DCS Comprehensive Health Plan

Individual Provider and Group Credentialing

Statement/Purpose

The Department of Child Safety Comprehensive Health Plan (DCS CHP) ensures that members have access to contracted network providers who are credentialed, recredentialed and reviewed.

Definitions

Arizona Association of Health Plans (AzAHP): AzAHP is an organization dedicated to working with elected officials, AHCCCS Health Care Plans, health care providers, and consumers to keep quality health care available and affordable for all Arizonans. AzAHP is involved in administration of the chart audit process for physical health plan sites and they collaborate with the Contractors with regard to the behavioral health chart audit process.

Credentialing Verification Organization (CVO): is responsible for receiving completed applications, attestations and primary source verification documents.

National Committee Quality Assurance (NCQA): is a private, 501 (c)(3) not-for profit organization dedicated to improving health care quality.

Primary Source Verification (PSV): The verification directly with an educational, accrediting, licensing, or other entity that the information provided by the provider applicant is correct and current.

Provider: A person, institution, or group engaged in the delivery of services, or ordering and referring those services, who has an agreement with AHCCCS to provide services to AHCCCS members.

Policy

DCS CHP contracts with a Managed Care Organization (MCO) to maintain a network of credentialed individual and organizational health care providers to provide members with access to quality care. The contracted MCO is required to credential and recredential individual and organizational providers in compliance with federal and state guidelines.

The contracted MCO utilizes the Arizona Health Plan Association Credentialing Verification Organization (CVO) to ensure all primary source verification completion, as part of its credentialing and re-credentialing process.

DCS CHP requires compliance with Federal requirements that prohibit employment or contracts with providers excluded from participation under either Medicare or Medicaid, or that employ individuals or entities that are excluded from participation [42 CFR 438.214(d)].

DCS CHP requires that its contracted MCO comply with the National Committee for Quality Assurance (NCQA) Standards for Credentialing.

Procedure

DCS CHP requires the contracted MCO to:

• Demonstrate that its providers are reviewed and credentialed through the Credentialing Committee [42 CFR 457.1230(a), 42 CFR 438.206(b)(6)], which is chaired by the CMO.

• Comply with AMPM Chapter 900 and Section F, Attachment F3, Contractor Chart of Deliverables for related reporting requirements.

• Comply with the National Committee for Quality Assurance (NCQA) Standards Credentialing Standards CR1 thru CR8.

• Maintain documentation of temporary/provisional credentialing, initial credentialing, and recredentialing for individual and organizational providers who have signed contracts or participation agreements of those who meet the requirement of AMPM Policy 950 [42 CFR 438.206(b)(1)-(2)] within the MCO Network

• Conduct credentialing processes that do not discriminate based on the provider applicant’s race, ethnic/national identity, gender, age, sexual orientation, or types of patients that the provider specializes in treating.

• Avoid discrimination against providers that serve high-risk populations or specialize in conditions that require costly treatment.

• Comply with federal requirements prohibiting the employment of, or contract with, providers excluded from participation in federal health care programs [42 CFR 457.1233(a), 42 CFR 438.214].

• Implement a well-defined credentialing process to maintain an adequate network of providers and organizational health care providers to provide care to DCS CHP members.

• Maintain confidential and secured initial and recredentialing provider credentialing files and related documents.

• Complete the credentialing and recredentialing process in its entirety within the required timeframes and directives established under AMPM 950.

• Comply with the rights of the applying provider as outlined in AMPM 950, to be able to view their credentialing application, correct erroneous information and receive notification on the status of their application on request.

• Include data, QOC concerns, grievances, performance measure rates, value-based purchasing results, and level of member satisfaction (as specified in the AMPM), to complete the credentialing or recredentialing files that are brought to the Credentialing Committee for a decision.

• Ensure ongoing monitoring of occurrences which may jeopardize the validity of the credentialing process at least annually and when needed.

The contracted MCO’s Chief Medical Officer (CMO) or designee oversees the credentialing process, implements the decisions made by the Credentialing Committee and acts as chair of the Credentialing Committee. DCS CHP’s CMO or designee participate on the Credentialing Committee as deemed appropriate for participation in the credentialing process specific to the DCS CHP population’s providers.

Credentialing

DCS CHP requires its contracted MCO to credential and recredential individual and organizational providers in compliance with federal and state guidelines, as outlined in AMPM 950.

Primary Source Verification

The CVO conducts primary source verification and submits files to the MCO. All new and re- credentialed providers are reviewed on a three (3) year rolling schedule as is determined by AzAHP in coordination with all the AHCCCS MCO’s to reduce provider burden.

Primary Source Verification (PSV) includes but is not limited to verification of active, unrestricted professional licenses; review for any license restrictions, disciplinary status, sanctions or license limitations; documentation of graduation from an accredited school and completion of required internship, residency or other post graduate training; board certification; continuing education requirements; work history; professional liability insurance, liability claims, judgments or settlements; and Medicare/Medicaid sanctions, exclusions or terminations for cause; through interrogation of Drug Enforcement Administration (DEA), National Practitioner Database (NPDB), Health and Human Services Office of Inspector General’s List of Excluded Individuals/Entities (LEIE), US General Services Administration, the appropriate Licensing Boards and other applicable sources.

The AzAHP performs an annual credentialing file and PSV audit of the CVO for the purpose of providing oversight, and to determine compliance with the delegated agreement/contract and NCQA standards.

Credentialing Requirements

The contracted MCO is responsible for meeting the requirements for credentialing and recredentialing as outlined in AMPM 950. This includes the provider submission/application through the AzAHP CVO for primary source verification of the credentialing process, review of any accommodations needed, legal history, disciplinary actions, malpractice coverage, work history and DEA and other license requirements, as well as professional liability claims, disciplinary status with any regulatory board or agency and any state Medicare/Medicaid sanctions, limitations of licenses, exclusions or terminations for cause.

DCS CHP requires credentialing and re-credentialing for the following provider types as outlined in AMPM 950:

• Physicians (Medical Doctor (MD),

• Doctor of Osteopathic Medicine (DO),

• Doctor of Podiatric Medicine (DPM),

• Nurse Practitioners (NP),

• Physician Assistants (PA),

• Certified Nurse Midwives acting as primary care providers, including prenatal care/delivering providers,

• Dental Providers (Doctor of Dental Surgery [DDS] and Doctor of Medical Dentistry [DMD]),

• Affiliated Practice Dental Hygienists,

• Psychologists,

• Optometrists,

• Certified Registered Nurse Anesthetists,

• Occupational Therapists,

• Speech and Language Pathologists,

• Physical Therapists,

• Independent behavioral health professionals, including;

  • Licensed Clinical Social Worker (LCSW),

  • Licensed Professional Counselor (LPC),

  • Licensed Marriage/Family Therapist (LMFT),

  • Licensed Independent Substance Abuse Counselor (LISAC), and

  • Clinical Nurse Specialist.

• Board Certified Behavioral Analysts (BCBAs),

• Naturopaths (Naturopathic Doctor (ND) or Naturopathic Medical Doctor (NMD)

• Any non-contracted provider that is rendering services and sees 50 or more of the Contractor’s members per contract year, and

• Covering or substitute oral health providers that provide care and services to members while providing coverage or acting as a substitute during an absence of the contracted provider. Covering or substitute oral health providers must indicate on the claim form that they are the rendering provider of the care or service.

Credentialing of Independent Masters level Behavioral Licensed Professionals and Licensed BCBA must meet the credentialing, supervision and continuing education requirements outlined in AMPM 950.

Affiliated practice dental hygienists must provide documentation of the affiliation with an AHCCCS registered dentist.

All providers must complete the individual credentialing and re-credentialing process through the AzAHP Alliance process.

The contracted MCO is responsible for the conduction of site visits for practitioners and facilities that require a site visit as part of initial credentialing, recredentialing and quality functions as outlined in AMPM 910, Attachment A. Site visits are conducted to verify provider office and medical/treatment record documentation, dissemination and storage practices meet established standards; vaccine and medication storage, emergency/resuscitation equipment and policies, comply with ADA standards; and adequacy of physical access, reasonable accommodations and accessible equipment for patients with physical and mental disabilities.

If a site visit is performed by another participating plan in the AzAHP and it is logged with the Council for Affordable Quality Healthcare (CAQH), another site visit is not necessary unless issues concerning non-compliance or quality are identified. In the event that an issue concerning non-compliance or quality is identified, DCS CHP and/or its contracted MCO may conduct a provider visit for review. The results are prepared to inform the credentialing process as necessary.

Delegated Entities

As part of the credentialing responsibilities on behalf of DCS CHP, the contracted MCO may delegate the credentialing responsibility to an external agency. In the event that this function is delegated, DCS CHP retains the right to approve, suspend or terminate any provider that meets the criteria of AMPM 950.

The DCS CHP CMO is ultimately responsible for the oversight of any delegated credentialing function. DCS CHP and its contracted MCO outlines permitted delegated functions.

Healthcare Professionals in a delegated entity are subject to the same credentialing standards and monitoring requirements as other providers.

The contracted MCO is required to review delegated entities credentialing procedures and policies to ensure adherence to the credentialing standards outlined in AMPM 950.

All providers must complete the individual credentialing and re-credentialing process through the AzAHP Alliance.

Provisional/Temporary Credentialing

The contracted MCO is required to meet AMPM 950 requirements for provisional/temporary credentialing in order to meet the needs of DCS CHP members, and to allow for the provision of care prior to the completion of the entire credentialing process.

This includes providers in the following groups even if they have not specifically requested their application be processed as temporary/provisional:

• Federally Qualified Health Center (FQHC) providers.

• FQHC look –alike providers.

• Rural Health Clinics.

• Hospital Employed physicians when appropriate.

• Providers needed in rural or urban medically underserved areas.

• Providers joining an existing and contracted oral health provider group.

• Covering/substitute providers who are covering a contracted providers absence.

• Providers eligible under the Substance Abuse and Mental Health Services Administration (SAMHSA) Certified Opioid Treatment Programs (OTPs) as specified in 42 CFR 8.11.

• Providers as directed by AHCCCS during federal and/or state-declared emergencies where delivery systems are, or have the potential to be, disrupted.

The contracted MCO is responsible for verifying the status of Locum Tenens providers with the Arizona Licensing Boards and national databases.

The contracted MCO reviews the requirements for provisional/temporary credentialing as outlined in AMPM 950, which include provider submission of a completed attestation of the correctness and completeness of the application, any accommodations needed, legal history, disciplinary actions, malpractice coverage, five year work history and DEA and other license requirements, as well as professional liability claims, disciplinary status with any regulatory board or agency and any state Medicare/Medicaid sanctions, limitations of licenses, exclusions or terminations for cause.

Following approval for provisional/temporary credentialing, the entire initial credentialing process must be completed.

Organizational Credentialing and Re-credentialing

The contracted MCO is required to conduct organizational credentialing and recredentialing.

The purpose of organizational credentialing is to confirm that organizational providers have maintained accreditation, are compliant with state and federal regulatory bodies, license requirements and review accreditation or certification by a nationally recognized accreditation body certified by the Centers for Medicare and Medicaid Services (CMS), or review, including on site quality assessment of providers who do not have certification, accreditation or licensing, on a routine basis to determine that they remain in good standing and are providing appropriate care.

CMS accreditation certification or state licensure review/audit may be submitted in lieu of the required site visit as long as the site visit was within three years prior to the credentialing date. The contracted MCO is required to verify the review/audit occurred and was approved by the appropriate accrediting body as specified by CMS or the state licensing agency.

Recredentialing of organizational providers is conducted every three years, and verifies that the provider remains in good standing with State and Federal entities, including licensure and accreditation or on-site quality review if not accredited, to review most current ADHS review and audits, supervision of staff and required documentation of direct supervision, verification of staff credentialing. Recredentialing activities may also incorporate provider specific grievances, utilization management data, Performance improvement QOC issues and any adverse actions as applicable.

Peer Review

The Peer Review Committee makes recommendations regarding credentialing and re-credentialing of providers See DCS CHP Policy HS-QM-05 Peer Review.

Peer Review is the final process in the credentialing process for all files.

Notification and Outreach to Providers

The contracted MCO provides notifications and outreach to providers as needed for credentialing, recredentialing efforts and determinations.

DCS CHP and its contracted MCO does not discriminate against providers solely on the basis of license or certification and, likewise, does not discriminate against providers serving high-risk populations or specializing in the treatment of costly conditions [42 CFR 438.214(c)].

Practitioners have the right to review and correct information that was evaluated on their credentialing application, attestation, or Curriculum Vitae (CV).

Monitoring and Reporting

DCS CHP conducts oversight activities of the contracted MCO credentialing activities and timeliness.

DCS CHP CMO participates in the MCO peer review process and has responsibility for oversight of the credentialing and re-credentialing activities.

Oversight activities review:

• Provisional, initial, organizational, and recredentialing processes, requirements and timeliness.

  • Conduct an annual OR audit of the credentialing process.

  • Utilization of standardized monitoring tools by provider type, as required by AHCCCS

  • Review the incorporation of IADs, QOCs, CAPs, on site reviews, Specific Services/Service Site Monitoring and other quality provider quality indicators into contracted MCO’s credentialing and re-credentialing process.

• Peer Review processes.

DCS CHP requires the most recent accreditation review to conduct oversight activities. DCS CHP maintains and secures provider credentialing documents provided by the MCO.

DCS CHP reviews all MCO reports regarding credentialing. DCS CHP reports to AHCCCS, reviewed and approved deliverables as outlined in the AMPM 950.

DCS CHP’s Quality function area provides oversight of the MCO’s credentialing process, which includes monitoring, auditing and attending the Credentialing Committee, as deemed appropriate.