MMA SRC #12, Attachment 4: Network Practitioner Credentialing … 08/MAGELLAN... · 2015-12-18 · John J. DiBernardi, Jr., Esq. December 30, 2016 Magellan Health, Senior Vice President

MMA SRC #12, Attachment 4: Network Practitioner Credentialing

and Recredentialing Policy and Standards

Policy and Standards Product Applicability: (For Health Insurance Marketplaces, policies and procedures are the same, unless contractual

requirements dictate a more stringent variation in which case customized documents are created.)

Commercial

Medicaid

Medicare:

Part C

Part D

Business Division and Entity Applicability:

Magellan Healthcare

Magellan Healthcare(B)

Magellan Complete Care(C)

Magellan Healthcare Provider Group(G)

AlphaCare of New York(L)

National Imaging Associates(N)

Magellan Rx Management

Magellan Rx Pharmacy(I)

MMA(A)

MPS(S)

Partners Rx(X)

CDMI(D)

Magellan Rx Manage-ment(R)

Magellan Admin-istrative Services(O)

Magellan Rx Medicare(K)

Corporate Policy:

Policy Number: CR.1102.18.B-C-N

Policy Name: Network Practitioner Credentialing and Recredentialing Date of Inception: November 1998

Previous Annual Review Date: December 18, 2015

Current Annual Review Date: October 19, 2016

Review Type:

New Policy

No Changes

Non-substantive

Substantive (material changes or initial documentation of current processes)

Previous Corporate Approval Date: January 29, 2016

Current Corporate Approval Date: December 30, 2016

Unit Effective Date: January 30, 2017

Corporate Policy Approvals:

Karen Amstutz, M.D. December 30, 2016

Magellan Health, Chief Medical Officer Date

John J. DiBernardi, Jr., Esq. December 30, 2016

Magellan Health, Senior Vice President & Corporate Compliance Officer Date

Dan Gregoire, Esq. December 29, 2016

Magellan Health, Executive Vice President, General Counsel Date

MMA SRC #12, Attachment 4: Network Practitioner Credentialing Policy and Standards

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Cross Reference(s)

Credentialing Program Description; Delegate and Subcontractor Contracting and Oversight

Policy Statement

The properly licensed affiliates and subsidiaries of Magellan Health, Inc. (“Magellan”) is dedicated to

the careful selection and credentialing of healthcare professionals for the provision of patient care

and treatment across the range of services managed by Magellan.

Purpose

Magellan uses credentialing criteria, which define the licensure, education and training criteria

practitioners must meet, and decision-making processes in the review and selection of healthcare

professionals for inclusion into Magellan’s practitioner/provider network.

To determine state or customer specific practitioner re-credentialing requirements, refer to the

Credentialing Criteria Database (CCD) and/or customer or state-specific policy addenda, as

appropriate. The materials are updated on a real-time basis and may change frequently.

Scope

Account Management

Claims (Service Ops)

Clinical Operations

Compliance

Corporate Physical Security Credentialing/Re-cred

EAP

Federal and State Affairs

Finance

Human Resources

Information Systems Security

Information Technology Security

Legal

Marketing/Comm/Sales

Network

Operations (Member Services)

Quality Improvement

Special Investigations Unit

Key Terms

None

Policy Terms & Definitions are available should the reader need to inquire as to the definition of a

term used in this policy.

To access the Policy Terms & Definitions Glossary in MagNet, click on the below link: (internal link(s)

available to Magellan Health employees only)

Policy Terms & Definitions Glossary

Standards

I. This policy is implemented as written unless superseded, in whole or in part, by

requirements that are more stringent specified by applicable law, regulation, or customer

contract. To determine if customer or state requirements for practitioners exceed Magellan’s

standard requirements, refer to the Credentialing Criteria Database (CCD) or appropriate

Magellan policy addenda.

II. Practitioner Network Determination


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http://magnet/OurBusiness/Dept/LegCompSec/PoliciesPages/MagPoliciesHome.aspx

A. Magellan, at both the corporate and local levels, determines the composition of the

practitioner network based on criteria related to quality of care, quality of service and

business needs including but not limited to:

1. Geographic and demographic information;

2. Relevant population served, including identified sub-groups with special health

status needs;

3. Future product designs and requirements;

4. Maintaining a broad access to the range of services provided within Magellan’s

delivery system;

5. Member feedback about network of practitioner services; and

6. Other internal and external stakeholder input regarding network adequacy.

B. The scope of Magellan’s practitioner credentialing program covers those practitioners

who are licensed, certified or registered by the state to practice independently, who have

an independent relationship with the organization and who provide care to members

under Magellan’s customers’ medical benefits.

Magellan may, at its sole discretion, extend the scope of its practitioner credentialing

program to include additional practitioners.

C. Based on current and future needs, Magellan identifies potential providers and the

provider makes available a completed provider participation application to the corporate

Credentialing Operations. This starts the formal credentialing process.

D. Practitioners approved through Magellan’s practitioner credentialing process and

contracted with Magellan agree to comply with Magellan’s utilization management and

quality management programs as a condition of ongoing network participation.

E. Practitioners previously credentialed by Magellan who terminate from Magellan’s

network and whose break in network participation is more than thirty (30) days undergo

initial credentialing again to apply to be admitted to the network.

1. The practitioner makes available an updated application to initiate the credentialing

process.

2. If accepted into the network, the practitioner’s credentialing cycle will be adjusted to

the practitioner’s new initial credentialing date.

3. Verifications for such practitioners are performed according to Standard XII. Verifications, below.

III. Practitioner Requirements

A. Practitioners are required to complete, sign and submit a Magellan Provider Application

or the Council for affordable Quality Healthcare (CAQH) application or other state-

mandated credentialing application.

B. Practitioners are required to submit any supporting documentation necessary to

complete the credentialing process.

C. Application Review - The submitted credentialing application is reviewed by

credentialing staff to determine:

1. Completeness;

2. Appropriate support documents accompany the application; and


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3. Practitioner signature, date and attestation indicating correctness and completeness

of the application are present and meet timeframe requirements.

D. A preliminary review of the application against Magellan criteria is conducted to

determine if the applicant meets Magellan’s professional provider selection criteria for

the practitioner’s professional level. Selection criteria follow.

IV. Criteria Pertaining to All Professionals

A. All professionals must hold a current license in their specialty at the highest level in the

state in which they practice. The license must be unrestricted, unencumbered, and

without other terms, conditions and/or limitations, including probationary status.

Licensure must be for independent practice.

B. Physicians must carry a minimum of professional liability insurance coverage of

$1,000,000 per occurrence and $3,000,000 aggregate. Required coverage for all other

health care professionals is $1,000,000 per occurrence and $1,000,000 aggregate. Limits

of professional liability insurance different than these amounts may be reviewed by

Magellan. Refer to the appropriate regional policy addendum.

C. Membership in a national professional association, which ascribes to a professional code

of ethics, is preferred.

D. For prescribers:

1. Hold a current and unrestricted Federal Drug Enforcement Administration (DEA)

Certificate of Registration; and

2. Hold a current and unrestricted state Controlled Dangerous Substances (CDS)

registration (if applicable).

3. If the practitioner is eligible to hold DEA or CDS and does not have a valid

certificate, Credentialing Operations obtains an explanation from the practitioner

that includes a description of arrangements for practitioner’s patients to obtain

medications that require these certifications to prescribe.

V. Additional Professional Criteria

A. Physicians (M.D. or D.O):

1. Graduation from medical school and completion of a residency program, appropriate

for the specialty, accredited by the Accreditation Council for Graduate Medical

Education (ACGME) or the American Osteopathic Association (AOA) or the Royal

College of Physicians and Surgeons of Canada (RCPSC); and

2. Be board certified by an American Board of Medical Specialties (ABMS) or American

Osteopathic Association (AOA) member affiliate board.

a) Those practitioners not yet board certified at initial credentialing are required to

achieve board certification within five (5) years of completion of their residency or

fellowship programs or within the timeframe established by their respective

specialty board. If board certification has not been achieved by recredentialing,

an explanation is requested and the provider is reviewed by the Credentialing

Committee.

b) Board Certification may be waived under selected circumstances. See

“Exceptions to Board Certification.”

B. Chiropractors (D.C.):


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1. Have graduated from a chiropractic college accredited the Commission on

Accreditation through The Council on Chiropractic Education and approved by the

U.S. Department of Education.

C. Podiatrists:

1. Have graduated from an accredited podiatry school;

2. Have completed a residency program, appropriate for the specialty; and

3. Board certification by the American Board of Podiatric Medicine (ABPM) or the

American Board of Foot and Ankle Surgery (ABFAS) (formerly the American Board

of Podiatric Surgery (ABPS)).

Board Certification may be waived under selected circumstances. See

“Exceptions to Board Certification”

D. Oral Surgeons (D.D.S. or D.M.D):

1. Have completed residency program in oral and maxillofacial surgery program

accredited by the Commission on Dental Accreditation (CODA); and

2. Be board certified by the American Board of Oral and Maxillofacial Surgery

(ABOMS).

Board Certification may be waived under selected circumstances. See

“Exceptions to Board Certification”

E. Advanced Practice Nurses: non-psychiatric

1. Master’s degree in Nursing;

2. Hold appropriate nursing licensure as required for advanced practice nursing in the

state in which they practice;

Maintain collaborative practice with a physician consistent with licensure

requirements in the state.

3. Be board certified in a practice specialty, as issued by the following certifying

agencies:

a) National Board of Certification & Recertification for Nurse Anesthetists

(NBCRNA);

b) American Midwifery Certification Board (AMCB);

c) American Nurses Credentialing Center (ANCC);

d) American Academy of Nurse Practitioners Certification Program (AANPCP);

e) Pediatric Nursing Certification Board (PNCB)

f) National Certification Corporation (NCC).

F. Therapists: Physical therapist, occupational therapist, speech and language pathologist:

1. Education and training:

a) Physical Therapist: graduate of a physical therapy education program accredited

by the Commission on Accreditation on Physical Therapy Education (CAPTE);

b) Occupational Therapist: graduate of an occupational therapy education program

accredited by the Accreditation Council on Occupational Therapy Education

(ACOTE);


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c) Speech Language Pathologist: graduate degree from a speech-language pathology

education program accredited by the Council on Academic Accreditation in

Audiology and Speech-Language Pathology Accreditation of the American Speech

Language Hearing Association (ASHA). Achieve Certificate of Clinical

Competence (CCC) as awarded by the Clinical Certification Board of ASHA.

2. Board certified, if required by state.

G. Physicians Assistants: non-psychiatric

1. Graduation from a physician assistant program from a college, university or

professional school.

2. Board certified by the National Commission on Certification of Physicians Assistants

(NCCPA);

3. Supervising physician is a Magellan participating physician.

H. Massage Therapists

1. Graduate from a massage therapy school/program with a minimum of 500 hours of

classroom and supervised training; and

2. Be board certified by the National Certification Board for Therapeutic Massage and

Bodywork (NCBTMB).

I. Acupuncturists

1. Must have completed a formal acupuncture training program meeting National

Certification Commission for Acupuncture and Oriental Medicine (NCCAOM)

requirements; and

2. Be NCCAOM certified.

J. Acupuncturists: M.D.s and D.O.s

1. Graduation from medical school and completion of a residency program, appropriate

to the specialty, accredited by the accreditation Council for Graduate Medical

Education (ACGME) or the American Osteopathic Association (AOA) or the Royal

College of Physicians and Surgeons of Canada (RCPSC);

2. Successfully completed a formal acupuncture program of at least 200 hours.

K. Behavioral health: Psychiatrist (M.D. or D.O.)

1. Have completed a psychiatric residency program accredited by the Accreditation

Council for Graduate Medical Education (ACGME) or the American Osteopathic

Association (AOA) or the Royal College of Physicians and Surgeons of Canada

(RCPSC); and

2. American Board of Psychiatry and Neurology (ABPN) or American Osteopathic

Board of Neurology and Psychiatry certification (AOBNP) is preferred.

L. Behavioral health: Addictions Medicine physician (M.D or D.O.):

1. Hold current Board Certification in any medical specialty by an American Board of

Medical Specialties (ABMS) or American Osteopathic Association (AOA) certification

board.

2. Hold one of the following:

a) Subspecialty Board Certification in Addictions Psychiatry by the American Board

of Psychiatry and Neurology (ABPN); or


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b) Subspecialty Board Certification in Addiction Medicine by the American

Osteopathic Board of Internal Medicine (AOBIM) or the American Osteopathic

Board of Neurology and Psychiatry (AOBNP); or

c) Board Certification in Addiction Medicine by the American Board of Addictions

Medicine (ABAM); or

d) Be eligible to sit for ABAM board certification as evidenced by written

notification issued by ABAM.

M. Behavioral health: Developmental-Behavioral Pediatrician, (M.D.)

1. Have completed a pediatric residency program accredited by the ACGME or the

RCPSC; and

2. Hold board certification from the American Board of Pediatrics (ABP); and

3. Hold ABP subspecialty certification in Developmental-Behavioral Pediatrics.

N. Behavioral health: Psychologists:

1. Are licensed as a psychologist at the doctoral level in the states in which they

practice at the independent practice level to furnish diagnostic, assessment,

preventive and therapeutic services

2. Hold a doctoral degree in psychology from a regionally accredited university or

professional school,

3. Have completed supervised clinical experience(s), inclusive of pre-doctoral

internships and post-doctoral supervised experience that have met state

requirements for licensure in the state in which they hold a doctoral-level

psychologist license.

O. Behavioral health: Clinical Social Workers:

1. Hold a masters’ degree or doctoral degree in Social Work from a school accredited by

the Council on Social Work Education; and

2. Be licensed at the highest level in the state for independent practice in the state in

which they practice; and

3. Have two (2) years post-masters’ degree experience of at least three thousand (3,000)

hours of supervised practice.

P. Behavioral health: Advanced Practice Nurses.

1. Hold Board Certification issued by the American Nurses Credentialing Center

(ANCC) as a Psychiatric- Mental Health Nurse Practitioner (PMHNP-BC) or

Psychiatric Mental Health Clinical Nurse Specialist (PMHCNS-BC) as:

a) Psychiatric-Mental Health Nurse Practitioner; or

b) Adult Psychiatric-Mental Health Nurse Practitioner; or

c) Family Psychiatric-Mental Health Nurse Practitioner; or

d) Child/ Adolescent Psychiatric -Mental Health Clinical Nurse Specialist; or

e) Adult Psychiatric- Mental Health Clinical Nurse Specialist.

2. Hold appropriate nursing licensure as required for advanced practice nursing in the

state in which they practice.

3. Additionally, for nurses with prescriptive authority the following must also be met:


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a) Hold current State licensure, that allows the Advanced Practice Psychiatric

Nurses to prescribe medication;

b) Attest to collaborative practice with a physician consistent with the licensure

requirements in the state in which they hold prescriptive authority.

Q. Behavioral health: Masters Prepared Therapists (other than Clinical Social Workers or

Nurses) must:

1. Hold a Magellan Health Services acceptable licensure or certification in an accepted

human services specialty (LPC, LMFT, etc.) at an independent practice level in the

state in which they practice; and

2. Hold state licensure which includes:

a) Successful completion of a written exam;

b) Master’s degree or doctoral degree in a human services-related field of study;

c) Two (2) years, totaling at least three thousand (3,000) hours, of documented post

masters’ clinical practice in mental health and/or substance abuse under a state

licensed/certified supervisor in the practitioner’s field of specialty; and

d) Primary source verification of written exam, degree and supervised experience is

completed by the state licensing board.

R. Behavioral health: Employee Assistance Program (EAP) Affiliates

1. In order to provide EAP services for Magellan, the EAP practitioners/providers must

meet criteria for credentialing as a behavioral health practitioner; and

2. Meet at least one of the following:

a) Certified as an Employee Assistance Professional (CEAP) issued by the Employee

Assistance Certification Commission (EACC) of the Employee Assistance

Professional Association (EAPA); OR

b) Have more than two (2) years’ experience in the provision of direct EAP services

as defined by EAPA and at least one training (continuing education units or

Professional Development Hours) in any area of Employee Assistance program

services within the past year; OR

c) Have less than two (2) years’ experience in the provision of direct EAP services as

defined by EAPA and minimum one year experience in the provision of substance

abuse treatment services, including assessment and referral, and at least one (1)

training (continuing education units or Professional Development Hours) in any

area of Employee Assistance program services within the past year.

S. Physicians Assistants: psychiatric

1. Graduation from a physician assistant program from a college, university or

professional school.

2. Board certified by the National Commission on Certification of Physicians Assistants

(NCCPA);

3. Supervising physician is a Magellan participating psychiatrist, addictionologist or

other Magellan acceptable behavioral health physician; and

4. One of the following.

a) Current NCCPA Certification with Added Qualifications (CAQ) in psychiatry; or


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b) Two years post-licensure supervised behavioral health experience.

T. Behavior Analysts

1. Certification and/or state licensure: Must meet at least one of the following:

a) Be a Board Certified Behavior Analyst(BCBA®) through the Behavior Analyst

Certification Board (BACB®); or

b) Hold a state-issued license, certificate, registration, credential or other

designation as a behavior analyst; or

c) Meet Magellan’s current individual practitioner credentialing criteria as a

licensed behavioral health provider and the coursework and supervision

indicated in the following criteria.

i) Coursework: Master’s degree or Doctoral degree in psychology, social work,

professional counseling, or other human services related field, with

coursework that includes, at a minimum, 40 coursework hours in behavior

analysis, behavior management theory, techniques, interventions and ethics;

and autism spectrum disorders; and

ii) Supervised experience: At a minimum, one (1) year (1500 hours) supervised

clinical experience inclusive of:

a. Minimum one year direct care services to children; and

b. Minimum one year direct care utilizing applied behavior analysis,

behavior techniques, interventions and monitoring of behavior plan

implementation; and

c. Experience must have included work with individuals with Autism

Spectrum Disorders

2. No sanctions or disciplinary actions on BCBA® or BCBA-D® certification and/or

state licensure;

3. Must have a completed criminal background check to include Federal Criminal, State

Criminal, County Criminal and Sex Offender reports for the state and county in

which the behavior analyst master’s-doctoral is currently working and residing.

a) Evidence of this background check is provided by the behavior analyst master’s-

doctoral or by the employer.

b) Criminal background checks must be performed at the time of hire and at least

every five (5) years thereafter.

Behavior analysts Masters/Doctoral that Magellan will be contracting as solo

practitioners must have background checks current within a year prior to

initial application for network participation. Background checks must be

performed at least every five (5) years thereafter.

VI. Exceptions to Board Certification (physicians, podiatrists, oral/maxillofacial surgeons)

A. Magellan includes in its network those practitioners who are board certified or intend to

become board certified in their practice specialty.

1. Practitioners are required to have formal training in the area of specialty practice

under which they wish to be listed in the Provider Directory. This formal training is

evidenced by Board Certification.


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Subspecialty certification and/or certificates of added qualifications from the

ABMS affiliate or acceptable certification board are required in order for

Magellan to recognize and list a practitioner in that specialty in the Provider

Directory.

2. Initial credentialing:

a) Practitioners who are not yet board certified at initial credentialing are required

to achieve board certifications within the timeframe established by their

respective specialty board, or within five (5) years of completion of their residency

or fellowship program.

b) Those practitioners who are beyond the timeframes above, or who indicate they

do not intend to become Board Certified, may be considered for credentialing

through the Board Certification waiver process.

3. Recredentialing:

a) Practitioners who were not Board Certified at initial credentialing, were

approved for credentialing, and remain non-Board Certified at recredentialing

are reviewed for intent and progress towards obtaining Board Certification. An

explanation from the practitioner is requested, along with any pertinent

documentation, for review by the Credentialing Committee.

b) Practitioners who do not maintain board certification are reviewed for intent and

progress towards recertification. An explanation is requested from the

practitioner, along with any pertinent documentation, for review by the

Credentialing Committee.

Specialists who are subspecialty certified are not be required to maintain

board certification/eligibility in their general specialty as long as the

subspecialty certification is maintained.

B. Board certification waiver process

1. Magellan may, at its sole discretion, waive board certification requirements for

member access for other circumstances. Such circumstances include, but are not

limited to:

a) Member access and availability needs:

i) Practitioner specialty and/or location of practice is necessary for Magellan to

meet customer or regulatory access and availability standards. Access needs

waivers are requested by the Network Department, include written

explanation of need for non-board certified practitioner(s), and is submitted

for Credentialing Committee review; or

ii) Practitioner practices solely in rural counties or in Medically Underserved

Area or Medically Underserved Populations (MUA/P) location.

b) Practitioner began practicing prior to the availability of the Board Certification;

c) Other exceptions, as determined.


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2. The Credentialing Committee reviews these requests. Guidelines for review include,

but are not limited to:

a) Completion of specialty training, including residency and fellowship;

b) History of prior board certification (initial or recertification);

c) Eligibility for board certification;

d) Hospital privileges;

e) Years in active practice;

f) Any adverse history: license disciplinary action; professional liability

settlements; OIG sanctions, other criminal or civil matters, etc.

g) For those in group practice: ratio of Board Certified to non-Board Certified

practitioners in the group

h) Access need for the practitioner type and/or specialty.

3. Non-board certified practitioners credentialed into the network prior to

implementation of this policy are “grandfathered’ into the network as regards the

Board Certification requirement.

VII. Provisional Credentialing

A. Practitioners may be provisionally credentialed when there is member access need or to

meet regulatory or account requirements. The Vice President, Network Operations and

the Chief Medical Officer or designees determine the need for practitioner provisional

credentialing.

B. One time provisional credentialing may be performed for practitioners applying to the

network for the first time.

C. The following are verified from sources indicated in XII. Verification

1. A current, valid license to practice;

2. The past five years of professional liability claims or settlements;

3. A current and signed application with attestation.

D. Once application and verifications are completed, the provisional credentialing file is

presented as either “clean” or referred for Credentialing Committee per XVI. Clinical Review and Determination.

E. Provisional credentialing is not performed for practitioners who were credentialed by a

delegate on behalf of Magellan.

F. Magellan does not hold practitioners in provisional status longer than sixty (60) calendar

days.

VIII. Application and Attestation

A. Magellan requires that each practitioner who applies for participation in the provider

network, and is within the scope of the credentialing program, submit an application for

credentialing. The application requests the practitioner include, at least, the following

information:

1. Reasons for any inability to perform essential functions of a network provider with or

without accommodation;


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2. Lack of present illegal drug use;

3. History of loss or restriction of license;

4. History of felony convictions;

5. History of all past or present issues regarding loss or limitation of privileges or

disciplinary activity at all facilities or organizations with which the practitioner has

had privileges;

6. Current malpractice coverage;

7. Means of availability or coverage for members in their care twenty-four (24) hours a

day, seven (7) days a week, as required;

8. Office hours;

9. Practice information;

10. History of education and professional training, including board certification status (if

applicable);

11. Relevant work history for at least the last five (5) years (or since credentialed by the

organization);

12. Current state licensure information;

13. Evidence of current Drug Enforcement Agency certificate and state controlled

substance license, if applicable;

14. History of professional liability claims that resulted in settlements or judgments paid

on behalf of the practitioner;

15. Hospital affiliations or privileges, if applicable;

16. A signed and dated statement authorizing Magellan to collect any information

necessary to verify the information in the credentialing application; and

17. A signed and dated statement attesting that the information submitted with the

application is correct and complete to the practitioner’s knowledge.

B. The applicant is notified of his/her right to be informed, upon his/her request, of the

status of the credentialing application.

1. The contract cover letter contains a reference to the publically available Provider

Handbook where information about how to obtain this status is communicated; or

2. The notification is included in the credentialing application attestation statement; or

3. A cover letter accompanying the application packet contact phone number where this

status can be obtained.

IX. Verification

A. As an integral component of the credentialing process, Magellan evaluates applicants for

inclusion in the practitioner network through the verification review process.

B. Where phone verification of any element is conducted, documentation in the provider’s

credentialing record includes, but is not limited to, the following information:

1. Name or signature of staff person who processed the verification call;

2. Date of the call; and

3. Name of the person at the verifying organization.


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C. Practitioner/provider credentials verified and methods of verification are as follows:

1. Element: Licensure verification

Verification Source(s):

a) Phone or written response to a query of the state licensing board; or

b) A report, in hard copy or electronic format, from the state licensing board; or

c) Verification via an approved internet state licensing board website.

d) Licenses are verified in all states where the practitioner provides care to

members.

2. Element: Licensure sanctions

Review of information on sanctions, restrictions on licensure and limitations on scope

of practice covers the most recent five (5)-year period available through the data

source. If a practitioner was licensed in more than one state in the most recent five-

year period, the query includes all states in which s/he held licensure.


a) State licensing board: via approved method(s) for verifying license sanctions at

this source. May include: phone query or written query directly to the board;

board-distributed written report; approved internet board website when sanction

information is provided at this source; or

b) National Practitioner Data Bank (NPDB) ; or

c) Federation of State Medical Boards (FSMB) (physicians only).

3. Element: Drug Enforcement Administration (DEA) Registration and Controlled

Dangerous Substance (CDS) Registration (as applicable)


a) For DEA:

i) National Technical Information Services tape or internet website,

DEANUMBER.com; or

ii) Copy of current DEA registration from the practitioner;

b) For CDS (if applicable):

i) Phone, written or internet verification from state licensing board or state

CDS agency; or

ii) Copy of the current CDS registration from the practitioner.

c) If the practitioner is eligible to hold DEA or CDS certification and does not have a

valid certificate, Credentialing Operations obtains an explanation from the

practitioner that includes a description of arrangements for practitioner’s

patients to obtain medications that require these certifications to prescribe.

Covering prescriber arrangements must be through a Magellan in-network

participating provider.

4. Element: Education and training


a) Phone or written response to a query of the school, institution or residency

training program; or


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b) Approved websites that provide verification of student attendance and award of

degree for participating institutions and universities via internet. National

Student Clearinghouse Degree Verify and Degree Check are used only when a

contract between the specific school and NSC to provide verifications exists; or

c) State licensing agency in instances where the appropriate board indicates

primary source verification of education and training is completed by the board

as a condition of issuing a license; or

d) Verification of Board certification or membership from a specialty board, registry,

or professional association where such organizations indicate primary source

verification of degree and/or physician residency and/or other professional

training program is completed as a condition of certification or membership (e.g.

American Board of Medical Specialties for board certified physicians); or

e) American Medical Association Physician Master File (AMA) or the American

Osteopathic Association (AOA) Physician Master File for non-board certified

physicians;

f) ECFMG for international medical graduates licensed after 1986; and

g) Transcripts that are in the institution’s sealed envelope with an unbroken

institution seal.

5. Element: Board Certification

Verification Source:

a) Physicians, Osteopaths:

i) American Board of Medical Specialties (ABMS) Official Directory of Board

Certified Medical Specialists or an official ABMS Display Agent where a

dated certificate of primary source authenticity has been provided, CertiFacts

On-Line website; or

ii) American Medical Association (AMA) Physician Master File; or

iii) American Osteopathic Association (AOA) Official Osteopathic Physician

Profile Report or Physician Master File website; or

iv) American Board of Addictions Medicine (ABAM) website.

b) Podiatrists:

i) American Board of Podiatric Medicine (ABPM) website; or

ii) American Board of Foot and Ankle Surgery (ABFAS) website (formerly the

American Board of Podiatric Surgery (ABPS)).

c) Oral surgeons:

American Board of Oral and Maxillofacial Surgery (ABOMS) website.

d) Advanced Practice Nurses:

i) American Nurses Credentialing Center (ANCC) written response for

advanced practice registered nurse certification; or

ii) National Board of Certification & Recertification for Nurse Anesthetists

(NBCRNA) website; or

iii) American Midwifery Certification Board (AMCB) written response; or


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iv) American Academy of Nurse Practitioners Certification Program (AANPCP)

written response; or

v) Pediatric Nursing Certification Board (PNCB) written response;

vi) NCC written response.

f) (Massage Therapist): National Certification Board for Therapeutic Massage and

Bodywork (NCBTMB) website;

g) (Acupuncturist): National Certification Commission for Acupuncture and Oriental

Medicine (NCCAOM) website.

h) Physicians Assistants: National Commission on Certification of Physician

Assistants (NCCPA) website

6. Element: Work History

The work history provided should include the beginning and ending month and year

of each position in the employment history. If the practitioner has had continuous

employment in the same employment situation for five (5) years or more, there is no

gap in work history and provision of the year only is sufficient. If the practitioner

has practiced fewer than five (5) years from the date of verification of work history,

history starts at the time of initial licensure. Verbal explanations of work history

gaps must be properly documented in the credentialing file.


a) Completion of the work history grid on the application, which displays a

minimum five (5) years of relevant work history, with a written explanation of

gaps of six (6) months or more ; or

b) Submission by the practitioner of a curriculum vitae, which displays five (5)

years of relevant work history, with a written or verbal explanation of gaps of

exceeding six (6) months or more or written explanation of gaps exceeding one (1)

year.

7. Element: Professional Liability Claims

Magellan obtains confirmation of the past five (5) years history of malpractice

settlements from the verification source.

Verification Source:

a) National Practitioner Data Bank (NPDB) query; or

b) Written response from insurance carrier for previous claims settlement.

8. Element: Medicare/Medicaid Sanctions and Exclusions


a) National Practitioner Data Bank (NPDB) query; or

b) Department of Health and Human Services Office of Inspector General, “List of

Excluded Individuals/Entities” (OIG/LEIE) website; or

c) Federal government web-based System for Award Management (SAM); or

d) Federation of State Medical Boards (FSMB); or

e) AMA Physician Master File query.

f) For Medicaid state sanctions and exclusions: applicable State

Exclusions/Sanctions websites, lists and databases.


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9. Element: Professional Liability Insurance


a) Photocopy of the current professional liability face sheet issued by the insurance

carrier; submitted by practitioner or carrier; or

b) Practitioner application indicating coverage amount and date of coverage

expiration.

c) For practitioners with federal tort coverage: a copy of the federal tort letter or an

attestation from the practitioner of federal tort coverage.

10. Element: Institutional Accreditations


a) Council for Higher Education Directory; or Accreditation Council for Graduate

Medical Education (ACGME), or the American Osteopathic Association (AOA) or

the Royal College of Physicians and Surgeons of Canada (RCPSC); or the Royal

College of Family Physicians of Canada (RCFPC); or

b) AMA Physician Master File; or

c) American Psychological Association (APA) online directory of accredited

internship training programs; or

d) Council of Social Work Education (CSWE) directory; or

e) Official website maintained and sponsored by the institution of higher education

if accreditation is listed within website and source is approved by Magellan; or

f) State licensing board if institutional accreditation or programmatic accreditation

is verified by that board.

11. Element: Hospital/Clinical Privileges

Hospital/clinical privileges are self-reported by the provider on the application.

Primary source verification applies when privileging is required by state or

federal law or specific customers, and is then verified telephonically or in writing

through a representative from the organization to which the provider holds

clinical privileges. Verification may also be obtained using website provided by

hospital specifically for verification of privileges.

12. Element: Other federally funded healthcare programs

a) Web-based System for Award Management (SAM) (exclusions); and

b) Medicare opt-out: appropriate regional Medicare Administrative Contractor

(MAC) website.

D. Disciplinary action on license: Practitioners must have a current, unrestricted,

unencumbered license to practice without terms, conditions and/or limitations, including

probationary status. Any practitioner whose license does not meet this requirement does

not meet Magellan’s credentialing criteria and is not eligible for participation in

Magellan’s provider network. The practitioner is notified of the right to correct such

information if s/he believes it to be incomplete, inaccurate, conflicting or erroneous. The

practitioner may reapply once sanctions are lifted and terms and conditions are met.

E. Exclusion lists: Magellan reviews the Department of Health and Human Services Office

of Inspector General List of Excluded Individuals and Entities (OIG-LEIE), the federal

government’s System for Award Management (SAM), and any applicable State Medicaid

exclusions/sanctions verification sources during the provider credentialing and


16

recredentialing processes. All providers who are identified on the exclusions lists do not

meet Magellan’s administrative credentialing criteria and are not eligible to participate

in Magellan’s provider network. There is no offer of reconsideration. The practitioner is

notified of the right to correct such information if s/he believes it to be incomplete,

inaccurate, conflicting or erroneous. The practitioner may reapply once sanctions or

exclusions are lifted.

F. Verifications or preliminary application review that finds the applicant fails to meet

Magellan’s administrative credentialing criteria results in administrative credentialing

ineligibility.

1. The applicant is notified in writing of their ineligibility status and the reasons for

ineligibility; and

2. Informed of the process for reconsideration (except for license disciplinary action and

Medicaid/Medicare sanctions and exclusions). See Standard XVI Reconsideration of Professional Provider Credentialing Ineligibility below.

X. Review Process for Information Related to Potential Risks

A. Magellan maintains a process for the review of information related to potential risks

obtained through the process of primary source verification or reported on the provider

application that could impact the quality of care or quality of services to members,

including, but not limited to:

1. Lawsuits/claims/ settlements;

2. OIG/LEIE, SAM or state Medicaid exclusions or sanctions;

3. Loss of or restrictions on professional liability insurance coverage;

4. Criminal offenses/convictions;

5. Current activity, or history of any of the following: disciplinary action on license to

practice, including, but not restricted to terms, conditions, limitations, restriction or

encumbrance; investigations by licensing boards and/or professional associations; loss

or limitation of professional privileges, etc.

B. Additional documentation regarding such issues, including supporting documentation,

provider explanation, etc. may be collected by Credentialing Operations.

C. All materials are reviewed by the Medical Director to assess potential impact on quality

of care and service. Magellan’s Legal Department may be consulted, as needed. The

Medical Director may decide no further review is required or may present to the

Credentialing Committee for additional review.

XI. Review of Credentialing Information Prior to Submission to Credentialing Committee

A. Magellan has mechanisms to review credentialing information for completeness,

accuracy and conflicting information before review by the Credentialing Committee for

consideration.

B. Review of applicants’ credentialing information for completeness, accuracy or conflicting

information is conducted on all files by Credentialing Operations staff prior to further

consideration by the Credentialing Committee or unit Medical Director/ Credentialing

Committee chair.

C. Such review includes examination of applicants’ materials to assure that:

1. Application attestation signature date and work history are no more than three

hundred five (305) calendar days old when applicant materials are designated as


17

ready for Credentialing Committee or Medical Director (chair) review and are no

more than three hundred sixty five (365) days at time of determination;

See Standard XVI. A. below for customer Plans that have delegated credentialing

to Magellan under URAC accreditation standards.

2. Verification of information from primary sources is no more than one hundred twenty

(120) calendar days old when applicant materials are designated as ready for

Credentialing Committee or Medical Director review and are no more than one

hundred and eighty (180) days at time of determination ; and

3. Other applicant verification timeliness or other standards per state or contractual

requirements.

D. When such matters are identified through this review, the Credentialing Committee

Coordinator and Credentialing Operations work to resolve the issues so that final review

and determination can occur.

XII. Network and Credentialing Committees and Functions

The National Network and Credentialing Committee is maintained at the corporate level

and multiple Credentialing Committees at the regional levels to conduct various

credentialing and provider management functions. These committees and functions are

described in the Credentialing Program Description Policy, Network and Credentialing Committees.

XIII. Clinical Review and Determination

A. Upon submission of all required credentialing documentation and completed verification,

the credentialing information is forwarded by Credentialing Operations to the designated

Medical Director and Credentialing Committee for review.

B. All applicants’ credentialing information must be reviewed and approved by the

Credentialing Committee or Medical Director, as appropriate, prior to designation as a

participating provider in Magellan’s network.

C. Upon receipt of a complete credentialing file, the designated regional Medical Director(s)

review(s) the file contents against Magellan’s criteria for a “clean” file. If the Medical

Director determines that the file meets those criteria, the Medical Director may sign off

on the file as complete, clean, and approved. The date of the Medical Director’s signature

of approval will be considered the credentialing date.

1. A “complete” file is defined as a credentialing file that contains the required timely,

verified administrative data.

2. A credentialing file must meet the following criteria in order for the file to be

considered “clean”:

a) Practitioner’s signature on the application attestation and the work history is not

more than three hundred sixty-five (365) days old (or one hundred eighty (180)

days for URAC compliance) and other time-sensitive credentialing elements are

not more than one hundred eighty (180) days old at the time the credentialing

decision is to be made;

b) All licenses are current and valid, with no sanctions, restrictions or limitations in

scope of practice as defined by the state Board of Medical Examiners or licensing

agent; history of any such actions as reviewed by Medical Director;

c) DEA and/or CDS registration are current and valid, if applicable to practitioner

type;


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d) Degree/education and training has been verified and is appropriate for

practitioner type;

e) Board certification is current and valid, if practitioner indicated board

certification on application;

f) Five (5) years of continuous work history verified, with appropriate explanations

of any work gaps exceeding six (6) months, and work experience meets

requirement for practitioner type;

g) Professional liability claims/settlements against practitioner for the past five (5)

years have been reviewed by Medical Director;

h) No current Medicare/Medicaid sanctions or exclusions;

i) Regional, APA, Medical or Social Work accreditation is current and valid, as

applicable to practitioner type;

j) Clinical privileges are verified as current, if applicable;

k) Attestation practitioner is able to perform the essential functions of a network

provider;

l) Attestation that practitioner does not presently use illegal drugs;

m) Attestation that practitioner has no history of loss of license;

n) Attestation that practitioner has no history of felony convictions;

o) Attestation that practitioner has not lost or had any limitation of privileges or

disciplinary activity in any facility or organization with which the practitioner

has had privileges or any such actions have been reviewed by Medical Director;

p) Current malpractice insurance coverage that affirms dates and meets required

coverage amounts (Magellan or local requirement);

q) Attestation describing how the practitioner is available or has coverage for

member care twenty-four (24) hours per day/seven (7) days a week;

r) Attestation affirms the correctness and completion of application;

s) Statement authorizing Magellan to collect any information necessary to verify

the information in the credentialing application is signed and dated; and

3. The Medical Director may use a handwritten signature, handwritten initials, or

unique electronic identifier as documentation of sign-off and approval of the file (or

on a listing of such files). If an electronic signature is used, the electronic file must

be secured through password protection or a similar security measure that permits

access only by the Medical Director, to ensure that only the designated Medical

Director can enter his/her signature of approval in the system.

D. If the Medical Director determines that the credentialing file does not meet the criteria

for a “clean” file, the Medical Director forwards the complete file to the Credentialing

Committee for review, careful consideration and determination for credentialing and

network participation.

E. The Credentialing Committee credentialing determination is binding and not subject to

further appeal, except as required by state or local regulation or contract requirement.

The practitioner is informed that they may utilize XV.C.3. “Correction of Information: Credentialing Committee denial” process if they believe the


19

determination was based on incomplete, inaccurate, conflicting or erroneous

credentialing information.

F. The designated regional Medical Director or Credentialing Committee, depending on

which entity made the decision, forwards its decision regarding the practitioner’s

credentialing status to Credentialing Operations for data entry and practitioner

notification.

XIV. Practitioner Notification of Credentialing Determination

A. Magellan staff sends written notification of the credentialing decision to the practitioner

within sixty (60) calendar days of the determination.

See Standard XXV. B. below for Plans that have delegated credentialing to Magellan

under URAC accreditation standards.

B. The credentialing specialist identifies from the daily credentialing activity report

practitioner credentialing files whose review has been completed by the Medical Director

or Credentialing Committee, and documents the credentialing decision and date in the

credentialing system. The credentialing specialist sends written notification of the

credentialing determination to the practitioner within sixty (60) calendar days of the

credentialing determination.

C. Weekly reports tracking timeliness of written notification are reviewed by the Director of

Credentialing Operations, or designee, to assure adherence to requirements.

XV. Practitioner Rights in Credentialing

A. Practitioners have the following rights in the credentialing process:

1. To review information submitted to support their credentialing application;

2. To correct incomplete, inaccurate, conflicting or erroneous information; and

3. To be informed of the status of their credentialing or recredentialing application.

4. Notification of these rights:

a) The provider contract cover letter contains a reference to the publically available

Provider Handbook where information about how to exercise these rights is

available; or

b) The credentialing application attestation statement includes information about

these rights.

B. Review of information submitted to support credentialing application

1. Practitioners have the right to review material contained in their credentialing file

by submitting to Credentialing Operations, a written request for a copy of their

credentialing record.

2. A copy of the material in the practitioner’s credentialing file is forwarded to the

practitioner within thirty (30) days of receipt of the written request from the

practitioner.

3. The credentialing material returned to the practitioner is in accordance with

Magellan, state and federal policies and:

a) Includes: information obtained from any outside sources (state licensing boards,

insurance carriers, etc.);

b) Excludes: references, recommendations or other peer-review protected

information and data which is prohibited from being released (i.e. NPDB query).


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C. Correction of Information

1. Practitioners are notified of credentialing information received from other sources

which varies substantially from the information submitted by the practitioner, and

may impact the practitioner’s participation status in the network. Such information

may include, but is not limited to: current or past sanctions on license, clinical

privileges, Medicare, Medicaid; professional liability coverage or settlements; Board

Certification; education and training. The practitioner has the right to correct

information s/he believes to be incomplete, inaccurate, conflicting or erroneous prior

to and following Credentialing Committee review.

2. The practitioner is sent written notification by Credentialing Operations staff of such

information. Written notification includes directions on submission of requests for

correction. Requests for correction must be submitted to the Director of

Credentialing Operations within thirty (30) days of the date of this written

notification. The practitioner is instructed to submit such request in writing, and

include specific documentation supporting the practitioner’s contention that

information from or about the provider received by Magellan is incomplete,

inaccurate, conflicting or erroneous.

3. Practitioner requests for correction received by Credentialing Operations are

documented in the credentialing system by Credentialing Operations staff. The

practitioner’s request and supporting information is sent to the Director of

Credentialing Operations, or designee for resolution.

Credentialing Committee decision: If the request for correction is made as a

result of a Committee credentialing determination, the practitioner may submit

corrections to the Network Appeals Coordinator within thirty days of written

notification. These requests are reviewed by representatives of corporate clinical

and legal teams or their designees to evaluate practitioner’s request for

correction.

D. Informed of Application Status

1. The applicant has the right to be informed, upon his/her request, of the status of the

credentialing application.

2. The cover letter accompanying the provider contract directs the applicant to the

Provider Handbook where information about how to obtain this status is

communicated, or the information is included in the application attestation

statement.

3. Staff respond to such requests verbally or in writing within thirty (30) days of such

requests.

4. Credentialing information shared is in accordance with Magellan, state and federal

policies and can include current status of the application but excludes references,

recommendations or other peer-review protected information, data which is

prohibited from being released; e.g., NPDB.

XIV. Reconsideration of Professional Provider Credentialing Ineligibility

A. Practitioners who do not meet Magellan administrative credentialing criteria for network

participation are:

1. Notified in writing of their ineligible status and the reason for ineligibility (i.e.

area(s) of criteria not met, general liability concerns, etc.); and

2. Informed of the process for reconsideration.


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B. The practitioner submits a written request for reconsideration including pertinent

information to support the request for review.

1. The practitioner’s written request must be submitted within thirty-three (33)

calendar days of the date of Magellan’s written notification of ineligibility.

2. The reconsideration request and supporting information is sent to Credentialing

Operations.

3. Credentialing Operations documents receipt of the practitioner’s reconsideration

request and prepares document for reconsideration.

C. Upon receipt of all of the practitioner’s information, the file is forwarded to the

Credentialing Committee Coordinator for review and determination by the committee.

The Credentialing Committee has thirty (30) calendar days from the receipt of all

necessary information to make a determination. Possible reconsideration decisions are:

1. Accept: the Committee determines that the information presented by the practitioner

does meet Magellan credentialing standards and recommends that the practitioner’s

ineligible status be overturned and the practitioner be accepted into the network.

(The practitioner follows the credentialing process.)

2. Uphold: the Committee determines that the information submitted does not meet

Magellan standards and recommends that the ineligible status be upheld.

D. The Credentialing Operations notifies the practitioner in writing of Magellan’s decision

within sixty (60) calendar days of the decision.

E. The Credentialing Committee credentialing reconsideration determination is binding

and not subject to further appeal, except as required by state or local regulation or

contract requirement.

XVII. Confidentiality of Credentialing Records

A. All practitioners credentialing materials are considered confidential and are maintained

on imaged platters or in hardcopy in secure facilities.

B. Access to credentialing information is limited to the following:

1. Magellan personnel with legitimate cause to access credentialing information. This

includes, but is not limited to, Network Operations and Credentialing Operations

staffs, network management staff, NNCC and Credentialing Committee members,

designated regional Medical Directors, quality improvement staff, legal counsel,

clinical network management staff and personnel involved with off-site storage of

credentialing data.

2. Access to data within the Magellan credentialing database is limited by staff

function.

3. Customers that have delegated credentialing activities to Magellan have access to

credentialing data in accordance with their oversight responsibilities. Customers

that review credentialing data as part of their oversight activities execute a

confidentiality agreement prior to review of credentialing information.

4. Reviewers who conduct audits in accordance with national accreditation surveys

have access to credentialing data in accordance with review requirements pertaining

to the accreditation process. Reviewers sign a confidentiality statement prior to

review of credentialing data.


22

C. Subject to applicable state and federal law and customer requirements, credentialing

material contained in practitioner files is not made available to any other entities, except

those defined above, without the written authorization of the practitioner.

D. Magellan maintains the right to refuse release of the practitioner’s material to

individuals or entities other than those defined above if the request is considered

unreasonable or in violation of Magellan confidentiality policies.

XVIII. Recredentialing

A. Recredentialing of Magellan practitioners occurs at least every thirty-six (36) months (to

the month), unless a more frequent interval is mandated by applicable state law or

customer contract.

B. The recredentialing process is a collaborative effort of Credentialing Operations,

Credentialing Committees and clinical centers to evaluate practitioners for continued

participation within Magellan’s care delivery system.

C. The recredentialing process has two main components:

1. Administrative recredentialing functions, which include, but are not limited to,

reviewing, updating, and verifying a practitioner’s credentials. The administrative

functions are conducted by Magellan’s Credentialing Operations.

2. Clinical recredentialing functions, which include, but are not limited to, evaluation of

practitioner performance in clinical care, clinical service, and member service. These

functions are monitored and reported by the unit Quality Improvement and clinical

to the Credentialing Committees.

XIX. Recredentialing Administrative Review

A. Prior to the expiration of the practitioner’s current credentialing cycle, the provider may

be notified of the requirement to submit a recredentialing application and additional

required documents.

B. Practitioners receive follow-up communications regarding missing information required

to complete the recredentialing process.

C. Recredentialing Application

1. The provider has the following options available for application submission:

a) Credentialing application through use of the Council for Affordable Quality

Healthcare (CAQH) website and made available to Magellan; or

b) Recredentialing application available through state-sponsored websites in those

states where a state-mandated application is required;

c) Recredentialing application available on the Magellan provider website through

the provider’s personal account;

d) Magellan recredentialing application, as provided upon request, may be

submitted via standard mail, email or fax.

2. Practitioners are required to submit any supporting documentation necessary to

complete the recredentialing process. Additional materials are submitted by email,

fax and/or standard mail.

3. The submitted recredentialing application is reviewed by credentialing staff to

determine:

a) Completeness;


23

b) Appropriate support documents accompany the application; and

c) Practitioner signature, date and attestation indicating correctness and

completeness of the application.

4. A preliminary review of the application against Magellan criteria is conducted to

determine if the applicant meets Magellan’s ongoing professional provider selection

criteria for the practitioner’s professional level.

5. The practitioner must continue to meet the Criteria Pertaining to All Professionals

and Additional Professional Criteria.

6. Application and attestation at recredentialing is the same as that indicated in the

Application and Attestation.

XX. Verification at Recredentialing

A. As an integral component of the recredentialing process, Magellan evaluates applicants

for continued inclusion in the practitioner network through the verification review

process.

B. Practitioner/provider credentials are verified per IX.Verification Standard, above.

C. All elements are re-verified per the policy with the exception of education/degree,

institutional accreditations, work history and attestations for providers with prescriptive

authority and clinical supervision. However, education, or institutional accreditations

are re-verified if there is new information or a change to the information since the most

recent credentialing event.

XXI. Non-Compliance with Administrative Recredentialing Requirements

Practitioners who fail to meet requirements to submit recredentialing materials are

terminated from network participation based on administrative non-compliance with re-

credentialing requirements. See the Termination of Providers from the Network Policy.

XXII. Practitioner Administrative Credentialing Ineligibility at Recredentialing

A. Verifications and recredentialing application review that finds the practitioner fails to

meet Magellan’s administrative recredentialing criteria results in administrative

recredentialing ineligibility. Practitioners who do not meet Magellan’s administrative

recredentialing criteria are:

1. Notified in writing of their ineligible status and the reason for ineligibility; and

2. Informed of the process for reconsideration (with the exception of Disciplinary Action on License and Exclusions Lists, below). See “Reconsideration of Professional Provider Recredentialing Ineligibility.

B. Disciplinary Action on License: Practitioners must have a current, unrestricted,

unencumbered license to practice without terms, conditions and/or limitations, including

probationary status. Any practitioner whose license does not meet this requirement does

not meet Magellan’s credentialing criteria, is not eligible for continued participation in

Magellan’s provider network and will be terminated from network participation per the

Magellan policy: Termination of Providers from the Network. The practitioner is notified

of the right to correct such information if s/he believes it to be incomplete, inaccurate,

conflicting or erroneous. The practitioner may reapply once sanctions are lifted and

terms and conditions are met.

C. Exclusion Lists: Magellan reviews the Department of Health and Human Services Office

of Inspector General List of Excluded Individuals and Entities (OIG-LEIE), the Federal

government System for Award Management (SAM) and any applicable State Medicaid


24

exclusion list during the provider credentialing and re-credentialing process. All

providers who are identified on the exclusions lists do not meet Magellan’s

administrative credentialing criteria for participation in networks serving Medicaid,

Medicare, State Children’s Health Insurance Program (SCHIP) and other applicable

government funded benefit plans, are not eligible for continued participation in those

provider networks and will be terminated from network participation per the Magellan

policy: Termination of Providers from the Network. There is no offer of reconsideration

or appeal. Based on a case-by-case review, with input from the Account Management

Department, and if needed, the customer health plan, the National Vice President of

Network Management will determine if excluded providers are also terminated from

participating in Magellan’s provider network for commercial plans. The practitioner is

notified of the right to correct such information if s/he believes it to be incomplete,

inaccurate, conflicting or erroneous. The practitioner may reapply once sanctions or

exclusions are lifted.

XXIII. Review Process for Information Related to Potential Risks at Recredentialing

Review of information related to potential risks obtained through the process of primary

source verification or reported on the provider re-credentialing application that could impact

the quality of care or quality of services to members is managed at recredentialing as at

initial credentialing. See “Review Process for Information Related to Potential Risks”, above.

XXIV. Review of Recredentialing Information Prior to Submission to Credentialing Committee

Magellan has mechanisms to review recredentialing information for completeness, accuracy

and conflicting information before review by the Credentialing Committee for determination.

See Review of Credentialing Information Prior to Submission to Credentialing Committee.

XXV. Clinical Review and Recredentialing Determination

A. All practitioners’ recredentialing information must be reviewed and approved by the

Credentialing Committee or Medical Director prior to continuing as a participating

provider in Magellan’s network.

B. Review activity specific to recredentialing determination includes a re-review of provider

credentialing data sources, as well as quality data collected since the previous

credentialing event.

1. Units whose members utilize the practitioners under recredentialing review have

responsibility for conducting Quality Improvement (QI) activities, completing site

visits, if applicable, and maintaining any member satisfaction information as a part

of the recredentialing process.

2. Quality data may include, but is not limited to:

a) Member complaints about practitioner;

b) Adverse incidents involving practitioner;

c) Treatment record review results, if any have been conducted since previous

credentialing event;

d) Results from office site visits, if any have been conducted since the previous

credentialing event; and

e) Other pertinent clinical information.

3. Quality information pertaining to the participation of practitioners in the Magellan

network is maintained in centralized quality databases and at the unit where

membership served by that provider is managed.


25

C. Upon receipt of a complete recredentialing file, the designated regional Medical

Director(s) review(s) the file contents against Magellan’s criteria for a “clean” file. If the

Medical Director determines that the file meets those criteria, the Medical Director may

sign off on the file as complete, clean, and approved. The date of the Medical Director’s

signature of approval is considered the recredentialing date.

1. A “complete” file is defined as a recredentialing file that contains the required timely,

verified administrative data, and quality data. In the absence of quality data, the file

must contain documentation that unit reviewed complaint records and adverse

incidents records and found none for the practitioner.

2. A recredentialing file must meet criteria defined above, XIII.C.2.Clinical Review in

order for the file to be considered “clean:”

D. If the Medical Director determines that the recredentialing file does not meet the criteria

for a “clean” file, the Medical Director forwards the complete file to the Credentialing

Committee for review and careful consideration of the recredentialing elements prior to

the committee making a re-credentialing decision.

E. The Credentialing Committee reviews and determines continued practitioner network

participation based on the administrative and quality information for those

recredentialing files that do not meet Magellan’s criteria for a “clean” recredentialing file.

F. If the Credentialing Committee determination is to deny recredentialing and terminate

network participation, practitioners are:

1. Notified in writing of their denied status and the reason for denial; and

2. Informed of their right to appeal. See the Provider Network Participation Appeals policy.

XXVI. Notification of Recredentialing Determination; Practitioner Rights; Reconsideration

A. The recredentialing determination completes the recredentialing process and establishes

the timeframe for the next recredentialing cycle.

B. The practitioner is notified of the recredentialing determination in compliance with

applicable client, regulatory, and/or accrediting body requirements. Successful

recredentialing can be assumed if no written notification to the contrary is received, in

accordance with Magellan’s Provider Handbook.

See Standard XXV. B. below for customer Plans that have delegated credentialing to

Magellan under URAC accreditation standards.

C. Practitioners have the right to correct incomplete, inaccurate, conflicting or erroneous re-

credentialing information prior to Credentialing Committee review in accordance with

Practitioner Rights in Credentialing.

D. Confidentiality of practitioner recredentialing records is maintained per Confidentiality of Credentialing Records.

E. Practitioners who do not meet Magellan administrative credentialing criteria for network

participation are Notified in writing of their ineligible status and the reason for

ineligibility (i.e. area(s) of criteria not met, general liability concerns, etc.); and informed

of the process for reconsideration. See “Reconsideration of Professional Provider Credentialing Ineligibility.”

XXVII. Plans that have delegated credentialing to Magellan under URAC accreditation standards

A. Application attestation to Credentialing Committee review: Credentialing files subject to

URAC compliance: application attestation signature and work history date no more than


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one hundred eighty (180) days old when applicant materials are designated as ready for

Committee review and determination.

B. Practitioner Notification of Determination:

1. Magellan provides written notification to the practitioner within ten (10) business

days of the initial credentialing determination.

2. Successful recredentialing can be assumed if no written notification to the contrary is

received, in accordance with Magellan’s Provider Handbook.

Where written notification is otherwise required at recredentialing by applicable

client or regulation, the practitioner is sent written notification within ten (10)

business days of the recredentialing determination.

Associated Corporate Forms & Attachments (internal link(s) available to Magellan Health employees only)

None # # #


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Documents

MMA SRC #12, Attachment 4: Network Practitioner Credentialing … 08/MAGELLAN... · 2015-12-18 · John J. DiBernardi, Jr., Esq. December 30, 2016 Magellan Health, Senior Vice President