Credentialing and Recredentialing

Hospitals are required to:

• Assure that the credentialing/recredentialing plan meets 100 percent of National Committee for Quality Assurance (NCQA) credentialing/recredentialing standards, and execute these activities according to that plan.
• Achieve and maintain no less than 70 percent compliance with the plan's medical records criteria for each primary care physician (PCP).
• Measure and report, as a network, data elements necessary to determine compliance with Healthcare Effectiveness Data and Information Set (HEDIS^®) quality benchmarks.
• Achieve and maintain compliance with Department of Health and Human Services (HHS) standards.
• Achieve and maintain compliance with Centers for Medicare and Medicaid Services (CMS) standards.
• As applicable, maintain compliance/certification with Joint Commission on Accreditation of Healthcare Organization (JCAHO).

Health Net retains the right, based on quality issues, to terminate or suspend individual practitioners, providers, and sites, regardless of the credentialing delegation status of the PPG, IPA or entity.