05/22/2013

Hospital Credentialing What does the Aetna hospital credentialing process involve? Our credentialing policy and/or business participation requirements that are part of our contract with a participating hospital call for hospitals to be currently licensed and accredited by the The Joint Commission. If the hospital is not accredited by The Joint Commission, it must be accredited by the American Osteopathic Association (AOA), Det Norske Veritas Healthcare (DNV) or an accrediting entity deemed appropriate by Aetna policy and/or business participation requirements, or state/regulatory standards. Participating hospitals are required by contract to notify Aetna of any material changes of licensure or accreditation status, to maintain adequate malpractice and general liability insurance or self-insurance, and to provide evidence of such insurance upon request. Though the criteria may vary according to hospital type, in general, hospitals are required to:

• Provide evidence of accreditation from a recognized accrediting agency for services and sites where members are treated

• Provide evidence of good standing with state and federal regulatory bodies • Provide evidence that the provider is Medicare certified or approved for

certification when part of a Medicare market • Have current professional liability insurance in adequate amounts, as specified by Aetna.

Some of the specific information gathered includes: Hospital name: The hospital name is self-reported on the first questionnaire and on an updated questionnaire at least every three years or more often, according to state or federal requirements. It is also part of the continuing hospital contract information. Accreditations: Hospitals must send a letter or certificate of accreditation from an Aetna-recognized accrediting agency for services and sites where members are treated, evidence of good standing with state and federal regulatory bodies, and a letter of certification or approval for certification from the Centers for Medicare & Medicaid Services. Aetna-recognized accrediting agencies include: • TJC: The Joint Commission • AOA: American Osteopathic Association • DNV: Det Norske Veritas Healthcare The accreditation is checked when the hospital is first credentialed and every three years thereafter. Not all hospitals may be accredited. You may want to check the current accreditation by going to the accrediting agencies’ websites at: • The Joint Commission: • AOA: • DNV: Location: The hospital location is self-reported on the initial questionnaire and on an updated questionnaire every three years and is considered part of the hospital contract.