1. Credentialing/Recredentialing Criteria
All Practitioners must complete the Chartered credentialing process prior to their inclusion in the network.
Council for Affordable Quality Healthcare Process (CAQH)
Chartered Health Plan has identified an efficient process for credentialing/ recredentialing practitioners through CAQH. CAQH stands for Council for Affordable Quality Healthcare. It is a not-for-profit organization that is a catalyst for industry collaboration on initiatives that simplify healthcare administration.
CAQH promotes quality interactions between health plans and providers. When a practitioner completes the on-line application with CAQH that practitioner has the ability to utilize one application for many different health plans. This reduces time, cost and frustrations associated with healthcare administration. It takes approximately 1.5 hours to complete one application. When filling out paper applications for several different health plans it may take several hours.
For more information on CAQH you can contact the Chartered Health Plan Provider Relations Department at (202) 408-2237 or go to the CAQH website at http://www.caqh.org/
1.1. Initial Credentialing
A Practitioner is eligible to be credentialed if they:
The credentialing process begins when the Practitioner submits a completed, signed and dated credentialing application and Consent and Release Form accompanied by copies of their state license, DEA or CDS, malpractice face sheet, and curriculum vitae. The Credentialing staff will then complete Primary Source Verification (PSV). In addition, site reviews will be conducted for all Practitioners utilizing the Office Site Review Tool. The Medical Practitioner Office Site Evaluation Standards and Site Evaluation Tool are available below. The Behavioral Health Practitioner Office Site Evaluation Standards and Office Site Evaluation Tool are also available below. The application, PSV and site review results are forwarded to the Credentialing Committee for a decision. The Credentialing Committee consists of participating network Practitioners. All Practitioners are sent written notification of initial credentialing/recredentialing decisions.
- Hold a current un-restricted license to practice in their profession in the District of Columbia
- Hold a current Federal Drug Enforcement Agency (DEA) Certificate or Controlled Dangerous Substance (CDS) certificate, if applicable
- Hold the current malpractice insurance limits for their specific discipline as required by Chartered
- Agree to provide information on sanctions and/or disciplinary action imposed by any other health institution, professional health care organization, licensing authority and/or regulatory body, including voluntary or involuntary limitation, reduction, or loss of clinical and/or technical skills, and current competence.
- Demonstrate a degree of professional competence comparable to other network Practitioners in their specialty, as well as the ability to deliver cost effective health care and meet the geographic, specialty and business needs of Chartered
- Agree to participate in all quality management activities required by Chartered’s Quality Management Department.
- Provide information, which pertains to all education, training, and board certification information.
- Provide professional work history to include the beginning and ending month for each position listed. A gap in work history that exceeds one year must be clarified in writing.
All Practitioners must be recredentialed within two years of their last credentialing date. Chartered re-verifies the information that is subject to change over time. Static historical elements such as education are not re-verified. The intent of the recredentialing process is to identify any changes in the practitioner’s licensure, sanctions, certification, clinical privileges, competence, or health status that may affect the Practitioner’s ability to perform the services that they are under contract to provide. Chartered collects and conducts primary source verification on all recredentialing information and documentation. In addition, the recredentialing process incorporates an assessment of the practitioner’s performance with Chartered, which includes medical record review, access and site reviews, member complaints, member satisfaction, and information from quality improvement and Medical Management activities.
Medical Practitioner Office Site Evaluation Standards*
Medical Practitioner Site Evaluation Tool*
Behavioral Health Practitioner Office Site Evaluation Standards*
Behavioral Health Practitioner Office Site Evaluation Tool*
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