2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Credentialing and RecredentialingIf office staff completes the application, ensurethat the answers are correct.Ensure that all required documents aresubmitted with the completed and signedapplication and attestation.Practitioners can obtain an application at anytime by contacting their provider networkmanagement relationship executive(https://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00140718.pdf) or credentialing examiner at the healthplan. Once a request is made fromPresbyterian to the Council for AffordableQuality Healthcare, the practitioner may alsogo to https://upd.caqh.org/oas/ and submit anapplication online. It is important to notify yourrelationship executive if you are joining anexisting group. A practitioner who is notcurrently an in-network provider but would liketo become one must submit a letter of intent.A letter of intent form can be accessed athttps://www.phs.org/providers/Pages/becomecontracted-provider.aspx.Ensure timely completion of the application.After three requests for an application with noresponse, Presbyterian places the applicationrequest on hold. For recredentialingapplications, the practitioner or provider is atrisk for termination.Organizational providers receive their applicationdirectly from Presbyterian.Credentialing Review CommitteeThe Presbyterian Credentialing Review Committeeis a subcommittee of the Presbyterian QualityImprovement Committee and serves as acredentialing review body. The CredentialingReview Committee was established to provideexpertise about current credentialing practices inthe medical and behavioral health community,provide advice on modifying criteria, and maintain areview process for credentialing andrecredentialing.The committee is able to evaluate and improve thequality of health care services rendered by healthcare practitioners and providers and review thenature, quality, and cost of health care servicesprovided to enrollees or members of Presbyterian.The committee makes recommendations toPresbyterian regarding whether individual healthcare practitioners should be included inPresbyterian’s provider panel. The committee alsoprovides input into the corrective action planprocess, and reviews and makes determinations onthe appropriateness of the responses to requestsfor corrective action while providing oversight onwhether the practitioner’s or provider’s membershipon the Presbyterian provider panel should belimited, suspended, or revoked.ConfidentialityPresbyterian maintains the confidentiality of allinformation obtained about the practitioners andproviders it credentials and recredentials, asrequired by state law, federal law, and accreditationstandards.16-22014 Practitioner and Provider Manual - Ver. 3