Section
3.20 Credentialing and Privileging
3.20.1 Introduction
3.20.2 References
3.20.3 Scope
3.20.4 Definitions
3.20.5 Did you know…?
3.20.6 Objectives
3.20.7 Procedures
3.20.7-A. General process for credentialing
and privileging
3.20.7-B. Temporary Credentialing Process
3.20.7-C. Credentialing requirements for clinicians
who are registered by AHCCCS to bill independently
3.20.7-D. Credentialing requirements for
other clinicians conducting assessments/ serving as clinical liaisons
3.20.7-E. Recredentialing
3.20.7-F. Privileging of clinicians conducting
assessments/serving as Clinical Liaison
3.20.7-G. Additional credentialing standards
for hospitals and behavioral health facilities
3.20.1
Introduction
The credentialing and privileging processes are an integral component
of the ADHS/DBHS quality management program. The credentialing and
privileging processes help to ensure that only qualified behavioral
health clinicians who are capable of meeting the needs of the persons
who are seeking and/or receiving behavioral health services participate
in the ADHS/DBHS provider network.
The credentialing
requirements differ depending on the type of clinician. All behavioral
health professionals who are registered to bill independently must
be credentialed prior to providing services in the ADHS/DBHS behavioral
health system. Other behavioral health professionals and behavioral
health technicians must be credentialed if the clinician will be
conducting assessments and/or serving as a Clinical Liaison. In
addition to being credentialed, any behavioral health professional
or behavioral health technician who will be conducting assessments
and serving as a Clinical Liaison must be privileged.
The specific
requirements associated with the credentialing and privileging processes
for each type of clinician are discussed below.
3.20.2
References
The following citations can serve as additional resources for this
content area:
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3.20.3
Scope
To whom does this apply?
This section
applies to behavioral health professionals and behavioral health
technicians who are or will be providing behavioral health services
to persons enrolled in the ADHS/DBHS behavioral health system.
3.20.4
Definitions
Behavioral
Health Professional
Behavioral
Health Related Field
Behavioral
Health Technician
Clinical
Liaison
Credentialing
Primary
Source Verification
Privileging
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3.20.5
Did you know?
- If the T/RBHA
delegates any of the credentialing/re-credentialing or selection
of clinician responsibilities, the T/RBHA must retain the right
to approve, suspend, or terminate any clinicians selected and
may revoke the delegated function if the delegated performance
is inadequate.
3.20.6
Objectives
The objectives of the credentialing and privileging processes
are to:
- Maintain
fair credentialing and privileging processes in which standards
are applied consistently throughout the state;
- Obtain application
information about a potential clinician’s background and
work history;
- Verify credentials
and other information (e.g., malpractice or sanction activity)
with primary sources;
- Provide
flexibility in the process (i.e., expedited credentialing) so
that any gaps in service provider networks can be expeditiously
addressed; and
- Determine
competency of credentialed clinicians who will be conducting assessments
and/or serving as Clinical Liaisons.
3.20.7
Procedures
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3.20.7-A.
General process for credentialing and privileging
Responsible Entity.
Each T/RBHA or its designee must establish credentialing and privileging
processes that are in compliance with the standards set forth in
this section. The Gila River RBHA delegates responsibility for credentialing
and privileging physicians, nurse practitioners, physician assistants,
psychologists and independent master’s level therapists employed
by or contracted with behavioral health agencies under contract
with the RBHA to the provider agency pursuant to Gila River RBHA
Policy 1.2.6 Credentialing, Recredentialing and Privileging Physicians,
Physician Assistants, Nurse Practitioners, Psychologists and Independent
Master’s Level Therapists. Credentialing and privileging practitioners
employed by or contracted with the Gila River Health Care Corporation
(GRHCC) is conducted by GRHCC.
Accreditation
by a nationally recognized accreditation organization.
Accreditation by a nationally recognized accreditation organization
will meet ADHS/DBHS credentialing standards. T/RBHAs must ensure,
to the extent possible, that clinicians are not subjected to duplicative
credentialing processes.
Fairness
of Process.
The T/RBHAs or their designee shall maintain a fair credentialing
and privileging process which:
- Does not
discriminate against a clinician solely on the basis of the professional’s
license or certification; or due to the fact that the clinician
serves high-risk populations and/or specializes in the treatment
of costly conditions;
- Affords the
clinician the right to review information gathered related to
his/her credentialing application and to correct erroneous information
submitted by another party;
- Notifies
the clinician when the information obtained through the primary
source verification process varies substantially from what the
clinician provided; and
- Ensures credentialing/privileging
information is kept confidential.
Clinician File.
The T/RBHAs must maintain an individual credentialing/re-credentialing
file for each credentialed clinician. Each file must include:
- The initial
credentialing and all subsequent re-credentialing applications;
- Information
gained through credentialing and re-credentialing queries; and
- Any other
pertinent information used in determining whether or not the clinician
meets the T/RBHA’s credentialing and re-credentialing standards.
Notification
Requirement.
The T/RBHAs must have procedures for reporting to appropriate authorities
(AHCCCS, the clinician’s regulatory board or agency, Adult
Protective Services, Child Protective Services, Office of the Attorney
General, etc.) any serious quality deficiencies that could result
in a clinician’s suspension or termination from the T/RBHA’s
network. If the issue is determined to have criminal implications,
a law enforcement agency should also be notified. The T/RBHA must:
- Maintain
documentation of implementation of the procedure, as appropriate;
- Have an appeal
process for instances in which the T/RBHA chooses to alter the
clinician’s contract based on issues of quality of care
and/or service; and
- Must inform
the clinician of the appeal process.
Additional
Standards.
Other standards related to the credentialing process include the
following:
- The credentialing
process must be in compliance with federal requirements that prohibit
employment or contracts with providers excluded from participation
under either Medicare or Medicaid;
- Mechanisms
must be put in place to ensure that credentialed clinicians renew
licenses or certifications required by the appropriate licensing/certifying
entity and continuously practice under a current and valid license/certification;
and
- Behavioral
health care clinicians who are part of the T/RBHA network are
subject to an initial site visit as part of the initial credentialing
process.
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3.20.7-B:
Temporary Credentialing Process
If an expedited or temporary credentialing process is utilized,
the following minimum requirements must be met:
A clinician
must complete a signed application that must include the following
items:
- Reasons
for any inability to perform essential functions of the position,
with or without accommodation;
- Lack of present
illegal drug use;
- History
of loss of license and/or felony convictions;
- History
of loss or limitation of privileges or disciplinary action;
- Current
malpractice insurance coverage; and
- Attestation
by the applicant of the correctness and completeness of the application.
In addition
the applicant must furnish the following information:
- Minimum
five year work history or total work history if less than five
years; and
- Current Drug
Enforcement Agency (DEA) or Controlled Dangerous Substances (CDS)
certificate.
The T/RBHA must
conduct primary source verification of the following:
- Licensure
or certification; and
- National
Practitioner Data Bank (NPDB) query; or
- In lieu
of NPDB query, all of the following:
- Minimum
five year history of professional liability claims resulting
in a judgment or settlement; and
- Disciplinary
status with regulatory board or agency; and
- Medicare/Medicaid
sanctions.
The T/RBHA must
ensure compliance with all applicable credentialing requirements
within six months following the granting of temporary credentials.
If the clinician has not been credentialed during this six month
time period, then the T/RBHA may issue a second temporary credential.
All credentialing must be completed by the end of the second six-month
period.
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3.20.7-C:
Credentialing requirements for clinicians who are registered by
AHCCCS to bill independently
Individual clinicians who meet the AHCCCS criteria to bill
independently and as such are required to register with AHCCCS must
be credentialed prior to the provision of covered behavioral health
services (including conducting assessments and performing the duties
of clinical liaison). These clinicians include the following behavioral
health professionals:
- Physicians
(MD and DO)
- Licensed
Psychologists
- Nurse Practitioners
- Physician
Assistants
- Licensed
Clinical Social Workers (only required if they will be billing
independently)
- Licensed
Professional Counselors (only required if they will be billing
independently)
- Licensed
Marriage and Family Therapists (only required if they will be
billing independently)
- Licensed
Independent Substance Abuse Counselors (only required if they
will be billing independently)
The initial
credentialing process for these clinicians must include the following
components:
A written application
to be completed signed and dated by the potential clinician that
attests to the following elements:
- Reasons
for any inability to perform essential functions of the position,
with or without accommodation;
- Lack of
present illegal drug use;
- If applicable,
history of loss of license and/or felony convictions;
- If applicable,
history of loss or limitation of privileges or disciplinary action;
- Current
malpractice insurance coverage; and
- Correctness
and completeness of the application.
In addition,
the applicant must furnish the following:
- Minimum
five year work history or total work history if less than five
years; and
- Drug Enforcement
Administration (DEA) or Chemical Database Service (CDS) certification
as applicable.
For credentialing
of physicians, nurse practitioners, physician assistants and psychologists,
primary source verification of:
- Licensure
by the appropriate state licensing board;
- Board certification,
if applicable, or highest level of credentials attained;
- If the T/RBHA
lists provider schooling information in member materials or on
the T/RBHA website, documentation of graduation from an accredited
school and completion of any required internships/residency programs,
or other postgraduate training; and
- National
Practitioner Data Bank (NPDB) query; or
- In lieu
of NPDB query, all of the following must be verified:
- Minimum
five year history (or total history if less than five years)
of professional liability claims resulting in judgment or
settlement;
- Disciplinary
actions and licensure status with regulatory board or agency
if applicable; and
- Medicare/Medicaid
sanctions if applicable.
For credentialing
of independent masters level behavioral health therapists who are
registered by AHCCCS to bill independently, primary source verification
of:
- Licensure
by the Arizona Board of Behavioral Health Examiners;
- A review
of complaints received and disciplinary status through the Arizona
Board of Behavioral Health Examiners;
- Minimum five
year history, or total history if less than five years, of professional
liability claims resulting in a judgment or settlement; and
- Medicare/Medicaid
sanctions, if applicable.
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3.20.7-D.
Credentialing requirements for other clinicians conducting assessments/
serving as clinical liaisons
Other Behavioral Health Professionals. The following other licensed
behavioral health professionals must be credentialed prior to performing
assessments and/or serving as clinical liaisons:
- Licensed
Clinical Social Worker (if not registered with AHCCCS to bill
independently
- Licensed
Professional Counselor (if not registered with AHCCCS to bill
independently)
- Licensed
Marriage and Family Therapists (if not registered with AHCCCS
to bill independently)
- Licensed
Independent Substance Abuse Counselor (if not registered with
AHCCCS to bill independently)
- Licensed
Master Social Worker
- Licensed
Baccalaureate Social Worker
- Licensed
Substance Abuse Counselor
- Licensed
Associate Counselor
- Licensed
Associate Substance Abuse Counselor
- Licensed
Associate Marriage and Family Therapist
- Registered
nurse with at least one year of full-time behavioral health experience
The initial
credentialing process for these clinicians must include the following
components:
- A written
application to be completed, signed and dated by the potential
clinician that attests to the following elements:
- Reasons
for any inability to perform essential functions of the position
with or without accommodations;
- Lack
of present illegal drug use;
- If applicable,
history of loss of license and/or felony convictions;
- If applicable,
history of loss or limitation of privileges or disciplinary
activity; and
- Correctness
and completeness of the application.
- Minimum
five year work history or total work history if less than five
years; and
- Primary source
verification of:
- Licensure
by the Arizona Board of Behavioral Health Examiners or Board
of Nursing; and
- A review
of complaints received and disciplinary status through the
Arizona Board of Behavioral Health Examiners or Board of Nursing.
Behavioral
Health Technicians
Only certain qualified behavioral health technicians will be eligible
to perform assessments and/or serve as clinical liaisons and therefore
will need to be credentialed if they are to perform these functions.
To be considered a qualified behavioral health technician, a person
must have one of the following combinations of education, license
and/or behavioral health work experience:
- Master’s
degree in a behavioral health related field;
- Bachelor’s
degree in a behavioral health related field and two years behavioral
health work experience;
- Master’s
degree in non-behavioral health related field and 30 semester
hours in behavioral health education (see PM Attachment 3.20.1)
and two years behavioral health work experience;
- Bachelor’s
degree in a non-behavioral health related field and 30 semester
hours in behavioral health education (see PM Attachment 3.20.1)
and four years behavioral health work experience;
- Associate’s
degree in behavioral health related field and four years behavioral
health work experience;
- Associate’s
degree in non-behavioral health related field and 30 semester
hours in behavioral health education (see PM Attachment 3.20.1)
and five years behavioral health work experience;
- Licensed
Physician Assistant (who is not working as a medical clinician)
and two years of behavioral health work experience; or
- Certified
Psychiatric Rehabilitation Practitioner (CPRP), certified through
the Psychiatric Rehabilitation Certification Program.
The initial
credentialing process for these clinicians must include the following
components:
- A written
application to be completed, signed and dated by the potential
clinician that attests to the following elements:
- Reasons
for any inability to perform essential functions of the position
with or without accommodations;
- Lack
of present illegal drug use and/or felony convictions;
- For
Physician Assistants, history of loss of license;
- For
Physician Assistants, history of loss or limitation of privileges
or disciplinary action; and]
- Correctness
and completeness of the application.
- Minimum
five year work history or total work history if less than five
years;
- For Physician
Assistants, primary source verification of:
- Licensure
by the Arizona Regulatory Board of Physician Assistants; and
- Disciplinary
actions and licensure status obtained through the Arizona
Regulatory Board of Physician Assistants.
- For non-licensed
behavioral health technicians:
- Verify
educational degree; and
- Review
and verify authenticity of college course transcripts (See PM
Attachment 3.20.1).
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3.20.7-E.
Recredentialing
The T/RBHAs or designee must ensure that all credentialed
clinicians described in subsections 3.20.7-C and 3.20.7-D are recredentialed.
The recredentialing process must:
- Occur at
least every three years; and
- Update information
obtained during the initial credentialing process with the exception
of:
- History
of loss of license and/or felony convictions;
- Minimum
five year work history;
- Board
certification, if the clinician is Board certified; and
- Initial
site visits performed for all behavioral health care clinicians
who are part of the T/RBHA network.
The recredentialing
of individual clinicians must include a process for ongoing monitoring
and intervention if appropriate, clinician sanctions, complaints
and quality issues, which include, at a minimum, reviews of:
- Medicare/Medicaid
sanctions;
- State sanctions
or limitations on licensure;
- Behavioral
health recipient concerns including grievances (complaints) and
appeals information; and
- Quality issues.
3.20.7-F.
Privileging of clinicians conducting assessments/serving as Clinical
Liaison
ADHS/DBHS requires that all clinicians who will be conducting assessments
and/or serving as a clinical liaison must be privileged as well
as credentialed (see subsections B and C above).
In order to
be privileged the following standards must be met:
- All behavioral
health professionals and behavioral health technicians must complete
ADHS/DBHS designed training classes on the Arizona assessment
process and the role of the clinical liaison; and
- In addition
all behavioral health technicians must complete an additional
ADHS/DBHS designed training session on the assessment process,
(e.g., mental health status exam, DSM, clinical formulation).
Behavioral health technicians must also demonstrate competence
by completing a minimum of three adequate assessments under the
supervision of a behavioral health professional.
The behavioral
health professional supervising the behavioral health technician
must complete the following documentation:
- An attestation
to the clinician’s competencies for performing assessments
and serving as a Clinical Liaison. ADHS/DBHS has developed PM
Form 3.20.1, which may be used to document this requirement;
and
- Reporting
on the behavioral health technician’s case supervision.
ADHS/DBHS has developed PM
Form 3.20.2, which may be used to document this requirement.
3.20.7-G.
Additional credentialing standards for hospitals and behavioral
health facilities
Hospitals and behavioral health facilities (OBHL licensed Level
I, II, III, outpatient clinics and ADHS/DBHS Title XIX certified
community service agencies) must ensure the following:
- The provider
is licensed to operate in Arizona as applicable and is in compliance
with any other applicable state or federal requirements; and
- The provider
is reviewed and approved by an appropriate accrediting body, or
if not accredited, Centers for Medicare and Medicaid Services
(CMS) certification, ADHS/DBHS Title XIX certification or state
licensure review may substitute for accreditation. In this case,
the provider must provide a copy of the report to the contracted
T/RBHA that verifies that a review was conducted and compliance
was achieved.
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3.20
Credentialing and Privileging
Last Revised: 12/09/2004
Effective Date: 04/15/2005
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