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CREDENTIALING AND RECREDENTIALING

Carelon’s 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 Carelon’s participating providers. The following is not intended to be an exhaustive list; Carelon reserves the right to amend this list of standards.

All providers who participate in Carelon’s network must be credentialed/recredentialed according to Carelon’s 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.

Carelon also requires:

• Current, adequate malpractice insurance coverage;
• An appropriate work history for the provider’s specialty;
• No adverse record of failure to follow Carelon’s 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 Carelon’s 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, Carelon conducts a structured site visit of potential high volume practitioners’ offices. This visit includes an evaluation against Carelon’s site and operations standards and an evaluation of the practitioner’s clinical record-keeping practices to ensure conformity with Carelon’s standards.

Organizational providers (facilities) must be evaluated at credentialing and recredentialing. Those who are accredited by an accrediting body accepted by Carelon (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 Carelon’s standards. Status with state and federal authorities and programs will be verified.

Credentialing

Initial credentialing processes begin with submission of completed and signed applications, along with all required supporting documentation using one of the following methods:

• After completing the online universal credentialing process offered by the Council for Affordable Quality Healthcare (CAQH), give Carelon access to your credentialing information and ensure a current attestation. Call the CAQH Help Desk at (888) 599-1771 for answers to your questions related to the CAQH application or website; or
• Complete a Carelon application by going to our website, www.carelonbehavioralhealth.com

This includes without limitation attestation as to: (a) any limits on the provider’s ability to perform essential functions of their position or operational status; (b) with respect to individual practitioner providers, the absence of any current illegal substance or drug use; (c) any loss of required state licensure and/or certification; (d) absence of felony convictions; (e) with respect to individual practitioner providers, any loss or limitation of privileges or disciplinary action; and (f) the correctness and completeness of the application.

Failure of a provider to submit a complete and signed credentialing application, and all required supporting documentation timely and as provided for in the credentialing application and/or requests from Carelon, may result in rejection of request for participation status with Carelon.

Recredentialing

Carelon 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 and can be accomplished using one of the following methods:

• After completing the online universal credentialing process offered by the Council for Affordable Quality Healthcare (CAQH), give Carelon access to your credentialing information and ensure a current attestation. Call the CAQH Help Desk at 1-888-599-1771 for answers to your questions related to the CAQH application or website; or
• The mailing of a re-credentialing application via USPS to the participating provider or notification by Carelon to the participating provider via email, voicemail or facsimile that their online re-credentialing application is available via ProviderConnect.

Required documentation includes without limitation attestation as to: (a) any limits on the participating provider’s ability to perform essential functions of their position or operational status; (b) with respect to individual practitioner participating providers, the absence of any current illegal substance or drug use; and (c) the correctness and completeness of the application (including without limitation identification of any changes in or updates to information submitted during initial credentialing).

Failure of a participating provider to submit a complete and signed re-credentialing application, and all required supporting documentation timely and as provided for in the re-credentialing application and/or requests from Carelon, may result in termination of participation status with Carelon and such providers may be required to go through the initial credentialing process.

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 Carelon) 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 Carelon’s standards. This review will include an evaluation against Carelon’s site and operations standards and an evaluation of the practitioners’ clinical record keeping practices to ensure conformity with Carelon’s standards.