Revised 7/2007; May 2008
ECHO COMMUNITY HEALTH CARE, INC.
PROVIDER PRIMARY SOURCE VERIFICATION
and CREDENTIALING
Policy Statement
The physician and nurse practitioner providers and nurse midwifes are essential to ECHO Community Health Care, Inc. (ECHC) ability to provide comprehensive primary care. Therefore, to assure quality of care and best practices by the provider, ECHC evaluates and screens potential provider credentials through a series of medical resources and professional screening mechanisms. This is accomplished by the following the guidelines established below.
Guidelines for Providers and Mid Levels
1A.The following components will be used to screen potential and employed physician, nurse practitioner and nurse midwife providers;
These components are verified by the Administrative Assistant:
· Careful review & primary verification of curriculum vitae including graduation from an accredited medical school. Need primary source verification; Defined as: Current licensure/certification or registration is verified at the time of hire or licensure renewal via a secure electronic communication or by telephone is acceptable, if verification is documented.
· A query of the National Practitioner Data bank on the internet at: http://www.npdb-hipdb.hrsa.gov/welcomesq.html prior to employment and annually. If provider is employed outside the organization, a query will be done twice a year. Organization will pay for queries done after employment. This will be done before acceptance.
· Proof of postgraduate training (three or more years of residency). – Primary Verification.
· Completion of a national licensing examination. – Primary Verification.
· Review of State License with relevant scope of services initially and each (2) years.
New Hires: Confirmation of Licensure by print out from IN Licensing web site, sign and date copy of each license
Annually: All appropriate staff renewing licensure within the year. (NP’s MW’s and Providers)
· Exclusion lists reviewed for all ECHC employees annually, through the Specially Designated Nationals website www.treas.gov/offices/eotffc/ofac/sdn and the Excluded Parties Listing System’s (50 federal agencies) website, www.epls.gov/servlet/EPLSSearchMain/1
· If foreign schooling; notify Educational Commission for Foreign Medical Graduates (Web site: http://www.ecfmg.org/)
1B.These components are completed by the Clinical Director or the Executive Director for
the Providers and Mid Levels:
· Procurement of three (3) primary references from the most recent training program or current employer.
· Proof of Specialty BOARD certification, Internal Medicine, Pediatrics, Obstetrics, or Family Practice, as applicable. This will be validated through the Official ABMS Directory of BOARD Certified Medical Specialists.
· Proof of current malpractice insurance up to date of employment as applicable.
· Proof of current general liability insurance up to date of employment as applicable.
Credentialing Process:
The Reimbursement Specialist for Credentialing:
1. For a new provider the Reimbursement Specialist initiates the credentialing process by contacting either Deaconess Health Plans (DHP Credentialing Specialist Phone # 450-2031) or Anthem (Contact # is 469-7581). They will contact CAQH to obtain a number for the new provider.
a. Once the CAQH number is obtained, the Reimbursement Specialist can go online at https://caqh.geoaccess.com/oas/ and set up a user name and password to give to the provider so they can complete the application.
b. Once the new provider completes their application then the Reimbursement Specialist can proceed with all other applications based on the information the provider has entered on the CAQH application. Any updates or changes to the CAQH application (license, other provider numbers, etc.) can be done by ECHC.
2. If the provider has already been established and has a CAQH number the Reimbursement Specialist will contact CAQH and they will reset the user name and password for ECHC once we can provide the SSN, DOB, etc.
3. If the provider is already established with the Health Plans/Anthem, ECHC needs to contact them, to add this location. For Medicaid ECHC can use the same number and attach it to the ECHC facilities. For each payer the ECHC Reimbursement Specialist will need to contact and add to our facilities.
4. NPI letter must be sent with Medicare application for credentialing.
Reimbursement Specialist to apply for NPI number on the web site at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart
5. Valid CSR number for the state of Indiana; apply at http://www.in.gov/pla/bandc/isbp/reqapp/csrindex.html and maintained every 3 years.
Paid for at the Director’s discretion.
For current providers the Reimbursement Specialist will apply for location addition or change.
6. Valid DEA number for federal application apply at http://www.deadiversion.usdoj.gov/drugreg/reg_apps/index.html
and maintained every 3 years. Paid for at the Director’s discretion.
For current providers the Reimbursement Specialist will apply for location addition or
change
7. Eligible for hospital courtesy privileges at both St. Mary’s Health Care Services and at Deaconess Hospital. This includes: unlimited and unrestricted licensure restrictions to practice in Indiana with no suspended licensures in any state. The technical ability to perform and successfully pass certifications and competency evaluations done by the hospitals.
8. Upon completion the administrative assistant marks information ‘confidential’ and distributes: “Provider Credentialing Information” to CFO, Executive Director, Clinical Director, Site Manager, and QI and Compliance Coordinator
9. Clinical and PAP staff are to receive a copy of the DEA, CSR, IN State Licensure number and NPI; stamp ‘confidential’. Make sure the staff understand this information is not to be posted in any clinical area.
Recredentialing for all Providers
The Medical Director, Executive Director and the Clinical Director are responsible for reviewing performance of all providers on an annual basis. The Medical Director’s performance will be evaluated annually by the Clinical Director in conjunction with the Executive Director.
· The Administrative Assistant (AA) will initiate the review Process.
· The Clinical Director will verify the review of the Provider contract with the Executive Director
· The AA will A run a query of the National Practitioner Data bank on the internet at http://www.npdb-hipdb.hrsa.gov/welcomesq.html prior to employment and annually. If provider is employed outside the organization, a query will be done twice a year.
· The AA will review of State License with relevant scope of services initially and each (2) years; print verification for file administrative assistant to initial and date.
· Current licensure
· No licensure restrictions
· The Clinical Director will verify annual CME’s (CME’s are to be turned with request for reimbursement and prior to distribution of reimbursement for the seminar or training received).
· The AA will verify copies of current specialized training including a CPR card are on file.
· The AA will verify that Exclusion lists are reviewed for all ECHC employees annually, through the Specially Designated Nationals website www.treas.gov/offices/eotffc/ofac/sdn and the Excluded Parties Listing System’s (50 federal agencies) website, www.epls.gov/servlet/EPLSSearchMain/1
· The Clinical director will complete the annual evaluation with risk management audit results verified by the QI and Compliance Coordinator and accepted practice from peer review audits.
Components verified by the Reimbursement Specialist for credentialing processes:
· Update hospital and current hospital privileges.
· Renew DEA number and CSR every 3 years
· Update Access the CAQH information at https:caqh.geoaccess.com/oas/;update every 90 days
· Update credential process with each payer as required including but not limited to:
Medicare:855I- www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf
855R – www.cms.hhs.gov/gov/cmsforms/downloads/cms855r.pdf
Private Insurances including PPO: Hospital Courtesy Privileges – Contact at Deaconess Health Plans – 450-2031 Contact at St. Mary’s Select is 485-6995 Anthem – www.11.anthem.com/jsp/mwpmf/PMFControllerServlet Maintenance form for Anthem Enrollment
Medicaid:- www.indianamedicaid.com/ihcp/index.asp
Choose Forms Folder
Provider Enrollment – select the appropriate form you need to complete.
Anthem MCO:-Fax the Indiana Sponsored Business Practice Info (located on the finance server/everyone/mco’s folder) form to Credentialing at 877-652-1236.
Accountability
The Clinical Director is responsible for validating, clarifying, investigating, and completing references. Deaconess Hospital and St. Mary’s HealthCare Services credential as part of the conditions of initial and on going provider hospital privileges.
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