Health Network 7.1

N-CR 11 - Credentialing Application Review

Submited by: Tom Goddard

The Basics

This standard requires that, before a provider is designated as a participating provider and included in the provider directory, your organization first review the application and approve that application.
There are two ways you organization may approve an application to become a participating provider. First, your credentialing committee could vote to approve it. Second, if it is a "clean" application, your senior clinical staff person may approve the application.
There is one exception to this requirement, that is, if, for clinical reasons, there is a compelling reason to grant "provisional" dissipation to a provider, your senior clinical staff person may grant such an approval. This usually comes up in connection with the need to provide continuity of care to a patient. In such a case, your organization should move that provider's credentialing process forward as quickly as possible.

Management Tips

Among the most important things to assure as a manager of the provider credentialing process is that no providers end up in the provider directory who have not been through your organization's credentialing process. It is difficult to imagine an organization receiving full accreditation if it allows providers who have not been through the credentialing process to be listed in the provider directory.
The reviewer is looking in your credentialing plan for an explanation that, once a file is approved, credentialing triggers the provider to an active status. That action may inform the contracting department to add the provider to the directory or, simply to change the status so that such activities can occur to activate the provider. In addition, many credentialing plans or policies begin with language that state no provider can be activated in the organization until he/she has completed the credentialing process and therefore has been approved to participate in the network.

Accreditation Tips

Desktop Review
Submit the credentialing plan, which should be explicit in providing that no provider shall be considered to be a participating provider who has not gone through the credentialing process.
Validation Review
The on-site review will focus on interviews with clinical leadership and credentialing staff.
Document Review
The URAC reviewer will conduct a review of credentialing committee meeting minutes over the last four years.

  • Core 4.0 / 06.20.2018

    C-RM 1-2: Policy Addressing Reporting of Violations

    This standard requires your organization’s compliance policies to:Protect individuals reporting violations of ethical, regulatory, or legal requirements;Address the consequences of failing to report violations; andProtect the confidentiality of anyone reporting violations.

  • Core 4.0 / 06.18.2018

    C-RM 1-1: Regulatory Compliance and Internal Controls

    This standard, which bears a strong resemblance to Core 4 in the previous versions of Core, describes the fundamental aspects of an effective compliance program:Tracking applicable laws and regulations. This is an ongoing process of tracking existing laws and regulations and keeping up with changes in those laws and regulations. So, you need to identify -- in a clear and specific policy and proced...

  • Core 4.0 / 06.18.2018

    C-CPE 2-3: Monitoring and Oversight of Ethical Healthcare Practices

    Once an organization has defined ethical practices, as required by the previous standard, it must implement mechanisms to monitor for violations of its ethical standards and address those violations. Such mechanisms must spell out how it:Identifies appropriate authorities to remediate particular situations involving ethical transgressions;Will take action in the event of ethical issues; andWill re...