Health Plan (7.4) 7.4

P-CR 5 - Credentialing Application

Submited by: Tom Goddard

The Basics

This standard describes, in some detail, the requirements for the credentialing application that every practitioner must complete in order to seek admission to your organization's provider network. Note that this applies only to practitioners, not facilities.
The requirements include:

  • educational and professional training history (including Board certification status);
  • an up-to-date history of all licensure; 
  • documentation of current controlled dangerous substance certificates, federal (DEA) or state;
  • documentation of liability insurance;
  • liability claims history;
  • sanctions history;
  • professional disciplinary history (including state boards and Medicare/Medicaid);
  • hospital privileges;
  • any issues that could impede the petitioner's ability to provide quality health care (including disability or substance abuse);
  • an attestation that the application is complete and accurate;
  • a statement authorizing your organization to collect verifying information (signed and dated).
Again, this standard applies only to practitioners, that is, the individuals who provide health care services within your network. The organization has more flexibility about how to design any application for facilities, such as hospitals, skilled nursing facilities, etc.

Management Tips

If your organization uses one of the many standard credentialing applications used across the United States, make sure that it complies completely with the standard. If it does not, you may need to develop an amendment to collect the information not in that application that is required by this standard. However, if your organization uses the most current universal credentialing application developed by the Council for Affordable Quality Healthcare (CAQH), that application will comply with the standard.
Electronic signatures will suffice for purposes of this standard.
Make sure that your application requires at least five years of licensure and privilege history from the practitioner.
If you collect a liability insurance cover sheet from your practitioners, make sure that it includes the name of the practitioner, the policy's expiration date, and the liability coverage. The policy must be current when the practitioner is presented to the credentialing committee. Note that a provider's attestation is not sufficient documentation of liability insurance, nor is the mere provision of the insurer's name, policy number, amount of coverage, and expiration date. So, if you don't have a DEC sheet, you'd better get an attestation from the insurer. If the cover sheet doesn't have the name of the insured, you have two alternatives:

  • obtain a copy of those covered under the plan on a sheet that includes the insurer’s letterhead, or
  • make sure the the policy states the types of health care practitioners covered by the policy, such as “employed health care practitioners” or “contracted health care practitioners” who are employed or contracted with the entity covered by the policy.

Accreditation Tips

Desktop Review
For the desktop review, all you need to present is your credentialing plan (describing the application requirement) and a sample template of your application.
Validation Review
Document Review
Compliance with the standard will be checked during the on-site review as the reviewer goes through the three dozen or so initial credentialing and recredentialing files that he or she will pull at random, selected from your provider directory.

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