Credentialing

• Purpose of Credentialing
• Who is Credentialed?
• Credentialing Standards
• Ongoing and Performance Monitoring
• Military Leave Process
• Denial and Termination
• Delegated Credentialing

Credentialing is the process of performing a background investigation, as well as validation of a practitioner and provider's credentials and qualifications. The credentialing and recredentialing processes also encompass a complete review of, to include but not limited to, malpractice histories, quality of care concerns and licensure status. Gateway prides itself on the integrity and quality of the composition of the practitioner and provider networks.

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), Doctor of Optometry (OD), Doctorate of Psychology (Ph.D), and Doctorate of Philosophy (Ph.D). (This listing is subject to change.)

Extenders: Physician Assistant (PA), Certified Nurse Practitioner (CRNP), and Certified Nurse Midwife (CNM). (This listing is subject to change.)

Facility and Ancillary Service Providers:

Gateway has established credentialing and recredentialing policies and procedures that meet CMS, DOH, DPW, ODI and NCQA standards.

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.

In addition, extenders (PAs, CRNPs, and CNMs) are required to submit a copy of their collaborative/written agreement with a Gateway participating supervising practitioner. This agreement should include the extender’s responsibilities and must be signed by both the extender and the Gateway participating supervising practitioner. Any time there is a change in the extender’s supervising physician, the extender will be required to submit to Gateway, a current copy of his/her new collaborative/written agreement as indicated in his/her approval letter. Where applicable, the submittal of the collaborative/written agreement to Gateway must include a copy of the letter of approval from the State.

Gateway’s standards, include but are not limited to, the following:

• Active individual Master Provider Index (MPI) number
• Active status of participation in the Medicare and/or Medical Assistance Programs and free of sanctions
• Acceptable malpractice history
• Unexpired professional liability coverage of no less than $500,000 per occurrence, $1,500,000 per aggregate and coverage provided by the Medical Care Availability and Reduction of Error Fund (Mcare) or Federal Tort Coverage
• Licensure in good standing
• Active staff/clinical privileges (where applicable) in appropriate specialty that are current and in good standing
• Chiropractors are exempt from hospital privileges
• Board certification is required in certain geographic locations
• Board certification may be exempt in rural areas with acceptable CME documentation
• Board intent is considered on a case by case basis – certain standards apply
• Foreign graduates must submit an ECFMG certificate
• Gateway recognizes the American Board of Medical Specialties (ABMS)
• Acceptable references
• Copy of valid DEA certificate
• Fully completed and signed application
• Curriculum Vitae and/or Work History to include month and year
• Other items as deemed appropriate

The credentialing/recredentialing process involves primary sourced verification of practitioner credentials.

Gateway’s Credentialing Department will notify practitioners, in writing, within ten (10) business days of receiving any information obtained during the credentialing or recredentialing 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 ten (10) business days from the date of Gateway’s notification to submit written corrections and supporting documentation to Gateway’s Credentialing Department. A credentialing decision will not be rendered until the ten (10) business 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 (NPDB) and/or Healthcare Integrity Practitioner Data Bank (HIPDB) 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 at least every three (3) years in order to continue participation with Gateway. This helps to ensure Gateway’s continued compliance with National Committee for Quality Assurance (NCQA), Department of Public Welfare (DPW), Center for Medicare and Medicaid Services (CMS), Department of Health (DOH) and the Ohio Department of Insurance (ODI) regulations, as well as to uphold the integrity and quality of the networks. Extensions of this timeframe will only be considered in the event the practitioner is on maternity leave, military leave or sabbatical. Otherwise extensions cannot be granted.

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

Gateway’s Credentialing Department conducts ongoing monitoring of sanctions, licensure disciplinary actions and member complaints.

Sanction information is reviewed by utilizing the Office of Inspector General’s (OIG) report, the Medicare Opt Out Listing (CMS), the Excluded Parties Listing Service (EPLS) and MediCheck in Pennsylvania. Information can also be obtained from the American Medical Association (AMA) and the Healthcare Integrity Practitioner Data Bank (HIPDB) as needed.

On a monthly basis monitoring of limitations on licensure is conducted by utilizing Pennsylvania State Board of Medicine listing, as well as the Ohio State Board listing.

If a Gateway participating practitioner is found on the OIG, Medicare Opt Out List, or State Board of Medicine disciplinary action report, the practitioner’s file is immediately pulled for further investigation. Depending on severity level of the sanction, the practitioner may be sent to the Medical Director for review and recommendation, sent to Quality Improvement/Utilization Management Committee for review and decision and/or immediately terminated. In all instances, the information is reported to the QI/UM Committee.

Monitoring of Member Complaints is conducted on a monthly basis. The Gateway Credentialing Department runs and reviews a complaint report, which reveals member complaints, filed against practitioners. The Credentialing Department will review and investigate all complaints regarding: attitude of provider, provider treatment, quality issues of physician, and any complaints regarding adverse events. If after investigation the complaint is considered viable, it is documented. Depending upon the severity level of the complaint(s), the practitioner may be sent to the Medical Director for review and recommendation, sent to Quality Improvement/Utilization Management Committee for review and decision and/or immediately terminated and outcome presented to Quality Improvement/Utilization Management Committee.

Gateway’s recredentialing process includes a comprehensive review of a practitioner’s credentials, as well as a review of any issues that may have been identified through a member complaint report and/or quality of care database.

Gateway continues to follow a special process for practitioners called to active military leave. It is however, up to the practitioner or their office to notify Gateway that the practitioner has been called to active duty and approximately when they will be leaving and returning. The letter should also include the practitioner who will be covering during his or her leave. The Gateway Credentialing Department will not terminate the practitioner if they are called to active duty and have coverage. Practitioner/practitioner’s office should notify Gateway of practitioners return, as soon as possible, but not exceeding 14 days from the practitioners return to the office. The Gateway Credentialing Department will determine, based upon the length of time the practitioner was on active duty, if the practitioner will have to complete a recredentialing application.

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.

Gateway does not make credentialing decisions based on an applicant’s type of procedures performed, type of patients, 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 Disabilities Act whereby no individual with a disability shall on the sole basis of the disability be excluded from participation.

If a practitioner does not meet Gateway’s baseline credentialing criteria, the QI/UM Committee will make a final determination on participation or continued participation. If a practitioner fails to submit information and/or documentation within requested time frames, processing of the practitioner application may be discontinued or terminated. All requests for recredentialing updates must be completed and returned in a timely manner. Failure to do so could result in denial or termination of participation.

Termination decisions that are made based on quality concerns can be appealed and are handled according to Gateway’s Due Process Policy and Procedure. If necessary, the information is reported to the National Practitioner Data Bank and Bureau of Quality Management and Provider Integrity in compliance with the current 45 CFR Part 60 and the Health Care Quality Improvement Act, as well as State licensing boards.

Practitioners who want to appeal a termination other than quality of care concerns must submit a written appeal letter and supporting documentation to Gateway within sixty (60) calendar days of the date of the certified notification. Gateway's Due Process Policy and Procedure will be implemented.

Delegation is the formal process by which Gateway has given other entities the authority to perform credentialing functions on the behalf of Gateway. Gateway may delegate certain activities to a credentialing verification organization (CVO), Independent Practitioner Association (IPA), hospital, medical group, or other organizations that employ and/or contract with practitioners. Organizations must demonstrate that there is a credentialing program in place and the ability to maintain a program that continuously meets Gateway’s program requirements. The delegated entity has authority to conduct specific activities on behalf of Gateway. Gateway has ultimate accountability for the quality of work performed and retains the right to approve, suspend, or terminate the practitioners and site. Any further sub delegation shall occur only with the approval of Gateway and shall be monitored and reported back to Gateway.