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Recredentialing

Recredentialing Process

To ensure the highest quality of care and efficient processing, CCHP partners with a Credentialing Verification Organization (CVO), Symplr Payer. This partnership allows us to streamline the recredentialing process, performing thorough and timely primary source verifications of practitioner credentials such as licenses, education, and certifications. Providers may interact directly with Symplr Payer for credentialing applications and verifications, while CCHP maintains responsibility for final credentialing decisions and network participation.

Symplr Payer is an NCQA certified CVO. Achieving CVO certification from NCQA demonstrates that Symplr Payer has the systems, process and personnel in place to thoroughly and accurately verify providers' credentials and help health plan clients meet their accreditation goals.

Practitioner Recredentialing

Practitioners

Each Practitioner applying for continued participation in CCHP's Network must submit all required supporting documentation.

For recredentialing, practitioners are required to submit the following information, which will be verified through primary sources:

  1. A complete recredentialing application and required supplemental information/attachments without material omissions or misrepresentations.
  2. A signed and dated attestation, consent and release.
  3. Current, valid, unrestricted license to practice in each state in which the Practitioner provides care to Covered Persons.
  4. No current federal sanction and no new history of federal sanctions (per OIG and OPM Reports or on NPDB report).
  5. Current DEA certificate and/or state-controlled substance certification without history of or current restrictions if applicable.
  6. Current professional liability insurance of not less than $1,000,000 per occurrence and $3,000,000 in the general aggregate with an insurer licensed to provide medical malpractice insurance in Wisconsin, or show similar financial commitments made through an appropriate Wisconsin approved alternative, as determined by CCHP and appropriate secondary coverage by the Wisconsin Injured Patients and Families Compensation Fund. The pertinent Network Agreement may require coverage that exceeds the minimum level described above.
  7. No current hospital membership or privilege restrictions and no new (since prior credentialing review) history of hospital membership or privilege restrictions; OR for Practitioners in a specialty defined as requiring hospital privileges who practice solely in the outpatient setting there exists a defined referral relationship with a Network Provider of similar specialty at a Network Organizational Provider who provides inpatient care to Covered Persons needing hospitalization.
  8. No new (since previous credentialing review) history of or current use of illegal drugs or alcoholism No new (since previous credentialing review) impairment or other condition which would negatively impact the ability to perform the essential functions in their professional field
  9. No new (since previous credentialing review) history of criminal/felony convictions, including a plea of no contest.
  10. Malpractice case history reviewed since the last Credentialing Committee review; if no new cases are identified since last review, malpractice history will be reviewed as meeting criteria; if new malpractice history is present, then a minimum of last five years of malpractice history is evaluated and criteria consistent with initial credentialing is used.
  11. No new (since previous credentialing review) involuntary terminations from an HMO or PPO.
  12. No QA/PI data or other patient care related performance data, including complaints, above set thresholds.

Organizational Recredentialing

Organizations

Ongoing assessment is the process through which CHCP will update and verify pertinent information regarding network organizational providers. It is CCHP’s policy to reassess these providers at least every 3 years. Each Organizational Provider applying for continued participation in CCHP's Network must submit all required supporting documentation.

The ongoing assessment Process applies to the following organizational providers seeking membership into the CCHP network:

  • Hospitals
  • Skilled nursing facilities
  • Home Health Agencies
  • Free standing surgical centers
  • Behavioral health facilities that provide behavioral health and/or substance abuse treatment in an inpatient, residential or ambulatory setting

Organizational ongoing assessments include:

  1. A complete organizational Provider application, if needed.
  2. A signed and dated attestation, consent and release, if needed.
  3. Current and valid State license for organization to provide care to Covered Persons.
  4. No current federal sanction and no new history of federal sanctions (per OIG and OPM Reports or on NPDB report).
  5. Current DEA certificate without history of or current restrictions if applicable.
  6. Current CLIA certificate, if applicable.
  7. Valid and current Medicaid certificate.
  8. Current general/comprehensive liability insurance of not less than $1,000,000 per occurrence and $3,000,000 in the general aggregate. The pertinent Network Agreement may require coverage that exceeds the minimum level described above.
  9. Proof of current accreditation status and survey results, if applicable (accreditation report, certificate or decision letter).
  10. Most current State survey/inspection report including Corrective Action Plan letter, if applicable.

Reference Policies

Credentialing Manual Provider Termination Appeal Rights Organizational & Ongoing Assessment

Documents

Provider Update/Change Form Practitioner Credentialing Request Form

Contact Credentialing

For questions about our credentialing process, contact our credentialing department.
844-229-2776
cchp-credentialing@chorushealthplans.org