Participation Guidelines

All practitioners wishing to participate with The Health Plan must be credentialed. Our Provider Relations Department has formulated a descriptive credentialing policy and procedure that are reviewed annually to assure compliance with NCQA (http://www.ncqa.gov), Medicare/Medicaid (http://www.cms.hhs.gov), and any state or regulatory agency requirements.

The Health Plan has established participation guidelines. To ensure practitioners are qualified and meet participation standards the following information is evaluated, stored, and maintained current:

• Office Location(s)
• Accepting New Patients – Updated as needed and including every three (3) years during re-credentialing process.
• Board Certification of MDs and Dos (if not Board Certified, education and residency training.) Updated every three (3) years during re-credentialing process.
  American Board of Medical Specialties (http://www.abms.org) – verification tool for Medical Board Certification
  American Osteopathic Association (http://www.ostepathic.org) – verification tool for verification of Osteopathic specialty
• Hospital Admitting Privileges – Updated as needed but every three (3) years during re-credentialing process.
• Medical Group Affiliation – if available.
• Languages spoken in office – Self reported.

All hospitals are required to be JCAHC (http://www.jointcommission.org), DNV/NIAHO (http://www.dnv.com/industry/healthcare), American Osteopathic Association (AOA)(http://www.osteopathic.org), CARF (applicable to Rehabilitation Facilities and Mental Health Facilities)(http://www.carf.org), and HFAP (Healthcare Facilities Accreditation Program(http://www.hfap.org) accredited and in good standing with Medicare and are not followed by expiration of these certifications.

The Durable Medical Equipment (DME) providers and Infusion providers shall be JCAHO (Joint Commission Accreditation of Hospital Organizations) (http://www.jointcommission.org), CHAPS (Community Health Accreditation Program) (http://www.cdc.gov/nccdphp/dach/chaps), or HQAA (Healthcare Quality Association on Accreditation)(http://www.hqaa.org) accredited or in the process of obtaining accreditation.