VBH-PA: Provider Manual: Credentialing and Recredenialing

Provider Manual

CREDENTIALING AND RECREDENTIALING

ValueOptions^®’ program for credentialing and recredentialing providers is designed to comply with national accrediting organization standards as well as local, state and federal laws. The program described below applies to VBH-PA’s participating providers. The following is not intended to be an exhaustive list; ValueOptions^® reserves the right to amend this list of standards.

All providers who participate in VBH-PA’s network must be credentialed/recredentialed according to ValueOptions^®’ requirements. Among these requirements is primary source verification of the following information:

Current, valid license to practice as an independent practitioner at the highest level certified or approved by the state for the provider’s specialty or facility/program status;
License current and valid and not encumbered by restrictions, including but not limited to probation, suspension and/or supervision and monitoring requirements;
Clinical privileges in good standing at the institution designated as the primary admitting facility, with no limitations placed on the practitioner’s ability to independently practice in his/her specialty;
Graduation from an accredited professional school and/or highest training program applicable to the academic degree, discipline or licensure;
Board certification, if indicated on the application;
A copy of a current DEA or CDS Certificate, as applicable;
No adverse professional liability claims which result in settlements or judgments paid by or on behalf of the practitioner, which disclose an instance of, or pattern of, behavior which may endanger patients;
No exclusion or sanctions from government programs;
Current specialized training as required for practitioners;
No Medicare and/or Medicaid sanctions.

ValueOptions^® also requires:

Current, adequate malpractice insurance coverage;
An appropriate work history for the provider’s specialty;
No adverse record of failure to follow ValueOptions^®’ policies, procedures or Quality Management activities. No adverse record of provider actions which violate the terms of the provider agreement;
No adverse record of indictment, arrest or conviction of any felony or any crime indicating patient endangerment;
No criminal charges filed relating to the provider’s ability to render services to patients;
No action or inaction taken by provider that, in ValueOptions^®’ sole discretion, results in a threat to the health or well-being of a patient or is not in the patient’s best interest;
At credentialing or recredentialing, VBH-PA conducts a structured site visit of potential high volume practitioners’ offices. This visit includes an evaluation against ValueOptions^®’ site and operations standards and an evaluation of the practitioner’s clinical record-keeping practices to ensure conformity with ValueOptions^®’ standards.

Organizational providers (facilities) must be evaluated at credentialing and recredentialing. Those who are accredited by an accrediting body accepted by ValueOptions^® (currently JCAHO, CARF, COA and AOA) must have their accreditation status verified. In addition, non-accredited organizational providers must undergo a structured site visit to confirm that they meet ValueOptions^®’ standards. Status with state and federal authorities and programs will be verified.

ValueOptions requires that individual practitioners and organizational providers undergo recredentialing every three years.

Organizational providers must be recredentialed every three years.

Recredentialing will begin approximately six months prior to the expiration of the credentialing cycle. Providers are sent a recredentialing application that must be completed in its entirety, signed and returned to ValueOptions as soon as possible, with all requested information attached.

Credentialing information that is subject to change must be re-verified from primary sources during the recredentialing process. The practitioner must attest to any limits on his/her ability to perform essential functions of the position and attest to absence of current illegal drug use.

High-volume practitioners (as defined by ValueOptions) that have added a new practice location or changed group affiliations since the previous credentialing decision must undergo a structured site review to ensure conformity with ValueOptions^®’ standards. This review will include an evaluation against ValueOptions^®’ site and operations standards and an evaluation of the practitioners’ clinical record keeping practices to ensure conformity with ValueOptions^®’ standards.