Practitioners subject to credentialing or recredentialing and contracting directly with Network Providers, LLC (NPLLC) must submit a completed NPLLC-approved application.

Organizational providers subject to initial certification, contracting directly with Network Providers, LLC (NPLLC) must submit a completed NPLLC-approved application. An application is not required when being recertified.

By submitting a completed application, the practitioner or provider:

The NPLLC Credentialing Committee or physician designee reviews rosters of practitioners and organizational providers meeting all NPLLC criteria and approves their admittance or continued participation in the NPLLC network.

A peer review process is used for practitioners with a history of adverse actions, complaints, negative quality improvement (QI) activities, impaired health, substance abuse, health care fraud and abuse, criminal history, or similar conditions to determine whether a practitioner should be admitted or retained as a participant in NPLLC network.

Practitioners are notified of all decisions regarding approval, denial, limitation, suspension, or termination of credentialing status consistent with health plan, state and federal regulatory requirements and accrediting entity standards. All initial credentialing files are processed within 90 days of receipt of a complete application. This notice includes information regarding the reason for denial determination. If the denial or termination is based on health status, quality of care or disciplinary action, the practitioner is afforded applicable appeal rights.

Practitioners who fail to respond to recredentialing requests may be subject to administrative termination from the NPLLC network.

Practitioners who have been administratively denied are eligible to reapply for network participation as soon as the administrative matter is resolved.

Practitioners are notified of the Credentialing Committee decision within 60 calendar days of the decision.

The following information applies only to Physician providers.

Prison Health Care Provider Network (PHCPN) participating providers who would like to deliver services onsite at a California Department of Corrections and Rehabilitation (CDCR) institution must complete California Correctional Health Care Services (CCHCS) credentialing requirements in addition to the Network Providers, LLC (NPLLC) credentialing process. Providers must submit a completed credentialing application via the State’s Electronic Credentialing Tool (MD-App) and receive approval from the CCHCS Credentialing and Privileging Support Unit (CPSU) before beginning onsite services.

Participating providers can view and print CCHCS credentialing requirements from the CDCR website. Providers can also contact the CDCR by email or phone to request credentialing applications.

MD-App Authorization and Consent form are only accepted from PHCPN providers that have completed and satisfied NPLLC credentialing requirements. Providers submit the completed MD-App Authorization and Consent form to NPLLC. NPLLC submits the MD-App request to CCHCS on behalf of providers. NPLLC will notify the provider via email of CPSU’s credentialing decision.

All practitioners participating in the Network Providers, LLC (NPLLC) network must comply with the following NPLLC standards for participation in order to receive or maintain credentialing.

Applicants seeking credentialing and practitioners due for recredentialing must complete all items on an approved credentialing application and supply supporting documentation, if required. The verification time limit for a NPLLC approved application is 180 days. Prospective providers must submit a completed application based on the application developed by the Council for Affordable Quality Healthcare (CAQH) that complies with federal and state regulatory requirements and NCQA standards. Applications can be accessed on the CAQH website at www.caqh.org via the Universal Provider DataSource link. Supporting documentation includes:

Investigations

NPLLC investigates adverse activities indicated in a practitioner or provider's initial credentialing or recredentialing application materials or identified between credentialing cycles. NPLLC may also be made aware of such activities through primary source verification utilized during the credentialing process or by state and federal regulatory agencies. NPLLC may require a practitioner or provider to supply additional information regarding any such adverse activities. Examples of such activities include, but are not limited to:

At NPLLC's request, a practitioner or provider must assist NPLLC in investigating any professional liability claims, lawsuits, arbitrations, settlements, or judgments that have occurred within the prescribed time frames.

An organizational provider (OP) is an institutional provider of health care that is licensed by the state or otherwise authorized to operate as a health care facility. Examples of OPs include, but are not limited to, hospitals, home health agencies, skilled nursing facilities (SNFs), and ambulatory surgical centers (ASCs).

OPs that require certification and recertification by Network Providers, LLC (NPLLC) or its delegated entities include:

Providers contracting directly with NPLLC must submit a completed, signed NPLLC approved hospital or ancillary facility credentialing application for initial inclusion into our network and any supporting documentation to NPLLC for processing. The documentation, at a minimum, includes:

Organizational providers are recertified at least every 36 months to ensure each entity has continued to maintain prescribed eligibility requirements.

A practitioner has the right to review information obtained by Network Providers, LLC (NPLLC) for the purpose of evaluating that practitioner's credentialing or recredentialing application. This includes non-privileged information obtained from any outside source (such as, malpractice insurance carriers, state licensing boards or the National Practitioner Data Bank), but does not extend to review of information, references or recommendations protected by law from disclosure.

A practitioner may request to review such information at any time by sending a written request via letter or fax to NPLLC's credentialing manager or supervisor. The manager or supervisor of credentialing notifies the practitioner within 72 hours of the date and time when such information is available for review at NPLLC's Credentialing Department. Upon written request, the NPLLC Credentialing Department provides details of the practitioner's current status in the initial credentialing or recredentialing process.

Practitioners are notified in writing, via letter or fax, when information obtained by primary sources varies substantially from information provided on the practitioner's application. Examples include reports of a practitioner's malpractice claim history, actions taken against a practitioner's license or certificate, suspension or termination of hospital privileges, or board certification expiration when one or more of these examples have not been self-reported by the practitioner on his or her application. Practitioners are notified of the discrepancy at the time of primary source verification. Sources are not revealed if information obtained is not intended for verification of credentialing elements or is protected from disclosure by law.

A practitioner who believes that erroneous information has been supplied to NPLLC by primary sources may correct such information by submitting written notification to the Credentialing Department. Practitioners must submit a written notice via letter or fax, along with a detailed explanation, to NPLLC's Credentialing Department manager or supervisor. Notification to NPLLC must occur within 48 hours of NPLLC's notification to the practitioner of a discrepancy or within 24 hours of a practitioner's review of his or her credentials file. Upon receipt of notification from the practitioner, NPLLC re-verifies the primary source information in dispute. If the primary source information has changed, a correction is made immediately to the practitioner's credentials file. The practitioner is notified in writing, via letter or fax, that the correction has been made. If, upon re-review, primary source information remains inconsistent with the practitioner's notification, the Credentialing Department notifies the practitioner via letter or fax.

The practitioner may then provide proof of correction by the primary source body to NPLLC's Credentialing Department via letter or fax within 10 business days. The Credentialing Department re-verifies primary source information if such documentation is provided. If after 10 business days the primary source information remains in dispute, the practitioner is subject to administrative denial or termination.

The Network Providers, LLC (NPLLC) Credentialing Department obtains and reviews information on a credentialing or re-credentialing application and verifies the information in accordance with the NPLLC primary source verification practices. NPLLC requires participating physician groups (PPGs) to which credentialing has been delegated to obtain primary source verification* in accordance with NPLLC standards of participation, state and federal regulatory requirements and accrediting entity standards.

*Primary Source Verification

Organizational Providers

The Network Providers, LLC (NPLLC) credentialing program establishes criteria for evaluating continuing NPLLC participating practitioners. This evaluation, which includes applicable primary source verifications, is conducted in accordance with health plan, state and federal regulatory requirements and accrediting entity standards. Practitioners are subject to recredentialing within 36 months. Only licensed, qualified practitioners meeting and maintaining NPLLC standards for participation requirements are retained in the NPLLC network.

Practitioners due for recredentialing must complete all items on an approved NPLLC application and supply supporting documentation, if required. Documentation includes, but is not limited to:

Network Providers, LLC (NPLLC) notifies California Correctional Health Care Services (CCHCS) as required under state law if a practitioner's contract participation status is terminated. NPLLC oversees reassignment of patients to another participating provider where appropriate.