Dental Plan with Health Insurance Marketplace (HIM) 7.2

DPHIM-CR 16 - Recredentialing and Participating Provider Quality Monitoring

Submited by: Tom Goddard

The Basics

This standard fleshes out the recredentialing requirement by requiring that your organization:

  • requires providers to submit an application updating any information that is subject to change;
  • verifies that information that is subject to change;
  • implements a process to collect and include in the recredentialing decision any information about the provider's performance, such as any information collected through the organization's quality management program.
Your organization's policies and procedures on recredentialing, which likely are in the credentialing plan, should spell out which elements need to be resubmitted in the recredentialing application and reverified. In addition, those policies should explain how the credentialing department interfaces with the quality management program to make sure that any data collected regarding the provider's performance is considered in the recredentialing decision.

Management Tips

The easy part of complying with this standard is deciding what elements are subject to change and need to be included in the recredentialing application and reverified. What is slightly more difficult is designing a process to make sure that the provider's track record over the last three years gets into the hands of the credentialing committee. Typically, this involves the credentialing department letting the quality management program know which participating providers are going through recredentialing and requesting from the QM program a report on any complaints, provider profiles, or other quality of care or quality of service information collected by the program about providers undergoing recredentialing review.
It is important that your organization not consider economic factors to be more important than quality of care factors in considering a provider for recredentialing. It is probably so important, in fact, that this should be described in the credentialing plan.

Accreditation Tips

Desktop Review
In addition to submitting the credentialing plan, your desktop review documentation should include sample provider profile reports or other information providing feedback about provider performance that might be considered in the recredentialing process. In addition, it is advisable to submit a sample of credentialing committee meeting minutes that demonstrate that such information is considered in the recredentialing process.
Validation Review
Document review
The onsite reviewer will verify compliance with this standard through both the previously-described file review and an examination of credentialing committee meeting minutes.
During the on-site review, the reviewer will interview credentialing management and staff regarding the requirements of the standard.

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