Conduct a thorough provider enrollment application review

When an application is received, an initial review should be performed by the credentialing staff to determine whether all of the required information has been returned, completed, and appropriately signed. At this point in time, remember the confidentiality requirements that must be followed. A leading practice is to have everyone involved with the credentialing process—from the credentialing staff to the credentialing committee—sign a specific confidentiality agreement. Based on a health plan’s criteria outlined in its policies and procedures, a high-level determination can be made about whether to proceed with processing the application. The following situations may occur, and the specific steps taken by the plan should be outlined in its credentialing policy:

1. Criteria not met: The applicant is notified in writing of the deficiency in his or her credentials that does not allow for processing of the application, such as lack of licensure in the applicable state or lack of board certification (if required by plan). In some plans, this may be referred to as an administrative denial because it is based on foundational criteria that must be met. There would be no requirement to report this type of action or offer a right of appeal. However, the plan may offer the practitioner the opportunity to reapply once the specific criterion (or criteria) is met.
2. Application incomplete: The applicant may meet all basic eligibility criteria, but some supporting documentation may be missing from the application. The plan would notify the applicant in writing of the missing information, and depending on the level of incompleteness, the entire application may be returned. In situations where only a specific element is missing, such as explanation of a work history gap, the notification would request that the information be provided within a specified time frame. If the information is not provided as requested, then the application may be closed at that time and deemed to be a voluntary withdrawal.
3. Application complete: Based on the review of information received, the applicant meets all eligibility criteria and all requested information has been provided. The plan will then commence with processing the application pursuant to its policies and procedures. Some health plans may proactively notify the practitioner that they received the application, and they may provide a high-level outline and time frame for the process, including the practitioner’s rights (if not provided with the application packet) and contact information.

Source: Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities

Did you know?
Platinum Plus members of the Credentialing Resource Center (CRC) have unrestricted access to CRC’s ever-growing collection of industry-leading eBooks, including Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities. To learn more about your current CRC benefits, click here.To join or renew your membership to the premier destination for credentialing, privileging, and peer review expertise, click here.