CurrentBaylor Scott & White Health PlanPolicy SWHP.PNO.011.P

Practitioner Rights

Governs the rights of practitioner applicants in the SWHP/ICSW credentialing and re-credentialing process, including review, notification, and correction of credentialing information; applies to all lines of business and providers applying to the SWHP/ICSW network.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyPractitioner Rights

Policy CodePolicy SWHP.PNO.011.P

Change TypeNo material change

Effective DateApr 14, 2021

Next Review Date

Key ActionPractitioners may inquire about credentialing status and must be notified of information obtained during credentialing that substantially differs from their application.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15 working daystime allowed to submit corrections to credentialing information

All Linesapplicability of the policy

90%minimum site review score for facility management

$1M/$3Mminimum malpractice limits generally required

Credentialing Criteria and Practitioner Rights

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Credentialing criteria and practitioner rights

Criteria and rights relevant to practitioner credentialing, quality, member needs, personal attributes, organizational fit, and other considerations.

ALL of the following

ALL of the following
- Practitioners can review information obtained from outside sources used to evaluate their credentialing application, except references/recommendations or other peer‑review protected information.
ALL of the following
- Practitioners may inquire about the status of their credentialing/re‑credentialing application at any time and are informed of verification status and possible timeframe for submission to the SWHP/ICSW Credentialing Committee upon request.
ALL of the following
- When information obtained during credentialing differs substantially from the applicant's submission (e.g., actions on license, malpractice claims history, board certification decisions), the Credentialing Coordinator and/or Delegate notifies the applicant by phone, email, or letter.
- Following notification, the applicant has 15 working days to submit written corrections to the Credentialing Coordinator and/or Delegate.
- The Credentialing Coordinator and/or Delegate documents receipt of corrected information in the practitioner's credentialing file and incorporates the new information into the credentialing process.

ALL of the following

ALL of the following
- Valid Texas State license is required.
- Practitioner must have hospital privileges at a SWHP/ICSW contracted facility or provide a signed agreement to send SWHP/ICSW members to a contracted facility; specialists who do not normally admit must provide a letter of agreement from the admitting physician/group.
- ABMS board certification is required or the practitioner must be in active pursuit of board certification or an equivalent MOC program; practitioners who completed residency prior to 1985 and are not board certified must complete 50 AMA PRA Category 1 CME credits per year (or equivalent) with specified specialty content and submit agreement with their application.
ALL of the following
- Maintain malpractice limits of at least $1,000,000/$3,000,000 or the minimum required by the SWHP/ICSW affiliated hospital where privileged; higher coverage may be required as determined necessary by SWHP/ICSW.

ALL of the following

ALL of the following
- When a reasonable member complaint is received, an office site visit is conducted to review physical accessibility, appearance, adequacy of waiting/exam space, appointment availability, and adequacy of treatment record keeping; a site review score of at least 90% is expected.
ALL of the following
- Quality of service and utilization levels are evaluated to ensure SWHP/ICSW standards are met and utilization is appropriate.
ALL of the following
- Practitioners cooperate with data collection for quality initiatives and adopt Joint Commission standards (including 'Time Out' policies) for procedures requiring consent to avoid wrong site/wrong procedure events.

ALL of the following

Appointment Availability Standards include: eye refraction within 6 weeks; urgent care within 24–48 hours; emergency care same day; primary care within 5 days; preventive care within 6 weeks.
Additional access considerations include geographic location, distance from other similar practice sites, hours of operation/after‑hours coverage/emergency call provisions, membership growth trends, comprehensiveness and scope of service, and unique expertise not found among other practitioners.

ALL of the following

Good communication skills and language enhancements.
Experience in the field, in the geographic area, and with SWHP/ICSW.
Stability, commitment to professionalism, professional appearance and attire, and commitment to patient safety protocols and initiatives.

ALL of the following

Professional reputation, practice and referral patterns, commitment to patient care, cost appropriateness relative to member need, and commitment to community.
Efficient, solvent, and properly managed business practice patterns; demonstrates cooperation and willingness to work within SWHP/ICSW.
Providers must submit to billing audits and demonstrate accurate and appropriate billing practices.

Discretionary factors: Other factors that may enhance or dilute the ability to provide comprehensive, personalized, high quality, cost‑effective care are considered.

Inquiry, Notification, and Practitioner Actions

Documentation Required

Inquiry, Notification, and Correction Rights and Timelines

Practitioners may inquire about the status of their credentialing/re‑credentialing application at any time by contacting Provider Relations; they have the right to be informed of verification status and the expected timeframe for submission to the SWHP/ICSW Credentialing Committee. If information obtained during credentialing substantially differs from their application (e.g., actions on license, malpractice claims history, board certification decisions), the Credentialing Coordinator/Delegate will notify the applicant (phone, email, or letter). After notification, the applicant has 15 working days to submit written corrections, which will be documented and incorporated into the credentialing file.

Right to inquire about credentialing status at any time via Provider Relations (contact for current status).
Right to be informed of verification status and possible timeframe for Credentialing Committee submission.
Notification provided if credentialing obtains information substantially different from the application.
Applicants have 15 working days after notification to submit written corrections; corrections are documented and incorporated.

OpenPayer

Practitioner Rights

Credentialing Criteria and Practitioner Rights

Malpractice and Coverage Thresholds

Inquiry, Notification, and Practitioner Actions

Definitions and Reference Terms