PRIMEWEST HEALTH SYSTEM

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PRIMEWEST HEALTH SYSTEM

• Credentialing Process

Presented by Credentialing and Network Department
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What is Credentialing?

• The purpose of credentialing is to establish that
  applicants meet the minimum criteria for
  appointment and to determine whether applicants
  are clinically competent to perform requested
  services.
• The National Committee Quality Assurance (NCQA)
  defines credentialing and recredentialing as the
  process for evaluating and selecting licensed
  independent practitioners to provide care to
  members.

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Why do Health Plans Credential Providers?

• Ensure high-quality patient care by protecting
  the public from incompetent practitioners
• Minimize the health plans legal risk
• Requirement of Department of Human Services (DHS)

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What Happens First?

• The Provider is directed to the PrimeWest Website
  link to complete the Minnesota Uniform
  Credentialing application or sent an application
  via fax or email

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The Minnesota Uniform Credentialing Application
includes

• Personal Data
• Primary or Pending location
• Billing Information
• Additional Practice Location (s)
• Medical/Graduate/Professional Education
• ECFMG
• Internship/Residency/Fellowship/
  Post-Graduate/Professional Training
• Professional and Academic/Faculty Affiliation
• Chronological Employment/Practice History
  including Military Service Addendum Page for
  additional information
• Time Gaps explain time gaps
• Primary Hospital Affiliation and Other Hospital
  Affiliations Addendum Page for additional
  information
• Specialty/Subspecialty Certification
• Licensure
• Drug Enforcement Administration Registration
• State Controlled Substance Certification/Registrat
  ion
• Liability Insurance
• Professional/Peer References
• Life Support Certification

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Upon Receipt of the Completed Application

• Credentialing and Network Staff screens
  application for gaps in time frame, completeness,
  etc.
• If not complete, application is returned and
  practitioner is asked to fill in all blank spaces.

• When the application is deemed complete, primary
  source verification of information begins which
  may include degree(s), residency, board
  certification (if applicable)

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Upon Receipt of the Completed Application (Cont.)

• All of the data we collect is entered into our
  credentialing software

• If not Board Certified three peer references are
  requested and highest level of training is
  verified
• Electronic Queries are made to
• The National Practitioner Data Bank, who
  maintains information on every malpractice case
  settled on behalf of the applicant
• To the Licensing Board(s) for any derogatory or
  investigative information regarding applicant
• Office of the Inspector General (OIG) for
  Medicare/Medicaid Sanctions,
• AMA or AOA for board certification

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When Everything is Complete

• Credentialing and Network Staff screens
  application and flags any gaps in service, any
  liability cases, etc
• Credentialing and Network Staff looks for any
  inconsistencies in information

• The file is presented to the Senior Medical
  Director for his review and comments
• Application is taken to QCCC for recommendations
  and decision

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Quality Care Coordination Committee (QCCC)

• The QCCC is a multidisciplinary committee with
  representatives from various types of
  practitioners and specialties.
• The QCCC is responsible for the credentialing
  activities including credentialing,
  recredentialing, discipline, and termination of
  practitioners and organizational providers and
  credentialing policies/procedures and
  credentialing plan.
• The QCCC shall make recommendations for
  credentialing and recredentialing decisions.

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The Wrap-Up

• Credentialing and Network Coordinator/Specialist
  makes sure the Medical Director has reviewed,
  made recommendations, and signed the credential
  files.
• The Quality Care Coordination Committee make
  recommendations for credentialing and
  recredentialing decisions.
• The Quality Care Coordination Committee
  recommendations are forwarded to the Joint Powers
  Board.

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To the Board

• The Joint Power Board reviews the recommendation
  of the Quality Care Coordination Committee.
• The Joint Power Board makes final decision of the
  Quality Care Coordination Committee
  recommendation.

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Thats Not Quite the End!

• The provider will receive a letter welcoming
  him/her to PrimeWest Health and informing him/her
  that they have been approved for the PrimeWest
  Network for three years.

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What If Its Not Approved?

• More documentation may be required of the
  applicant
• If application is denied, practitioner may appeal
  via the Appeal Process

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Recredentialing Process

• All providers at PrimeWest Health must be
  recredentialed every three years.
• The application process for recredentialing is
  similar in many ways to the original
  credentialing process...

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Recredentialing

• Six months prior to the recredentialing date, the
  Credentialing and Network department sends out a
  recredentialing application.
• Upon receipt of recredentialing application, it
  is checked for completeness and primary
  verifications are obtained on all information
  submitted.

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Recredentialing Process (Cont.)

• When the application is deemed complete, it is
  reviewed by the Senior Medical Director.
• Upon recommendation for approval by the Senior
  Medical Director, the application is forwarded to
  QCCC.
• The QCCC recommendations are presented to the
  Joint Power Board.

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Delegated Credentialing

• The delegated entity enters into a contractual
  agreement with PrimeWest Health to provide
  credentialing services to PrimeWest Health.
• The delegated entity conducts credentialing
  activities for practitioners employed by or
  holding privileges at the delegated entity.
• The delegated entity warrants that is maintains
  standards, policies, and procedures for
  credentialing activities that enable to perform
  the delegated credentialing activities.

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Delegated CredentialingPredelegation
Assessments

• Prior to signing delegation agreement PrimeWest
  Health conducts a predelegation assessment to
  determine if the Delegated Entity meets the
  National Committee for Quality Assurance (NCQA),
  the Centers for Medicare and Medicaid (CMS),
  and/or Health Insurance Portability and
  Accountability (HIPAA) standards and requirements
  of PrimeWest Health for the provision of the
  Delegated Activities.

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Delegated CredentialingRegular Reporting

• PrimeWest Health and the delegated entity shall
  jointly develop a Standard Reporting Package
• Cover letter indicating credentialing actions of
  Board for the delegated entities practitioners
• Provider Profile Report
• Practitioner Identification Sheet

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Delegated Credentialing Audit

• Annual basis an audit of the delegated entity
  will be conducted to ensure the entity is in
  compliance with all requirements of the Delegated
  Agreement
• PrimeWest Health may perform more frequent audits
  as it deems necessary based on the predelegation
  assessment, any Corrective Action Plan, or in
  performance of its ongoing oversight of the
  Delegation Agreement
• PrimeWest Health will contact the Delegated
  Entity to schedule an audit

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Delegation Audit Results

• PrimeWest will provide a written report of the
  audit results
• Delegated Entity is not in compliance PrimeWest
  and the Entity will develop a Corrective Action
  Plan (CAP)
• Corrective Action Plan will specify timelines for
  correction of deficiencies

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Delegation Agreement Records

• The state and federal government and any of their
  authorized representatives shall have the right
  in accordance with state and federal laws and
  regulation, to audit, evaluate, or inspect any
  records or copies of such which are pertinent to
  and involved transactions related to the Agreement

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Delegated Credentialing

• Delegated Entity Credentialing Responsibilities
• Recredentialing
• Delegated Entity Recommendations to PrimeWest
  Health
• PrimeWest Health Right of Acceptance,
  Termination, and Disciplinary Action
• Annual Audit and Ongoing Oversight
• Right of Appeal and Reporting Responsibility
• Responsibility for Organizational Provider
  Credentialing
• Specific Delegated Credentialing Activities
• Monthly Reporting Requirements
• Annual Reporting Requirements

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Whats so Important about Credentialing?

• Our bottom line is to provide quality care and
  the kind of health care we would want for
  ourselves and our families, in partnership with
  those we serve.
• We can never assume someone else has done the
  work for us.
• We must go through the proper process to protect
  our members from any unfair practices.

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Who is in the Credentialing and Network
Department?

• Director
• Marcie Vickerman
• Manager
• Robin Zimmerman
• Credentialing Network Coordinator
• Marie Hamborg
• Credentialing Network Specialists
• Stephanie Revering
• Amanda Henning
• Leah Imdieke
• Administrative Assistant
• Shana Stevens
• Database Specialist
• Sharon Larsen

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What If I Have Questions or Concerns?

• Credentialing
• Marie Hamborg, Credentialing Network Coordinator
  at 320-335-5379, or at marie.hamborg_at_primewest.org
  
• Stephanie Revering, Credentialing Network
  Specialist at 320-335-5230, or at
  stephanie.revering_at_primewest.org
• Contracting
• Amanda Henning, Credentialing Network Specialist
  at 320-335-5245, or at amanda.henning_at_primewest.or
  g
• Leah Imdieke, Credentialing Network Specialist at
  320-335-5272, or at leah.imdieke_at_primewest.org