Credentialing

• Who is Credentialed?
• Purpose of Credentialing
• Credentialing Standards
• Termination
• Delegated Credentialing

Practitioners: Medical Doctor (MD), Doctor of Osteopathy (DO), Doctor of Podiatric Medicine (DPM), Doctor of Chiropractic (DC), Doctor of Dental Medicine (DMD), Doctor of Dental Surgery (DDS),

Extenders: Physician Assistant (PA), Certified Nurse Practitioner (CRNP), Certified Nurse Midwife (CNM),

Facility and Ancillary Service Providers: Hospitals, nursing homes, skilled nursing facilities, home health, home infusion, and hospice agencies, rehabilitation facilities, freestanding surgery centers, and freestanding radiology centers.

To conduct thorough background investigation of the qualifications of practitioners, facilities, and ancillary service providers applying for affiliation and for continued participation with Gateway to ensure that only the most qualified practitioners, facilities, and ancillary service providers care for our members.

Credentialing Standards

Gateway has established policies and procedures for the credentialing and recredentialing of practitioners.  All information must be current and up-to-date to begin the credentialing process.  Therefore, it is important to submit all applications and attachments in a timely manner with the most current information available.  This includes physician extenders (CRNPs, CNMs, and PAs) who are required to submit a copy of their collaborative/written agreement with a Gateway participating practitioner.  This agreement should include the extender's responsibilities and must be signed by both the extender and the Gateway participating practitioner. Any time there is a change in the extender's supervising physician, they will be required to submit to Gateway, a current copy of his/her new collaborative/written agreement as indicated in his/her approval letter. It is important to note that physician extenders, with the exception of nurse midwives, are not issued individual provider numbers, and thus are not permitted to bill separately for services. The credentialing/recredentialing process involves verification of practitioner credentials.  Some items verified during the process are:  active licensure, DEA, MPI number, malpractice insurance coverage and claims history, board certification, education and training, CMEs, hospital privileges, work history and professional references. Gateway's Credentialing Department will notify practitioners in writing or verbally within thirty (30) calendar days of receiving any information obtained during the credentialing process that varies substantially from the information provided by the practitioner. Practitioners have the right to correct erroneous information submitted by another party or to correct his or her own information submitted incorrectly.  Applicants have fourteen (14) calendar days from the date of Gateway's notification to submit written corrections and supporting documentation to Gateway Credentialing Department.  A credentialing decision will not be rendered until the fourteen calendar (14) days have expired.  Practitioners upon request, have the right to be informed of the status of their credentialing or recredentialing application.  Practitioners also have the right to review any information submitted in support of their credentialing applications except for National Practitioner Data Bank reports, letters of recommendation, and information that is peer review protected.  A practitioner must submit a written request to review their credentialing information.  All appropriate credentialing information will be sent by Certified Mail, overnight mail or carrier to the practitioner within fourteen (14) days from the date that the Credentialing Department received the request.  All practitioners must be recredentialed every 2 years in order to continue their participation with Gateway.  This helps to ensure Gateway's continued compliance with National Committee for Quality Assurance, Department of Public Welfare, and Department of Health regulations.  Extensions cannot be granted. 

Gateway is committed to protecting the confidentiality of all practitioner information obtained by the Credentialing Department as outlined in Gateway's Confidentiality of Practitioner/Provider Credentialing Information Policy and Procedure.

If a practitioner does not meet Gateway's baseline credentialing criteria or fails to submit information and/or documentation within requested time frames, processing of the practitioner application may be discontinued.  All requests for recredentialing updates must be completed and returned in a timely manner.  Failure to do so could result in termination of participation.In accordance with Gateway's business practices, the inclusion of a practitioner in the Gateway Practitioner/Provider Network is within the sole discretion of Gateway, however, Gateway does not make credentialing decisions based on an applicant, type of procedures performed, or a practitioner's specialty, marital status, race, color, religion, ethnic/national origin, gender, age, sexual preference or disability.  Gateway understands and abides by the Federal Regulation of the Americans with Disability Act whereby no individual with a disability shall on the sole basis of the disability, be excluded from participation.

Practitioners, who want to appeal a denial or a termination decision based on quality of care concerns, are handled according to Gateway's Due Process Policy and Procedure.  Practitioners who want to appeal a decision, denial or termination other than quality of care concerns must submit written appeal letter and supporting documentation to Gateway within thirty (30) calendar days of the certified notification to warrant consideration.  For information regarding all of the requirements for credentialing and recredentialing, which each practitioner must meet, please contact the Credentialing Department at 1-412-255-4320.

Delegation is the formal process by which Gateway has given other entities the authority to perform credentialing functions on our behalf.  Gateway's present delegates have been approved to perform data collection, primary verification and practitioner approval on behalf of Gateway.