Tip: MCOs, consider provisional credentialing

Provisional credentialing is an optional process that a health plan may incorporate into its credentialing policy. This process provides a managed care organization with the ability to add practitioners to its network prior to completing the full credentialing process. The intention of provisional credentialing is to allow a plan to meet its members’ needs for continuity or quality of care, similar to a hospital’s ability to grant temporary privileges for an immediate patient care need under Joint Commission standards.

The medical director or credentialing committee may provisionally credential a new applicant on a one-time basis. NCQA specifically requires that the following elements are obtained and appropriately verified:

  • Current, valid medical license in state(s) where treating patients
  • Past five years of malpractice history
  • Current, signed application and attestation

Note: Under CMS (Medicare) regulations, only those applicants whose education and training were completed within the past 12 months are eligible for this streamlined process.

Provisional credentialing is only valid for 60 calendar days. By that time, the health plan must complete the full credentialing process using the medical director or credentialing committee review process, as appropriate. URAC does not define the time limit for provisional credentialing and only requires that the full process be completed as quickly as possible.

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