Health Plan (7.4) 7.4

P-CR 7 - Review of Credentialing Information

Submited by: Tom Goddard

The Basics

The standard requires that your organization implement a mechanism by which you check the accuracy and completeness of your provider applications before you submit them for approval by the Credentialing Committee.
Your organization's policy and procedure or credentialing plan should contain a detailed description of this process, so be sure you are familiar with that. The process is likely to involve having a member of the staff who did not initially collect the credentialing information from the applying provider to check off the file for completeness, and then sign off on it.

Management Tips

The preferred approach to this requirement is to have a member of the credentialing staff who was not involved in the initial collection of information to review the file. This review is typically facilitated by a cover sheet for the file that contains all of the required elements for the file and a place for initial staff member to verify that each required element is present. In addition, that cover sheet should provide a place for the reviewer to document that he or she has reviewed the file and found it to be complete. Remember, URAC takes the perspective that it has not happened if it has not been documented.
You may also want to consider implementing a quality assurance process. Many organizations take a percentage of credentialing files (e.g. 25%) and have a staff member who was not involved in either the initial collection or the pre-committee review to examine the files for completeness. Remember, if you implement such a procedure, document it.

Accreditation Tips

Desktop Review
At the desktop review phase, it will suffice to present your credentialing plan and a sample of the checklist or on a form used to assure completeness of credentialing files.
Validation Review
Document Review
During the on-site review, the reviewer will check your compliance with the standard during the audit of three dozen credentialing files.
In addition, interviews of both management and staff members for an understanding of this process will be conducted by the reviewer.

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