2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Credentialing and Recredentialingcomplaints, appropriate clinical staff, includingPresbyterian medical directors, are consulted inconjunction with the review of the complaint, andmay include a review of relevant medical records.Upon completion of the initial investigation, thefindings may be reported to the appropriate medicaldirector, the credentialing review committee, andthe provider network management director.Corrective action plans are developed in situationswhere there is an identified need for improvementin quality of care or service. Presbyterian offers aformal appeal process and reports the action asappropriate whenever a practitioner or provider isterminated or suspended for quality of careconcerns.Fair HearingIn the course of the credentialing decision-makingprocess, applicants are given the opportunity toprovide additional information that may addressconcerns raised by the committee that may lead todenial of the application.Practitioners and providers that are deniedmembership at credentialing or recredentialing, orare terminated for cause, have the right to appealthe decision through either the initial denial reviewprocess or fair hearing process.Practitioners and providers should submit thecompleted application and all required documentsto:Presbyterian Health Plan and PresbyterianInsurance CompanyProvider Network Management CredentialingDepartmentP.O. Box 27489Albuquerque, NM 87125-7489Individual practitioners can also submit theapplication online at http://www.caqh.org/.16-62014 Practitioner and Provider Manual - Ver. 3