i. policy persons/departments ... - health essentials...

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

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.

jdunn

Stamp

Subject:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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:








Approved by:




2014


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

http://www.npdb-hipdb.hrsa.gov/welcomesq.html


http://www.npdb-hipdb.hrsa.gov/hipdb.html


http://www.fsmb.org/fcvs.html


http://oig.hhs.gov/fraud/exclusions/listofexcluded.html

Subject:








Approved by:




2014


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:








Approved by:




2014


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







Approved by:


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:








Approved by:

John Wong, MD

Credentialing Committee Chair

Revision Dates:


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:








Approved by:


Revision Dates:


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:








Approved by:

John Wong, MD


Revision Dates:


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






Approved by:

John Wong, MD



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


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


C. Credentialing



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








Approved by:

John Wong, MD



May 21, 2014


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:


i. NPDB

ii. HIPDB

iii. FSMB

iv. List of Excluded Individuals and Entities (maintained by the OIG)


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


i. Physicians

1. NPDB

2. HIPDB

3. FSMB

Subject:

Ongoing Monitoring








Approved by:

John Wong, MD



May 21, 2014


4. The appropriate state agencies

ii. Non-physician behavioral health care professionals


2. HIPDB

3. State licensure or certification board


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








Approved by:

John Wong, MD



May 21, 2014


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








Approved by:

John Wong, MD



May 21, 2014


V. DEFINITIONS

A. CMS


B. FSMB

Federation of State Medical Boards. http://www.fsmb.org/fcvs.html

C. NCQA


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)


F. Practitioner


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

http://www.mbc.ca.gov/

http://www.mbc.ca.gov/subscribers.html

http://www.mbc.ca.gov/subscribers.html

http://www.mbc.ca.gov/Publications/Disciplinary_Actions/

http://www.mbc.ca.gov/Publications/Disciplinary_Actions/

mailto:[email protected]

http://www.ombc.ca.gov/

http://www.ombc.ca.gov/consumers/enforce_action.shtml

http://www.ombc.ca.gov/consumers/enforce_action.shtml


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


PH: (916) 263-2647

Fax:(916) 263-2651

Email: [email protected]

Enforcement Program

Central File Room

Medical Board of California



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

http://www.abms.org/Who_We_Help/Professional_Organizations/pdf/DisplayAgentList.pdf





http://www.bpm.ca.govhttp/www.bpm.ca.gov/

http://www.bpm.ca.govhttp/www.bpm.ca.gov/

http://www.bpm.ca.gov/enforce/dispsumm.shtml

http://www.bpm.ca.gov/enforce/dispsumm.shtml


Board of Behavioral Sciences

1625 N Market Blvd., Suite S-200


PH: (916) 574-7830

Fax: (916) 574-8625

E-Mail:

[email protected]

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


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


[email protected]

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


disciplinary actions:

https://www.dca.ca.gov/webapps/p

sychboard/subscribe.php

Link to Consumer


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


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


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


http://www.bbs.ca.gov/

https://www.dca.ca.gov/webapps/bbs/subscribe.php

https://www.dca.ca.gov/webapps/bbs/subscribe.php


http://www.psychboard.ca.gov/

http://www.psychboard.ca.gov/consumers/actions.shtml

http://www.psychboard.ca.gov/consumers/actions.shtml

https://www.dca.ca.gov/webapps/psychboard/subscribe.php

https://www.dca.ca.gov/webapps/psychboard/subscribe.php

http://www.chiro.ca.gov/

http://www.chiro.ca.gov/

http://www.chiro.ca.gov/enforcement/actions.shtml





Acupuncture Board

1747 N. Market Blvd

Suite 180


PH: (916) 515-5200

Fax: (916) 928-2204


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



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



PH: (916) 263-2300

PH: (877)729-7789 Toll Free

Fax #: (916) 263-2140


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


http://www.acupuncture.ca.gov/

http://www.acupuncture.ca.gov/consumers/board_actions.shtml

http://www.acupuncture.ca.gov/consumers/board_actions.shtml

https://www.dca.ca.gov/webapps/acupuncture/subscribe.php

https://www.dca.ca.gov/webapps/acupuncture/subscribe.php


http://www.dbc.ca.gov/

http://www.dbc.ca.gov/consumers/hotsheets.shtml

http://www.dbc.ca.gov/consumers/hotsheets.shtml


Board of Occupational Therapy

2005 Evergreen St.

Suite 2050


PH: (916) 263-2294

Fax: (916) 263-2701

email: [email protected]

OT, OTA www.bot.ca.gov


Actions:

http://www.bot.ca.gov/consumers/

disciplinary_action.shtml



https://www.dca.ca.gov/webapps/b

ot/subscribe.php



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:

[email protected]

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


PH:(916) 575-7292

Consumer toll-free

(866) 585-2666

Fax (916) 575-7292


OD www.optometry.ca.gov


Actions:

http://www.optometry.ca.gov/cons

umers/disciplinary.shtml


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.


http://www.bot.ca.gov/

http://www.bot.ca.gov/consumers/disciplinary_action.shtml

http://www.bot.ca.gov/consumers/disciplinary_action.shtml

https://www.dca.ca.gov/webapps/bot/subscribe.php

https://www.dca.ca.gov/webapps/bot/subscribe.php



http://www.optometry.ca.gov/

http://www.optometry.ca.gov/consumers/disciplinary.shtml

http://www.optometry.ca.gov/consumers/disciplinary.shtml


Physical Therapy Board of

California

2005 Evergreen St.

Suite 1350


PH: (916) 561-8200

Fax: (916) 263-2560

PT www.ptb.ca.gov


Actions:

www.ptbc.ca.gov/consumers/enfor

cement/index.shtml



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


PH: (916) 561-8780

FAX(916) 263-2671


PA/PAC www.pac.ca.gov


Actions:

www.pac.ca.gov/forms_pubs/disci

plinaryactions.shtml

Link to Consumers


Link to Month within the year at

bottom of the page

Practitioners listed via month, then Alpha

Monthly

http://www.ptb.ca.gov/

http://www.ptbc.ca.gov/consumers/enforcement/index.shtml

http://www.ptbc.ca.gov/consumers/enforcement/index.shtml

https://www.dca.ca.gov/webapps/ptbc/interested_parties.php

https://www.dca.ca.gov/webapps/ptbc/interested_parties.php


http://www.pac.ca.gov/

http://www.pac.ca.gov/forms_pubs/disciplinaryactions.shtml

http://www.pac.ca.gov/forms_pubs/disciplinaryactions.shtml


CA Board of Registered Nursing

1747 North Market Blvd,

Suite 150


Mailing Address:

Board of Registered Nursing

P.O. Box 944210


Phone: (916) 322-3350

FAX (916) 574-7693.

Email:

[email protected]

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


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



Email:

[email protected]

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.


http://www.rn.ca.gov/

http://www.rn.ca.gov/enforcement/dispaction.shtml#actions

http://www.rn.ca.gov/enforcement/dispaction.shtml#actions


http://www.speechandhearing.ca.gov/

http://www.speechandhearing.ca.gov/

http://www.speechandhearing.ca.gov/consumers/enforcement.shtml

http://www.speechandhearing.ca.gov/consumers/enforcement.shtml


DEA Office of Diversion Control

800-882-9539

[email protected]

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


.

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


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


.

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)

mailto:[email protected]?subject=Diversion%20Web%20Site

http://www.deadiversion.usdoj.gov/

https://www.deadiversion.usdoj.gov/webforms/validateLogin.jsp

https://www.deadiversion.usdoj.gov/webforms/validateLogin.jsp




http://www.nursys.com/

https://www.nursys.com/EN/ENDefault.aspx

https://www.nursys.com/EN/ENDefault.aspx


http://www.oig.hhs.gov/

http://exclusions.oig.hhs.gov/

http://www.oig.hhs.gov/fraud/exclusions/exclusions_list.asp

http://www.oig.hhs.gov/fraud/exclusions/exclusions_list.asp

http://service.govdelivery.com/service/multi_subscribe.html?code=USHHS&custom_id=2042


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

https://med.noridianmedicare.com/web/jea


https://med.noridianmedicare.com/web/jeb

https://med.noridianmedicare.com/web/jeb



https://med.noridianmedicare.com/web/jea/contact/mailing-addresses

https://med.noridianmedicare.com/web/jea/contact/mailing-addresses

https://www.noridianmedicare.com/parta/


https://www.noridianmedicare.com/dme/

https://www.dmepdac.com/

http://www.sam.gov/


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

http://www.medi-cal.ca.gov/

http://files.medi-cal.ca.gov/pubsdoco/bulletins_menu.asp






http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspa_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspc_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/bulletins/docs/susplist_20110101.doc

http://files.medi-cal.ca.gov/pubsdoco/manual/man_query.asp?wSearch=%28%23filename+%2A%5F%2Az03%2A%2E%2A%29&wFLogo=Suspended+and+Ineligible+Provider+List&wFLogoH=32&wFLogoW=418&wAlt=Suspended+and+Ineligible+Provider+List&wPath=pubsdoco%2Fpublications%2Fmasters%2DMTP%2FzOnlineOnly%2Fsusp100%2D49%5Fz03%2F&prevP=search



http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspa_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspc_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspf_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspo_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspp_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspr_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/susps_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspt_z03.doc

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/zonlineonly/susp100-49_z03/suspu_z03.doc


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.

http://www.alirts.oshpd.ca.gov/Default.aspx

http://www.alirts.oshpd.ca.gov/Default.aspx

http://www.alirts.oshpd.ca.gov/LFIS/LFISHome.aspx


http://www.dhs.ca.gov/LNC/default.htm


http://www.alirts.oshpd.ca.gov/default.aspx

http://www.alirts.oshpd.ca.gov/AdvSearch.aspx


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

[email protected]

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.

https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do

https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do

https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=ind

https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=ind

https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=org

https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=org

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

http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/partl201304.asp

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

[[email protected]]

Wednesday, May 01, 2013 5:05 PM


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.




http://www.mbc.ca/

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.


[search •

http://www/

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


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


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


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


Rubinoff, Craig Henry, DDS 35327


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







Approved by:


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


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:








Approved by:


Revision Dates:


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:








Approved by:


Revision Dates:


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:








Approved by:


Revision Dates:


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:








Approved by:


Revision Dates:


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


E. Credentialing Verification Organization (CVO)

An independent contractor who performs primary source verification for the

Credentialing process on a delegated basis

F. NCQA



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:








Approved by:


Revision Dates:


A practitioner, institution, or organization that provides services for

HealthEssentials or its designee

VI. SOURCES

A. Standards set by NCQA effective July 1, 2014


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



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



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





Supporting Documents: Y N X


Approved by:



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.




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

https://med.noridianmedicare.com/web/jeb/enrollment/opt-out/opt-out-listing;jsessionid=078F02847E21225DDB41EBEAB6CD7FA0

https://med.noridianmedicare.com/web/jeb/enrollment/opt-out/opt-out-listing;jsessionid=078F02847E21225DDB41EBEAB6CD7FA0

Subject:








Approved by:

John Wong, MD



May 21, 2014


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


B. Credentialing Verification Organization (CVO)

An independent contractor who performs primary source verification for the

Credentialing process on a delegated basis

C. NCQA



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:








Approved by:



May 21, 2014


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



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


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)


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


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


Reviewer and date

Medi-Cal Hotlines

Border Providers (916) 636-1200

Source

Reviewer and date of review

http://files.medi-cal.ca.gov/pubsdoco/bulletins/artfull/partl201304.asp

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

[[email protected]]

Wednesday, May 01, 2013 5:05 PM


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.




http://www.mbc.ca/

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.


[search •

http://www/

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


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


Javahery, Simin, 47104


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


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


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


Rubinoff, Craig Henry, DDS 35327


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






Approved by:



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




C. Credentialing Department



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:







Approved by:

John Wong, MD


Revision Dates:


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:







Approved by:




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



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



VIII.ATTACHMENTS

None

Subject:

Credentialing Administrative Terminations







Approved by:


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





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:








Approved by:

John Wong, MD


Revision Dates:


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:








Approved by:


Revision Dates:


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


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


VII.ATTACHMENTS

None

Subject:

Credentialing Quality Improvement (QI) File

Audit Policy and Procedure



Number of Pages: 2 pages Supporting Documents: Y X N


Approved by:


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.


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





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


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:

___________


___________


___________

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





Approved by:


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.




C. Credentialing


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:







Approved by:

John Wong, MD Credentialing Committee Chair

Revision Dates:


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:







Approved by:


Revision Dates:


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:







Approved by:


Revision Dates:


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


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


C. HIPAA 1996


VIII.ATTACHMENTS

A. Conflict of Interest Statement

B. Confidentiality Statement

Subject:

Credentialing Practitioner Changes







Approved by:


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.




C. Credentialing


E. Administration


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







Approved by:

John Wong, MD


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







Approved by:


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.




C. Credentialing




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:









Approved by:

John Wong, MD


Revision Dates:


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:


i. NPDB

ii. HIPDB

iii. FSMB

iv. List of Excluded Individuals and Entities (maintained by the OIG)


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


i. Physicians

1. NPDB

Subject:









Approved by:


Revision Dates:


2. HIPDB

3. FSMB


ii. Non-physician behavioral health care professionals


2. HIPDB

3. State licensure or certification board


i. Shall evaluate both specific complaints and the practitioner’s history

of issues.

ii. Significant specific complaints or trends shall be monitored at least


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:









Approved by:

John Wong, MD


Revision Dates:


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


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:









Approved by:


Revision Dates:


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)


E. CMS


F. NCQA



G. Practitioner


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:









Approved by:

John Wong, MD


Revision Dates:


VI. SOURCES





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






Approved by:


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.




C. Credentialing



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:








Approved by:

John Wong, MD


Revision Dates:

Confidential


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:








Approved by:


Revision Dates:

Confidential


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:








Approved by:

John Wong, MD


Revision Dates:

Confidential


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



C. California Business and Professional Codes 805 and 809





D. CR 08 Administrative Terminations policy and procedure


F. CR 17 Fair Hearing policy and procedure

Subject:

Credentialing Office (or facility) Site Visit Policy and Procedure





Approved by:


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




C. Practitioner Applicants

D. Credentialing


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:






Approved by:







ABMULATORY SETTING


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:






Approved by:







ABMULATORY SETTING


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:






Approved by:







ABMULATORY SETTING


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:






Approved by:







ABMULATORY SETTING


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


Practitioner A clinical professional who provides health care services.


care

VI. SOURCES


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


C. CR 12 Sanctions, Complaints and Quality Issues Monitoring

Subject:

Credentialing Organizational Providers (Facilities)






Original Date of Issue: Not Applicable

Approved by:


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:








Approved by:

XXXX XXXXX, MD


Revision Dates:




surveys


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

http://www.jointcommission.org/

Subject:








Approved by:


Revision Dates:




surveys


American Osteopathic Association (AOA)


of the provider

- website: http://www.osteopathic.org/index.cfm?PageID=findado_main

Community Health Accreditation Program (CHAP)


of the provider

- website: http://www.chapinc.org

Commission on Accreditation or Rehabilitation Facilities (CARF)


of the provider

- website: http://www.carf.org

Continuing Care Accreditation Commission (CCAC) (this is part of CARF)


of the provider

- website: http://www.carf.org

Accreditation Association for Ambulatory Health Care (AAAHC)


of the provider

- website: http://www.aaahc.org

American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF)


of the provider

- website: http://www.aaaasf.org

COLA


of the provider

- website: http://www.cola.org/search_lab.html

CLIA

http://www.osteopathic.org/index.cfm?PageID=findado_main

http://www.chapinc.org/

http://www.carf.org/

http://www.carf.org/

http://www.aaahc.org/

http://www.aaaasf.org/

http://www.cola.org/search_lab.html

Subject:








Approved by:

XXXX XXXXX, MD


Revision Dates:




surveys



of the provider

- website: http://wwwn.cdc.gov/clia/oscar.aspx

CAP


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

http://wwwn.cdc.gov/clia/oscar.aspx

http://www.cap.org/apps/cap.portal?_nfpb=true&_pageLabel=accreditation

Subject:








Approved by:


Revision Dates:




surveys


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:








Approved by:

XXXX XXXXX, MD


Revision Dates:




surveys


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



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


Approved by:



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


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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


(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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


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:




Approved by:



May 21, 2014, July 18, 2014, October 10, 2014


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




care

D. NPDB National Practitioner Data Bank VI. SOURCES


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



D. CR 08 Administrative Terminations policy and procedure

