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Credentialing and Recredentialing

1.0 SCOPE

Practitioners are within the scope of credentialing if the criteria below is met:

  • Practitioners have an independent relationship with Empassion (an independent relationship exists when Empassion directs program participants to see a specific practitioner or group of practitioners).
  • Practitioners that provide care to program participants under Empassion’s care management model

Credentialing Criteria apply to practitioners in the following settings:

  • Individual or group practices
  • Telehealth
  • In home setting

2.0 PURPOSE

This policy defines the credentialing and recredentialing process for selection and evaluating licensed and independent practitioners and the assessment process for organizational providers who provide care under Empassion’s care coordination model. Consistent with Empassion’s mission to assist program participants in achieving well-being, the goal of this policy is to enable selection of qualified practitioners and providers.

In some circumstances, Empassion is subject to certain credentialing requirements, such as state and federal regulations, that exceed or differ from those outlined in this policy. Empassion will ensure compliance with state requirements that meet or exceed current Centers for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) requirements.

3.0 DEFINITIONS

Independent Relationship: exists when Empassion directs program participants to see a specific practitioner, including all practitioners whom a program participant can select for services, to provide care under a specific statement of work.

Licensed practitioner is defined as physicians (MD, DO), nurse practitioners (CRNA, ARNP, CNM, FNP), physician assistants (PA), Masters in Social Work (LCSW, MSW), and any other independent, licensed practitioner as required by law and/or licensure who are authorized and approved to provide medical care services to Empassion’s program participants.

Practitioner: This term may be used interchangeably to represent an individual practitioner or facility.

Program Participant: any person enrolled with Empassion to receive palliative care services through one of Empassion’s Network Practitioners.

4.0 REQUIREMENTS

I. Types of Practitioners to Credential and Recredential

Practitioners who require credentialing include all participating practitioners who fall within the scope of credentialing, including, but not limited to:

  • Medical Practitioners:
  • Medical Doctors
  • Osteopaths
  • Nurse Practitioners
  • Physician Assistants
  • Other medical practitioners who may be within the scope of credentialing and who are licensed, certified or registered by the state to practice independently or as required by state regulations.

Behavioral health Practitioners:

  • Psychiatrists and other physicians
  • Addiction medicine specialists
  • Doctoral or master’s level psychologists who are state certified or licensed
  • Master’s level clinical social workers who are state certified or licensed
  • Master’s level clinical nurse specialists or psychiatric nurse practitioners who are nationally or state certified or licensed
  • Other behavioral health specialists who may be within the scope of credentialing and who are licensed, certified or registered by the state to practice independently or as required by state regulations.

Other Practitioners:

  • Registered Nurses who are state certified or licensed
  • Bachelor’s level clinical nurses who are state certified or licensed
  • Licensed Practical or Vocational nurses who are state certified or licensed


All practitioners requiring credentialing should complete the credentialing process prior to the provider’s contract effective date and prior to providing care to Program Participants, except where required by state regulations. All credentials must be current at the time of the credentialing committee decision.

II. Verification Sources for Credentialing and Recredentialing

Verification of credentialing information should come from one of the following sources:

  • The primary source (or its website), the entity that originally conferred or issued the credential
  • A contracted agent of the primary source (or its website)
  • Another NCQA accepted source (or the source’s website) listed for the credential

Appropriate documentation of verifications include:

  • Credentialing documents signed (or initialed) and dated by verifier
  • A checklist, including the name of the source used, the date of verification, the signature or initials of the person who verified the information and the report date, if applicable. If the checklist does not include these requirements, appropriate credentialing information should be included
  • Copies of credentialing information and checklist. If the checklist does not include checklist requirements, appropriate credentialing information should be included.
  • The checklist must have a single signature and a date for all verifications that has a statement confirming the signatory verified all the credentials on that date. The statement should include the source and report date of each verification, if applicable.

Education and training verifications do not expire, are valid indefinitely and must be completed prior to Credentials Committee decisions. DEA verification must be completed prior to Credentials Committee decisions. All other credentialing verifications and Credentialing Application must be completed within 120 calendar days prior to the Credentialing Committee’s decision date.
The following sources may be used to verify credentialing information:

Licensure: (must be current and valid in all states where the practitioner provides care)

Verification should come directly from the state licensing or certification agency. Compact licensures are accepted in states that are actively issuing and accepting compact privileges. A physician or non-physician practitioner working under the authorization of a compact must meet both the licensure requirements outlined in the primary state of residence and those established by the compact laws adopted by the legislatures of the interstate compact states.

Physicians and other practitioners providing Telehealth services must hold appropriate licensure, certifications, and registrations and comply with applicable professional practice standards and telehealth requirements in the state(s) in which they practice and also in the state(s) in which any program participant receiving Telehealth services is located at the time of such encounter.

DEA and a controlled dangerous substance (CDS) certificate: (current and valid in all states where the practitioner provides care) (if applicable)

  • Confirmation with the state pharmaceutical licensing agency, where applicable
  • DEA and CDS certificate
  • Documented visual inspection of the original certificate
  • Confirmation with the DEA and CDS agency
  • American Osteopathic Association (AOA) Physician Profile Report or Physician Master File (DEA only)


If a practitioner is practicing in a state where a CDS is not required, only DEA will be required.

Education and Training:

Verification of the highest of the three levels of education and training obtained by the practitioner:

  • Graduation from medical or professional school
  • Residency, if appropriate
  • Board certification, if appropriate

Physician (M.D. or D.O.) - Graduation from medical school

Verification of the highest of the three levels of education and training obtained by the practitioner:

  • Medical school
  • AMA Physician Master File
  • AOA Official Osteopathic Physician Profile Report or AOA Physician Master File
  • Educational Commission for Foreign Medical Graduates (ECFMG) for international medical graduates licensed after 1986
  • Association of schools of the health professions, if the association performs primary source verification of graduation from medical school
  • State licensing agency, if the state agency performs primary source verification. At least annually, Empassion should:
    • Obtain confirmation from the state licensing agency that it performs primary source verification of practitioner education and training information -OR-
    • Obtain a printed, dated screenshot of the state licensed agency website displaying the statement that it performs primary source verification of practitioner education and training information

Completion of Residency training - Residency training program

  • AMA Physician Master File
  • AOA Official Osteopathic Physician Profile Report or AOA Physician Master File
  • Educational Commission for Foreign Medical Graduates (ECFMG) for international medical graduates licensed after 1986
  • Association of schools of the health professions, if the association performs primary source verification of graduation from medical school
  • State licensing agency, if the state agency performs primary source verification. At least annually, Empassion should:
    • Obtain confirmation from the state licensing agency that it performs primary source verification of residency training of practitioner education and training information -OR-
    • Obtain a printed, dated screenshot of the state licensed agency website displaying the statement that it performs primary source verification of practitioner education and training information including residency training
  • The Federation Credentials Verification Services (FCVS) for closed residency programs

Other healthcare professional:

  • Professional school
  • Specialty board or registry, if the board or registry performs primary source verification of professional school training.
  • State licensing agency, if the state agency performs primary source verification of professional school training. At least annually, Empassion should:
    • Obtain confirmation from the state licensing agency that it performs primary source verification of practitioner education and training information including professional school training -OR-
    • Obtain a printed, dated screenshot of the state licensed agency website displaying the statement that it performs primary source verification of practitioner education and training information including professional school training

Board Certification:

Physician (M.D. or D.O.)

  • American Board of Medical Specialties (ABMS) or its member boards, or an officials ABMS display agent, where a dated certificate of primary source authenticity has been provided.
  • AMA Physician Master File
  • AOA Official Osteopathic Physician Profile Report or AOA Physician Master File
  • Boards in the United States that are not members of the ABMS or AOA. For non-ABMS or non-AOA boards, Empassion will decide which specialty boards to accept and should include the information in its policies and procedures.
  • State licensing agency, if the state agency performs primary source verification of board status. At least annually, Empassion should:
    • Obtain written confirmation from the state licensing agency that it performs primary source verification of board status -OR-
    • Obtain a printed, dated screenshot of the state licensing agency website displaying the statement that it performs primary source verification of practitioner education and training information including board status

Other healthcare professional:

  • Appropriate specialty board, if Empassion provides documentation that the specialty board performs primary source verification of education and training.
  • State licensing agency, if the state agency performs primary source verification of board status. At least annually, Empassion should:
    • Obtain written confirmation from the state licensing agency that it performs primary source verification of board status -OR-
    • Obtain a printed, dated screenshot of the state licensing agency website displaying the statement that it performs primary source verification of practitioner education and training information including board status
  • Registry, if Empassion provides documentation that the registry performs primary source verification of board status.

Work History

Most recent five years of relevant work history included on the application or curriculum vitae. If the practitioner has fewer than five years of work history, the time frame starts at the initial licensure date. Any explanation of any gaps in employment that exceed one year should be supplied in writing. An explanation of any gaps in employment greater than six months but less than one year can be supplied verbally or in writing.

Malpractice History

Confirmation of the past five years of malpractice settlements from the malpractice carrier or query to the National Practitioner Data Bank (NPDB). The five year period may include residency or fellowship years. The organization is not required to obtain confirmation from the carrier for practitioners who had a hospital insurance policy during a residency or fellowship.

National Provider Identifier (NPI) and Healthcare Provider Taxonomy

  • National Plan and Provider Enumeration System

State sanctions and restrictions on licensure

  • Appropriate state agencies
  • NPDB

Medicare and Medicaid sanctions and exclusions

  • NPDB
  • List of excluded individuals and entities maintained by the Office of the Inspector General (OIG)
  • General Services Administrations (GSA) via the System for Award Management (SAM)
  • Current Medicare opt-out list (Medicare only)
  • State Medicaid agency or intermediary and Medicare intermediary, if applicable

Other Requirements (collected not verified)

  • Race
  • Ethnicity
  • Gender
  • Languages Spoken

III. Practitioner Educational and Training Requirements

General Practitioner

  • Medical school, and
  • Verifiable one year U.S. or Canadian residency program
  • Independent and unrestricted license. A provisional license is not accepted

IV. Telehealth Credentialing and Recredentialing

Licensure

Physicians and other practitioners providing Telehealth Services must hold all applicable licensure, certifications, and registrations and comply with the applicable professional practice standards in the state(s) in which they practice and also in the state(s) in which any Empassion program participant receiving Telehealth Services is located at the time of such encounter.

Recredentialing

Empassion shall conduct recredentialing in accordance with its existing policies (see Recredentialing and Sanction information), but may elect to recredential physicians and practitioners providing Telehealth Services more frequently than every 36 months.

V. Decision making criteria for Credentialing and Recredentialing

The decision to credential or recredential practitioners is based on the criteria listed below, including, but not limited to, the information gathered through the credentialing and recredentialing process. While contracted with Empassion, practitioners are required to meet Empassion’s criteria for Credentialing and Recredentialing at all times. Empassion may de-credential a practitioner at any time for failure to meet Empassion’s criteria for Credentialing and Recredentialing.

Administrative Criteria:

Practitioners must meet the following requirements. Any decisions to deny credentialing based on Administrative Criteria are final and not subject to reconsideration rights unless otherwise noted below. Practitioner may notify the credentialing team if they believe an error has occurred.

Education and Training

Practitioner has completed the appropriate education and training for applied specialty.

Eligible for Medicare

Practitioner demonstrates current eligibility for participation in Medicare as applicable.

Eligible for Medicare

Practitioner demonstrates appropriate work history of employment and clinical practice. Practitioner should explain any gaps in work history greater than six months. Explanations shall be reviewed by the Chief Medical Officer, and if necessary, reviewed by the Credentialing Committee.

Medical License

Practitioner holds a current state professional license, certification or registration in the state(s) in which Practitioner will treat Empassion program participants.

DEA and/or CDS Certificate

Where applicable, Practitioner shall hold a current federal DEA certificate and/or a CDS certificate in all states where the Practitioner provides care to Empassion program participants.

Professional Liability Insurance with Acceptable Claims History

Where applicable, Practitioner holds current professional liability insurance (PLI) in contracted amounts, has completed the PLI exception procedure or has documentation of coverage under the Federal Tort Claims Act for professional liability coverage. Practitioner has acceptable liability claims history as determined by the uniformly applied business standards established by Empassion. Failure to meet such uniformly applied business standards shall result in denial.

OIG, SAM Exclusion

Regardless of line of business, practitioner is not excluded by OIG, has not been sanctioned and are not listed as excluded by GSA as reported by the SAM exclusion list.

Current Medicare opt-out list

Practitioner must not be on the Medicare opt-out list.

Certain Felony Convictions

Practitioner has not been convicted, found guilty, nor pled no contest to any felony which is either a crime of violence or a sex offense.

Criteria Eligible for Practitioner’s Opportunity to Request Reconsideration:

A Practitioner will be denied for failure to meet the following criteria, unless the Credentialing Committee determines there are no continuing quality of care concerns. Practitioners may request a reconsideration of such denials and the Practitioner may be deemed to meet criteria if upon reconsideration, the Practitioner can demonstrate to the satisfaction of the Credentialing Committee that there is not continuing quality of care concern. Please refer to Empassion’s Peer Review Policy.

Licensure and Other Adverse Actions:

Practitioner should not have a history of any action in effect within the last five years which revoked, denied, or placed Material Limitations on the Practitioner that was taken by any federal, state or local government, including, but not limited to the applicable state licensing body; a hospital, health plan, or other healthcare entity; or any professional society. Additionally, the Practitioner’s professional license, certificate or registration should not be suspended or revoked and should be free of any other Material Limitations. For purposes of this Policy, Material Limitations are sanctions, probations or other conditions that include:

  • Any requirement to obtain a second opinion for diagnosis or treatment
  • Any restriction or limitation on the ability to prescribe medicine (where applicable) or treat
  • Amy requirement for the presence of a second person during any examination, diagnosis or procedure, or
  • Any other serious restriction or limitation


Unless otherwise required by a government agency, Medicare preclusion is not considered to be Material Limitation.

Relinquishments:

Practitioner, within the last five years, should not have voluntarily relinquished any membership, license, privileges or participation status or other ability to render healthcare services, including but not limited to a state license or clinical privileges, while under investigation by the entity providing such membership, privileges, participation status or other ability to render healthcare services, or in return for such entity not conducting any investigation.

Other Convictions:

Practitioner has not been convicted, found guilty, nor pled no contest to any other felony than those prohibited in the Administrative Criteria, Certain Felony Convictions provisions set forth above. Additionally, the Practitioner shall not have been convicted, found guilty, nor pled no contest to any misdemeanor that is reasonably related to the Practitioner’s qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual misconduct.

Physical or Mental Impairment:

Practitioner should not be physically or mentally impaired, including impairments due to a substance use disorder that may affect the practitioner’s ability to practice or may pose a risk of harm to patients.

Quality:

For recredentialing purposes only, practitioners should demonstrate an acceptable performance record related to Empassion’s program participants with no evidence of quality issues (please refer to Empassion’s Clinical Peer Review Policy). This record includes activities and findings collected through Empassion’s quality improvement programs, utilization management systems, handling of grievances and appeals, program participant satisfaction surveys and other plan activities. “Quality” refers to the measure of competence, professional conduct, care and safety that a practitioner affords a program participant.

Empassion acts only upon complete credentialing and recredentialing applications. A complete application is defined as a submitted application form that is fully filled in with responsive and accurate information, date and signed as required and accompanied by all required and requested documents. Any completed credentialing applications must be completed and attested to within 120 calendar days prior to the Credentialing Committee’s decision date The burden of submitting a complete application rests solely on the applicant. Empassion may return any incomplete application as unprocessed. An applicant’s failure to respond to Empassion’s request for application information may result in a denial of credentialing or recredentialing on an administrative basis. Upon receipt of a complete credentialing application, the credentialing process should be completed within sixty (60) days or as required by state or federal regulations. The credentialing staff should designate files that meet all of the Credentialing Criteria as Category I or Clean files. Credentialing staff should designate as Category II, or unclean, each file that does not meet all Credentialing Criteria.

The Chief Medical Officer may approve any Category I file that meets all Credentialing Criteria. The Chief Medical Officer review and approval should be recorded in each such file or include a report with a signature, or electronic signature that lists all required credentials for all practitioners with clean files and includes the approval date being after appropriate review.

Category II files that fail to meet any of the Credentialing Criteria eligible for Credentialing Committee reconsideration will be reviewed, approved, or denied by the Credentialing Committee. All other Category II files, including those that fail to meet Administrative Criteria, will be reviewed, approved or denied as specified by the Credentialing Committee. The Chief Medical Officer should present all Category II files to the Credentialing Committee. The Credentialing Committee may postpone a decision on a Category II file to receive additional information. Empassion should process the credentialing or recredentialing decision as follows:

Approvals:

Practitioners with Category II files approved by the Credentialing Committee should be notified of the decision. Empassion should notify the applicant in writing of the Credentialing Committee’s approval within 30 days or sooner as required by state or federal regulations. Notice of approvals will be provided as required under “Practitioner Rights”.

Denials:

The Credentialing Committee must notify a practitioner of a denial based on Credentialing Criteria. The notice must inform the practitioner of the reasons for the denial, and in the base of a denial based on Credentialing Criteria eligible for Credentialing Committee reconsideration, will provide notice of such opportunity to request reconsideration of the decision in writing within 30 days of the notice or sooner as required by state or federal regulations. Unless otherwise noted, denials based on a failure to meet Administrative Criteria are final with no reconsideration rights. Where applicable, in the event such reconsideration is timely requested, the Credentialing Committee may affirm, modify, or reverse the initial decision. Empassion will notify the applicant in writing of the Credentialing Committee’s reconsideration decision within 60 days. Practitioners who have been denied are eligible to reapply for network participation once they meet the minimum Credentialing Criteria.

Adverse Actions:

Adverse actions are actions or recommendations that limit, reduce, restrict, suspend, revoke, terminate, deny or fail to renew a practitioner’s participation with Empassion for reasons relating to quality and that adversely affect, or could adversely affect, a patient’s health or welfare. Such actions may include decredentialing or the denial of credentials or recredentialing upon Credentialing Committee reconsideration or action based on Credentialing Criteria eligible for Credentialing Committee reconsideration. Adverse actions lasting longer than 30 days entitle the applicant to prompt notice of his or her right to request a hearing.

VI. Nondiscrimination in Credentialing and Recredentialing

Empassion does not make credentialing decisions based on an applicant’s race, ethnic/national identity, gender, age or sexual orientation or on the type of procedure or patient in which a practitioner or organizational provider specializes. Credentialing and re-recredentialing decisions are made solely based on the results of the verification process. Empassion does not discriminate against a Practitioner on the basis of the practitioner’s license or certification or because the Practitioner services high risk populations and/or specializes in the treatment of costly conditions.

Annually, the Credentialing Committee members sign an affirmation confirming that the credentialing and re-credentialing decisions are not made based on an applicant’s race, ethnicity/national identity, gender, age, sexual orientation, or area in which a Practitioner specializes. Applicant’s demographic information is not provided to the Credentialing Committee. The Credentialing Associate conducts audits on all initial/re-credentialing files prior to submission to CMO and the Credentialing Committee as well as all complaints regarding discriminatory credentialing decisions. All Credentialing/Re-Credentialing applications are logged, and their status (Approved/Denied) recorded. Annually, the Credentialing Associate reviews a summary report. The purpose of this report is to review all denials; and assess whether discrimination played a role in any case. The CMO and/or the Credentialing Associate is responsible for identifying trends in discrimination, and the Credentialing Committee is responsible for ensuring that a plan of corrective action has been implemented and followed.

VII. Confidentiality of Credentialing Information and System Controls

Credentialing information is confidential and shall be held in strict confidence, pursuant to the applicable guidelines in Empassion’s Privacy & Information Security Policy Manual (“Privacy and Security Manual”) for protecting sensitive data. These guidelines include, without limitation, that Empassion shall keep credentialing files and committee meeting minutes locked in a secure area. Access to electronic credentialing information (i.e., the credentialing system) should be password protected using strong passwords that are regularly updated and limited to staff that requires access for business purposes. See Section 3.2 of the Privacy & Security Manual (Passwords) for the complete list of password requirements.

Primary source verifications are received directly from the issuing entity, such as the state licensing board, educational institution, or an authorized source of such organizations, as described within this policy. The staff conducting such verifications will ensure the document is saved in portable document format (PDF), digitally uploaded to the credentialing system and saved within the specific record of review. The credentialing system electronically adds the verification date as dictated by the user, and an automated process adds the unique electronic identifier of that specific user, the verification source and the date of the report, as applicable.

Informational modifications are only permitted by an authorized user prior to final committee review and are tracked in the historical data within the automated credentialing system. Authorized user roles include:

  • VP, Network Development and Credentialing
  • Provider Credentialing Associate

 

Informational modifications are authorized when:

  • Credentialing committee members request additional documentation or provider clarification
  • Updating of information is required to correct typographical errors or omissions identified through system review
  • Updated or clarification documents are received from practitioners or providers, to include:
    • Addition of a new Statement of Work, specialty, new education
    • Address change
    • Expiration updates to license, DEA/CDS certificates, board certification
    • Updated professional liability information
    • New information to request reconsideration
  • Practitioners are being credentialed for reasons that include sanctions, retirement, deceased, unable to locate, failure to respond, practitioner request and/or contract closure
  • Credentialing Department staff do not delete provider information from the system

 

Four processes are in place to oversee the credentialing department’s adherence to its processes:

  • Credentialing management oversees internal weekly audits of each authorized associate who performs practitioner and provider credentialing verifications
  • Credentialing management team conducts weekly random audits to ensure the adherence to policies, procedures and data entry accuracy
  • Empassion’s compliance department administers audits at least annually to ensure the compliance of policies, procedures, accreditation standards as well as state specific requirements
  • Annually, the Provider Credentialing Associate conducts a modification audit of all modifications using a random sample size of the lessor of 5% or 50 records

 

Unauthorized modifications or deletions are prohibited. Identification of an unauthorized modification or deletion by any of the four areas listed above is researched and addressed through education, corrective action and monitored quarterly until improvement is achieved. Disciplinary action can include, but is not limited to, coaching, performance improvement plans or termination as warranted.

Quality management files that contain peer review information are highly confidential and should be kept separate from credentialing files. Credentialing files should not be produced for outside parties without prior approval from the Legal team. Records should be retained for at least 10 years as applicable to Empassion’s Record Retention Policy. See Section 10 of the Privacy & Security Manual (Data Retention Policies) for the complete list of data retention requirements.

VIII. Chief Medical Officer (CMO) Responsibility

The CMO is responsible for overall compliance with the credentialing process. The CMO, or designee, is the chairperson of the Credentialing Committee. The chairperson oversees committee voting procedures and verifies approval of each report and file. The CMO, or designee, do not have voting privileges except in the event of a tie vote by the committee. In that event, the chairperson may vote to break the tie.

IX. Practitioner Rights

Practitioners have the right to review information obtained to evaluate their credentialing application, attestation or CV and the right to correct erroneous information. Empassion notifies practitioners when credentialing information obtained from other sources varies substantially from information provided by the practitioner. The practitioner should be notified within 7 days of the discrepancy. The notification should indicate which part of the application is discrepant, the format for submitting corrections and the person to whom corrections should be submitted. If the application, attestation and/or CV must be updated, only the practitioner may attest to the update, a staff member may not. The practitioner has 14 business days to respond in order to resolve the discrepancy. The receipt of any corrections should be documented in the credentialing file.

Practitioners have a right, upon request, to be informed of the status of their application.
Practitioners applying for initial participation are sent a letter when their application is received
by Empassion and are notified of their right to be informed of the status of their application in this letter. The practitioner can request to be informed of the status of their application by telephone, email or mail. Empassion will respond to the request within three business days. Empassion may share with the practitioner where the application is in the credentialing process to include any missing information or information not yet verified. Empassion does not share with or allow a practitioner to review references or recommendations, or other information that is peer-review protected.

Once a practitioner application for initial credentialing has been approved or denied, the practitioner should be notified within 30 days. Credentialing denials will be communicated to the practitioner by the CMO, or a designee, in writing, and shall include the reason(s) for the denial and should be provided within 30 days of denial.

Empassion will make available all application and verification policies and procedures upon written request from the applying healthcare professional.

X. Credentialing Committee

Empassion designates a Credentialing Committee that uses a peer review process with program participants from the type of practitioners participating in its network to make recommendations regarding credentialing decisions. The Credentialing Committee uses participating providers to provide advice and expertise for credentialing decisions. The Credentialing Committee reviews credentials for practitioners who do not meet Empassion’s established criteria and gives thoughtful consideration to the credentialing information. The Credentialing Committee has final approval or disapproval decision making authority for credentialing and recredentialing applications.

The Credentialing Committee has representation from internal constituents that represent the types of practitioners the committee is reviewing. Clinical peer input from non-committee members may be accessed when discussing Credentialing Criteria for specific specialties. Members of the Credentialing Committee are required to sign a confidentiality and conflict of interest agreement. The Credentialing Committee meets monthly, for the purpose of conducting credentialing and recredentialing activities and reviewing, offering input and approving credentialing and recredentialing policies and procedures. Meetings and decision making may take place in the form of real time virtual meetings. Meetings may not be conducted only through email.

Evidence of the Credentialing Committee’s discussions and decisions are documented in meeting minutes. The chairperson, or designee, should sign and date the committee minutes.

Empassion’s corporate credentialing and recredentialing policy is reviewed at least annually by the Credentialing Committee.

XI. Initial Credentialing and Sanction Information

The following items are verified through primary or NCQA-approved sources prior to initial credentialing, unless otherwise noted:

  • Current and valid license to practice
  • Current and valid DEA or CDS certificate, as applicable
  • Education and training and board certification, as applicable
  • Work History
  • History of professional liability claims that resulted in a settlement or judgment paid on behalf of the practitioner (NPDB)

 

The following sanction or exclusion information is documented prior to initial credentialing, unless otherwise noted:

  • State sanctions, restrictions on licensure and limitations on scope of practice
  • Medicare and Medicaid (as applicable) sanctions and exclusions
  • Current Medicare opt-out list (Medicare only)

XII. Application and Attestation

Practitioners are required to complete an application for initial credentialing and recredentialing that includes a current, signed attestation regarding their health status and any history or loss or limitation of licensure or privileges. In some cases, practitioners may designate a employee within their organization to complete/provide the credentialing application details in an alternate format (i.e. Excel spreadsheet). If an application is completed, it should be signed by participant or organizational designee within 120 days of the credentialing decision and should include any necessary explanations, as applicable. Applicant signatures may be faxed, digital, electronic, scanned or photocopied. Signature stamps are not acceptable. The submission of false information or deliberate omission of requested information on the application may constitute grounds for the denial of credentialing or recredentialing.

The signed and dated application should include detailed information concerning:

  • Current state professional license number(s)
  • Current federal DEA certificate number(s) or state CDS certificate number(s) (if applicable)
  • Current Medicare/Medicaid provider number (if applicable)
  • Professional education, residency and board certification (if applicable)
  • Work history of at least 5 years
  • Current professional liability insurance coverage and claims history
  • Signed and dated consent and release form

 

The signed and dated application also includes an attestation that addresses the following:

  • Reasons for an inability to perform the essential functions of the position
  • Lack of present illegal drug use
  • History of loss of license and felony convictions
  • History of loss or limitation of privileges or disciplinary action
  • Current malpractice coverage (if applicable)
  • Current and signed attestation confirming the correctness and completeness of the application

XIII. Recredentialing and Sanction Information

Empassion formally credentials its practitioners at least every 36 months. The following items are re-verified through primary or NCQA approved sources prior to recredentialing, unless otherwise noted:

  • Current and valid license to practice
  • Current and valid DEA or CDS certificate, as applicable
  • Board certification, as applicable
  • History of professional liability claims that resulted in a settlement or judgment paid on behalf of the practitioner (NPDB)
  • Performance indicators

 

The following sanction or exclusion information is documented prior to recredentialing, unless otherwise noted:

  • State sanctions, restrictions on licensure and limitations on scope of practice
  • Medicare and Medicaid (if applicable) sanctions and exclusions
  • Current Medicare opt-out list (Medicare only)

 

Practitioners in areas affected by an emergency declaration issued by the federal or state government will be reviewed for possible extension or grace period to respond to requests for credentialing and recredentialing materials. Such extension will begin on the effective date of the emergency declaration and continue until the expiration of the emergency declaration.

Practitioners who have been administratively credentialed may be reactivated within a 30 calendar day period. Any practitioner who has been decredentialed for longer than 30 calendar days should undergo the initial credentialing process.

Practitioners who have missed the 36 month time frame for recredentialing may be administratively credentialed. Empassion may recredential the practitioner within 30 calendar days of missing the deadline. If recredentialing is not completed within 30 calendar days, Empassion will complete an initial credentialing review of the practitioner.

XIV. Ongoing Monitoring and Interventions

Empassion monitors practitioner sanctions, complaints and quality issues between recredentialing cycles and ensures that corrective actions are undertaken and effective when it identifies occurrences of poor quality (refer to Empassion’s Policy #EH-CO-01, Clinical Peer Review).

Ongoing monitoring and appropriate interventions up to and including removal from the network are implemented by collecting and reviewing the following information within 30 calendar days of its release:

  • Medicare and Medicaid sanctions and exclusions
  • Current Medicare opt-out list (Medicare only)
  • Sanctions and limitations on licensure
  • Complaints
  • Identified adverse events

 

Evidence of sanction and exclusion reviews is available from the Credentialing Department. Evidence of practitioner complaints and identified adverse event reviews are available from the Clinical Operations Department.

XV. Notification to Authorities and Practitioner Review Rights

When the Credentialing Committee recommends an adverse action lasting longer than 30 days against a practitioner, Empassion must offer the applicant the right to request a hearing in accordance with the Empassion Credentialing Peer Review Policy, #EH-CR-02, Credentialing Peer Review Policy. Empassion must report to the National Practitioner Data Bank all final adverse Clinical Privilege Actions against practitioners and any Other Adjudicated Actions or Decisions as defined in and required by federal law. Empassion also may be required to report certain actions to state authorities and must do so in accordance with applicable state laws.

For details pertaining to hearing and reporting requirements, please refer to the Empassion #EH-CR-02, Credentialing Peer Review Policy.

XVI. Terminations from Practitioner Network

Any terminations from the network, regardless of reason, shall be reported to the applicable upstream Payor. This reporting shall be done in accordance with specific upstream Payor reporting requirements.

5.0 DISCLAIMER

Empassion follows all applicable federal and state laws and regulations. This document is intended as a best practice guideline. Situations may arise in which professional judgment may necessitate actions that differ from the guideline. Circumstances that justify the variation from the guideline should be noted and submitted to the appropriate business area for review and documentation, including legal review as appropriate. This policy is subject to change or termination by Empassion at any time. Empassion has full and final discretionary authority for its interpretation and application.

6.0 Noncompliance

Failure to comply with any part of Empassion’s policies, procedures, and guidelines may result in disciplinary actions up to and including termination of employment, services or relationship with Empassion. In addition, state and/or federal agencies may take action in accordance with applicable laws, rules and regulations.

Any unlawful act involving Empassion’s systems or information may result in Empassion turning over all evidence of unlawful activity to appropriate authorities.