2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Credentialing and RecredentialingNew Mexico Practitioners and ProvidersFor practitioners and providers that arequalified under the New Mexico MedicalMalpractice Act, Presbyterian requires that thepractitioner and provider maintain professionalliability insurance in the amounts required bythe act, currently $200,000 per occurrenceand $600,000 aggregate.For those practitioners and providers that areNOT qualified under the New Mexico MedicalMalpractice Act, Presbyterian requires that thepractitioner or provider maintain professionalliability insurance in the following amounts: $1million each occurrence and $3 millionaggregate.Any obstetrician/gynecologists and otherprimary care practitioners who practice in NewMexico and who deliver babies as a part oftheir practice must also carry limits of $1million per occurrence and $3 millionaggregate, regardless of insurance coveragewith the New Mexico Medical Malpractice Act.Practitioners and Providers Outside of New MexicoFor those practitioners and providers locatedoutside of New Mexico, we accept insurance in theamounts and types required by the law of thejurisdiction in which the practitioner or provider islocated, or in the absence of a legal requirement,the following amounts: $1 million per occurrenceand $3 million aggregate.Site VisitSite visits are included as part of the initialcredentialing process for primary care practitioners,obstetrics and gynecology practitioners, and highvolumebehavioral health specialists. In addition tothe initial site visit, a site visit is conducted on anyprovider that receives two or more complaintswithin 12 months regarding their office or practice.Initial applicants who fail a site visit are notified thatthe credentialing process has been discontinued.The applicant may contact Presbyterian forinformation about how to improve their site and torestart the credentialing process once thedeficiencies have been corrected.Any provider that receives two or more complaintsregarding their office or practice within 12 monthshas a site visit scheduled immediately. Should theprovider’s office fail the site visit, they are notifiedand the practitioner or provider must develop acorrective action plan within 30 days to address thedeficiencies. A follow-up review is conducted withinsix months to determine compliance. If thepractitioner or provider fails to submit the correctiveaction plan within the specified time frame, it isconsidered a breach of contract and may result intermination from the network.Ongoing MonitoringThe Office of Inspector General’s List of ExcludedIndividuals and Entities Exclusion Program and theGeneral Services Administration’s System forAward Management (previously Excluded PartiesLists System), and applicable state licensingagencies are monitored monthly for sanctions orlicensure limitations.Investigations are conducted on all quality of careand service complaints. For quality of clinical care16-52014 Practitioner and Provider Manual - Ver. 3