Policy/Procedure Number: MP CR 5 / Lead Department: Provider Relations
Policy/Procedure Title: Review Standards for Credentials, Re-credential Process / ☒External Policy
☐ Internal Policy
Original Date: 11/01/1998 / Next Review Date:
Last Review Date: 08/09/2017
Applies to: / ☒ Medi-Cal / ☐ Employees

Policy/Procedure Number: MP CR 5 / Lead Department: Provider Relations
Policy/Procedure Title:Review Standards for Credentials, Re-credential Process / ☒External Policy
☐Internal Policy
Original Date: 11/01/1998 / Next Review Date:
Last Review Date: 06/13/2018
Applies to: / ☒Medi-Cal / ☐ Employees
Reviewing Entities: / ☒ IQI / ☐ P & T / ☐ QUAC
☐OPerations / ☐Executive / ☐Compliance / ☐Department
Approving Entities: / ☐BOARD / ☐COMPLIANCE / ☐FINANCE / ☐ PAC
☐ CEO / ☐COO / ☒Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Marshall Kubota, MD / Archived Date:06/30/2018
  1. RELATED POLICIES:N/A
  1. IMPACTED DEPTS:
  2. Provider Relations
  1. DEFINITIONS:N/A
  1. ATTACHMENTS: N/A
  1. PURPOSE:
  1. POLICY / PROCEDURE:Each practitioner’s credentialing file is reviewed by the PHC Provider Relations Department for accuracy based on Credentialing Criteria prior to presentation to the PHC Credentialing Committee. Any file identified with exceptions or potential exceptions is referred to the Chief Medical Officer or designee. Subsequently the Credentialing Committee reviews each file.
    Credentialing files are forwarded to the PHC Chief Medical Officer or designee for review if any one of the following issues are identified:
  2. Any denial, limitation, restriction, suspension, revocation, forfeiture of, or subject to probationary condition, disciplinary action, or voluntarily or involuntary relinquishment, or such pending action, of practitioner’s:
  3. State License
  4. DEA Registration
  5. Hospital Clinical Privileges
  6. Professional Organization Membership
  7. PHC will confirm the practitioner is free of sanctions by conducting a query on the following sites:
  8. Medicare/Medicaid Sanction Verification using website of Office of Inspector General (OIG), and the
  9. Medi-Cal Suspended and Ineligible Report Verification website, and the
  10. NoridianMedicare Opt-Out websites for both Northern and Southern regions website, and the
  11. System for Award Management (SAM) website, and the.
  12. National Practitioner Data Bank (NPDB).
  13. A query and documentation is obtained from the NPDB to address malpractice history.
  14. Any YES response on the Practitioner Application Attestation Questionnaire, A-K.
  15. Any NO response on the Practitioner Application Attestation Questionnaire, L.
  16. Any YES response on the CAQH Application Attestation Questionnaire 1-26.
  17. Any cases found through inquiry of the NPDB/HIPDB not reviewed during a previous credentialing cycle.
  18. Refusal to comply with a Corrective Action Plan based on a facility site or medical chart audit, or non-compliance with Peer Review Committee recommendations.
  19. Practitioner appears on the Medi-Cal Sanction Report, lists of parties Excluded from Federal Procurement and Non Procurement Program, Medi-Cal Participation Exclusion Report, the Medical Board Hot Sheet Report and Medicare Opt Out Report.
  20. Member complaints exceed threshold.
  21. Relevant practitioner-specific data as compared to aggregate data, when provided by the Over/Under Utilization Workgroup (as defined in MPUP3006).
  1. REFERENCES:
  2. NCQA
  1. DISTRIBUTION:PHC Provider Manual
  1. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:Credentialing Supervisor
  1. REVISION DATES:

2/1/2000, 8/8/2001, 2/13/2002, 4/10/2002, 3/12/2003, 3/10/2004, 2/9/2005, 7/13/2005, 7/12/2006, 7/11/2007, 7/9/2008, 7/8/2009, 7/14/2010, 7/13/2011, 8/8/2012, 9/11/2013, 8/13/2014, 8/12/2015, 08/10/2016, 08/09/2017, 06/13/2018

PREVIOUSLY APPLIED TO:

N/A

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