Credentialing
Credentialing is the process by which the appropriate committee reviews documentation for each individual physician/provider to determine participation in the health plan network. Such documentation may include, but is not limited to, the applicant’s education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history, professional competency, and physical and mental impairments. The credentialing process includes verification that the information obtained is accurate and complete. The physician/provider must respond to any reasonable CarePlus Health Plans, Inc. (CarePlus) request for additional information including, but not limited to, a medical record review as well as a site visit as applicable.
CarePlus recognizes the physician’s/provider’s right to review information submitted in support of the credentialing application to the extent permitted by law and to correct erroneous information. Providers may obtain information regarding the status of their credentialing or recredentialing process by calling CarePlus.
The credentialing process generally is required by law. The fact that the physician/provider is credentialed is no intended as a guarantee or promise of any particular level of care or services.
Council for Affordable Quality Healthcare (CAQH): CarePlus thru its parent company Humana Inc., is a member of the Council for Affordable Quality Healthcare (CAQH), which is an online single, national process that eliminates the need for multiple credentialing applications. Physicians/providers who are members of CAQH can provide CarePlus with the appropriate information in lieu of completing a CarePlus credentialing or re-credentialing application. Additional information may be requested.
CarePlus Credentials Committee: Is conducted at a corporate level thru its parent company in Louisville, KY. The Credentials Committee is composed of a chairperson and employed and participating physicians/providers. Functions of the committee include credentialing, ongoing and periodic assessment, recredentialing, and establishment of credentialing and recredentialing policies and procedures. The physician’s/provider’s documentation is provided to the corporate credentials committee for approval or denial for participation in the network. Notification of approval or denial of credentials is sent to the physician/provider.
Recredentialing: Recredentialing is conducted at least every three (3) years in accordance with the CarePlus credentialing and recredentialing process. The recredentialing process is conducted with the same standards as those for initial credentialing. The decision concerning re-appointment or failure to re-appoint will be conveyed to the physician/provider in writing.
