2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Credentialing and RecredentialingProvider RightsCredentialing Right to Review InformationEvaluation of the credentialing application includesinformation obtained from any outside source (suchas, malpractice insurance carriers, state licensingboards), with the exception of references,recommendations, or other peer-review protectedinformation.Right to Correct Erroneous InformationPresbyterian notifies practitioners whencredentialing information obtained from othersources varies substantially from that provided bythe practitioner. Presbyterian provides thefollowing:The time frame for changesThe format for submitting correctionsThe person to whom corrections must besubmittedDocumentation of receipt of the correctionsRight to Be Informed of Application StatusAll applicants have the right to be informed of theirapplication status. Application status inquiriesshould be directed to the appropriate credentialingstaff.Right to Be Notified of These Rights DelegationPresbyterian may delegate to designated entities allor some of the credentialing responsibilities. Theperformance of the entity is monitored on anongoing basis for compliance with Presbyterian’srequirements and all applicable regulatory andaccreditation standards. Presbyterian retains theright, based on quality issues, to approve, suspend,or terminate individual practitioners and providerseven in situations where it has delegatedcredentialing responsibilities.Standard Eligibility CriteriaPractitionersPractitioners must meet the following standardeligibility criteria, which includes but is not limited toA current unrestricted license to practicewithin the states where services are provided;temporary licenses are not acceptable to fulfillthis requirement for behavioral health ormedical practitionersAppropriate training within the area of practiceAbsence of felony convictionsProvision of quality, appropriate, and timelycareConfirmation of the primary care practitioner’sability to meet applicable required access andavailability standardsNo sanctions, suspensions, or terminationsimposed by Medicare, Medicaid, or otherdesignated federal/regulatory bodiesWhen contracted to see Medicare or Medicaidpatients, has not opted out of the Medicare orMedicaid programPractitioners who serve Medicare membersmust be Medicare-approvedValid Drug Enforcement Agency (DEA)certificate and applicable state pharmacyregistration for controlled substances16-32014 Practitioner and Provider Manual - Ver. 3