Virginia Premier Health Plan, Inc.

Credentialing

Virginia Premier Provider Application Form

2010 Credentialing Program Description

The Virginia Premier Health Plan, Inc. (VPHP) Credentialing Program is comprehensive to ensure that its practitioners and providers meet the standards of professional licensure and certification. The process enables VPHP to recruit and retain a quality network of practitioners and providers to serve its members and ensure ongoing access to care. It consistently and periodically assesses and evaluates a practitioner's or provider's ability to deliver quality care between credentialing and recredentialing cycles, and it emphasizes and supports a practitioner's and provider's ability to successfully manage the health care of network members in a cost-effective manner.

The Credentialing Program enables VPHP to ensure that all practitioners and providers are continuously in compliance with the Centers for Medicare and Medicaid Services (CMS) requirements, the Department of Medical Assistance Services (DMAS) or its designee's requirements, the National Committee for Quality Assurance (NCQA) standards, VPHP policies and procedures, and any other applicable regulatory or accreditation entity's requirements and/or standards.

Practitioner's Five Rights

(1) PRACTITIONER RIGHT: TO CORRECT ERRONEOUS INFORMATION
VPHP's policy does not preclude the right of practitioners to review and correct erroneous information obtained to evaluate their credentialing application from outside primary sources to include, but not limited to, malpractice insurance carriers, state licensing boards, etc., with the exception of references, recommendations or other peer-review protected information, if applicable. VPHP is not required to reveal the source of information if the information is not obtained to meet organizational credentialing verification requirements or if the law prohibits disclosure.

VPHP policies and procedures state the practitioner's right to correct erroneous information submitted by a source. The policy clearly states:

• The time frame for changes
• The format for submitting corrections
• The person to whom corrections must be submitted
• The documentation of receipt of the corrections
• How practitioners are notified of their right to correct erroneous information (avenues identified under Right to review information, above, are appropriate).

Upon acceptance by the Committee, each new practitioner and provider, as applicable, is provided training materials in compliance with Privacy Rule workforce training mandates of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

(2) PRACTITIONER RIGHT: TO REVIEW INFORMATION

VPHP ensures that practitioners can access their own information obtained by VPHP during the credentialing process and used to support their credentialing application. Practitioners shall be notified, in writing, of this right via one or more of the following methods:

• Applications
• Contracts
• Practitioner and/or Provider manuals
• Provider Newsletters
• Mail
• Email
• Fax
• Website
• Other Suitable Method

(3) PRACTITONER RIGHT: TO BE INFORMED OF APPLICATION STATUS

VPHP's written policy is to notify a practitioner of his/her application status, upon request. The process allows for phone calls, emails, letters, or faxes from practitioners. If either the credentialing staff or another department receives a request it shall be responded to within 72 hours of receipt. If another department receives a request, it will be routed to the Credentialing Department within one business day for follow-up and resolution, by the Credentialing staff, within 72 hours of initial receipt.

The Credentialing Department staff can advise the practitioner, once key information is verified, of the following information via phone or in writing, if requested by the practitioner:

• The date the application was received
• The status of the application – pending for additional information, etc.
• The date the application is tentatively scheduled to be presented to the Committee
• Answer any questions the practitioner may ask

Prior to disclosing any practitioner information via phone, as credentialing information is confidential, the following must be verified by the Credentialing staff and confirmed by the practitioner:

• Practitioner's full name
• Practitioner's primary office location
• Practitioner date of birth
• The name, city and state of the school the practitioner graduated
• Year practitioner joined the VPHP Network

(4) PRACTITIONER RIGHT: TO BE NOTIFIED OF HIS/HER RIGHTS

Each prospective and existing practitioner has the right to be notified of the aforementioned rights and will be notified via once of the methods listed under “Right to Review Information” described above.

(5) PRACTITIONER RIGHT: TO BE INFORMED OF THE APPEAL PROCESS AND APPEAL AN ADVERSE DECISION (BASED ON QUALITY REASONS) RELATED TO NETWORK PARTICIPATION

Each prospective and existing practitioner has the right to be informed regarding the steps to appeal an adverse action, based on quality issues, in the event that participation status is altered. The Appeal Instructions are below.

Urgent Reminders:

• NPI numbers: Claims will not be paid, after May 23, 2008, if your NPI number is not on file. We need the individual number as well as the group number (if applicable). Click to go to the NPI Submission Form.
• Cultural Competency: If you have not taken the VPHP prescribed cultural competency course, please do so today. If you have taken a like course, of your own choosing, please contact Kimberly Paige, Credentialing Manager, at 800-727-7536, ext 5323, so that your credentialing record can be updated.
• Preferred Application Process - CAQH: Effective May 1, 2004, all health care professionals, not just MDs and DOs, are now able to participate with CAQH. Every practitioner is highly encouraged to participate by visiting CAQH's website: www.caqh.org. As of February 25, 2008, 51% of our participating practitioners utilize this service. The goal is 100% participation.

Benefits of participating with CAQH:

• The service is FREE for practitioners.
• Each practitioner submits one application to one central database to meet the needs of all of the health plans and networks participating in the CAQH effort. To obtain a listing of health plans, please visit www.caqh.org. Please note: A typical practitioner contracts with more than twenty (20) healthcare organizations, each of which requires the practitioner to complete a lengthy credentialing application. So, this process significantly reduces the administrative burdens for practitioner offices.
• Practitioners may easily update their information online or via fax 24 hours a day/7 days a week. All practitioners have to do is re-attest their CAQH application once a quarter.

Other Reminders that will prevent the delay of processing existing credentialing applications:

• Please remember to re-attest your CAQH Application quarterly.
• Please make certain that your license and DEA certificates are current at all times.
• Please notify VPHP immediately once you have obtained your board certification, if applicable.
• VPHP must obtain a minimum of five years of relevant work history through the practitioner's application or CV; relevant experience includes work as a health professional; if the practitioner has practiced fewer than five years from the date of verification of work history, it starts at the time of initial licensure; experience practicing as a nonphysician health professional (e.g., registered nurse, nurse practitioner, clinical social worker) within the five years should be included.

A gap exceeding six months must be reviewed and clarified either verbally or in writing; a CV or application must include the beginning and ending month and year for each position in the practitioner's employment experience; if a practitioner has had continuous employment for five years or more, then there is no gap and no need to provide the month and year, if the year meets the intent; verbal communication must be appropriately documented in the credentialing file; a gap in work history that exceeds one year must be clarified in writing.

Please remember to return your Recredentialing Packets within thirty (30) days of receipt.

• Please fax any credentialing related documents to 804-819-5171.

Contact Information: