What is credentialing and re-credentialing - definition

Credentialing

Credentialing  is  the  process  by  which  the  appropriate  committee  reviews  documentation  for  each individual physician/provider to determine participation in the health plan network. Such documentation may  include,  but  is  not  limited  to,  the  applicant’s  education,  training,  clinical  privileges,  experience, licensure, accreditation, certifications, professional liability insurance, malpractice history, professional competency, and physical and mental impairments. The credentialing process includes verification that the  information  obtained  is  accurate  and  complete.  The  physician/provider  must  respond  to  any reasonable CarePlus Health Plans, Inc. (CarePlus) request for additional information including, but not limited to, a medical record review as well as a site visit as applicable. 

CarePlus recognizes the physician’s/provider’s right to review information submitted in support of the credentialing application to the extent permitted by law and to correct erroneous information. Providers may obtain information regarding the status of their credentialing or recredentialing process by calling CarePlus. 

The  credentialing  process  generally  is  required  by  law.  The  fact  that  the  physician/provider  is credentialed is no intended as a guarantee or promise of any particular level of care or services. 
 
Council for Affordable Quality Healthcare (CAQH): CarePlus thru its parent company Humana Inc., is a member of the Council for Affordable Quality Healthcare (CAQH), which is an online single, national process  that  eliminates  the  need  for  multiple  credentialing  applications.  Physicians/providers  who  are members  of  CAQH  can  provide  CarePlus  with  the  appropriate  information  in  lieu  of  completing  a CarePlus credentialing or re-credentialing application. Additional information may be requested. 

CarePlus Credentials Committee: Is conducted at a corporate level thru its parent company in Louisville, KY.  The  Credentials  Committee  is  composed  of  a  chairperson  and  employed  and  participating physicians/providers. Functions of the committee include credentialing, ongoing and periodic assessment, recredentialing,  and  establishment  of  credentialing  and  recredentialing  policies  and  procedures.  The physician’s/provider’s documentation is provided to the corporate credentials committee for approval or denial  for  participation  in  the  network.  Notification  of  approval  or  denial  of  credentials  is  sent  to  the physician/provider. 

Recredentialing:  Recredentialing  is  conducted  at  least  every  three  (3)  years  in  accordance  with  the CarePlus  credentialing  and  recredentialing  process.  The  recredentialing  process  is  conducted  with  the same standards as those for initial credentialing. The decision concerning re-appointment or failure to re-appoint will be conveyed to the physician/provider in writing.