Credentialing
Program Manual
Credentialing Program Manual
Table of Contents
I. Introduction................................................................................................................................................4
II. Confidentiality.........................................................................................................................................4
III. Non-Discrimination.............................................................................................................................5
IV. Committee and Staff Structure...................................................................................................6
V. Provider Credentialing.......................................................................................................................6
A. Application........................................................................................................................................6
B. Administrative Review...............................................................................................................9
C. Credentialing Committee Process...................................................................................11
D. Appeals.............................................................................................................................................12
VI. Provider Recredentialing.............................................................................................................12
A. Triennial Process.........................................................................................................................12
B. Recredentialing Process.........................................................................................................12
C. Primary Source Verification.................................................................................................13
D.Recredentialing Criteria.........................................................................................................13
E. Ongoing Performance Monitoring...................................................................................13
F. Credentialing Committee......................................................................................................14
G.Board of Directors......................................................................................................................14
H.Appeals.............................................................................................................................................14
VII. Listings in Provider Directories and Other Member Materials.........................14
VIII. Facility Credentialing and Recredentialing..................................................................15
Credentialing............................................................................................................................................15
A. Administrative Review............................................................................................................15
B. Medical Director..........................................................................................................................17
C. Credentialing Committee......................................................................................................17
D. Board of Directors......................................................................................................................17
Recredentialing.......................................................................................................................................17
A. Administrative Review............................................................................................................17
B. Medical Director..........................................................................................................................18
C. Credentialing Committee......................................................................................................18
IX. Delegated Credentialing/Recredentialing......................................................................19
Appendix A....................................................................................................................................................21
Appendix B....................................................................................................................................................24
Appendix C....................................................................................................................................................26
Appendix D...................................................................................................................................................29
2
Credentialing Committee Membership
Internal Medicine – Medical Director (chair and voting member).................Deepa Varghese M.D.*
Internal Medicine (voting member).................................................................................Kristin Polga M.D.
Psychiatry (voting member)..................................................................................................Jenna Saul M.D.
Internal Medicine – Medical Director (voting member)......................................Sumedha Pathak M.D.*
Osteopathic Manipulative (voting member)..............................................................Jonathon R Kirsch DO
Internal Medicine (voting member).................................................................................Dana Habash-Bseiso M.D.
Dentist (voting member)........................................................................................................Nagarjuna Meesa D.D.S.
Assistant General Counsel – SHP Legal Services....................................................Lisa Boero*
Credentialing Specialist – Credentialing and Privileging..................................Karen Blaszkowski
Credentialing Coordinator – Credentialing and Privileging.............................Michelle Millard*
Credentialing Coordinator – Credentialing and Privileging.............................Julie Freimund
Credentialing Specialist – Credentialing and Privileging..................................Kari Watson
Contract Manager – Contracting Manager..................................................................Kathy Schmutzer, B.S.N. R.N.*
Director – Director of Payor Strategy and Network Contracting...................Dave Nyman*
Other SHP Staff
(Attend at an Ad Hoc basis)
Robyn Schindler, C.M.*
Scott Milach, C.M.*
Rhonda Lokken C.M.*
Julie Brussow, C.E.O.*
*Designates Security Health Plan Staff
3
Credentialing Program Manual
I. Introduction
The credentialing process for Security Health
Plan of Wisconsin, Inc. (SHP) enables SHP to
appropriately affiliate quality physician and
non-physician providers for medically necessary
services. The credentialing process ensures that
providers are properly trained and qualified,
and are accessible to participants within SHP’s
service area. SHP does not make credentialing and
recredentialing decisions based on an applicant’s
race, ethnic/national identity, gender, age, sexual
orientation or the types of procedures or types of
patients the provider specializes in.
This Credentialing Program Description outlines
the standards, policies and processes for the
affiliation of providers. In addition, the “Protocol
for Assessing the Quality of an Affiliated Provider
Practice” (ATTACHMENT A), outlines the process for
disciplining and terminating affiliated providers.
SHP may deny or restrict participation by a
provider, terminate a provider’s participation or
take other disciplinary action in accordance with
the provider’s written contract, this Credentialing
Program Description, or the due process document.
This Credentialing Program Description, along with
the due process document, may be changed at the
discretion of SHP’s Credentialing Committee and/
or SHP’s Board of Directors. Any change in legal,
regulatory, or accreditation requirements will be
automatically incorporated into this plan as of
the requirement’s effective date. Changes will be
effective for all new and existing providers from
the effective date of the change.
SHP’s credentialing program also includes the
review of facilities and organizations contracted
to provide services to SHP members, including
hospitals, home health agencies, residential,
4
inpatient, and ambulatory mental health facilities,
skilled nursing facilities, rehabilitation centers,
and ambulatory surgery centers, hospice,
comprehensive outpatient rehabilitation facilities
(CORF’s), end stage renal, portable imaging
suppliers, rural health clinics (RHC’s), clinical
laboratories, and federally qualified health
centers (FQHC’s).
SHP’s Medical Director and Legal Services review
all SHP credentialing/recredentialing policies and
procedures no less than every two years unless the
policy and procedure is considered administrative.
In addition, SHP’s credentialing program
description outlines SHP’s criteria for a delegation
of credentialing/recredentialing agreement
with SHP.
II. Confidentiality
Information acquired through the credentialing/
recredentialing process is considered confidential.
All individuals with file access are responsible for
ensuring that all credentialing/recredentialing
information remains confidential except as
otherwise provided by law (see SHP policy
D144). When a law enforcement agency or other
government agency seeks provider credentials
information, a Legal Department representative
will be consulted prior to the release of
any information.
The provider prohibits the release of any
information obtained through the credentialing/
recredentialing process without a written, signed
and dated consent to the release of
the information.
III. Non-Discrimination
The credentialing and recredentialing process
ensures that providers are properly trained and
qualified, and are accessible to participants within
SHP’s service area. SHP does not make credentialing
and recredentialing decisions based on an
applicant’s race, ethnic/national identity, gender,
age, sexual orientation or the types of procedures
or types of patients the provider specializes in. SHP
requires its’ affiliated providers and facilities to
adhere to its non-discrimination policy (see
Non-Discrimination Policy D367).
IV. Committee and Staff
Structure
A. Board of Directors: SHP’s Board of Directors
while delegating credentialing/recredentialing
responsibilities to the Credentialing Committee
retains ultimate responsibility for and authority
over all credentialing decisions.
B. Medical Director: The Medical Director or his/
her physician designee is chair and a member of
the Credentialing Committee and is responsible
for overseeing credentialing/recredentialing
processes and policies. The Medical Director
or his/her physician designee reviews provider
applications that meet SHP’s Administrative
(Section IV, B1) and Professional Criteria (Section
IV, C 1) and facility information that meets SHP’s
Administrative Review (Section VI). The Medical
Director has the authority to approve provider
and facility credentialing/recredentialing
applications that meet SHP’s Administrative and
Professional Criteria and facility Administrative
Review (Clean File Definition). The Medical
Director acts as a resource to credentialing staff.
C. Credentialing Committee: The Credentialing
Committee is a standing Committee that meets
twice a month. Members are nominated by SHP
management and approved by the President
of SHP’s Board of Directors. The Committee is
responsible for establishing and implementing
credentialing and recredentialing policies
and procedures. In addition, the Committee is
responsible for reviewing provider credentialing/
recredentialing applications that do not
meet SHP’s Administrative and Professional
Criteria. The Committee also performs related
performance monitoring. The Committee,
per SHP Board delegation, has authority to
approve/disapprove provider credentialing/
recredentialing. (ATTACHMENT B)
The Credentialing Committee is an all physician
committee, which includes representatives of
family practice, dentistry, behavioral health,
plus medical and surgical subspecialties. Staff
of the Committee includes: a contract manager,
credentialing specialist(s), SHP legal services and
Director of Provider Relations and Contracting.
Current membership and staff are listed on the
attached APPENDIX.
Annually, the Credentialing Committee reports
on its activities to the Quality Improvement
(QI) Committee. These reports will include
any changes in policies and procedures;
recommendations for the reduction,
suspension or termination of provider or facility
participation; and summary data on credentialing
efforts such as the number of site visits
conducted.
D. Credentialing Staff: The credentialing staff
verifies provider information through primary
sources, as outlined in this document. The
5
Credentialing Program Manual
credentialing staff forwards the files of providers
to the Medical Director or his/her physician
designee or Credentialing Committee (as
specified in Section IV.B.2) along with specific
information on each applicant credentialing/
recredentialing for final determination. All
credentialing information is available to all
Credentialing Committee members.
V. Provider Credentialing
A. Application
1. Providers Subject to Credentialing
SHP currently credentials physicians (MDs,
DOs), dentists, oral surgeons, podiatrists, ODs,
clinical psychologists, MSWs, SAC and CSAC,
chiropractors, and other licensed independent
providers (i.e. nurse midwives, audiologists,
PTs, OTs, SLPs, NPs, PAs, Autism providers),
with whom SHP contracts who treat members
outside the inpatient setting and who fall
within SHP’s scope of authority and action. In
addition, any provider who disaffiliates from
SHP’s network (whether voluntarily, lay off or
through termination) and later wishes to reaffiliate is subject to credentialing (if the break
in affiliation is 30 or more calendar days).
Locum tenen practitioners are credentialed in
the same manner as all other practitioners.
6
SHP currently subcontracts with Allied Health
of Wisconsin for management of chiropractic
services. Subsequently, Allied Health of
Wisconsin, per Delegation of Credentialing
Agreement, performs credentialing/
recredentialing.
SHP currently subcontracts with Essentia for
management of the medical services provided
through its own health system. Subsequently,
Essentia, per Delegation of Credentialing
Agreement, performs credentialing/
recredentialing.
SHP currently subcontracts with Aspirus
Network Inc for management of the medical
services provided through its own health
system. Subsequently, Aspirus Network Inc,
per Delegation of Credentialing Agreement,
performs credentialing/recredentialing.
SHP currently subcontracts with Megellan
Health for management of chiropractic
services. Subsequently, Megellan Health,
per Delegation of Credentialing Agreement,
performs credentialing/recredentialing.
SHP currently subcontracts with Meriter
Health Services Inc for management of the
medical services provided through its own
health system. Subsequently, Meriter Health
Services Inc, per Delegation of Credentialing
Agreement, performs credentialing/
recredentialing.
SHP currently subcontracts with University
of Wisconsin Hospital and Clinics for
management of the medical services provided
through its own health system. Subsequently,
University of Wisconsin Hospital and Clinics,
per Delegation of Credentialing Agreement,
performs credentialing/recredentialing.
SHP currently subcontracts with Ministry
Health Care Inc for management of the
medical services provided through its own
health system. Subsequently, Ministry Health
Care Inc, per Delegation of Credentialing
Agreement, performs credentialing/
recredentialing.
SHP currently subcontracts with Monroe
Clinic for management of the medical services
provided through its own health system.
Subsequently, Monroe Clinic, per Delegation
of Credentialing Agreement, performs
credentialing/recredentialing.
SHP currently subcontracts with ProHealth
Solutions for management of the medical
services provided through its own health
system. Subsequently, ProHealth Solutions,
per Delegation of Credentialing Agreement,
performs credentialing/recredentialing.
SHP currently subcontracts with Group Health
Cooperative of South Central Wisconsin for
management of the medical services provided
through its own health system. Subsequently,
Group Health Cooperative of South Central
Wisconsin, per Delegation of Credentialing
Agreement, performs credentialing/
recredentialing.
SHP currently subcontracts with ThedaCare
ACO for management of the medical services
provided through its own health system.
Subsequently, ThedaCare ACO, per Delegation
of Credentialing Agreement, performs
credentialing/recredentialing.
SHP currently subcontracts with Bellin Health
Partners for management of the medical
services provided through its own health
system. Subsequently, Bellin Health Partners
per Delegation of Credentialing Agreement,
performs credentialing/recredentialing.
SHP currently subcontracts with Holy Family
for management of the medical services
provided through its own health system.
Subsequently, Holy Family per Delegation
of Credentialing Agreement, performs
credentialing/recredentialing.
2. Site Visits/Medical Record Keeping and
Ongoing Monitoring
Site Visit/Medical Record Keeping Standards
SHP Contract Manager (CM) will, as part of
contracting, require the potential offices of
any new practice to complete and submit a
Self-Site Visit Survey form prior to signing
an Affiliated Provider Agreement. The
purpose of completion of this form is to
assess compliance with minimal SHP site
visit and medical record keeping standards
prior to contracting. In addition, a complete
copy of SHP’s Site Visit and Medical Record
Keeping Standards are attached to the form to
educate potential providers on SHP complete
performance expectations. As needed, CM may
conduct a complete on-site visit to a practice.
See Site Visit/Medical Record Keeping Review
policy for complete standards, compliance and
follow-up requirements on on-site visits.
Ongoing Monitoring
The CR 5 CM will monitor member complaints
reports, monthly, to detect deficiencies after
an initial site visit. Complaints will be reviewed
to identify practice site quality issues relating
to physical accessibility, physical appearance
and adequacy of waiting and examining room
space. If the SHP’s Practice Site Complaint
Threshold is met, the CR 5 CM will notify the
appropriate CM to conduct an office-site visit.
This visit will be conducted within 45 calendar
days of the complaint threshold being met.
In addition, SHP staff responsible for NCQA
standard QI 6, Member Satisfaction, reviews
member complaints to identify complaints
7
Credentialing Program Manual
related to the quality of an affiliated practice
sites. Staff forwards this information to CR
5 CM who will review the practice sites file
and complaint with the Medical Director.
If the below complaint threshold is met or
the Medical Director believes the complaint
warrants an on-site visit, the appropriate
Contract Manager is notified to conduct an
onsite visit. See Site Visit/Medical Record
Keeping Review policy (D167) for complete
standards, compliance and follow-up
requirements.
3. Application Process
a. The credentialing process requires
completion of a standard application for
affiliation. Any interested physician
(MD/DO) may complete an application.
Non-physician providers may complete
an application if SHP determines that a
business need exists for their services
(Section IV, page 4, letter b for details).
Applications must contain all required
information and be signed prior to
submission to SHP. SHP will return all
incomplete applications. SHP is not
required to reimburse for services
provided to members prior to credentialing
approval.
b. For new practice sites, office managers
are required to complete the Practice
Information form.
c. The application includes a statement
informing the applicant that the National
Practitioner Data Bank (NPDB) and the
relevant state licensing board will be
queried and reviewed as part of the
application process.
8
d. A signed attestation from the applicant,
indicating that the application is complete
and correct, is required. In addition, the
attestation includes questions regarding
any reason for the provider’s inability to
perform the essential functions of his/her
position with or without accommodation,
lack of present illegal drug use, history
of loss of license and felony conviction,
history of loss or limitations of privileges
or disciplinary actions, current malpractice
insurance coverage, and the completeness
and correctness of the application.
4. Primary Source Verification
SHP will collect and verify all provider
credentials in accordance with NCQA standards
for primary source verification. Applicants
will fully cooperate with SHP in obtaining
all documents requested by SHP to satisfy
primary source verification requirements
(ATTACHMENT C for verification details).
Primary source verification includes the
following components:
a. previous education, training, and board
certification (as applicable); provisional
credentialing may take place if their
education/training has been completed in
the previous 12 months but cannot be in
provisional status for more than 60 days
b. professional state licensure via query of
the appropriate professional state licensing
board
c. copy of current registered DEA certificate
or verification of a registered DEA via
National Technical Information Service
(NTIS) query or CDS via copy of current
certificate (as applicable) for the state
providing services in. For DEA or CDS
eligible practitioners who do not
prescribe medications requiring DEA or
CDS certificates, the practitioner must
provide an explanation why they do not
prescribe medications and an arrangement
for patients who need prescriptions
for medications requiring DEA or CDS
certification.
d. hospital privileges in good standing at
the hospital designated as the primary
admitting facility via attestation on the
application (as applicable)
e. sanctions by Medicare or Medicaid via the
NPDB query or CIN-BAD
f. sanctions or disciplinary actions on
licensure via query of the appropriate
professional state licensing boards and
the NPDB.
B. Administrative Review
1. Administrative Criteria
Prior to submitting an application to the
Medical Director or Credentialing Committee,
the credentialing staff determines whether
the applicant satisfies all administrative and
contracting requirements. SHP administrative
and contracting requirements include, but are
not limited to:
a. All physician and non-physician providers
must maintain their primary office in SHP’s
service area.
b. All non-physician practice sites (allied
practice sites) are affiliated based on
business need. The determination of
business need includes, but is not
limited to:
• whether or not the allied provider’ (s)
of the practice site are part of an already
affiliated practice
• the need for the allied practice site’s
expertise in a given geographic area
• the network’s ability to provide
“reasonable access” to members
• the availability of timely appointments
for members
h. history of malpractice claims or denial of
professional liability via NPDB query
• current and projected enrollment
• significant continuity of care issues
i. current, adequate malpractice insurance
per contract specifications (Section
4.04) via provider application or copy of
malpractice face sheet
• member requests
g. gaps in work history greater than 6 months
identified through review of application
and/or CV. The most recent 5 years of
relevant work history must be obtained. If
the provider has practiced fewer than five
years, the time frame starts at the date of
initial licensure.
c. An applicant’s level of professional liability
insurance must meet minimum limits
as determined by SHP and stated in the
contract.
9
Credentialing Program Manual
d. An applicant must maintain hospital
privileges in good standing to allow for
necessary member hospital admissions if
his/her practice requires it (see Hospital
Privileges policy D146).
source verification (PSV) identifies a
substantial discrepancy in information,
SHP will notify the applicant by telephone
and follow-up in writing and allow him/
her to review and correct potential PSV
erroneous information (see Provider’s Right
to Review Information Obtained During the
Credentialing/Recredentialing Process policy
D160). Information received from the NPDB
cannot be shared per federal law.
e. An applicant must have graduated from an
acceptable training program, as defined
by the appropriate state licensing or
registration agency of the applicant’s
profession, or as otherwise defined by SHP.
j. An applicant has the right, upon request,
to be informed of the status of his or
her application. Upon request from the
provider, the credentialing staff will inform
him or her of the status of the application.
The applicant will not be allowed to review
references, recommendations or other
information that is peer review protected or
information obtained from NPDB or similar
restricted sources.
f. An applicant must have completed the
appropriate post-graduate training or
residency program, as required by state
licensing agencies, SHP or NCQA. An
appropriate post-graduate training or
residency program is defined as a program
being accredited by the Accreditation
Council for Graduate Medical Education
(ACGME) in the United States or by the
College of Family Physicians of Canada
(CFPC) or the Royal College of Physicians
and Surgeons of Canada. (See Professional
Qualifications policy D155).
g. An applicant must have current unrestricted
licensure or certificate /registration to
practice in his/her profession in the state
where services are being provided.
• the physical accessibility of the office
• the physical appearance of the office
• the adequacy of waiting and examining
room space
h. An applicant must have a current and valid
DEA certificate in the state in which they
provide services, as appropriate or CDS via
copy of current certificate (as applicable)
• the availability of appointments and
follow-up with patients
• polices and procedures
• fire/safety
• the adequacy of medical record keeping
• the adequacy of medical record filing
and confidentiality
i. An applicant must not have
misrepresented, misstated or omitted
relevant or material facts on the
application, disclosure statements or
any other documents provided as part
of the credentialing process. If primary
10
k. An applicant must allow SHP to conduct a
site review and an audit of medical records,
which will include, but is not limited to:
An applicant must provide information relative
to after-hours and weekend coverage.
2. Administrative Action
If the application is complete and meets all
elements of the established administrative
and professional criteria, the Medical Director
or his/her physician designee may approve
the applicant for affiliation or reappointment.
If the application is complete but does not
meet one or more elements of the established
administrative and professional criteria, the
application is forwarded to the Credentialing
Committee for consideration.
If the application is not complete, staff
will return the application and request a
completed application. SHP then requires that
the applicant supply the missing information.
C. Credentialing Committee Process
1. Professional Criteria
Upon receipt of a completed application and
administrative review by the credentialing
staff, the application will be taken to the
Medical Director and/or Credentialing
Committee for consideration and delegated
approval action. Each applicant must satisfy
the criteria contained in this section. The
Committee reserves the right to request
additional information when reviewing
applications. In addition, the Committee
consults with affiliate providers of various
specialties, as appropriate, to review any
questionable credentials of providers.
The Committee may elect to waive one or
more criteria, if it is determined that one or
more criteria are not relevant to a particular
applicant or that noncompliance with one or
more criteria does not indicate a potential or
existing professional performance issue.
a. The applicant has not engaged in conduct
that violates state or federal law or the
ethical standards of professional conduct
governing his/her practice.
b. The applicant has not been the subject
of professional disciplinary action by a
managed care plan, insurer, clinic, hospital,
medical review board, peer review
organization, or other administrative body
or government agency. This includes
but is not limited to, the imposition of
disciplinary or administrative sanctions
for inappropriate, inadequate or tardy
completion of medical records.
c. The applicant has not been the subject of
disciplinary action by a licensing board. A
physician may receive disciplinary action
but may obtain a stay of action enabling
him/her to practice.
d. The applicant has not been sanctioned by
Medicaid or Medicare, and has not been
the subject of “adverse action.”
e. The applicant has not engaged in any
conduct resulting in a gross misdemeanor
or felony conviction, charge or indictment.
f. The applicant does not have a history of
professional liability lawsuits or other
incidents that constitute a pattern and/or
indicate a potential competency or quality
of care problem.
g. The applicant has not been involuntarily
terminated from professional employment
or a hospital medical staff or resigned
from professional employment or hospital
medical staff after knowledge of an
investigation into his/her conduct, or in lieu
of disciplinary action.
11
Credentialing Program Manual
h. The applicant has no history of denial
or cancellation or failure to renew
professional liability insurance.
i. The applicant has no current substance
abuse, medical or physical condition likely
to adversely affect the essential functions
of his/her profession or constitute a direct
threat to the health or safety of others.
2. Credentialing Committee Action
The Credentialing Committee and Medical
Director or his/her physician designee will use
good faith discretion in reviewing applications
and making credentialing decisions. The
Committee and Medical Director or his/her
physician designee will base its decisions
on any facts and circumstances it deems
appropriate and relevant.
The credentialing process will be completed
within 180 days of the date of the applicant’s
signature on the application.
• If process exceeds 180 days, the
credentialing staff will return the application
to the applicant.
• The applicant may complete a new
application or resubmit the application with
an updated signature attesting to the
accuracy and completeness of the
information.
The credentialing staff will notify the practice
within 2 business days via telephone or email
of the Committee’s credentialing decision.
Within 60 calendar days, a letter is sent to the
provider communicating SHP’s credentialing
decision.
3. Board of Directors: The SHP Board, while
delegating credentialing responsibilities to the
12
Credentialing Committee and Medical Director
or his/her physician designee, retains the
ultimate responsibility for and authority over
all credentialing decisions.
D. Appeals
Applicants who are denied initial affiliation based
on credentialing issues can appeal the denial by
following SHP’s New Provider
Appeal Policy.
While there is no appeal process for denials based
on lack of business need (Section IV, page 4, letter
b), these applicants may reapply after twelve (12)
months.
VI. Provider Recredentialing
A. Triennial Process
SHP will recredential affiliated providers using the
process outlined below, every 3 years (36 months)
with the exception of Family Health Center (FHC)
contracted providers. FHC contracted providers will
be recredentialed every 2 years (24 months). Any
provider not recredentialed within 36 or 24 months
is considered non-compliant with SHP policy. An
exception to this is if a provider is on active military
leave, maternity leave or sabbatical and will not
meet the 36/24-month recredentialing time frame
the provider’s license will be verified prior to
them seeing members and recredentialing will be
completed within 60 days of the provider’s return
to practice.
B. Recredentialing Process
1. SHP will send each affiliated provider an
App Central invite via email with their
recredentialing application, requesting review
and update of professional information.
Applications must contain all required
information and be signed prior to submission
to SHP. SHP will return any incomplete
application.
2. A signed attestation from the applicant,
indicating that the information is complete
and correct, is required. In addition, the
attestation includes questions regarding any
reason for the provider’s inability to perform
the essential functions of the position with
or without accommodation, lack of present
illegal drug use, history of loss of license and
felony conviction, history of loss or limitations
of privileges or disciplinary actions, current
malpractice insurance coverage, and the
completeness and correctness of
the application.
C. Primary Source Verification
SHP will collect and verify all recredentialing
information in accordance with NCQA standards for
primary source verification. Providers are required to
fully cooperate with SHP in obtaining all information
requested by SHP to satisfy primary source
verification requirements. Primary source verification
for recredentialing includes (ATTACHMENT D for
verification details):
1. board certification for continuance and if the
provider states that he/she became board
certified since original credentialing e.g.
ABMS Certi Facts or the American Osteopathic
Association
2. professional state licensure via query of the
appropriate professional state licensing board
3. copy of current registered DEA certificate
or verification of a registered DEA via NTIS
query or CDS via copy of current certificate (as
applicable) for the state providing services in
4. hospital privileges in good standing at the
hospital designated as the primary admitting
facility via attestation on the application (as
applicable)
5. sanctions by Medicare or Medicaid via the
NPDB query or CIN-BAD query
6. sanctions or disciplinary actions on licensure
via query of the NPDB or the appropriate
professional state licensing board
7. history of malpractice claims or denial of
professional liability via NPDB query
8. current, adequate malpractice insurance per
contract specifications (Section 4.04) via
provider application or copy of malpractice
face sheet
D. Recredentialing Criteria
SHP will evaluate an affiliated provider based on the
administrative criteria set forth in the Administrative
Criteria section and the professional criteria set
forth in the Professional Criteria section. Failure
to satisfy any of the Administrative or Professional
Criteria or have an acceptable performance profile at
recredentialing may be grounds for disaffiliation or
other disciplinary action.
E. Ongoing Performance Monitoring
If, at any time during a provider’s affiliation with SHP,
a member lodges a complaint or files a grievance
against the provider for issues concerning quality
of care or service, the Medical Director or his/her
physician designee will communicate the member’s
complaint to the provider. The provider will be
given the opportunity to respond to the member’s
13
Credentialing Program Manual
Recredentialing applications are emailed via
App Central approximately five months prior to
recredentialing due date. App Central sends out
reminder emails every week for four weeks if the
application is not activated during this time. The
credentialing staff will follow up with the provider or
contact person as needed to ensure applications and
any information needed to get the recredentialing
process complete is done. The credentialing staff
will involve the contract manager if needed.
The recredentialing process will be completed within
180 days of the date of the applicant’s signature on
the application.
G. Board of Directors
The SHP Board, while delegating recredentialing
responsibilities to the Credentialing Committee,
retains the ultimate responsibility for and authority
over all recredentialing decisions.
H. Appeals
Providers have the right to appeal a decision by the
SHP Board of Directors to deny continued affiliation
with SHP. Please refer to the Protocol for Assessing
the Quality of an Affiliated Provider Practice
(ATTACHMENT A).
VII. Listings in Provider
Directories and Other
Member Materials
Provider information that is supplied through
member materials (i.e. provider directories, member
newsletters) will be consistent with information
that was obtained during the credentialing process.
This includes the provider’s education, training, and
certification in regard to specialty areas (see Provider
Directories DLR 62).
14
VIII. Facility Credentialing
and Recredentialing
CREDENTIALING
SHP has established policies and procedures for
the initial approval and re-approval of facilities
and organizations contracted to provide services
to SHP members. The scope of facilities approved
includes Hospitals, Skilled Nursing Facilities (SNFs),
Rehabilitation Centers (RCs), Home Health Agencies
(HHAs), freestanding Ambulatory Surgical Centers
(ASCs), Residential, Inpatient and Ambulatory Mental
Health, Substance Use Facilities or Additional
Organization Facility, Hospice, End Stage Renal
(ESRDs), Portabel Imaging Suppliers, Rural Health
Clinics (RHCs), Clinical Laboratories, Federally
Qualified Health Centers (FQHCs), Day Treatment
Centers.All facilities are credentialed before
services are approved to SHP members, and are
recredentialed at least every three years.
The Provider Relations & Contracting Department
is responsible for assessing facility credentials. The
credentialing specialist coordinates this process.
A. Administrative Review
1. Administrative Criteria: All facilities that
intend to affiliate with SHP must provide the
following:
a. information about the facility, including
legal name, address, facility type and
contact person
b. a copy of the facility’s current valid
Wisconsin license (except for ASCs and
DME’s)
c. the facility’s Medicare and Medicaid
provider numbers
d. a copy of the facility’s malpractice liability
insurance declaration
e. if the facility is accredited, documentation
(certificate or letter of notification) from a
recognized accrediting body
SHP recognizes the following accreditation:
Facility Type
Accrediting Body
Ambulatory Surgical Centers (ASCs) – free standing
Joint Commission (JC), Bureau of Quality Assurance
(BQA) or Accreditation Association for Ambulatory
Health Care (AAAHC)
Home Health Agencies (HHAs)
JC or Continuing Care Accreditation Commission
(CCAC)
Hospitals
JC or HFAP
Mental Health Facilities
JC
Rehabilitation Centers (RCs)
JC or Commission on Accreditation of Rehabilitation
Facilities (CARF)
Skilled Nursing Facilities (SNFs)
JC or CARF
Chart continued on next page
15
Credentialing Program Manual
Chart continued from previous page
Facility Type
Accrediting Body
Hospice
JC or BQA
Comprehensive Outpatient Rehabilitation
Facilities (CORF)
JC, CARF, or BQA
End Stage Renal Disease Providers
JC
Portable Imaging Consultants
BQA
Rural Health Clinics (RHC)
JC or AAAASF/RHC
Clinical Laboratories
Clinical Laboratory Improvement Amendment (CLIA)
Federally Qualified Health Centers (FQHC)
JC or CLIA
2. Verification of Credentials for Accredited
Facilities: For accredited facilities, SHP will
verify that the facility has met all state and
federal licensing and regulatory requirements
and has been approved by a recognized
accrediting body by reviewing the documents
listed in the administrative criteria section.
In addition to the documents listed in the
administrative criteria section, SHP requires
the submission of the following items for the
specific facility types noted below:
• findings of the two most recent surveys from
the Centers for Medicare and Medicaid
(CMS) – SNFs and RCs
The credentialing specialist will conduct a
review of the facility’s Medicare and Medicaid
sanction history and will verify adequate
malpractice liability insurance coverage.
3. Verification of Credentials for
Non-Accredited Facilities: If a facility is not
accredited by a recognized accrediting body,
SHP requires submission of the following
information, in addition to the documents
listed in the administrative criteria section:
16
a. copy of the facility’s Quality Assurance (QA)
plan
b. copy of the facility’s medical record
keeping policies and procedures
c. copy of the facility’s medical staff service
plan that includes (if applicable) the
process for verifying individual provider
credentials
d. hospital and mental health facilities only:
copy of the facility’s Utilization Review
(UR) plan
e. SNF/RC and HHA only: copy of the Clinical
Laboratory’s Improvement Amendments
(CLIA)
f. findings of the two most recent surveys
from the State of Wisconsin Bureau of
Quality Compliance or CMS
The credentialing specialist will conduct a review
of the facility’s Medicare and Medicaid sanction
history and will verify adequate malpractice liability
insurance coverage.
In addition, if the facility’s CMS review does not meet
SHP’s standards, SHP will conduct an on-site facility
audit, as described below.
4. Site Visits for Non-Accredited Facilities:
The contract manager will conduct a quality
assessment to any site that is unable to prove
acceptable JC; AAAHC; BQA; CARF; HFAP;
AAAASF/RHC or CCAC accreditation; or CMS
review that meets SHP’s standards. SHP may
conduct a site visit to any other facility. Such
visits will be conducted in accordance with
SHP standards for site visits.
For facilities seeking initial approval, the
contract manager will evaluate medical record
policies and procedures.
For hospitals, mental health facilities and
ambulatory surgery centers, SHP will also
review a sample of at least five (5) records
verifying the credentials of individual
providers.
B. Medical Director
does not demonstrate that the facility is in good
standing with regulatory bodies, the Credentialing
Committee will withhold approval until further
review can demonstrate that the facility meets SHP
requirements.
D. Board of Directors
The SHP Board, while delegating recredentialing
responsibilities to the Credentialing Committee,
retains the ultimate responsibility for and authority
over all organizational provider credentialing/
recredentialing decisions.
RECREDENTIALING
A. Administrative Review
The Provider Relations & Contracting Department
will conduct a review of the facilities credentials no
less than every 3 years during the contract period.
1. Administrative Criteria: At the time of
recredentialing, all facilities must provide the
following:
The Medical Director or his/her physician designee
reviews facility information that meets SHP’s
Administrative Review (Section VI). The Medical
Director has the authority to approve facility
credentialing/recredentialing information that meets
SHP’s Administrative Review.
a. a copy of the facility’s current valid
Wisconsin license (except for ASCs)
C. Credentialing Committee
d. if the facility is accredited, documentation
(certificate or letter of notification) from a
recognized accrediting body
The Committee is responsible for reviewing
facility credentialing/recredentialing information
that does not meet SHP’s Administrative Review.
The Committee, per SHP Board delegation,
has authority to approve/disapprove provider
credentialing/recredentialing. If any of the required
documentation is not provided, or if the assessment
b. the facility’s Medicare and Medicaid
provider numbers
c. a copy of the facility’s malpractice liability
insurance declaration
2. Verification of Credentials for Accredited
Facilities: For accredited facilities, SHP will
verify that the facility continues to meet all
state and federal licensing and regulatory
requirements and continues its accreditation
17
Credentialing Program Manual
status. In addition to the documents listed
in the Administrative Criteria section, SHP
requires the submission of the following items
for the specific facility types noted below:
a. findings of the most recent survey from
CMS for SNFs
b. findings of the most recent survey from
CMS for RCs
The credentialing specialist will conduct a review of
the facility’s Medicare and Medicaid sanction history
and will verify continued adequate malpractice
liability insurance coverage.
3. Verification of Credentials for NonAccredited Facilities: If a facility is not
accredited by a recognized accrediting body,
SHP requires submission of the following
information at the time of recredentialing,
in addition to the documents listed in the
Administrative Criteria section:
• findings of the most recent survey from
the CMS
The credentialing specialist will conduct a
review of the facility’s Medicare and Medicaid
sanction history and will verify continued
adequate malpractice liability insurance
coverage.
In addition, if the facility’s CMS review does
not meet SHP’s standards, SHP will conduct an
on-site facility audit, as described below.
4. Site Visits for Non-Accredited Facilities:
The contract manager will conduct a quality
assessment to any site that is unable to prove
acceptable JC; AAAHC; BQA; CARF; HFAP;
AAAASF/RHC or CCAC accreditation; or CMS
review that meets SHP’s standards. SHP may
18
conduct a site visit to any other facility. Such
visits will be conducted in accordance with
SHP standards for site visits.
The contract manager will randomly select
and review a sample of at least five (5)
medical records of SHP members to determine
compliance with SHP standards for medical
records.
For hospitals, mental health facilities and
ambulatory surgery centers, SHP will also
review a sample of at least five (5) records
verifying the credentials of individual
providers.
B. Medical Director
The Medical Director or his/her physician designee
reviews facility information that meet SHP’s
Administrative Review (Section VI). The Medical
Director has the authority to approve facility
credentialing/recredentialing information that
meets SHP’s Administrative Review.
C. Credentialing Committee
The Committee is responsible for reviewing
facility credentialing/recredentialing information
that does not meet SHP’s Administrative Review
criteria. The Committee, per SHP Board delegation,
has authority to approve/disapprove provider
credentialing/recredentialing. If any of the
required documentation is not provided, or if the
assessment does not demonstrate that the facility
is in good standing with regulatory bodies, the
Credentialing Committee will withhold approval
until further review can demonstrate that the
facility meets SHP requirements.
IX. Delegated Credentialing/
Recredentialing
Security Health Plan delegates credentialing/
recredentialing of chiropractic providers to Allied
Health of Wisconsin and HSM, and Security Health
Plan delegates credentialing/recredentialing of
medical providers to Essentia, Aspirus Network Inc.,
UWHC, Ministry Health Care, Monroe Clinic, Meriter,
ProHealth Solutions, Group Health Cooperative
of South Central Wisconsin, ThedaCare ACO and
Bellin Health Partners, Holy Family. Credentialing/
recredentialing of providers may be delegated by
SHP in the event the following criteria are met by the
delegated organization (refer to delegation policy):
A. SHP and the delegated organization sign a
written contract or letter of agreement which
describes in detail the following:
1. The responsibilities of both parties
2. The delegated activities
3. The process by which SHP evaluates the
performance of the delegated organization
and
4. The remedies, including revocation of
the delegation, available to SHP if the
delegated organization does not fulfill its
responsibilities as outlined in the written
contract.
5. Agreement to comply with all applicable
Medicare laws, regulations and CMS
instructions
B. The delegated organization must have written
policies and procedures for the credentialing
and recredentialing of physicians and other
licensed health care providers, which meet or
exceed the requirements of JC or NCQA.
C.The delegated organization must have a
credentialing committee or other peer
review body that reviews applications
and makes credentialing/recredentialing
recommendations and/or decisions.
D. The delegated organization must have
documented screening criteria, which is
equivalent to or more stringent than the
screening criteria of SHP.
E. The delegated organization’s initial and
recredentialing applications must be signed
and dated by the provider and include
statements regarding:
1. Physical and mental health status
2. Lack of impairment due to illegal drug use
3. History of felony convictions
4. History of denial, revocation, suspension,
probation, disciplinary actions, reprimands,
limitation or surrender in lieu of action or
any action pending against providers for:
a. License in any state
b. DEA registration certificate
c. Hospital staff membership or privileges
and/or
d. Medicare/Medical Assistance or any
government program participation
5. Attestation to the accuracy and
completeness of information supplied by
provider and
6. Release of information statement
F. SHP will evaluate the delegated organization’s
ability to perform the delegated activities prior
to entering into a contract for delegation. SHP
19
Credentialing Program Manual
will also conduct an audit of provider files. If
the delegated organization is NCQA certified
or accredited in the areas being delegated an
evaluation and audit will not be required.
G.If the delegated organization is not NCQA
certified in the areas being delegated, SHP will
audit and evaluate no less than annually to
ensure the delegated organization’s activities
are being conducted in accordance with
SHP’s expectations and NCQA standards. This
assessment will include an audit of 5% of
files with a minimum of 10 credentialing files
and 10 recredentialing files or use the NCQA
“8/30” Methodology.
H. SHP retains the right, based on quality issues,
to approve and/or terminate individual
providers and or sites.
I. SHP requires delegated performance and
reporting requirements for Allied Health
of Wisconsin, Essentia, Aspirus Network
Inc., Health Services Management, Ministry
Health Care, Meriter, Monroe Clinic, ProHealth
Solutions,UWHC, Group Health Cooperative of
South Central Wisconsin, ThedaCare ACO and
Bellin Health Partners, Holy Family.
Credentialing/Recredentialing Process Draft –
11/02/95, Updated – 12/22/95, Reviewed/
Approved with changes by Credentialing
Committee 1/18/96, Reviewed/Approved by
the Board of Directors – 2/20/96, Presented to
Quality Improvement Committee – 4/18/96,
Reviewed and approved by New Applications
Review Committee – 11/4/97, Reviewed/revised
and approved by the Credentialing Committee
8/3/99, Revised and approved by the Credentialing
Committee 9/21/99, Revised and approved by
the Credentialing Committee 12/21/99, Revised
per policy changes 2/11/00, Revised per policy
20
changes and approved by the Credentialing
Committee 7/18/00, Reviewed/revised by the
Credentialing Committee 10/19/00, Reviewed/
revised/approved by the Credentialing Committee
6/21/01. Reviewed by the Quality Improvement
Committee August 9, 2001. Reviewed/revised/
approved by the Credentialing Committee October
3, 2002. Reviewed/approved by the Credentialing
Committee on June 5, 2003. Reviewed/revised/
approved by the Credentialing Committee on
November 6, 2003, May 6, 2004, July 7, 2005,
August 18, 2005, August 3, 2006, January 4, 2007,
February 2, 2009, January 21, 2010, January 27,
2011. January 12, 2012. January 10, 2013, October
24, 2013, January 8, 2015, October 8, 2015,
February 11, 2016. Reviewed/revised/approved by
the Credentialing Committee on January 12, 2017
Appendix A
Protocol for Assessing the Quality
of an Affiliated Provider Practice
NOT intended for routine recredentialing but for
exceptional circumstances.
• Under the direction of SHP’s Board of
Directors, the SHP chief medical officer
(Medical Director) and/or his/her physician
designee shall have the responsibility
and authority to review and evaluate the
professional activities and conduct, as well as
the utilization of services and reasonableness
of charges, of affiliated providers regarding
SHP members. Such review shall be performed
in accordance with this document, the
Affiliated Provider Contract and sections
146.37 and 146.38 of the Wisconsin statutes.
For purposes of this document, affiliated
providers include the following: affiliated
physicians (including SHP sponsor
physicians) affiliated hospitals, and all other
health care providers affiliated with SHP or
reimbursed by SHP.
Practices of affiliated providers may be
reviewed on the basis of any of the following:
index cases suggesting possible quality of
care and/or service problems; data generated
through SHP’s Quality Improvement Program;
charging patterns; utilization of medical
services; failure to adhere to the rules and
regulations of SHP; or any other matter
involving the care and treatment of
SHP members.
The purpose of review shall be to evaluate
an affiliated provider’s practice in relation
to affiliation with SHP. Documentation may
include positive and negative elements
of a practice and affiliation, which shall
be communicated to the provider. Where
indicated, SHP’s Medical Director, his/her
physician designee, any other affiliated
provider, SHP’s Credentialing Committee,
or SHP’s Quality Improvement Committee
may suggest corrective action. Requests for
corrective action shall be in writing where
appropriate, and shall be supported by
reference to the specific activities or conduct,
which constitute the grounds for the request.
• In addition to the review anticipated in the
section above, whenever the professional
activities or conduct, as well as the utilization
of services or reasonableness of charges of
any SHP affiliated provider is considered to
be unacceptable to the affiliated provider’s
professional peers, or are judged to be
seriously disruptive to SHP operations,
corrective action may be requested by any
affiliated provider or SHP member. All requests
for corrective action shall be in writing and
shall be made to SHP’s Medical Director
or his/her physician designee, and shall
be supported by reference to the specific
activities or conduct, which constitute the
grounds for the request.
• SHP’s Medical Director, and/or his/her
physician designee, shall investigate
and evaluate the complaint and, where
appropriate, may meet with and counsel the
affiliated provider and inform the provider
of those areas wherein it is considered
that the professional activities or conduct,
utilization of services or reasonableness of
charges are unacceptable. Alternatively, SHP’s
21
Credentialing Program Manual
Medical Director may refer the matter to the
Credentialing Committee for investigation and
evaluation.
• If the affiliated provider fails to improve the
activities or conduct in question within 60
days after being directed to do so by SHP’s
Medical Director and/or his/her physician
designee, the matter may be referred to SHP’s
Credentialing Committee.
• In those cases where a matter is referred to the
Credentialing Committee, the Credentialing
Committee will investigate and implement
peer review, as appropriate to evaluate the
provider’s practice and/or affiliation. The
affiliated provider shall, as appropriate, be
evaluated as to the ability to diagnose and
treat patients, the ability to work with others,
patient relationships, utilization of services,
and charging patterns. In addition to the
foregoing, the Credentialing Committee
may consider the following elements in its
investigation: adequacy of medical records,
ethical behavior, judgment, patient complaints,
and complications from patient care, use as
a consultant, and proper use of consultants,
technical proficiency and procedure for filing
claims. The affiliated provider shall have an
opportunity to meet with the Credentialing
Committee to discuss, explain or refute the
activities or conduct in question.
22
SHP’s Credentialing Committee shall prepare
a recommendation and report that includes
the reasons for the action within 30 days of
referral to the Committee unless additional
information is needed. This report shall
be sent certified mail and will advise of
the appeal rights referenced below. The
Committee may, where indicated, recommend
further professional training, a limitation in the
provider’s practice, a limitation on utilization of
services or charging practices, or disaffiliation
as a SHP affiliated provider. Additionally,
the Committee may recommend better
work habits; improvement in interpersonal
relationships, peer supervision, or the
Committee may recommend counseling or
impose other sanctions. The affiliated provider
shall have an opportunity to meet with the
Committee to discuss, explain or refute the
activities or conduct in question.
• An affiliated provider may, within thirty
days after receipt of a copy of SHP’s
Credentialing Committee’s report, appeal the
recommendation and report to SHP’s Quality
Improvement Committee. SHP’s Quality
Improvement Committee may accept the SHP
Credentialing Committee’s report or substitute
its own recommendation and report after
its own investigation. The affiliated provider
shall have the opportunity to meet with SHP’s
Quality Improvement Committee to discuss,
explore, or refute the activities or conduct
in question. The affiliated provider shall
receive a copy of SHP’s Quality Improvement
Committee’s report.
• As an alternative appeal mechanism, in lieu
of (but not in addition to) appealing SHP’s
Credentialing Committee’s recommendation
and report to SHP’s Quality Improvement
Committee, an affiliated provider may request
a meeting before a three-member panel
appointed by SHP’s Credentialing Committee
Chair. Two of the three panel members will be
in a practice similar to the affected provider.
None of the three panel members shall be in
direct economic competition with the affiliated
provider in question. If the affiliated provider
requests a meeting, SHP shall give at least 30
days notice regarding the place, time and date
of the meeting. The meeting will be chaired by
the Chair of the Credentialing Committee. The
Panel shall prepare a recommendation and
report.
• SHP shall allow the affiliated provider to be
represented by an attorney or another person
of their choice.
• SHP’s Quality Improvement Committee may
accept the panel’s report, as appropriate,
or substitute its own recommendation and
report after its own investigation. The affiliated
provider shall receive a copy of Quality
Improvement Committee’s decision, which
shall be final. (See SHP’s Reporting Serious
Quality Deficiencies and/or Adverse Clinical
Privileges Actions policy)
• Notwithstanding the above, SHP’s Medical
Director and/or his/her physician designee,
shall have the authority, whenever action
must be taken immediately in the best
interest of SHP members, to summarily
suspend all or any portion of the affiliation of
an affiliated physician or provider and such
summary suspension shall become effective
immediately upon imposition. An affiliated
provider whose affiliation has been summarily
suspended or limited shall have the right,
upon request to SHP’s Quality Improvement
Committee, to have the suspension reviewed
de novo by SHP’s Quality Improvement
Committee within 7 days of the suspension.
Original October 7, 2004 signed document on
file in Legal Services Department. Reviewed and
approved by the Board of Directors on 12/19/95.
Document reviewed by the Credentialing Committee
on 01/18/96 and approved with changes. Presented
to and approved by the Quality Improvement
Committee on 04/18/96. Reviewed and approved
by Credentialing Committee on 02/03/98.
Reviewed and approved by the Credentialing
Committee on 08/03/99. Reviewed and revised by
the Credentialing Committee 09/21/99. Revised
per policy changes February 8, 2000. Reviewed/
revised by the Credentialing Committee October
19, 2000. Reviewed/revised/approved by the
Credentialing Committee June 21, 2001. Reviewed
by the Credentialing Committee October 3, 2002.
Reviewed by the Credentialing Committee December
18, 2003. Reviewed/revised by the Credentialing
Committee October 7, 2004, July 7, 2005, August 10,
2006, January 24, 2008, February 2, 2009, January
21, 2010, January 27, 2011, Document reviewed by
the Credentialing Committee on January 10, 2013
and approved with changes. Document reviewed by
the Credentialing Committee on October 24, 2013
and approved with changes. Document reviewed by
the Credentialing Committee on October 8, 2015
and approved with changes. Document reviewed by
the Credentialing Committee on February 11, 2016
and approved with changes. Document reviewed
by Medical Director and approved with changes
8/15/16. Document reviewed by the Credentialing
Committee on October 13, 2016 and approved with
changes. Document reviewed by Medical Director
and approved with changes 10/24/16. Reviewed/
revised/approved by the Credentialing Committee
on January 12, 2017
On motion duly made and seconded, Credentialing
Committee of Security Health Plan of Wisconsin, Inc.,
this 8th day of October 2015, reviewed the above
protocol for annual approval.
Deepa Varghese, MD
SHP Credentialing Committee Chair
23
Credentialing Program Manual
Appendix B
Committee Descriptions – Security
Health Plan Quality Improvement
CREDENTIALING COMMITTEE
PURPOSE: To assure that SHP providers are of high
quality and provide a high level of service to SHP
members.
MEETINGS: Twice a month
REPORTS TO: Quality Improvement Committee
CHAIR: Medical Director or his/her physician
designee
VOTING MEMBERS: Six or more physicians to include
representatives of family practice, behavioral
health, internal medicine, plus medical and surgical
subspecialties
ATTENDING STAFF: Director of Provider Relations
& Contracting, Contract Manager, (2) Credentialing
Specialist, Chief Executive Officer ad hoc, Legal
Services Representative and Contract Manager(s)
ad hoc
QUORUM: Minimum of 3 voting members present for
Committee to conduct business
RESPONSIBILITIES:
1) Reviews/approves the Administrative and
Professional Criteria used by the Medical
Director to make credentialing/recredentialing
decisions. The Credentialing Committee
has delegated to the Medical Director the
authority to approve provider and facility
credentialing/recredentialing applications that
meet SHP’s Administrative and Professional
Criteria and facility Administrative Review.
24
2) Review credentials of and approve or
disapprove affiliation of applicant providers
that do not meet one or more of SHP’s
Administrative and Professional Criteria.
3) Review credentials, peer review materials,
complaints and other information as
appropriate to approve/disapprove continued
affiliation of SHP providers.
4) Guide the development, establish standards
for and participate in provider performance
monitoring including:
• assessment of provider performance
• evaluation of provider complaints
• review of specific provider or practices as
needed
5) Conduct both initial and ongoing assessment
reviews (at least every 3 years) of facilities
and other organizational providers with
which SHP contracts to provide services
to members. The focus of these reviews is
to determine if the facility meets licensing
and regulatory requirements and other
credentialing standards set by SHP. The
Credentialing Committee will credential/
recredential the following: hospitals, skilled
nursing facilities, home health agencies,
free-standing ambulatory surgery centers and
residential, inpatient and ambulatory mental
health facilities, durable medical equipment,
orthotics and prosthetics suppliers, hospice,
comprehensive outpatient rehabilitation
facilities (CORF), end-stage renal providers,
portable imaging suppliers, rural health clinics
(RHC), clinical labs, and federally qualified
health centers (FQHC).
6) Create and annually review/revise SHP’s
Credentialing Program Description.
7) Provide feedback and direction to the
Credentialing Specialists and Contract
Manager on the implementation of
credentialing and recredentialing policies and
procedures.
8) Initially approve, and annually evaluate the
performance of, any agency delegated to
provide credentialing or recredentialing
services for SHP.
APPROVED:
Quality Improvement Committee (as part of QI
Program Description) 01/21/99. Credentialing
Committee 02/02/99. Reviewed/revised and
approved by the Credentialing Committee 08/03/99.
Approved by the QI Committee 2/10/00 via the
Credentialing Program Description. Reviewed/
revised and approved by the Credentialing
Committee October 19, 2000. Reviewed/revised
and approved by the Credentialing Committee
June 21, 2001. Reviewed/revised/approved by
the Credentialing Committee October 3, 2002.
Reviewed/revised/approved by the Credentialing
Committee November 6, 2003. Revised March 16,
2004 due to changes in committee membership.
Reviewed/approved as part of Credentialing Program
Description July 7, 2005, January 24, 2008, February
2, 2009, January 21, 2010, January 27, 2011, January
12, 2012, Revised/reviewed/approved by the
Credentialing Committee January 10, 2013. Revised/
reviewed/approved by the Credentialing Committee
October 24, 2013, January 8, 2015, October 8, 2015,
February 11, 2016. Reviewed/revised/approved by
the Credentialing Committee on January 12, 2017
25
Credentialing Program Manual
Appendix C
Credentialing Primary Source Verification Details
Item
Source of Verification
Method
1. Current valid state
professional license
Query of the issuing state’s licensing
board
As of October 1999 verification is
obtained on-line with the State of
Wisconsin. For providers licensed
in Minnesota, Illinois or Michigan,
licensure verification is obtained
on-line for the applicable state.
2. Privileges in good
standing at a SHP
hospital (MD or DO) or
Admitting Agreement
Applicant
Completed application
SHP requires an explanation when a
provider indicates he/she does not
have hospital privileges or has applied
for hospital privileges.
For FHC contracted providers, the
hiring entity retains the responsibility
of retaining privileges on file.
3. DEA or CDS
Copy of certificate or National
Technical Information Service (NTIS)
The States of Wisconsin, Minnesota
and Illinois do not require CDS
certification, Michigan does.
Verification of registered DEA via
online NTIS query for the state
providing services in, copy of current
CDS certificate for Michigan providers
OR
If the provider’s DEA is pending, SHP
requires written confirmation that
an affiliated provider, with a valid
registered DEA certificate for the state
providing services in, will
sign-off on all prescriptions requiring
a DEA number until the subscribing
provider’s DEA is finalized
OR
If a provider is qualified to prescribe
a medication requiring a DEA or CDS
certificate, but chooses not to, SHP
will obtain an explanation of why the
practitioner is not prescribing. The
explanation will include arrangements
for the providers patients who
need prescriptions for medications
requiring DEA or CDS certification.
26
Item
Source of Verification
Method
4. a. Board certification
American Board of Medical Specialists
(ABMS) or American Osteopathic
Association (AOA) or American
Board of Podiatric Orthopedics
and Primary Podiatric Medicine
(ABPOPPM), American Board of
Oral and Maxillofacial Surgery
(ABOMS) or American Board of
Podiatric Surgery (ABPS) or American
Medical Association (AMA) physician
master file or or American Medical
Association (AMA) physician profile
Royal College of Physicians &
Surgeons of Canada
Credentialing staff verifies the ABMS
by on-line verification.
Residency Program Director or
State of Wisconsin Department of
Regulation and Licensing or American
Medical Association (AMA) physician
master file or American Medical
Association (AMA) physician profile
Letter to Residency Program Director,
oral verification, or copy of State of
Wisconsin proof of primary source
verification letter. Credentialing staff
verifies the AMA online.
State of Wisconsin Department of
Regulation and Licensing or National
Student Clearinghouse
Letter to Office of the Registrar of
Medical School or copy of State of
Wisconsin proof of primary source
verification letter or on-line query to
National Student Clearinghouse.
OR
b. Residency
completion (MD, DO
or DDS only)
OR
c. Graduation from
professional school (for
DCs, DDSs, or DPMs), and
all other non-physician
providers.
Credentialing staff verifies the
AOA, ABPOPP, and ABPS by direct,
written, on-line or verbal verification.
Credentialing staff verifies the AMA
online.
Credentialing staff verifies Royal
College of Physicians & Surgeons of
Canada online.
SHP allows 60 days of provisional
credentialing for those providers
who completed a residency or
fellowship 12 months prior to the
SHP Credentialing Committee and/
or Medical Director decision. The
provisional file is maintained by
the credentialing specialist(s).
Verification letter/telephone call is
placed and tracked bi-weekly. Upon
verification of residency or fellowship
completion and notification to the
Credentialing Committee or Medical
Director, provisional status will end
and provider’s profile sheet will be
updated to reflect verification.
27
Credentialing Program Manual
Item
Source of Verification
Method
5. Work history
Applicant
Completed application or curriculum
vitae
SHP reviews any gap in work history
of greater than 6 months. Any work
history gap that exceeds 1 year is
clarified in writing.
SHP obtains a minimum of 5 years
of relevant work history. Relevant
experience includes work as a health
professional. If the provider has
practiced fewer than 5 years from the
date of credentialing, the work history
starts at the time of initial licensure
6. Malpractice insurance
Applicant/copy of face sheet or
completed application
Copy of current malpractice declaration
with amounts and dates of coverage
OR
Completion of malpractice coverage
information on SHP’s credentialing
application
28
7. Professional liability
claims history
National Practitioner Data Bank
(NPDB)
On-line electronic report from NPDB.
8. Medicare sanction
activity
NPDB or Computer Information
Network-Board Action Databank
(CIN-BAD)
On-line electronic report from NPDB
or CIN-BAD
9. Medicaid sanction
activity
NPDB or Computer Information
Network-Board Action Databank
(CIN-BAD)
On-line electronic report from NPDB
or CIN-BAD
10. Adverse action
reports
NPDB and state licensure
On-line electronic report from NPDB
and query to state licensing boards
11. Health Fitness –
ability to perform without
direct threat to the health
or safety of others.
Credentialing application disclosure
question.
Disclosure question on the
credentialing application.
12. Government issued
photo ID, immunization
status, life support
training, verification of
competency
Hiring entity
For FHC contracted providers, the
hiring entity retains the responsibility
of retaining these components on file
Written statement of malpractice
and liability claims and issues from
applicant.
Appendix D
Recredentialing Primary Source Verification Details
Item
Source of Verification
Method
1. Current valid state
professional license
Query of the issuing state’s licensing
board
As of October 1999 verification is
obtained on-line with the State of
Wisconsin. For providers licensed
in Minnesota, Illinois or Michigan,
licensure verification is obtained online for the applicable state.
2. Privileges in good
standing at a SHP
hospital (MD or DO) or
Admitting Agreement
Applicant
Completed application
SHP requires an explanation when a
provider indicates he/she does not
have hospital privileges or has applied
for hospital privileges.
For FHC contracted providers, the
hiring entity retains the responsibility
of retaining privileges on file.
3. DEA or CDS
Copy of certificate or NTIS for DEA
The State of Wisconsin does not
require CDS certification.
Copy of current registered DEA
certificate or verification of registered
DEA via NTIS online query for the
state providing services in, copy of
current CDS certificate for Michigan
providers.
If the provider has not renewed
his/her DEA, SHP requires written
confirmation that affiliated providers
with a valid registered DEA certificate
for the state providing services in, will
sign-off on all prescriptions requiring
a DEA number until the subscribing
provider’s DEA is finalized
OR
If a provider is qualified to prescribe
a medication requiring a DEA or CDS
certificate, but chooses not to, SHP
will obtain an explanation of why the
practitioner is not prescribing. The
explanation will include arrangements
for the provider’s patients who
need prescriptions for medications
requiring DEA or CDS certification.
29
Credentialing Program Manual
Item
Source of Verification
Method
4. Board certification
American Board of Medical Specialists
(ABMS) or American Osteopathic
Association (AOA) or American
Board of Podiatric Orthopedics
and Primary Podiatric Medicine
(ABPOPPM), American Board of Oral
and Maxillofacial Surgery (ABOMS) or
American Board of Podiatric Surgery
(ABPS) Royal College of Physicians &
Surgeons of Canada
Credentialing staff verifies the ABMS
by on-line verification.
Applicant/copy of face sheet or
completed application
Copy of current malpractice
declaration with amounts and dates of
coverage.
5. Malpractice insurance
Credentialing staff verifies the AOA,
ABPOPP, and ABPS by direct, written,
on-line or verbal verification.
Credentialing staff verifies Royal
College of Physicians & Surgeons of
Canada online.
OR
Completion of malpractice coverage
information on SHP’s recredentialing
application.
30
6. Professional liability
claims history
National Practitioner Data Bank
(NPDB)
On-line electronic report from NPDB.
7. Medicare sanction
activity
NPDB or CIN-BAD
On-line electronic report from NPDB
or CIN-BAD
8. Medicaid sanction
activity
NPDB or CIN-BAD
On-line electronic report from NPDB
or CIN-BAD
9. Adverse action reports
NPDB and state licensure
On-line electronic report from NPDB
and query to state licensing boards
10. Health Fitness –
ability to perform without
direct threat to the health
or safety of others
Recredentialing application disclosure
question
Disclosure question on the
recredentialing application
11. Government issued
photo ID, immunization
status, life support
training, verification of
competency
Hiring entity
For FHC contracted providers, the
hiring entity retains the responsibility
of retaining these components on file
Written statement of malpractice
and liability claims and issues from
applicant.
1515 N Saint Joseph Avenue
PO Box 8000
Marshfield, WI 54449-8000
1-800-472-2363
715-221-9555
TTY 711
HP-00130 (01/17)
© 2017 Security Health Plan of Wisconsin, Inc.