Highmark Group Credentialing Services for your Independent Practice

Prior to network entrance, providers are accredited and re-credentialed at least every three years. Highmark conducts practitioner verification in compliance with company rules, state and federal regulations, and accrediting requirements.

This unit focuses on the credentialing process and provides an overview of Highmark’s credentialing criteria and methodology. This is not meant to be an exhaustive list of all credentialing criteria and procedures.

Purpose

Highmark staff undertake the credentialing and re-credentialing processes in collaboration with network practitioners to guarantee that members have access to only those practitioners who meet Highmark’s high standards of professional credentials.

Our Specialist will promptly assist you in acquiring credentialing

We will evaluate your educational history, work experience, credentials, and registration to practice in a healthcare setting primarily throughout the credentialing process. We will track your progress during the credentialing examination to determine your education, training, credentials, and registration to practice health care in a health care context. We will do a thorough evaluation of all of your documents to ensure that you are accredited by one of the world’s most renowned healthcare specialists. As a team, we are committed to long-term growth. We will assist you in obtaining the services that you require. This is how we demonstrate our gratitude to our clients and our commitment to their satisfaction.

General credentialing criteria

The following is an overview of the general credentialing requirements used by Highmark for all practitioners.

• In each state where the practitioner performs services, the practitioner must maintain an active state license.

• A five-year work history that is acceptable for initial certification;

• Professional liability insurance in accordance with the regulations of the state(s) in which the physician practices (for further information on malpractice insurance requirements, please see the section in this subject on malpractice insurance requirements);

• Acceptable history of malpractice;

• Proof of Medicare eligibility and the fact that you have not opted out of the Medicare Part B programme for the Medicare Advantage network(s) in Pennsylvania or West Virginia;

• There will be no Medicare or Medicaid sanctions.

Initial Credentialing

Highmark staff adheres to a well-defined process when credentialing professional providers for the Premier Blue Shield, Western Region managed care, and Medicare Advantage networks in Pennsylvania; the Commercial Exclusive Provider Organization (EPO) and Independent Practice Association (IPA) networks in Delaware; and the Commercial Preferred Provider Organization (PPO) and Point of Service (POS) networks in New Jersey. Furthermore, we have outsourced credentialing arrangements to a small number of institutions, which we have examined to ensure compliance with our credentialing criteria.

The initial credentialing process includes, but is not limited to:

• Completion of a CAQH online application

• Signed attestation verifying all information on the application and stating any reasons for inability to perform essential duties, lack of illegal drug use, and loss of license/privileges, felony, and disciplinary action

• Primary source verification

• Inquiry to National Practitioner Data Bank for sanction history

• Other verification as needed

To be considered a participating practitioner and support Highmark managed care products, including Medicare Advantage in Pennsylvania and West Virginia, all new practitioners must complete the CAQH online credentialing application, be approved by Highmark through a routine assessment process or by the Highmark Network Quality and Credentials Committee, as applicable, and then sign a contract. The practitioner’s participation and ability to treat Highmark members does not begin until the signed contract is returned and the contract is executed by Highmark. A welcome letter specifying the effective date of participation will be sent along with a copy of the executed contract.

When practitioners are credentialed

A practitioner who has never been credentialed by Highmark must be credentialed when:

• Establishing a solo practice; or

• Joining an established network practice. Additionally, a practitioner who wishes to rejoin the network(s) will be required to undergo initial credentialing if the following conditions are met:

• The practitioner submitted a signed, explicit document stating that he or she no longer wishes to be a participating provider and there has been a break in service/contract of more than thirty (30) days.

• The practitioner was terminated by Highmark throughout the re-credentialing process, and there was a more than thirty (30) day break in service/contract.

Re-credentialing

Highmark completes the re-credentialing process with any applicable physicians and allied health professionals in the Premier Blue Shield, Western Region managed care, and Medicare Advantage networks at least once every three years. In Pennsylvania; the Delaware Commercial EPO and IPA networks; and the

In West Virginia, PPO and POS networks, as well as the Medicare Advantage network, are available.

For the protection of our members, our internal policies must be reviewed.Furthermore, Highmark’s three-year credentialing cycle is in line with NCQA.CMS, Pennsylvania DOH, Delaware State, and West Virginia State standards. The re-credentialing procedure contains many of the same components as the initial process. Credentialing with a few extra components when it comes to re-credentialing, a quality check is carried out. When available, member feedback is included in this evaluation. Member satisfaction, member concerns about administrative and quality of serviceconcerns with care, malpractice history, medical record reviews, and office locationinformation pertaining to clinical quality actions or punishment activitywill be evaluated for continuing network involvement as well.

Monitoring

Highmark’s Provider Data Management regularly examines network providers’ reports coming with credentialing/re-credentialing standards. Monitoring includes, but is not limited to, the following:

• U.S. Department of Health and Human Services, Office of Inspector General (OIG),

• List of Excluded Individuals/Entities (providers barred from participating in Medicare, Medicaid, and other federal health programmes) (monthly)

If it is resolute or presumed that a supplier is no longer in compliance with credentialing, re-credentialing, or contractual requirements (e.g., license revocation or suspension, OIG sanction), and the issue will be investigated intensively to the relevant Highmark Network Quality and Credentials Committee (or the medical director in emergency situations) for appropriate course of action.

Highmark Group Phone Number

In the event that providers require assistance, they should call provider services at 800-241-5704. (Toll-free).

Highmark Group Email Address

Write to us at: crifcare@crifhighmark.com.

Highmark Group Enrollment Form