credentials for recommendation of disposition in the CAZ provider network by:

  • Applying established criteria to practitioners’ professional information for initial credentialing;
  • Reviewing practitioners that exceed the credentialing and re-credentialing criteria/standards;
  • Exploring practitioners’ concerns as they relate specifically to credentialing criteria;
  • Discussing whether practitioners are meeting reasonable standards of care;
  • Accessing appropriate clinical peer input when discussing standards of care for a particular type of practitioner;
  • Evaluating and reporting to the QMC the effectiveness of the credentialing program and;
  • Reviewing and approving Credentialing Policies and Procedures and the CAZ Credentialing Program Description at least annually

Changes in the credentialing criteria are recommended to reflect changes in federal, state, professional, and payer guidelines. The CC is also charged with evaluating the effectiveness and timeliness of the CAZ Credentialing Department and reports this information to the QMC.

Committee Decisions:
The CC has the authority to approve or deny an applicant’s participation in the CAZ Provider Network. All decisions shall be shared in writing with applicants within 14 calendar days of the committee decision. In the event that a CAZ credentialing designee or the CAZ Credentialing Committee decides not to extend participation status to a practitioner, the practitioner will be notified via mail, email or fax of the CC denial decision. The letter of denial will include information on the practitioner’s right to request a reconsideration or appeal as appropriate.

To ensure that the CAZ Credentialing Program Description has a mechanism in place to validate that the Credentialing Committee approval process does not deviate from the standards the following processes have been aligned with state credentialing guidelines:

  • The Credentialing Committee Members will receive summary information on providers that has been deemed as adverse or exceeding thresholds.
  • The CMO or CAZ Credentialing Representative will introduce each of the adverse providers in the CC meeting.
  • The CAZ Committee Members are expected to review the information and provide appropriate peer input when discussing the adverse findings. The Committee Members will be asked for their professional feedback and be given an opportunity to vote on whether or not the provider should be accepted into CAZ’s Provider Network.
  • A complete discussion of this decision will be reflected in the CC meeting minutes.
  • The CC or designee must approve all credentialing applicants before a practitioner or facility is designated as a participating practitioner within the CAZ networks.

The CC, CMO or Medical Director may utilize an exception process should it be necessary to allow practitioners with adverse issues into CAZ network, this is in the case of certain provider types that can handle special needs or where network gaps may exist. 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 (6) year period, or claims judged to be of nuisance value. Exceptions will be granted and reviewed on an individual basis by the CC.
  • 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 6 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 CC.
  • When reviewing any opportunity to expand the network, additional criteria are considered, including current member enrollment, geographic needs, members’ 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.

Credentialing Program Activities:
Credentialing program activities contain initial credentialing review, re-credentialing, provisional credentialing, and continuous monitoring of providers licenses, Office of Inspector General (OIG) Excluded Provider Listing and AHCCCS’s provider certification, which designates practitioners have been certified to render services to its members.

Initial Credentialing Review:
Initial applications, can only be logged as received if the application has been submitted by the CAZ Provider Relations or Network Development staff. Applications, that have been received from an outside source will be scanned and logged in CAZ Credentialing Database. CAZ Credentialing will not start formal processing, unless approved by CAZ Provider Relations or Network Development staff.

Applicants have the option of requesting CAZ Credentialing Staff retrieve their application directly from the Council for Affordable Quality Healthcare (CAQH), a universal credentialing data source or completing CAZ Credentialing Applications and Demographic Forms which are posted on Cenpatico of Arizona’s Provider Portal at http://www.cenpaticoaz.com/.

Any provider that has changed their NPI, License Nbr, AHCCCS Nbr, or Organizational Providers who have moved locations will be required to submit a new credentialing application. Provider’s that have failed to re-credential timely, will also need to complete the initial credentialing review. To be considered, the Credentialing Application must be signed and complete. The signature cannot be more than 150 days old. The additional submission documents that are required to be submitted with the Credentialing Application are as followed;

  • Providers
    • Initial Credentialing Review: Current copy of provider’s State Licensure
    • Initial Credentialing Review: Current copy of provider’s DEA or Bureau of Narcotics and Dangerous Drugs Certificate (if applicable)
    • Initial Credentialing Review: Current copy of provider’s State Controlled Dangerous Substance Certificate (if applicable)
    • Initial Credentialing Review: Current copy of professional liability insurance policy face sheet, illustrating expiration dates, limits and the provider’s name
    • Initial Credentialing Review: Current copy of Board Certification if applicable
    • Initial Credentialing Review: Copy of certificate or letter certifying formal post graduate training for applicable providers
    • Initial Credentialing Review: Copy of Curricula Vita/Resume that includes work history. Any gaps within 6 months must be explained.
    • Initial Credentialing Review: Current copy of ECFMG Certificate (if applicable)
    • Initial Credentialing Review: Current copy of the W-9 for the contracted provider or contracted group
    • Initial Credentialing Review: Cenpatico of Arizona Provider Demographic Form

 

  • Organizational Providers
    • Initial Credentialing Review: Current copy of provider’s JCAHO/CARF/COA/or AOA accreditation letter with dates of accreditation. (If applicable)
    • Initial Credentialing Review: Current copy of the state or local license(s) and/or certificate(s) under which the facility operates.
    • Initial Credentialing Review: If none of the documents are submitted an On-Site inspection will be conducted by a staffer of Cenpatico of Arizona. The site inspection will be conducted to ensure compliance with service specifications as outlined in Arizona Health Care Cost Containment System AHCCCS Medical Policy Manual, Policy 950 Credentialing and Recredentialing Processes.
    • Initial Credentialing Review: Current copy of the provider’s CLIA license. (If applicable)
    • Initial Credentialing Review: Current copy of the provider’s Pharmacy license. (If applicable)
    • Initial Credentialing Review: Current copy of the provider’s professional and general liability insurance policy with the limits of coverage per occurrence and in aggregate amounts. The name of liability carrier, and insurance effective date and expiration date.
    • Initial Credentialing Review: Current copy of the W-9 for the contracted provider or contracted group
    • Initial Credentialing Review: Cenpatico of Arizona Provider Demographic Form

Applicants and providers submitting incomplete applications or submitting the incorrect application will be contacted within 21 days 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. The credentialing process will be completed and submitted for approval within 90 days from the date all the requested materials were received.

Initial Assessment of Health Delivery Organizations:
Prior to contracting with external health delivery organizations (HDO), Cenpatico verifies that organizations have been reviewed and approved by a recognized accrediting body or meets CAZ 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, crisis services providers, freestanding surgical centers and behavioral health facilities providing mental health or substance abuse services in an inpatient, residential or ambulatory care setting.

CAZ Credentialing will query the following accrediting bodies when applicable in the case of an Organizational Credentialing:

  • American Association for Accreditation of Ambulatory Surgery Facilities – AAAASF
  • Accreditation Association for Ambulatory Health Care – AAAHC
  • The Accreditation Commission for Health Care – ACHC
  • Commission on Accreditation of Rehabilitation Facilities – CARF
  • Continuing Care Accreditation Commission – CCAC
  • Community Health Accreditation Program – CHAP
  • Joint Commission on Accreditation of Healthcare Organizations – JCAHO
  • American Osteopathic Hospital Association – AOHA
  • Healthcare Quality Association on Accreditation – HQAA
  • National Committee for Quality Assurance – NCQA
  • Utilization Review Accreditation Commission/Accreditation HealthCare Commission Inc. – URAC

For those organizations that are not accredited and do not have a current Center for Medicare and Medicaid Services (“CMS”) certificate, or do not have an AHCCCS license that denotes a recent Site Survey an onsite inspection will be done by CAZ Provider Relations Specialist to determine the scope of services available at the facility, physical plant safety, reviews the HDO’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.
HDOs/Organizational Providers are recredentialed every three years and must adhere to all the guidelines outlined in the Application Review Process.

Initial submissions that are discontinued:
Initial practitioner’s that have failed to submit the applicable documents are notified by the CAZ Credentialing Department, a minimum of three times during the 90 day review period. Providers that have failed to submit the applicable documents or requested clarification within 90 days of the initial receipt date are deemed discontinued. If the provider submits the applicable document (s) or provides clarification after the 90th day, their receipt date will be reflected based on the date of the resubmission or clarified information obtained by the CAZ Credentialing Department.

Initial Credentialing Denials:
All practitioners and providers who are denied initial credentialing are given the right to ask the CC for reconsideration by submitting additional information to support the initial credentialing application. In addition, the Credentialing Department 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 practitioners listing and trend their specialty, participating group if applicable and other designated provider demographics to ensure there are no 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. Applicants will be notified within 14 calendar days of the committee decision.

Reconsideration Process:
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 thirty (30) days of formal notice of denial. All written requests will need to include additional supporting documentation in favor of the applicant’s reconsideration for network participation. Reconsiderations will be reviewed by the CMO or Medical Director Designee or at the next regularly scheduled Committee meeting, but in no case later than 60 days from the receipt of the additional documentation. The reconsideration is done by Committee members not involved in the initial denial. Applicants will be notified within 14 calendar days of the reconsideration decision.

Current Practitioners whose participation is suspended, reduced, or terminated, shall have the right to request reconsideration of the decision in writing within 30 days of receipt of the formal notice. The reconsideration is done by Committee members not involved in the initial denial. The reconsideration review will be scheduled no later than 30 days after the receipt of the request. The CMO or designee may uphold, reject or modify the initial CC recommendation.

Re-credentialing:
Re-credentialing is completed every three years. As part of the re-credentialing process providers are notified within 120 days of the expiration of their credentials. The CAZ Credentialing Department will mail, fax or email notifications to the providers at least 3 times within the notification cycle. The provider will be required to complete and sign the CAZ Credentialing Application and submit designated documents. The re-credentialing process follows the same steps that are outlined in the “Application Review Process” in the CAZ Credentialing Program Description. Providers that fail to submit timely will be presented to CAZ Credentialing Committee and designated as “failure to re-credential”. These practitioners will be notified by mail, fax or email of the Committee’s decision regarding the failure to complete the Re-credentialing process. Providers that fail to re-credential will have 30 days, from the CAZ Committee’s decision to submit completed materials to avoid termination. If providers submit materials on the 31st day and beyond they will have to following initial credentialing submission guidelines. If the completed credentialing information is submitted and the providers are approved, their effective date will be based on the date the initial credentialing submission is approved. Providers that fail to re-credential cannot request provisional credentialing status.
Termination notifications are mailed within fourteen (14) days of the decision stating the decision and reason. Practitioners whose participation is suspended, reduced, or terminated, shall have the right to request reconsideration of the decision in writing within 30 days of receipt of the formal notice. The reconsideration process can be conducted by the CMO or the CAZ Credentialing Committee. The CMO can elect to appoint a panel to review the adverse action and make the final determination. See the Reconsideration Process outlined in a previous section of this document.
The additional submission documents that are required to be submitted with the Credentialing Application for re-credentialing approval are as followed;

  • Providers
    • Re-Credentialing: Current copy of provider’s State Licensure
    • Re-Credentialing: Current copy of provider’s DEA or Bureau of Narcotics and Dangerous Drugs Certificate (if applicable)
    • Re-Credentialing: Current copy of provider’s State Controlled Dangerous Substance Certificate (if applicable)
    • Re-Credentialing: Current copy of professional liability insurance policy face sheet, illustrating expiration dates, limits and the provider’s name
    • Re-Credentialing: Current copy of Board Certification if applicable
    • Re-Credentialing: Current copy of the W-9 for the contracted provider or contracted group
    • Re-Credentialing: Cenpatico of Arizona Provider Demographic Form
  • Organizational Providers
    • Re-Credentialing: Current copy of provider’s JCAHO/CARF/COA/or AOA accreditation letter with dates of accreditation. (If applicable)
    • Re-Credentialing: Current copy of the state or local license(s) and/or certificate(s) under which the facility operates.
    • Re-Credentialing: If none of the documents are submitted an On-Site inspection will be conducted by a staffer of Cenpatico of Arizona. The site inspection will be conducted to ensure compliance with service specifications as outlined in Arizona Health Care Cost Containment System AHCCCS Medical Policy Manual, Policy 950 Credentialing and Recredentialing Processes.
    • Re-Credentialing: Current copy of the provider’s CLIA license. (If applicable)
    • Re-Credentialing: Current copy of the provider’s Pharmacy license. (If applicable)
    • Re-Credentialing: Current copy of the provider’s professional and general liability insurance policy with the limits of coverage per occurrence and in aggregate amounts. The name of liability carrier, and insurance effective date and expiration date.
    • Re-Credentialing: Current copy of the W-9 for the contracted provider or contracted group
    • Re-Credentialing: Cenpatico of Arizona Provider Demographic Form

Re-credentialing Terminations:
Participating Practitioners and or Providers who are at risk for termination 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 recommendation regarding the termination. Practitioners/Providers are notified of the termination effective date and their right to a reconsideration process. Practitioners/Providers will be notified within 14 calendar days of the Committee decision.

Any provider that has failed to submit their Re-credentialing documents before their 36 month anniversary are submitted to the committee as failure to re-credential. Providers are notified of the termination within 14 calendar days of the committee decision, and have 30 days from the committee date to submit applicable documents or information to avoid termination. If the credentials are received on the 31st day, the provider must undergo the initial credentialing process. The provider cannot request expedited or provisional credentialing request and they are terminated in Amisys until the credentialing has been completed and approved.

Terminating, restricting, limiting, and denying clinical privileges:
The CMO or CC designees have the authority to notify any practitioner with lapsed licensure/malpractice coverage that the practitioner may not provide services to CAZ members 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 will be taken by the CC.

In all CC actions that terminate, restrict, limit, or deny clinical privileges of a practitioner/ provider based on issues of quality of care and/or services, the CC shall notify the practitioner of the proposed action prior to action being taken unless there is thought to be imminent harm to members. The notification will include an explanation of the reasons for the action. All letters will denote methods for the practitioner to request reconsideration of the adverse decision.

Notification to Authorities:
Per Arizona Health Care Cost Containment System, Chapter 900, Policy 950 if an adverse action is taken with a provider due to a quality of care concern or any known serious issues and/or quality deficiencies that result in a provider’s suspension or termination from CAZ network, CAZ must report the adverse action to the AHCCCS Clinical Quality Management Unit.

Per Arizona Department of Health Services Provider Manual Section 3.20/Additional Standards, any provider that is found to be on the Health and Human Services Office of Inspector General (HHS-OIG) list of Excluded Individual/Entities (LEIE) or the General Services Administration (GSA) Excluded Parties List Systems (EPLS) will be terminated without the right to appeal.

Any notification of termination is given to the practitioner prior to the termination date.

Clean File Review:
Clean file reviews take place during the weeks when there is no formal Credentialing Committee meeting. The CMO or designee has 48 hours to approve or deny the submitted provider files. Providers denied by the CMO or designee are submitted to the next Credentialing Committee for committee review. Providers that are approved by the CMO or designee are denoted as such in the Credentialing Database and a subsequent report is sent to CAZ Provider Data Management Department for loading or updating the practitioner’s participation information in Amisys. A list of the Clean File Approvals is also presented at the next scheduled Credentialing Committee.

Adverse Review/Exceeding Thresholds:
The CMO or designee can review all applications exceeding established thresholds and make determinations or choose to forward the file to the CC for review. Examples of thresholds limits are a provider having;

  • Malpractice claims history: greater than three (3) claims in a six (6) year period;
  • History of impairment (physical or mental);
  • When applicable, office site visit scores less than 85%;
  • Office site does not meet appointment availability standards;
  • Previous sanction activity within the past 6 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

Provisional Credentialing:
Occasionally, it is in the interest of members to allow practitioner availability in the network prior to completion of the entire initial credentialing process. CAZ 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. Providers that are in a Provisional status, that do not clear the Initial Credentialing requirements, will be terminated. For practitioners entering into a provisional status the following documents must be primary source verified;

  • Provider’s AHCCCS ID
  • Provider’s NPI
  • A current and signed CAZ Credentialing application. The signature date cannot be older than 150 days from date of receipt
  • CAZ Provider Demographic Form
  • Verification of a current, valid license to practice
  • Verification that the provider has not had more than 3 malpractice claims or settlements in the past 6 years. This information is primary sourced in the National Practitioner Data Bank (NPDB) query

The practitioner is not listed on the Health and Human Services Office of Inspector General (HHS-OIG) list of Excluded Individual/Entities (LEIE) or the General Services Administration (GSA) Excluded Parties List Systems (EPLS)

Primary Source Verification (PSV):
As part of the credentialing and re-credentialing application review process, primary and secondary verification is conducted in a manner consistent with the process required by State guidelines and internal guidelines. The following sources are used in the CAZ PSV process;

Site Visits:
Site Visits are not required in the case of an Initial or Re-credentialing cycle review. Cenpatico of Arizona Credentialing Specialist will ensure Hospitals and behavioral health Facilities meet the following credentialing guidelines in lieu of a credentialing Site Visit:

  • The provider is licensed/certified to operate in Arizona as applicable and is in compliance with any other applicable state or federal requirements. Providers that do not have an active license or certification with the appropriate state agency will not be allowed into the network.
  • If applicable the appropriate accrediting body certification is within 3 years of the credentialing cycle review. If the Organizational entity is not accredited;
  • A Center for Medicare and Medicaid Services (CMS) certification that illustrates the Organizational entity is complaint and the certification has been completed within 3 years of the current credentialing review. If a CMS certification has not been conducted;
  • An ADHS/DBHS Title XIX certification or state licensure review may stand as a substitute. In this case, the provider must provide a copy of the report to the contracted T/RBHA that verifies that a review was conducted and compliance was achieved

Credentialing Specialist Application Review Process:
The CAZ Credentialing staff will review and ensure each application and the supporting documents that have been submitted are complete and accurate. To denote their findings, each file has to contain the CAZ Credentialing Check List document. This document denotes the dates the PSV was conducted, the source of the PSV, which Credentialing Specialist conducted the review and whether or not the file is deemed a clean or an adverse file. All Credentialing documents are scanned in order and saved in a secured location. Additionally certain components from the credentialing application and PSV documents are keyed into the Credentialing Database. Applications that have been designated as a “Clean File” are denoted on a weekly report that is submitted to the CMO or designee for approval. Applications that have been designated as adverse or exceeding thresholds are also submitted to the CMO or Medical Director designee for review for a determination or referral to the CC.

Ongoing monitoring process between re-credentialing cycles:
The CAZ Credentialing Department monitors on a monthly basis

  • Practitioner Medicare/Medicaid sanctions
  • Limitations or sanctions on state licensure
  • Adverse events and complaints between re-credentialing cycles
  • The Providers AHCCCS verification

Reports are provided to the Credentialing Committee during scheduled intervals. The CMO or designee working with the CC will initiate appropriate corrective action for providers when occurrences of poor quality are identified. The CMO, designee or CC reviews sanctions during regularly scheduled meetings or via an Ad Hoc emergency meeting. For records that have been submitted to the CC, the Committee Members will be asked for their professional feedback and be given an opportunity to vote on whether or not the provider should be allowed continuation in the CAZ Network or be placed on administrative review or corrective action.

File Maintenance:
Individual confidential files containing credentialing information for each credentialed practitioner are maintained electronically. Access to these files is limited to authorized CAZ personnel only. Electronic records are maintained in the credentialing database and on a designated CAZ network drive. Access to this drive is limited to appropriate personnel using secure logons in the Windows NT security system. All practitioners, changes or updates are maintained in the Credentialing Database. Changes requiring updates to the provider’s demographic information are forwarded to the CAZ PDM department for entry into CAZ main Provider system Amisys.

Maintenance of Confidentiality:
Practitioner/Provider information reviewed by the Credentialing Specialist and CAZ CC is considered privileged and confidential. This information is maintained in a secure area and is accessible only to staff with a direct need to access this information. CAZ Staff receive appropriate training on protecting the confidentiality of protected information such as credentialing files. At least annually, CAZ Credentialing staff will sign a confidentiality agreement affirming that they will protect confidential data.

Practitioner/Provider Directory:
Cenpatico maintains an on-line directory and updates the online Provider Directory on a quarterly basis. The data is generated from Amisys Provider Data Management systems and the CAZ Credentialing Database. The Provider Data Management records housed in Amisys or the Credentialing Database are audited by the CAZ Data Analyst team at the request of the Credentialing Manager. The CAZ Credentialing Department runs monthly checks to ensure proper codeset alignments exist on participating providers. These codesets should align with variables that are denoted in the credentialing database such as Specialty and AHCCCS Provider Types.
Additionally the CAZ Credentialing Specialist will randomly check twenty (20) providers on the CAZ Provider Directory each quarter to ensure that the practitioner/provider information appearing in the directory aligns with the Credentialing Provider Data such as the practitioners’ names, degrees, specialty, locations and telephone numbers.