Credentialing
Who is Credentialed?
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).
Extenders: Physician Assistant (PA), Certified Nurse Practitioner (CRNP), Certified Nurse Midwife (CNM), Certified Registered Nurse Anesthetist (CRNA), Anesthesiologist Assistant (AA), Licensed Clinical Social Worker (LCSW), and Licensed Professional Counselor (LPC).
Facility and Ancillary Service Providers: Hospitals, nursing homes, skilled nursing facilities, home health, home infusion, and hospice agencies, rehabilitation facilities, freestanding surgery centers, freestanding radiology centers, portable X-ray suppliers, end stage renal disease facilities, comprehensive outpatient rehabilitation facilities, clinical laboratories, providers of outpatient diabetes self-management training, outpatient physical therapy and speech pathology providers, rural health clinics, federal qualified health centers and orthotic and prosthetic providers.
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Purpose of Credentialing
To conduct thorough background investigation of the qualifications of practitioners, facilities, and ancillary service providers applying for affiliation and for continued participation with Gateway Health Plan® and to ensure that only the most qualified practitioners, facilities, and ancillary service providers care for our members.
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Credentialing Standards
Gateway has established policies and procedures for the credentialing and recredentialing of practitioners. Gateway's Credentialing Staff conduct all day-to-day business functions in accordance with the Gateway Health Compliance Program. 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 (PAs, CRNPs, and CNMs) 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. Physician extenders can now bill separately based on CMS requirements.
Gateway's standards require all practitioners to have applicable staff/clinical privileges in their practicing specialty at a Gateway participating hospital. Practitioner's without staff/clinical privileges in their practicing specialty must have written documentation of a formal coverage arrangement with another Gateway participating practitioner who has privileges at a Gateway participating hospital.
The credentialing/recredentialing process involves verification of practitioner credentials. Some items verified during the process are: active licensure, DEA, 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 at least tri-ennially 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, Center for Medicare and Medicaid Services, 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 Health Plan Medicare Assured® HMO Confidentiality of Practitioner/Provider Credentialing Information Policy and Procedure.
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Ongoing and Performance Monitoring
Gateway's Credentialing Department conducts ongoing monitoring of sanctions. Sanction information is reviewed by utilizing the Office of Inspector General's (OIG) report which is downloaded from the OIG website and the Medicare Opt Out Listing (CMS) which is located on the Medicare Regional Carrier website. On a monthly basis monitoring of Sanctions and Limitations on Licensure is conducted and the Gateway Credentialing Department reviews all disciplinary actions from the Pennsylvania State Board of Medicine. 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 and outcome presented to Quality Improvement/Utilization Management Committee. Practitioners must not be suspended, terminated or have Opted Out of the Medicare participation.
Monitoring of Member Complaints is conducted monthly as well. 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, and depending on 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 completed at least tri-ennially includes a comprehensive review of practitioner's credentials and a review of any problems that are identified through a member complaint report and a quality of care database.
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Military Leave Process
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 that the practitioner has been called to active duty and approximately when they will be leaving. 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.
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Denial and Termination
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, 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 or 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 termination of participation.
Denial and 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.
Practitioners who want to appeal a decision, denial or 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 certified notification.
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Delegated Credentialing
Delegation is the formal process by which Gateway has given other entities the authority to perform credentialing functions for Gateway. Gateway may delegate certain activities to a credentialing verification organization (CVO), Independent Practitioner Association (IPA), hospital, medical group, or other organization that employ and/or contract with practitioners. Organizations must demonstrate there is a credentialing program in place and their ability to maintain a program that continuously meets Gateway's program requirements. The delegated organization 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.
For information regarding all of the requirements for credentialing and recredentialing, which each practitioner must meet, please contact the Credentialing Department at 412-255-4320.
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