Elements to be included in an organization's credentialing program

All accrediting and regulatory bodies require policies and procedures that describe the credentialing program of an MCO or health plan. Policies and procedures provide the framework under which MSPs and credentialing specialists perform their work. They also define the credentialing and recredentialing criteria, enabling health plans to objectively evaluate and select network practitioners to provide care and to meet its goals for provider access and availability. Additionally, accreditors and regulators will look at an organization’s policies and procedures as the first step in determining compliance with standards. To ensure they stay up to date and meet these needs, policies and procedures should be reviewed and updated at least annually.

There are very specific elements that must be included in the health plan’s policies and procedures. Following are questions organizations should consider when developing its credentialing program:

  1. Provider types: Who and what will be credentialed?
  2. Criteria: What credentialing requirements do applicants have to meet in order to participate in the plan?
  3. Verification: What sources will be accepted to verify credentials?
  4. Review and decision process: How does the plan evaluate and make decisions on applicants?
  5. Files: How are provider files managed within the credentialing process?
  6. Delegation: Does the organization allow it? If so, how does it manage that process?
  7. Nondiscriminatory practices: Is the credentialing process performed in a manner that does not discriminate against applicants?
  8. Practitioner notifications: Under what circumstances and time frames does the plan communicate with its practitioners?
  9. Medical director: How does this role fit into the credentialing program?
  10. Confidentiality: What processes are in place to maintain the confidentiality of practitioner information?
  11. Directories: How is any provider data that is displayed to members maintained in an accurate and timely manner?