Credentialing

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:

• Current, unencumbered state medical license.
• Valid, unencumbered Drug Enforcement Agency (DEA) certificate, as applicable or Chemical Dependency Services (CDS) certificate, as applicable.
• Continuous work history for the previous five years with a written explanation of any gaps of a prescribed time frame (initial credentialing only).
• Evidence of adequate education and training for the services the practitioner is contracting to provide.
• Evidence of active admitting privileges in good standing, with no reduction, limitation or restriction on privileges, with at least one NPLLC participating hospital or surgery center, or a documented coverage arrangement with a NPLLC credentialed, participating practitioner of a like specialty.
• Professional/medical specialty information.
• Malpractice insurance coverage that meets NPLLC standards.
• Answers to all confidential questions and explanations provided in writing for any questions answered adversely.

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:

• State or local disciplinary action by a regulatory agency or licensing board.
• Current or past chemical dependency or substance abuse.
• Health care fraud or abuse.
• Complaints.
• Substantiated quality of care concerns activities.
• Impaired health.
• Criminal history.
• Office of Inspector General (OIG) Medicare/Medicaid sanctions.
• Federal Employees Health Benefits Program (FEHBP) debarment.
• Substantiated media events.
• Trended data.

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:

• Hospitals.
• Free-standing and ASCs, including abortion clinics.
• Dialysis/end-stage renal disease (ESRD) care providers.
• Laboratories.
• Office-based surgery suites.
• Comprehensive outpatient rehabilitation facilities.
• Physical therapy.
• Portable X-ray suppliers.
• Radiology/imaging centers.
• Behavioral health facilities (inpatient, residential and ambulatory).
• Urgent care centers.
• Federally qualified health centers and rural health clinics.
• Other providers as deemed necessary.

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:

• Evidence of a site survey that has been conducted by an accepted agency, if the provider is required to have such an on-site survey prior to being issued a state license. Accepted agency surveys include those performed by the state Department of Health and Human Services (DHHS), Department of Public Health (DPH) or Centers for Medicare and Medicaid Services (CMS).
• Evidence of a current, unencumbered state facility license. If not licensed by the state, the facility must possess a current city license, fictitious name permit, certificate of need, or business registration.
• Copy of a current accreditation certificate appropriate for the facility. If not accredited, then a copy of the most recent DHHS/DPH site survey as described above is required. A favorable site review consists of compliance with quality of care standards established by CMS or the applicable state health department. NPLLC obtains a copy of each surgery center's site survey report and ensures each provider has received a favorable rating. This may include a completed corrective action plan (CAP) and DHHS CAP acceptance letter.
• Professional and general liability insurance coverage that meets NPLLC requirements.
• Overview of the facility's quality assurance/quality improvement program upon request.

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

Right to Review/Request for Current Network Status

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.

Notification of Discrepancy

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.

Correction of Erroneous Information

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

• Audiologist.
• Dentist and dental hygienist.
• Doctor of medicine.
• Doctor of osteopathy.
• Doctor of podiatric medicine.
• Licensed clinical social worker.
• Optometrist.
• Oral and maxillofacial surgeon.
• Physician assistant.
• Physical therapist and occupational therapist.
• Psychologist.
• Registered nurse anesthetist, nurse practitioner and certified nurse midwife.

Organizational Providers

• Behavioral health facilities (inpatient, residential and ambulatory).
• Comprehensive outpatient rehabilitation facilities.
• Dialysis and end-stage renal disease care providers.
• Federally qualified health centers/rural health clinics.
• Freestanding and ambulatory surgery centers.
• Hospitals.
• Laboratories.
• Physical therapy.
• Portable X-ray suppliers.
• Radiology and imaging centers.
• Urgent care centers.

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:

• Current state medical license.
• Attestation to the ability to provide care to NPLLC patients without restriction.
• Valid, unencumbered Drug Enforcement Agency (DEA) certificate or Chemical Dependency Services (CDS) certificate, if applicable. A practitioner who maintains professional practices in more than one state must obtain a DEA certificate for each state.
• Evidence of active admitting privileges in good standing, with no reduction, limitation or restriction on privileges, with at least one NPLLC participating hospital or surgery center, or a documented coverage arrangement with a NPLLC credentialed or participating practitioner of a like specialty.
• Malpractice insurance coverage that meets NPLLC standards.
• Trended assessment of practitioner's complaints, quality of care and performance indicators.

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.