Section
3.20 Credentialing and Recredentialing
3.20.1 Introduction
3.20.2 References
3.20.3 Scope
3.20.4 Did you know…?
3.20.5 Definitions
3.20.6 Objectives
3.20.7 Procedures
3.20.7-A. General process for credentialing
3.20.7-B. Temporary Credentialing Process
3.20.7-C. Credentialing requirements
3.20.7-D. Credentialing requirements
individuals who are not licensed or certified
3.20.7-E. Recredentialing
3.20.7-F. Additional credentialing standards
for hospitals and behavioral health facilities
3.20.1
Introduction
The credentialing and recredentialing processes are integral components
of the ADHS/DBHS quality management program. The credentialing and
recredentialing processes help to ensure that qualified behavioral
health providers 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.
Credentialing
and recredentialing is an ongoing review process to assure the current competence
of practitioners by validating the training and competence of individual
practitioners in particular specialty areas. This level of review is intended to
provide verification that the appropriate training, experience, qualifications, and
ongoing competence has been demonstrated by individual practitioners for the services
they provide.
The credentialing
and recredentialing requirements differ depending on the type of
provider. Physicians, nurse practitioners, physician assistants, psychologists and
all other behavioral health professionals who are registered to bill independently
or provide behavioral health services for which they are licensed to perform must be
credentialed prior to providing services in the ADHS/DBHS behavioral health system.
The specific
requirements associated with the credentialing and recredentialing processes
for each type of provider 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 provider agencies and staff providing behavioral health services
to persons enrolled in the ADHS/DBHS behavioral health system.
3.20.4
Did you know?
- If the T/RBHA
delegates any of the credentialing/re-credentialing or selection
of provider responsibilities, the T/RBHA must retain the right
to approve, suspend, or terminate any providers selected and
may revoke the delegated function if the delegated performance
is inadequate.
3.20.5
Definitions
Behavioral
Health Professional
Behavioral
Health Technician
Credentialing
Independent Licensed Practitioners
Primary
Source Verification
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3.20.6
Objectives
The objectives of the credentialing and recredentialing processes
are to:
- Maintain
fair credentialing and recredentialing processes in which standards
are applied consistently throughout the state;
- Obtain application
information about a potential provider’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.
3.20.7
Procedures
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3.20.7-A. General process for credentialing
Responsible Entity.
Each T/RBHA or its designee must establish credentialing and
recredentialing 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 Gila River BHS to the provider agency pursuant to Gila River BHS Policy 2.10,
credentialing, re-credentialing 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.
Specific requirements and
guidelines are delineated in the Gila River BHS Policy 2.10.
Accreditation
by a nationally recognized accreditation organization.
Accreditation by a nationally recognized accreditation organization
will meet ADHS/DBHS credentialing and recredentialing standards. T/RBHAs must ensure,
to the extent possible, that providers are not subjected to duplicative
credentialing processes.
Fairness
of Process.
The T/RBHAs or their designee shall maintain fair credentialing
and recredentialing processes which:
- Does not
discriminate against a provider solely on the basis of the professional’s
license or certification; or due to the fact that the provider
serves high-risk populations and/or specializes in the treatment
of costly conditions;
- Affords the
provider the right to review information gathered related to
his/her credentialing application and to correct erroneous information
submitted by another party. The organization is not required to reveal
the source of information if the information is not obtained to meet
organization credentialing verification requirements or if disclosure
is prohibited by law;
- Notifies
the provider when the information obtained through the primary
source verification process varies substantially from what the
provider provided;
- Ensures credentialing/recredentialing
information is kept confidential; and
- States that practitioners
have a right to be informed of the status of their application upon request, and
must describe the process for responding to such request, including information
that the organization may share with practitioners with the exception that this
does not require the organization to allow a practitioner to review references,
recommendations or other peer-review protected information.
Provider File.
The T/RBHAs must maintain an individual credentialing/re-credentialing
file for each credentialed provider. 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
provider
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 provider’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 provider’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
provider’s contract based on issues of quality of care
and/or service; and
- Inform
the provider 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 providers 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 providers 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 provider
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 as applicable.
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 provider 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
The following behavioral
health professionals are subject to credentialing and
recredentialing:
- 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 providers must include the following
components:
A written application
to be completed signed and dated by the potential provider 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 individuals who are not licensed or
certified
Individuals who are not licensed or certified must be included in the credentialing
process and profiled as outlined in
A.A.C. R9-20-204.
3.20.7-E.
Recredentialing
The T/RBHAs or designee must ensure that all credentialed
providers described in subsection 3.20.7-C 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 provider is Board certified; and
- Initial
site visits performed for all behavioral health care
providers
who are part of the T/RBHA network.
The recredentialing
of individual providers must include a process for ongoing monitoring
and intervention if appropriate, provider 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.
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 Recredentialing
Last Revised: 07/15/2010
Effective Date: 07/15/2010
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