Dental Plan with Health Insurance Marketplace (HIM) 7.2

DPHIM-CR 15 - Recredentialing

Submited by: Tom Goddard

The Basics

This standard requires that your organization recredential every participating provider no less frequently than every three years.
The reason for the existence of this standard is that some credentials expire. For those that do, the organization must check to see that they are still valid. For those credentials that do not expire (e.g., education), re-verification is unnecessary. Therefore, this recredentialing process is not quite as complete as initial credentialing.
The 3-year credentialing cycle is to the month of the initial credentialing decision. 

Management Tips

Note that the recredentialing process requires that you present the application for recredentialing to the credentialing committee whether or not there are issues to discuss. However, you need not reverify those credentials that do not expire or change over time. An example of such credentials is education.
Note that several organizations opt to follow standard CR 3 d(ii) that allows a credentialing committee to delegate a senior clinical person in the organization such as the Medical Director, to approve files considered “clean” and therefore does not require peer review input to make a decision in between credentialing committee meetings. These “clean” files are later forwarded to the next possible credentialing committee meeting for a formal approval. This formal approval is the date by which the provider must be credentialed three years later.

Accreditation Tips

Desktop Review
Documentation at the desktop review phase should include both the credentialing plan, outlining the recredentialing process, and a sample of your credentialing committee minutes that includes approval of the recredentialing applications.
Validation Review
Document review
During the on-site review, compliance with this standard will be assessed as a part of the file review described in previous standards.
The onsite review will include an examination of credentialing committee minutes and an interview with credentialing department management and staff members.