The Basics

With this standard, you are required to answer the question, what services do we provide, and where do we provide them?

This standard is important to URAC reviewers, because it helps them understand the nature of your network.  Are you a general healthcare services network or specialty network?  Do you provide health care services in a small region, statewide, or nationally?  The rest of the review will be guided by the documentation and answers to interview questions that you provide in connection with this standard.

Your organization likely answers both of these questions in official documents, such as marketing documents, regulatory filings, and the geo-access maps that help you manage your provider network.  Make sure you are familiar with how your organization officially answers these questions.

Management Tips

Remember, it you do not get credit for doing things that you do not document.  So, the fact that you operate in a certain area and provide certain health care services is insufficient for purposes of this accreditation process.  Rather, you need to be able to document, with official company documents, what services you provide and where you provide them.  You are allowed a good deal of flexibility in how you do this.  Your documentation might be in marketing materials, regulatory materials, internal policies and procedures or plans, or reports.

URAC Accreditation Tips

Each of the two elements of this standard is weighted 4.

Your desktop review documentation is likely to be some combination of plans (business, marketing, strategic), service area maps, geo-access analyses, and regulatory filings.

The on-site reviewer will verify your compliance with the standard through an examination of your organizational documents and interviews with network management and provider relations management personnel.

The Basics

Some organizations delegate credentialing to other organizations, like facilities, provider groups, or credentials verification organizations (the "CVOs").  URAC has four standards in the Core module that address delegation generally (Core 6-9).  

This standard establishes two requirements in addition to the requirements contained in those four standards. 

• If your organization delegates credentialing to another organization, it must retain authority to make the final credentialing determination.  Part of this process is likely to involve your organization comparing a list of approved providers forwarded from the delegate to add to your network against a historical list of providers previously terminated or denied in order to determine whether the providers are to added to your network.
• In addition, the organization must conduct surveys of its credentialing contractors no less frequently than every three years.  These surveys must be on site visits, and should be conducted according to your credentialing plan or a policy and procedure that directly addresses the performance of on-site surveys of delegated entities that conduct credentialing for your organization.  Typically, a standardized audit form is used for such on-site audits.  The on-site audit should involve a random sample of complete credentialing files that the contractor has administered on your organization' behalf.  The sample size should be at least 10% of those files, but in no case fewer than 10 files nor more than 30 files.

Management Tips

If this is your organization's first time through the process of accreditation, you are allowed a three-year phase-in of your site visits for delegated entities.  You must complete 15% of your surveys by the end of the first year, 50% by the end of the second year, and the remaining reviews conducted by the end of the third year.

Naturally, if your organization does not delegates credentialing, this standard is not applicable.

URAC Accreditation Tips

One element is mandatory; the other is weighted 4.

At the desktop review stage, you should submit your credentialing plan, a template delegation agreement, your on-site audit tool, sample credentialing committee meeting minutes in which the committee demonstrates that it retains final authority for credentialing decisions, and/or sample committee meeting minutes that document a decision to delegate or not to delegate credentialing to another entity.

The on-site reviewer will examine credentialing committee meeting minutes from the last four years. In addition, the reviewer will look at "delegation binders" for each of several of your contractors.  Each delegation binders should contain the delegation agreement, reports submitted by the contractor, completed audit sheets from your on-site surveys, and documentation of other required oversight activity.

The Basics

This standard fleshes out the recredentialing requirement by requiring that your organization:

• requires providers to submit an application updating any information that is subject to change;
• verifies that information that is subject to change;
• implements a process to collect and include in the recredentialing decision any information about the provider's performance, such as any information collected through the organization's quality management program.

Your organization's policies and procedures on recredentialing, which likely are in the credentialing plan, should spell out which elements need to be resubmitted in the recredentialing application and reverified.  In addition, those policies should explain how the credentialing department interfaces with the quality management program to make sure that any data collected regarding the provider's performance is considered in the recredentialing decision.

Management Tips

The easy part of complying with this standard is deciding what elements are subject to change and need to be included in the recredentialing application and reverified.  What is slightly more difficult is designing a process to make sure that the provider's track record over the last three years gets into the hands of the credentialing committee.  Typically, this involves the credentialing department letting the quality management program know which participating providers are going through recredentialing and requesting from the QM program a report on any complaints, provider profiles, or other quality of care or quality of service information collected by the program about providers undergoing recredentialing review.

It is important that your organization not consider economic factors to be more important than quality of care factors in considering a provider for recredentialing.  It is probably so important, in fact, that this should be described in the credentialing plan.

URAC Accreditation Tips

The element requiring verification of information is mandatory; the other two elements are weighted 3 and 4.

In addition to submitting the credentialing plan, your desktop review documentation should include sample provider profile reports or other information providing feedback about provider performance that might be considered in the recredentialing process.  In addition, it is advisable to submit a sample of credentialing committee meeting minutes that demonstrate that such information is considered in the recredentialing process.

During the on-site review, in addition to the credentialing file review, the reviewer will examine committee meeting minutes and if you credentialing management and staff regarding the requirements of the standard.

The Basics

This standard requires that your organization recredential every participating provider no less frequently than every three years.

The reason for the existence of this standard is that some credentials expire.  For those that do, the organization must check to see that they are still valid.  Therefore, this recredentialing process is not quite as complete as initial credentialing.

For years, the "clock" for the three years required by the standard started on the date of the approval of the credentialing application.  However, in July 2010, this changed.  According to URAC, "per decision from Health Standards Committee 7/21/10, the 3-year credentialing cycle is to the month of the initial credentialing decision, not the specific day as indicated by previous guide language.  Rationale includes that ongoing quality monitoring checks occur (CR 16) and the 3-year cycle is not as precise as checking credentials upon expiration, so to the month is reasonable.  Per our research and Committee input, the industry’s interpretation of this cycle is to the month as well."

Management Tips

Note that the recredentialing process requires that you present the application for recredentialing to the credentialing committee whether or not there are issues to discuss.  However, you need not reverify those credentials that do not expire or change over time.  An example of such credentials is education.

Note that several organizations opt to follow standard CR 3 d(ii) that allows a credentialing committee to delegate a senior clinical person in the organization such as the Medical Director, to approve files considered “clean” and therefore does not require peer review input to make a decision in between credentialing committee meetings.   These “clean” files are later forwarded to the next possible credentialing committee meeting for a formal approval.  This formal approval is the date by which the provider must be credentialed three years later.

URAC Accreditation Tips

This standard is mandatory.

Documentation at the desktop review phase should include both the credentialing plan, outlining the recredentialing process, and a sample of your credentialing committee minutes that includes approval of the recredentialing applications.

The on-site review, in addition to the review of credentialing files, will include an examination of credentialing committee minutes and an interview with credentialing department management and staff members.

The Basics

This standard requires that your organization have an ongoing process to assure that your participating providers continue to comply with your criteria for participating in your network.  In addition, your organization must have mechanisms to respond to situations where you learn that a provider ceases to comply with those criteria.  A good example of such a circumstance would be if the provider has his or her license revoked or suspended.

The expectation here is that your organization continuously examine reports published by federal and state agencies (like the HHS Office of the Inspector General), as well as the National Practitioner Data Bank (NPDB).

Management Tips

Not only should you have a process in place that accomplishes this ongoing monitoring, your credentialing plan should clearly describe that process.  Many organizations have designated staff members who periodically go through all of the applicable state and federal reports.  Your credentialing plan or policies and seizures should describe that process clearly and in detail.

URAC Accreditation Tips

Both elements of this standard are mandatory.

The documentation you should submit for desktop review should include both the credentialing plan and any summary reports that demonstrate that you conduct ongoing monitoring of provider compliance with your credentialing criteria.  Examples of such reports include any reports published by your state licensing board or the HHS office of the Inspector General.

During the on-site review, in addition to the credentialing file review, the reviewer will interview your staff members responsible for ongoing monitoring and examine reports in which you have found that providers in your network have had their licenses suspended or revoked.

The Basics

This standard requires that your organization notify providers, in writing, of the determination of the providers' credentialing application within 10 calendar days of that determination. 

Make sure to check with your policy and procedure regarding notification of providers to see what documents, if any, should be included with that notification.  Some organizations require that a contract be sent along with the notification; some organizations do not.

Management Tips

This is a reduction from the previous version from 60 to 10, so if you based your P&Ps on the previous version of the standard, you'll need to change those P&Ps.  Also, be sure your delegated credentialing contractors are aware of this change, as they are require to follow this standard under Core 8(b).

URAC Accreditation Tips

The standard carries the weight of 3, and its only element is secondary.

The documentation you should submit at the desktop review phase and should include a credentialing plan that describes the notification process including this timeframe, a sample notification letter that complies with that policy, and any audit reports that you can produce that demonstrate that you are complying with the time frame imposed by this requirement.

The on-site reviewer will confirm compliance with this standard through a combination of interviews with credentialing staff and a review of three dozen or so credentialing files to verify that providers are being notified of the credentialing determination in a timely manner.

Some organizations do not maintain records of the acceptance letters and try to reproduce an electronic copy at the time of the onsite.  However some software packages may only be able to print the current date, rather than the date the letter was sent, to demonstrate correct implementation of this standard.  You may have to plan for how to demonstrate proof of this letter. 

The Basics

Under this standard, your organization may not submit a credentialing application that:

• is signed and dated more than 180 days prior to credentialing committee review, or
• has verification information collected more than six months before review.

The purpose of this standard is to make sure that the credentialing committee or senior clinical staff member are reviewing information that is relatively recent.  To accomplish this, your organization must have policies and procedures to move credentialing applications through the credentialing process in a timely manner.

Sometimes, however, credentialing committees review a particular application more than once.  The standard applies only to the first time an application comes before a credentialing committee in that cycle.

If an application should fall through the cracks and have stale data, you need not make the provider go through the entire credentialing process again.  Rather, you may have the provider re-sign the attestation that declares that the information on the application is still valid and accurate.

Management Tips

To help your staff make sure that no stale applications are submitted to the committee or the senior clinical staff person, your checklist or audit sheet for each credentialing file should have an element that allows the staff person checking the application to see whether this application complies with the timeframe requirements of this standard.

URAC Accreditation Tips

The two elements of this standard each carries a weight of 4.

Documents to be submitted in connection with the desktop review should include a credentialing plan that clearly describes the applicable time frames and a checklist or audit form that allows the staff member to confirm compliance with these time frames.

The on-site reviewer will both interview credentialing staff regarding these time frames and examine three dozen or so credentialing files to assure that no stale applications have been submitted to the committee or the senior clinical staff person.

The Basics

This standard requires that, before a provider is designated as a participating provider and included in the provider directory, your organization first review the application and approve that application.

There are two ways you organization may approve an application to become a participating provider.  First, your credentialing committee could vote to approve it.  Second, if it is a "clean" application, your senior clinical staff person may approve the application.

There is one exception to this requirement, that is, if, for clinical reasons, there is a compelling reason to grant "provisional" dissipation to a provider, your senior clinical staff person may grant such an approval.  This usually comes up in connection with the need to provide continuity of care to a patient.  In such a case, your organization should move that provider's credentialing process forward as quickly as possible.

Management Tips

Among the most important things to assure as a manager of the provider credentialing process is that no providers end up in the provider directory who have not been through your organization's credentialing process.  It is difficult to imagine an organization receiving full accreditation if it allows providers who have not been through the credentialing process to be listed in the provider directory.

The reviewer is looking in your credentialing plan for an explanation that, once a file is approved, credentialing triggers the provider to an active status.  That action may inform the contracting department to add the provider to the directory or, simply to change the status so that such activities can occur to activate the provider.  In addition, many credentialing plans or policies begin with language that state no provider can be activated in the organization until he/she has completed the credentialing process and therefore has been approved to participate in the network.

URAC Accreditation Tips

This standard is mandatory.

Documentation that the desktop review phase should focus on the credentialing plan, which should be explicit in providing that no provider shall be considered to be a participating provider who has not gone through the credentialing process.

The on-site review will focus on interviews with clinical leadership and credentialing staff, as well as a review of credentialing committee meeting minutes over the last four years.

The Basics

This extremely important standard requires that, if the credentialing process reveals information that indicates factors that may impact the quality of care or service provided to consumers, the organization conducts additional review and investigation of that provider.

Your organization's policy and procedure on this issue no doubt spells out the circumstances that should trigger further investigation.  Such circumstances are likely to include information about malpractice litigation, missing information, or inconsistent information.  What your policy probably provides for is closer examination of such files by a senior clinical staff person.  It's also very likely that your policy and procedure requires that such files be discussed in detail by the credentialing committee.

It will be particularly important that you follow the policy and procedure regarding how you document any such follow-up activities.  Documentation should be clear and detailed regarding what was done, who did it, and when the activity was conducted.

Management Tips

Your policy and procedure should be quite clear in providing guidance to credentialing staff members as to what should trigger further investigation.  Your policy also should provide clear guidance as to who should conduct investigations, and whether senior clinical personnel should be involved.  Finally, your policy should articulate explicitly how such a file should be presented to the credentialing committee.

URAC Accreditation Tips

This is a mandatory standard.

During the desktop review process, you should submit not only your credentialing plan, but some sort of description of the roles of various staff members, clinical or otherwise, in handling the identification and investigation of "problem files".  This documentation can come in the form of the credentialing plan, policies and procedures, or job descriptions.

During the on-site review, the standard will be verified through a review of credentialing files in which such investigations took place, as well as interviews with the senior clinical staff person and members of the credentialing staff.

The Basics

Your organization must verify state licensure and board certification (if applicable) or the highest level of education achieved by the practitioner, using primary sources.  "Primary source verification" is defined as "verification based on information obtained directly from the issuing source of the credential."

In other words, for these two categories (licensure and board certification or highest level of education), you must obtain written verification from the issuing source that the credential is valid and current.  Most commonly, this involves going to a website maintained by the issuing body and printing off a page that verifies the credential.  In the absence of that, a letter, or a documented phone call (including staff person making the call, date of call, and name of the person at the issuing entity with whom the staff person spoke) will suffice.  Whichever approach you take, make sure that you are following your organization's policies and procedures regarding primary source verification during credentialing.

Management Tips

The key component for management is to make sure that the applicable policy and procedure or credentialing plan addresses the means by which you will use primary source verification processes.  Whatever methods are chosen (website, letter, or telephone), it is essential that the documentation include sufficient information.  For example, for licenses, you must verify not only its present validity, but the expiration date.

If the board certification is of the type that does not expire, it must be verified only upon initial credentialing.  However, if there is a possibility of expiration of board certification, it must be reverified upon re-credentialing.

Make sure that your documentation includes an indication as to which member of the staff is doing the primary source verification.  This is an essential part of the documentation for this standard.

URAC Accreditation Tips

Both elements of this standard are mandatory.

It will be sufficient to provide the credentialing plan at the desktop review phase, so long as the credentialing plan is detailed in its description of the processes used for primary source verification.

Not only will the on-site reviewer examine your credentialing files to assure compliance with the standard, but he or she also will talk with members of the credentialing staff and may even observe members of the staff as they conduct primary source verification.