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Credentialing

Provider Type

  • Physicians 
  • Hospitals
  • Ancillary

Application Process

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:

  • Affirms the completeness and truthfulness of representations made in the application, including lack of present illegal drug use.
  • Indicates a willingness to provide additional information required for the credentialing process.
  • Authorizes NPLLC to obtain information regarding the applicant's qualifications, competence or other information relevant to the credentialing review.
  • Releases NPLLC and its independent contractors, agents and employees from any liability connected with the credentialing review.

Approval, Denial or Termination of Credentialing Status

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.

Last Updated: 06/23/2022