Credentialing policies – Arizona

Updated

In this article, you can find the applicable credentialing policies and procedures, a list of all the information required to be included in an application, a checklist of materials must be submitted in the credentialing process, and designated contact information. 

 

I. Credentialing Policies 

The purpose of the credentialing program is to assure that Headway Michigan Behavioral Health Services, P.C. and its subsidiaries’ networks consist of quality providers who meet clearly defined criteria and standards. It is the objective of Headway to provide superior mental health care to the community. Additional information is available in the credentialing policy and procedures, which are detailed below.

The decision to accept or deny a credentialing applicant is based upon primary source verification, secondary source verification, and additional information, as required. The information gathered is confidential, and disclosure is limited to parties who are legally permitted to have access to the information under State and Federal law.

The Credentialing Program has been developed in accordance with State and Federal
requirements and the standards of NCQA. The Credentialing Program is reviewed
annually, revised and updated as needed.

 

II. Non-Discriminatory Credentialing and Recredentialing

Headway does not make credentialing decisions based on applicant’s age, race, ethnic/national identity, gender, age, sexual orientation or client type in which the clinician specializes. Headway ensures all committee members are aware of its strict prohibition of discrimination against any clinician seeking qualification as a participating clinician. Headway Credentialing Committee does not consider any of the above when making credentialing decisions.

To this end, only the Committee Chair shall have access to Clinician identifying and demographic data. The Committee will make credentialing decisions based on licensure and professional qualifications only.

Headway monitors the credentialing and recredentialing process annually for discriminatory practices by reviewing files for Clinicians who were denied credentialing in order to identify possible instances of discriminatory credentialing decisions.

 

III. Clinicians Eligible for Inclusion as Headway Clinicians

The scope of the Credentialing Program is comprehensive and includes individual Behavioral Health Clinicians. Only those qualified Clinicians who provide services to individuals that access Headway are eligible for credentialing.

Headway credentials and re-credentials the following Clinician types:

  • Doctoral Level Licensed psychologists (Ph.D., Psy.D.)
  • Master’s Level Licensed Clinical Social Workers (LCSW, LICSW, etc... or the particular state equivalent)
  • Master’s Level Licensed Marriage and Family Clinicians
  • Master’s Level Licensed Counselors (LPC, LPCC – or the particular state equivalent)
  • Psychiatrist (MD/DO)
  • Nurse Clinician with Prescriptive Authority
  • Nurse Clinician without Prescriptive Authority

Headway does not currently credential HIV/AIDS specialists.

Standards of Participation

Clinicians Professional Criteria

Headway accepts Clinicians into its practice at its sole discretion based on the need for Clinicians in certain specialties, geographic areas, or other market reasons. Each Clinician must meet minimum established standards for participation prior to be considered. These guidelines are intended to comply with Headway policies.

 

Minimum Standards for Participation include:

  • Submission of a fully completed, signed CAQH application, or state specified uniform application where required, as well as submission of updated information as required
  • Current, unrestricted, and valid professional licensure to practice in any U. S. state in which the Clinician will be providing services. The Clinician must hold the highest clinical license in their state(s), allowing independent clinical practice and the ability to diagnose and treat all mental illness.
  • The expiration date of professional licensure is validated during initial credentialing and at recredentialing. The Clinician is responsible for maintaining a current, valid, and unrestricted license while practicing with the Headway practice.
  • Headway does not accept provisional licenses.
  • Clinician shall maintain a professional malpractice liability insurance policy.
    • For clinicians practicing in any state except FL or NC - If Clinician is a behavioral health prescriber, coverage limits shall be $1,000,000/$3,000,000. If clinician is not a prescriber, coverage limits shall be $1,000,000/$1,000,000.
  • For psychiatrists and nurses with prescriptive authority, current, unrestricted and valid Drug Enforcement Agency (DEA) license and Controlled Dangerous Substance (CDS) certificate as applicable; prescribers that do not possess this license/certificate, are required to provide documentation outlining who will prescribe on their behalf.
  • Nurses with prescriptive authority must be board certified by the American Nurses Credentialing Center (ANCC) with a psychiatric/mental health specialty.
  • For psychiatrists, residency must be completed and board certified. If the provider is not board certified, the Physician Chair reviews the requirements against payer specific criteria and makes a recommendation to the credentialing committee.
  • The following attestations: 
    • Disclosure of any and all malpractice suits, arbitrations, settlements, or adverse actions which have resulted in a settlement or adverse judgment;
    • Absence of any drug or alcohol abuse including illegal drug use, which might adversely affect judgment or competence, so as to substantially impede the Clinician’s ability to perform the essential functions of the Clinician’s practice/profession;
    • Any restriction which might adversely affect the Clinician’s ability to perform the essential functions of the Clinician’s practice/profession;
    • Free of conviction for any criminal offense punishable as a felony, or engagement in any improper act related to the qualifications, functions, or duties of a clinician, as defined in the contract.
  • Absence from OIG and Medicare/Medicaid sanctions, fines, or suspensions from either program.
  • Absence from the CMS Preclusion List provided by BCBS for all providers in North Carolina and New Jersey. Any provider found to be on the CMS Preclusion list will not be credentialed or allowed to participate in the BCBS Network.
  • Absence from any state/federal Debarment or Exclusion list provided by BCBS.
  • Absence from the Social Security Death Master list.
  • Possession of an independent NPI number, verified by CVO through NPPES.
  • Additionally, to participate in the Headway telehealth model, clinicians are required to possess the following:
    • Access to HIPAA-secure video equipment of Provider’s choice that is compliant with all applicable laws. Any costs associated with using said video equipment are the Provider’s sole responsibility
    • Computer equipment and connectivity to access and enter encounter information into the Headway clinician platform

 

IV. Credentialing Delegation

Headway utilizes CAQH for the following Credentialing Activities:

  • Use of the CAQH common application
  • Gathering and verifying completeness of all required application content defined in this policy for initial credentialing and re-credentialing
  • Providing Headway with all CR application data for designated clinicians
  • Maintaining up-to-date application content by prompting clinicians to submit or re-attest required information
  • Gathering and transmitting re-credentialing information prior to the re-credentialing due date or informing Headway of clinician’s non-response to update information
  • Non-PSV data (Administrative data) may be managed by Headway or Headway providers via CAQH.

In order to streamline the Headway credentialing process for a high volume practice, Headway selected a vendor to support the Primary Source Verification (PSV) and ongoing monitoring with our oversight.

Headway delegates to Andros, an NCQA certified Credentialing Verification Organization for the following delegated functions as of February 2021 to present:

  • Verifying completeness and accuracy of CAQH application and outreach to applicant to obtain any missing information. 
  • Primary Source Verifying required information as defined in this policy 
    • Any updates or corrections to PSV data after the credentialing event has completed will be performed only by authorized Andros staff.
  • Ongoing (at least monthly) Clinician monitoring of OIG, and state licensing boards and other sanction reports for all current Headway clinicians as defined in this policy.
  • Tracking credential and recredential dates

V. Initial Credentialing: Process and Requirements

All Clinicians are subject to Headway credentialing and approval by the CRC or Clinical Advisor (MD) prior to being accepted into the practice and providing any services as a Headway Clinician. The intent of the process is to validate credentials, which shall include primary source verification. State regulatory timeframes and the credentialing process (measured from the point of a complete application to credentialing decision) are completed within 45 days except where state requirements are more stringent; 

 

For any deficiencies or missing elements in the credentialing application, providers are notified within 15 days of any missing or incomplete information. If Headway is unable to receive required missing information within 60 days, the application process is ended and the provider is notified.  Although Headway has the ability to issue a temporary credential (if the applicant has a valid state license and no history of malpractice claims, substance use, mental health issues or licensing board disciplinary actions) Headway strives to achieve a final decision within 60 days of application submission.  If a temporary credential is issued (per state regulatory guidelines), the temporary credential remains in effect until the Medical Director or CRC approves or denies the provider’s application. 

 

For Arizona applicants, if the application is incomplete, Headway must notify the applicant within seven days. If the requested information is not received after 30 calendar days, the application can be withdrawn. Headway must inform a provider within seven days after the conclusion of the credentialing process if the application is approved, or denied. 

 

Impact of A Natural Disaster/Emergency Declarations: In the event of an emergency declarations, providers negatively impacted may experience a delay in the credentialing process. If this occurs, the provider file must contain supporting documentation and notification requirements as distributed by the Health Plan State and/or the Governor’s office.

 

VI. Recredentialing: Process and Requirements

Headway delegates to Andros the recredentialing of all Headway Clinicians within 36 months (3 years) of their last credentialing or recredentialing date. For customers with more stringent regulatory standards, the recredentialing is completed in accordance with the customer-specific standards. This includes assuring that the recredentialing process does not exceed 60 days from the point of receipt of a complete recredentialing application to committee decision. For Illinois, recredentialing applications are sent in accordance with the last digit of the provider’s social security number in the designated month. The intent of the recredentialing process is to identify any changes that may affect a Clinician’s ability to perform services as a Headway Clinician.

CAQH ensures the clinician updates and submits the following information in the application at recredentialing:

  • Additional Education and/or Board Certification, if applicable
  • Liability coverage
  • Liability claims history for the past 3 years, that resulted in settlement or judgment paid on behalf of the clinician
  • Sanction information (NPDB, OIG, SAM, Medicare Opt-out, Medicare/Medicaid State exclusions) in past 3 years
  • Response to Disclosure question related to:
  • Inability to perform the essential functions
  • Illegal drug use
  • History of loss of license and felony convictions (past 3 years)
  • Attestation as to the completeness and correctness of all information provided in the application
  • Attestation authorizing the organization to collect any information necessary to verify the information in the credentialing application

Andros conducts the following PSV at recredentialing:

  • State licensure
    • PSV through the state licensure board website
  • Practitioners are credentialed at the highest level of licensure, not education, in the following rank order:
    • Psychiatrist (MD/DO)
    • Psychologist (PSY)
    • LCSW, MFT, LPCC, PMRN, and PMNP
    • Practitioners who obtain a higher level license must be checked that education criteria for new licensure are met against the criteria for the applicable license level (e.g., upgrade from MFT to Psychologist).
  •  Sanctions
    • PSV through the Office of the Inspector General (OIG) and National Practitioner Data Bank (NPDB) respective verification websites
  • Social Security Death Master list
  • Liability Insurance Coverage- SSV with review of LI coverage page
  • Verification of DEA/CDS

Headway staff conducts the following internal clinician performance review:

  • Complaints
  • Adverse Events
  • Performance quality measures and/or trends, including but not limited to enrollee satisfaction

Additionally, Headway checks the clinician against the Medicaid Debarment lists provided by BCBS during recredentialing. 

Upon receipt from CAQH of a complete recredentialing file, the Credentialing Committee Review and Decision process described in a previous section of this document are followed.

 

Contact Information

For additional information or inquiries regarding credentialing in Arizona, please reach out via our contact form.

Other contact methods include: info@headway.co or +1 (978) 717-0915

Important note

The above contact number should only be used for inquiries regarding credentialing in Arizona. For all other inquiries, please use our contact form to reach our support team. Thank you! 

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