Health Plan (7.4) 7.4

P-CR 8 - Credentialing Communication Mechanisms

Submited by: Tom Goddard

The Basics

This standard carries two requirements. First, your organization must have mechanisms by which it communicates with providers about the credentialing status, upon request. Second, your organization must be willing and able to accept additional information from providers that they submit in order to correct incomplete, inaccurate, or conflicting credentialing information.
Note that this standard does not say that your credentialing committee cannot take conflicting information into account; only that it must allow the provider to submit information to try to clear up inconsistent information. If, after receiving such information, your credentialing committee is still concerned about the truthfulness of the information, it may act on that concern.

Management Tips

Often, organizations address the standard by sending providers cover letters that offer the provider information about how to contact your organization in the midst of the credentialing process to find out more information, including current status of the application.
Be sure your staff is well-trained on how to allow the provider to correct incomplete, inaccurate, or conflicting information in his/her file.

Accreditation Tips

Desktop Review
During the desktop review phase, you should submit your credentialing plan, which must include a description of how he organization responds to requests from providers about whether application is in the credentialing process.
Validation Review
Interviews
Members of the credentialing staff will be interviewed to see if they understand the organization's policies and procedures about responding to provide a request for information about the credentialing process.
Document Review
As is the case with many of the credentialing standards, most of the effort to assure compliance with this will be conducted during the review of three dozen credentialing files. 

  • Health Plan (7.4) 7.4 / 02.19.2021

    P-OPS 12 - Breach Handling

    This standard outlines the requirements for your organization when a privacy breach is discovered. The process must include:Recording the date your organization knew or should have known of the breach;Notifying the privacy and security official(s);Determining whether a breach actually occurred;Once it's determined that a breach did, in fact, occur, Recording the date of the breach;Mitigating the c...

    READ FULL POST
  • Health Plan (7.4) 7.4 / 02.19.2021

    P-OPS 11 - Oversight of Automated Review of Pharmacy Non-Certifications

    If your organization conducts automated review in connection with drug management, you must have written P&Ps that describe the oversight mechanism for such automated review. That oversight must be conducted by both a senior clinician and a clinical oversight body. That oversight body can be, but need not be, the P&T Committee.The oversight of automated review must be active and well-documented. O...

    READ FULL POST
  • Health Plan (7.4) 7.4 / 02.19.2021

    P-OPS 10 - Economic Formulary Considerations

    In order to assure that cost issues do not supercede clinical issues, this standard prohibits consideration of economic factors of a medication before its safety efficacy, therapeutic appropriateness, and side effects have been established. Once those issues have been considered, it is appropriate to evaluate equivalent alternative medications and therapies in terms of their impact on health costs...

    READ FULL POST
Top