The Basics

This standard requires that your organization have an ongoing process to assure that your participating providers continue to comply with your criteria for participating in your network.  In addition, your organization must have mechanisms to respond to situations where you learn that a provider ceases to comply with those criteria.  A good example of such a circumstance would be if the provider has his or her license revoked or suspended.

The expectation here is that your organization continuously examine reports published by federal and state agencies (like the HHS Office of the Inspector General), as well as the National Practitioner Data Bank (NPDB).

Management Tips

Not only should you have a process in place that accomplishes this ongoing monitoring, your credentialing plan should clearly describe that process.  Many organizations have designated staff members who periodically go through all of the applicable state and federal reports.  Your credentialing plan or policies and seizures should describe that process clearly and in detail.

URAC Accreditation Tips

Both elements of this standard are mandatory.

The documentation you should submit for desktop review should include both the credentialing plan and any summary reports that demonstrate that you conduct ongoing monitoring of provider compliance with your credentialing criteria.  Examples of such reports include any reports published by your state licensing board or the HHS office of the Inspector General.

During the on-site review, in addition to the credentialing file review, the reviewer will interview your staff members responsible for ongoing monitoring and examine reports in which you have found that providers in your network have had their licenses suspended or revoked.