Tip: Confirm a managed care file is ready for credentialing committee review

Once a managed care application is successfully submitted and verified, a final review should occur to confirm that the file meets the plan’s requirements before it is presented for final consideration by the credentialing committee or, if authorized, the medical director. This can be accomplished through one or more of the following practices:

1. Self audit: The credentialing specialist who processed the file may audit it using a predeter­mined checklist that must be completed, signed, and included in the file.
2. Peer audit: Another credentialing specialist or the credentialing manager may review a completed file using the same standard checklist. In some plans, there may be a designated auditor to perform this function.
3. Database audit: A report may be run from the credentialing database that pulls all of the required elements, including date received and date verified, to ensure that all elements are accounted for within the required time frames. There may also be a feature within the data­base that automatically checks the file for completeness based on predetermined business rules preventing the file from being closed if anything is missing or out of date.

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