CREDENTIALING - How to do with SHP insurance

Overview

SHP is responsible for all aspects of the credentialing and recredentialing process for all providers who join or participate in the SHP Network. This process is under the QI Department and is designed to meet all regulatory and accreditation requirements and standards. In accordance with those standards, SHP members will not be referred or assigned to a provider until the credentialing process has been completed.

SHP recognizes and accepts the Council for Affordable Quality Healthcare’s (CAQH) credentialing information and application or SHP’s own practitioner application that includes specific profile elements as required by the State of Florida. SHP may contract with medical groups/IPA’s that have approved credentialing function capabilities as entities with delegated credentialing


Required Information

As a practitioner requesting initial credentialing or recredentialing with SHP, you are required to submit adequate information that will allow the Plan to complete a thorough evaluation which includes your background, experience, education and training; demonstrate the ability to perform
as an SHP provider without limitations, including physical and mental health status as permitted by law.

If the application in incomplete in any way, you will receive a request from SHP, or its delegated entity, to provide the necessary information

Site Reviews

o Site reviews are required for the following provider offices:

* All Primary Care Physicians (PCP’s), which include Family Practice, General Practice, Pediatrics, and Internal Medicine

 *  Women’s Health Care Providers

*  OB/GYNs

* High Volume Behavioral Health Providers

o Once SHP’s Credentialing Department receives a practitioner’s credentialing application, a Provider Relations representative will schedule an office site visit. The provider must have a review score of 80% or greater to pass the review for the credentialing application process. In the event the provider does not receive a passing score and a corrective action plan is implemented, it is in the best interest of the provider to work with the site reviewer in developing the corrective action plan and correcting any deficiencies so as not to delay the credentialing process.

Credentialing Review Committee (CRC)
o All SHP providers must be credentialed and approved by the CRC prior to their contract becoming effective

o SHP’s Credentialing Review Committee (CRC) voting members are professional peers

o Once the requesting provider’s credentialing file is complete it is submitted to the CRC for
review and decision

o If the CRC is unable to make a determination based on the available information in the file and requires additional information, the Credentialing Department will request such information on behalf of the CRC

o On occasion, the CRC may, in its sole discretion, request that an applicant requesting credentialing appear for an interview

o SHP’s Board of Directors has delegated the authority to approve or deny applicants who apply for credentialing through the CRC

Verification Process

The Credentialing Department is responsible for verification of the applicant’s information such as
medical license, education and training, NPDB, etc., prior to being presented to the CRC.

Recredentialing

o Once a provider is credentialed by the CRC to provide service for SHP’s members, recredentialing will be performed every three (3) years

o The providers will receive a recredentialing application in a Provider Profile format approximately six (6) months prior to their credentialing expiration date. Only information that has changed since the last credentialing needs to be updated

o Failure of the provider to return the recredentialing form to the Plan will result in an administrative termination from SHP’s Provider Network as a non-compliant provider

o Information will be verified and presented to the CRC for recredentialing include:

* Basic qualifications continue to be met

* Quality performance information (i.e. medical record reviews, member satisfaction surveys, Member Services reports)

o In the event a provider’s DEA, medical license and/or liability insurance expires prior to a provider’s next recredentialing date, the provider will receive a request for the updated information. Failure to provide the requested information with the specified time frame will result in automatic suspension and/or termination from SHP’s Provider Network



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