1. CERTIFICATION FOCUSED STUDY PROGRAM
EDGE-U-CATE, LLC
CERTIFICATION
FOCUSED STUDY PROGRAM
for CPCS
2017
Section 1
Developed by Janet Wilson, CPMSM, CPCS
©Edge-U-Cate, LLC This documentation is proprietary and cannot be used or 
duplicated without the express permission of Edge-U-Cate, LLC

2. WHY CREDENTIAL?
HOSPITALS/SURGERY CENTERS = Assure that only qualified practitioners are granted membership and privileges
MANAGED CARE = Assure that only qualified practitioners are approved to provide services to members

3. Review of Accreditation and Regulatory Entities
The Joint Commission (TJC) accredits subscriber hospitals, ambulatory care centers, surgery, rehab centers, long term care centers, etc.
Healthcare Facilities Accreditation Program (HFAP) provides accreditation programs for allopathic and osteopathic acute care hospitals, critical access hospitals, ambulatory surgical centers, ambulatory care/office based surgery, clinical laboratories, and behavioral health facilities. While previously primarily osteopathic focused, HFAP is now authorized by the Centers for Medicare and Medicaid Services (CMS) to survey all hospitals for compliance with the Medicare Conditions of Participation and Coverage.
The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS is the federal agency that administers the Medicare program and monitors the Medicaid programs in each state.

4. Review of Accreditation and Regulatory Entities
The National Committee for Quality Assurance (NCQA) manages voluntary accreditation programs for individual physicians, health plans, medical groups. NCQA also manages certification programs for CVO’s.
URAC, formerly known as the Utilization Review Accreditation Commission promotes healthcare quality by accrediting healthcare organizations including medical management organizations (disease management, case management, health call centers, Independent Review Organizations, etc.), health plans (HMOs, PPOs, etc.), hospitals and health websites

5. Review of Accreditation and Regulatory Entities
The Accreditation Association for Ambulatory Health Care (AAAHC), accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as managed care organizations, such as health maintenance organizations and preferred provider organizations.

6. REVIEW OF CREDENTIALING STANDARDS/
REQUIREMENTS

7. State Mandated Applications Addendums
Pre-Application
State Mandated Applications
Addendums
CAQH (Council for Affordable Quality Healthcare)
Don’t Modify Applications – legal document

8. Complete Application Best Practice
Don’t start verification process until all information complete and attachments received
Reality
Use best judgment based on documents received and required turn around times
Follow bylaws/policies

9. Verification Process
(I) = Initial Application Process (R) = Reappointment/ Reappraisal Process

10. Practitioners Credentialed- TJC
Licensed Independent Practitioner (LIP) = Any LIP permitted by law and organization to provide care, treatment, and services without direction or supervision within the scope of the individual’s license and consistent with individually granted privileges.
Traditionally MD, DO, DMD, DDS, DPM

11. APN or PA - TJC
If APN or PA function as LIP, they must be credentialed through organized medical staff
If non-LIP APN or PA, may be credentialed through medical staff standards or human resources equivalent process. Equivalent process must be approved by governing body and must include communication and input from MEC

12. APN or PA - TJC Equivalent process must include:
- a documented evaluation of the applicants credentials
- a documented evaluation of the applicants current competence
- documented peer recommendations
- process must include input from individuals and committees,including the medical executive committee, on order to make an informed decision regarding request for privileges

13. Practitioners Credentialed – NCQA
P&P’s that apply to all licensed practitioners who provide care to the organization’s members
All LIP’s certified or registered by the state to practice independently
Must be credentialed - Physicians (MD/DO), Oral Surgeon/Dentists, Podiatrists, Chiropractors, non- physician practitioners with independent relationship with organization. Further defined as when organization selects and direct members to individual or group (ie. practitioners members can select as PCP)

14. Practitioners Credentialed – NCQA
Must credential behavioral health specialists who are licensed, certified or registered by state and practice independently including
Psychiatrists, Addiction Medicine Specialists, MSN, MSW who practice independently
Do not have to credential:
Practitioners contracted to practice exclusively in inpatient setting (Pathologists,Radiologists,Anesthesiologists, Hospitalists, Telemedicine, Neonatologists, ED phy)
Dentists who provide primary dental care
Locum Tenens

15. Practitioners Credentialed - CMS
Governing body determines, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff
At a minimum, medical staff must be composed of physicians (MD/DO)
Other practitioners may be included as defined by Social Security Act (DDS/DMD, OD, DC)
Others as defined by governing body (ie. NP, PA, CRNA, Midwives)

16. Practitioners Credentialed - CMS
Non-physicians performing surgical tasks (dentists, podiatrists, RN first assistant, NP, surgical techs)
Requires definition of surgical procedures that must be supervised and degree of supervision (ie. present in OR, in line of sight)
Practitioners may be granted privileges without membership

17. Practitioners Credentialed - HFAP
Governing body determines, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff
At a minimum, medical staff must be composed of physicians (MD/DO)
Other practitioner disciplines as defined by governing body
Medical staff membership limited to licensed physicians, DDS, DPM

18. Practitioners Credentialed - HFAP
Allied health practitioners (AHP) may be granted privileges
Governing body, following consultation with medical staff, determines AHP disciplines
All practitioners that provide medical/surgical care either directly or under supervision must be credentialed

19. Practitioners Credentialed - URAC
Credentialing Program Plan defines participating providers and facilities who must be credentialed. At a minimum:
Participating providers who are contracted to provide health care services to consumers
Facilities that provide covered health care services to consumers
Practitioners/facilities listed in directory

20. Practitioners Credentialed - AAAHC
As approved by the Board, Bylaws or P&P, establish minimum training, experience, and other requirements for physicians and other healthcare practitioners. At a minimum, physicians and dentists.

21. Primary Source Verification
The original source that can verify the accuracy of a credential, qualification, or other information reported by the practitioner
Required by all accrediting bodies

22. Designated Equivalent Source (DES) - TJC
Primary source may designate another organization as its agent
Entities that have been determined to maintain specific credentials information identical to information at primary source
AMA, AOA, ECFMG, etc.

23. Secondary Source – TJC First must attempt to verify primary source
If entity closed or records not available..
- may contact another hospital to verify information
- may contact practitioner who served at hospital at same time

24. Medical Education TJC Requirement
(I) primary source verification from Medical School
Accepted designated equivalent sources:
AMA Profile (US and Puerto Rico), AOA Profile, ECFMG
NCQA Requirement
(I) Primary source verification from Medical School
Not required if board certified or if residency has been verified
Alternate sources: Medical School, AMA/AOA profile,ECFMG (after 1986), state licensing agency
If state licensing agency is utilized, documentation must be updated annually

25. Medical Education CMS Requirement
Medical staff must have a mechanism to examine evidence of professional education
Must be included in criteria for membership/privileges
CMS does not specify acceptable sources for verification
HFAP Requirement
Primary source verification required
Additional source:
AMA Profile, AOA Profile, ECFMG

26. Medical Education URAC Requirement
Credentialing application includes history of education
PSV not required if board certified
May use state licensing board if documented
AAAHC Requirement
PSV required at initial appointment

27. Post Graduate Training
TJC Requirement
(I) Primary source verification from training programs
Accepted Designated Equivalent Sources for U.S. and Puerto Rico:
AMA Profile, AOA Profile
NCQA Requirement
(I) Primary source verification from residency training program
Alternate sources:
AMA Profile, AOA Profile, state licensing agency
Not required if board certified

28. Post Graduate Training
CMS Requirement
Medical Staff must have a mechanism to verify training and experience
Governing Body ensures criteria for selection is based on :
(1)character
(2)competence,
(3)training
(4)experience
(5)judgment
HFAP Requirement
Training must be sufficient to support requested privileges
PSV required through training program, AMA Profile, or AOA Profile

29. Post Graduate Training
URAC Requirement
If not board certified must verify highest level of education.
Must document history of education/training on application
Time limit: six months
AAAHC Requirement
Primary source verification required at initial appointment

30. Board Certification TJC Requirement
Not required unless bylaws/privileges require board certification
(I & R) Verify through ABMS Display Agents, AMA/AOA profile or specialty board
NCQA Requirement
Not Required
(I & R) Verify through ABMS display agents, AMA/AOA profile, state licensing agency if board certified
May not use ABMS consumer website
(I & R) Lifetime certification must be documented
180/120 day time limit

31. NCQA Definitions 180/120 day time limit
When document is submitted to Credentials Committee, verification date may not be older than 180 days.
When CVO submits verification to Health Plan, verification date may not be older than 120 days.
365/305/180 Medicare Advantage - time limit
When file is submitted to Credentials Committee, attestation date may not be older than 365 days.
When CVO submits file to Health Plan, attestation date may not be older than 305 days.
If physician on Medicare Advantage plan, attestation may not be older than 180 days.

32. Board Certification CMS Requirement No requirements
Organization may not make decisions based solely on board certification – must consider all elements (license, training, experience, etc.)
ABMS Display Agents, AMA Profile, AOA Profile
HFAP Requirement
Not required
Membership and Privileges cannot be dependent solely upon certification, fellowship or membership in specialty body / society
Must include other criteria, training, character, competence, judgment.
Must document certification status and verification must include sanction information
ABMS Display Agents, AOA Profile

33. Board Certification URAC Requirement Not Required
Verify through ABMS display agents, AMA Profile, AOA Profile, state licensing agency if board certified
(I) Verify at initial and upon expiration
Six month time limit
AAAHC Requirement
Not Required
PSV verify if organization requires board certification
Continuous monitoring required – verify upon expiration

34. STATE LICENSE TJC Requirement
(I & R) Primary source verification required at initial appointment, reappointment, revision/addition of privileges; also at expiration
Verify through state licensing board
NCQA Requirement
Statement on application re: history of loss of license
(I & R) Primary source verification thru state licensing board -required for all states where practitioner provides care
License must be current when file presented to Credentials Committee
NOTE: Utilize AIM DocFinder only if directed to site by state board
180/120 time limit

35. STATE LICENSE CMS Requirement HFAP Requirement
Medical staff must have mechanism to verify current license
No defined acceptable sources – assumption would be licensing board
Silent regarding verification at time of expiration
HFAP Requirement
PSV required for all states where practitioner practices or intends to practice
Also PSV all previous licenses held
Telemedicine – must be licensed in state practitioner and patient are located

36. STATE LICENSE URAC Requirement PSV required
Verification must include date of expiration, date verified and sanction status
License must be current and valid when presented to Credentials Committee
AAAHC Requirement
PSV required
Ongoing monitoring required

37. License Sanctions TJC Requirements NCQA Requirements
(I & R) The doctor must provide information regarding challenges to licensure or registration & voluntary/involuntary relinquishment of license or registration
Info must be evaluated before recommending privileges
TJC silent on verification - May be verified thru licensing board NPDB or FSMB
NCQA Requirements
(I & R) Primary source verification of sanctions, restrictions on licensure, limitations on scope of practice for past five years in all states where applicant licensed
Verify through state license board, NPDB,FSMB,HIPDB
180/120 time limit

38. License Sanctions HFAP Requirement CMS Requirement
Not addressed
HFAP Requirement
(I) PSV of license sanctions for all current licenses, state of current practice or intended practice, all previous licenses held
(R) PSV all current licenses
Include previously successful and/or currently pending challenges to license; voluntary/ involuntary relinquishment of license
NPDB & FSMB or FACIS

39. License Sanctions URAC Requirement
List all current and historical licenses/sanctions on application
PSV required for past five years practice history
AAAHC Requirement
List current/past license revocation, suspension, voluntary status, probationary status on application
PSV and review at initial and reappointment

40. Malpractice Insurance
TJC Requirements
Not Required
Primary source verification not required unless required by bylaws.
(I & R) Verify through carrier or by current copy of policy showing dates and amount of coverage
NCQA Requirement
Primary source verification not required
(I & R) Attestation by doctor, or policy face sheet showing dates and amount of coverage
365/305/180Medicare Advantage - time limit

41. Malpractice Insurance
CMS Requirement
Not required
PSV not required
HFAP Requirement
PSV not required unless stated in bylaws
(I & R) Verify through carrier or by current copy of policy showing dates and amount of coverage

42. Malpractice Insurance
URAC Requirement
Copy of cover sheet or attestation required for proof of insurance; must include name of practitioner, expiration date, and liability covered.
If cover sheet does not include the name of the practitioner, then a copy of those covered under plan should be printed on insurer's letterhead and attached to cover sheet.
AAAHC Requirement
Evidence of policy if required by organization
Applicant provides evidence of refusal or cancellation of coverage at initial and reappointment

43. Malpractice History TJC Requirement
(I & R) Applicant must provide information regarding claims history (at a minimum must include final judgments/settlements)
(I & R) Medical Staff must evaluate evidence of unusual pattern or excessive # of actions resulting in final judgment
May verify with carrier or NPDB
NCQA Requirement
(I&R) Doctor must provide malpractice history for past five years.
Five years history verified through carrier or NPDB (self query info from applicant not acceptable)
180/120 time limit

44. Malpractice History CMS Requirement Not addressed in standards
HFAP Requirement
5 year history evaluated
Malpractice history required from carrier or NPDB

45. Malpractice History URAC Requirement
Organization defines time frame for history that must be provided by applicant and then evaluated
Malpractice history (settlements and final judgments required from carrier or NPDB
AAAHC Requirement
Applicant must provide claims history on application
Organization must evaluate

46. Work History TJC Requirement NCQA Requirement Term not used,
However, evidence of current competence is required
Organization should obtain information regarding licensure, education, training, experience and competence.
NCQA Requirement
(I) Doctor must provide five year work history on application or CV (should include month and year in all dates)
No verification required but must explain gaps of 6 months or more verbally or in writing; if gap more than one year must explain in writing
365/305/180

47. Work History CMS Requirement Terminology not addressed in standards
However, examination of experience and competence is required
HFAP Requirement
Applicant must provide healthcare employment and affiliation
PSV required to include pending investigations, disciplinary actions, voluntary resignations, relinquishment of memberships/privileges/contracts

48. Work History URAC Requirement Not specifically addressed
AAAHC Requirement
Applicant to provide work history with explanation of time gaps
Experience reviewed for continuity and relevance

49. CURRENT COMPETENCE Initial Application - TJC
Primary source verification from post graduate training facilities, hospitals or other relevant organizations
Must contain informed opinions of applicant’s professional performance
Can use peer reference if specific questions about competency included on verification form
Should include information about six general competencies

50. ACGME/ABMS - Six General Competencies
Patient Care
Medical/Clinical Knowledge
Practitioner-based learning and improvement
Interpersonal and communication skills
Professionalism
Systems-based practice