提供者手册

认证和再认证

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:

  • 当前有效的独立从业者执业许可证，由州认证或批准的最高级别的提供者的专业或设施/计划状态；
  • 许可证当前有效且不受限制，包括但不限于缓刑、暂停和/或监督和监控要求；
  • 在指定为主要录取机构的机构中享有良好的临床特权，对从业者在其专业领域独立实践的能力没有限制；
  • 从认可的专业学校和/或适用于学位、学科或执照的最高培训计划毕业；
  • 董事会认证，如果在申请中注明；
  • 当前的 DEA 或 CDS 证书的副本（如适用）；
  • 没有不利的专业责任索赔，导致由执业者或代表执业者支付的和解或判决，这些索赔披露了可能危及患者的行为实例或模式；
  • 不排除或制裁政府计划；
  • 从业者目前所需的专业培训；
  • 没有医疗保险和/或医疗补助制裁。

Carelon also requires:

  • 当前的、足够的医疗事故保险；
  • 提供者专业的适当工作经历；
  • 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;
  • 没有任何重罪或任何表明危及患者的罪行的起诉、逮捕或定罪的不良记录；
  • 没有因提供者向患者提供服务的能力而提起刑事指控；
  • 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.

必须在认证和再认证时对组织提供者（设施）进行评估。那些被认可的认可机构认可的人 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.

认证

初始认证流程从使用以下方法之一提交已完成和签名的申请以及所有必需的支持文件开始：

  • 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

这包括但不限于以下方面的证明： (a) 供应商履行其职位或运营状态的基本职能的能力的任何限制； (b) 对于个体从业者，目前不存在任何非法物质或药物使用； (c) 所需的国家许可和/或认证的任何损失； (d) 无重罪定罪； (e) 对于个体从业者，特权或纪律处分的任何损失或限制； (f) 申请的正确性和完整性。

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.

重新认证

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

组织提供者必须每三年进行一次重新认证。

重新认证将在认证周期到期前大约六个月开始，可以使用以下方法之一完成：

  • 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.

所需文件包括但不限于以下方面的证明： (a) 参与提供商履行其职位或运营状态的基本职能的能力的任何限制； (b) 对于个体从业者参与提供者，目前不存在任何非法物质或药物使用； (c) 申请的正确性和完整性（包括但不限于识别初始认证期间提交的信息的任何更改或更新）。

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.

在重新认证过程中，必须从主要来源重新验证可能发生变化的认证信息。从业者必须证明他/她执行该职位基本职能的能力受到任何限制，并证明当前没有非法吸毒。

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.