MHP has established standard credentialing and re-credentialing policies and procedures for practitioner and facility participation throughout all regions. Providers are required to participate in and comply with credentialing and re-credentialing procedures. Failure to do so is grounds for termination from MHP.
MHP may delegate credentialing authority to participating PHOs, networks, or other provider groups after their credentialing program has been audited for compliance with MHP’s credentialing guidelines.
Each practitioner applicant and/or re-applicant must have an independent relationship with MHP, complete an application for participation, and meet the following minimum requirements:
Completed, signed, and dated application;
Attestation of history of loss of license and/or clinical privileges, disciplinary actions, and felony convictions;
Attestation to lack of current substance and/or alcohol abuse;
Attestation to mental and physical competence to perform the essential duties of the profession;
Attestation to the correctness/completeness of the application;
Signed and dated release of information form;
Execution of a current Participating Provider Agreement;
Current unrestricted license in the state where practice is located (absent of current restriction and/or sanctions);
Current liability insurance in compliance with minimum limits set by Plan’s provider agreement; however, in no case will this amount be below state mandated requirements by provider type;
Board certification. If not board certified, proof of graduation from highest level of training and three letters of recommendations are required for validation purposes;
Acceptable Credentialing Committee (CC) findings determinations of risk in regards to professional liability claims history for the immediate past five years for new applicants and recent three-year period for re-applicants;
Current federal Drug Enforcement Agency (DEA) certificate and State Bureau of Narcotics and Dangerous Drugs (BNDD) Controlled Substance License (as applicable);
Complete work history, with fully explained gaps for periods greater than thirty (30) days, for the immediate past ten (10) years for new applicants and recent three-year period for re-applicants;
Current unrestricted Medicare (if applicable to product) participation;
No history of Medicare or Medicaid sanctions or limitations; and
Current privileges in good standing at an in-network admitting facility, including privileges to perform all procedures the provider is qualified to provide at that facility (or acceptable coverage arrangements).
Re-credentialing occurs every three years, verifying a practitioner’s credentials and evaluating his/her performance through analysis of:
Member satisfaction;
Quality reviews;
Claims and encounter data;
Member complaints; and
Medical record reviews.
A reminder letter is sent to the practitioner at least four months before the re-credentialing due date. The practitioner is asked to update application information on Council for Affordable Healthcare (CAQH) website or submit an application directly to MHP. If a practitioner does not respond to requests for re-credentialing information after two written requests termination activities are initiated.
The Credentialing Committee reviews the re-credentialing information and makes recommendations for or against the physician’s continued participation with MHP. MHP’s chief medical officer reviews and establishes a corrective action plan where necessary. Their determinations are considered final unless the practitioner appeals the decision. Appeal rights will be detailed in a letter sent to the practitioner. All appeals must include additional supporting documentation in favor of the practitioner’s reconsideration for initial or continued participation with MHP.
Practitioners are required to hold members harmless and support continuity of care for up to 90 days after a termination from MHP participation or until the member(s) can be safely transitioned to an in-network practitioner, whichever is less.