Currentsanford health planPolicy N/A
Practitioner Credentialing Program
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Defines Sanford Health Plan's systematic approach to primary source verification, eligibility, scope of credentialing, and rights/duties for Practitioner applicants and participating Practitioners; affects applicants, participating Practitioners, Provider Relations, Provider Contracting, Credentialing Services, Credentials Committee, and Medical Management.
Policy Summary
Payersanford health plan
PolicyPractitioner Credentialing Program
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date
Last ReviewOct 11, 2022
Next Review DateOct 11, 2022
Key ActionApplicant must provide and verify all information; incomplete applications will not be processed.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
WeeklyVPMO review cadence
180Primary source recency (days)
60Locum Tenens threshold (days)
36Recredentialing interval (months)
3Malpractice payout threshold (claims)
Credentialing Coverage Criteria
inv-01: Credentialing Criteria
Credentialing inclusion requires meeting scope and threshold criteria, providing verifiable information, and demonstrating qualifications for requested scope of practice.
Applicant meets Scope of Credentialing as defined in Appendix A (practitioner falls within Plan's defined inclusion criteria and is not excluded).
Applicant meets Threshold Eligibility Criteria (see Appendix B) for Participating Practitioners; failure to meet thresholds renders the practitioner ineligible to apply.
Applicant provides verifiable information and bears the burden of proof for statements on the Application; until all requested information is received and verified the Application is incomplete and will not be processed.
Applicant demonstrates qualifications for the requested scope of practice based on recent and relevant education, training, experience, demonstrated competency, references and conformance with Plan criteria regarding qualifications for performance of such procedures.
inv-02: Credentialing application and verification criteria
Application acceptance, required contents, verification, and determination of completeness
Application submitted via Sanford Hub online Application (paper accepted only case-by-case); electronic signatures accepted.
Initial check-in completed within 48 hours to confirm required sections, supplemental materials, disclosures, and signatures; Practitioner notified of missing information and the Application will not be accepted into the system until missing information is provided.
Primary source verifications required for items listed in Appendix C (licenses, DEA/CSR when applicable, education, residency, board certification, malpractice, sanctions, etc.) and verifications must be obtained within 180 days of the Credentials Committee decision date; license and DEA must be current at time of Committee decision.
A complete Application requires: all applicable verifications received (Appendix C), eligibility criteria met (Appendix A and B), no unresolved omissions/ discrepancies between Application and verification results, verifications and signatures within required timeframes, and all information needed to evaluate issues obtained.
When verification discrepancies are found, the Practitioner will be notified in writing and afforded ten (10) business days to clarify or correct; if discrepancies remain unresolved additional evaluation will occur and if Practitioner fails to respond to requests for new information within 30 days the Application will be considered automatically withdrawn with a one-year reapplication waiting period.
inv-03: File review and committee decision criteria
File categorization and committee decision processes
File categorization: Following determination that an Application is complete, files are evaluated within 3 business days to determine Clean File vs Committee File; all initial Clean Files undergo a second quality review.
Clean File process: Clean Files are listed weekly, reviewed by Credentialing Manager (or designee), and presented to the VPMO or designee for sign-off; VPMO signature is considered the Credentials Committee approval date; determinations commonly within 30 days but at least within 45 days of file completion.
Committee File process: Files that do not meet Clean File criteria are designated Committee Files; Practitioner notified within 3 days of file completion; Committee File placed on next Credentials Committee agenda and Committee typically determines within 30 days but may extend to 75 days of file completion.
Credentials Committee composition and decision rules: chaired by the VPMO or delegate, includes participating Practitioners, meets monthly, quorum is 50% of Committee membership, determinations by majority vote.
Possible Committee actions include: approve for a full cycle (commonly 2 years, up to 36 months), request additional information, deny or modify participation status.
inv-04: Credentialing scope and eligibility
Criteria determining which practitioners/settings are within scope for credentialing and which are excluded.
Inclusion — Practitioner must: (1) be licensed/certified/registered to practice independently in applicable state(s); (2) have an independent relationship with Sanford Health Plan (SHP) such that SHP selects or directs Members to the Practitioner or group; and (3) provide care to Members under SHP's medical benefits.
Included practice settings — individual or group practices, facilities, rental networks (subject to delegation and used for out-of-area coverage), telemedicine (practitioner must hold an active license in the patient's state), and locum tenens practitioners who practice at the same facility for more than 60 consecutive days.
Exclusion — Practitioners who practice exclusively within the inpatient setting and provide care to Members only because Members are directed to the inpatient setting (examples: pathologists, radiologists, anesthesiologists, neonatologists, ER physicians, hospitalists, hospital-based CRNAs, pharmacists working for PBMs, board-certified consultants) do not need credentialing by SHP.
Exclusion — Practitioners who practice exclusively within free-standing facilities and provide care to Members only because Members are directed to those facilities (examples: mammography centers, urgent care centers, ambulatory surgical centers, ambulatory behavioral health centers) do not need credentialing by SHP.
Eligible practitioner disciplines include: MDs, DOs, oral/maxillofacial surgeons, dentists, chiropractors, optometrists, podiatrists, PAs, APRNs (CNP, CNM, CRNA, CNS), behavioral health practitioners (psychiatrists, psychologists, licensed social workers, addiction medicine specialists), audiologists, PTs, STs, OTs, registered dieticians, certified diabetic educators, and acupuncturists with NCCAOM certification and current state licensure.
Advanced Practice Professionals must have an agreement with a licensed physician or physician group unless state law permits independent practice; the Plan will require collaborative agreements where state law mandates them.
inv-05: Credentialing and Clean File Criteria
Threshold eligibility, primary source verifications, and Clean File criteria
Eligibility threshold conditions — Applicant must meet practice setting Scope of Practice eligibility (Appendix A), possess current licensure in practice state(s), not be excluded/precluded from Federal Medicare/Medicaid, not have had an Application automatically withdrawn within the prior year (unless Credentials Committee waives), possess required professional liability insurance limits, and possess DEA/CDS when applicable (or submit required waiver).
Verification requirements — Primary source verify: current state licensure in each state where Practitioner provides care; Federal DEA or signed waiver when applicable; highest level of medical/professional education, residency training, and board certification; malpractice history for past 5 years from NPDB or malpractice carrier; current professional liability coverage documentation; and query sanctions/exclusion databases (NPDB, state Medicaid exclusion lists, OIG, SAM, CMS Preclusion lists, Medicare/Medicaid sanctions). Verifications must be placed in the electronic file and documented per Appendix C and be within 180 days of the Credentials Committee decision date.
Minimum documentation for work history — For initial credentialing provide a minimum five-year relevant work history; gaps over six months require explanation and gaps over one year must be explained in writing.
Professional liability minimum limits — Applicant must provide Certificate of Insurance showing minimum limits of either $1,000,000 per occurrence/$3,000,000 aggregate OR $2,000,000 per occurrence/$2,000,000 aggregate (unless covered by federal tort policy with acceptable attestation).
Clean File criteria — To qualify as a Clean File the Applicant must have: current unrestricted/unencumbered license with no history of revocation/suspension; never been excluded/precluded from Medicare/Medicaid or other federal/state programs; never had medical staff appointment/clinical privileges denied/revoked/terminated; no convictions for Medicare/Medicaid/third-party payor fraud or program abuse; malpractice history that does not exceed 3 paid claims in the most recent 10 years, no paid claim >= $1,000,000, no claims (excluding those closed/dismissed without payment) involving unexplained death or serious injury, and no pending litigation combined with other red flags; and no concerning unexplained gaps in work history or recent DUI/felonies as detailed in Appendix D.
Codes, Verification & Thresholds
Scope of Practice / Approved Proceduresmixed
| Scope of clinical procedures/payment limited to those approved pursuant to this Credentialing Policy; approved scope based on Applicant's education, training, experience, competency, references and conformance with Plan criteria |
Primary source verificationsmixed
| Information listed on Appendix C shall be primary source verified; verifications must be obtained within 180 days of the Credentials Committee decision date (primary source, contracted agent of primary source, or other NCQA accepted source); license and DEA must be current at decision |
Referenced standardsmixed
| NCQA CR 1 | NCQA credentialing standard referenced |
| NCQA CR 2 | NCQA credentialing standard referenced |
Sanctions and exclusions checksmixed
| Databases and sanction lists to be queried including National Practitioner Data Bank, state Medicaid exclusion lists (Iowa, Minnesota, North Dakota, Nebraska, etc.), OIG List of Excluded Individuals/Entities, System for Award Management excluded parties, Office of Foreign Assets Control, Medicare Opt Out websites, Social Security Death Master File, and other state licensure or certification boards |
Threshold Eligibility Criteria — Appendix B and exception timing
Eligibility sourcePractitioner must meet the applicable qualifications listed in Appendix B (Threshold Eligibility Criteria) to be eligible for consideration as a Participating Practitioner.
Failure consequenceIf a Practitioner does not meet Threshold Eligibility Criteria the CVO Manager will notify them in writing and the application will be considered automatically withdrawn unless an exception is requested.
Exception request timingThe Practitioner may request consideration for extenuating circumstances and provide supporting documentation within 30 days of the notification.
Committee waiverThe Credentials Committee may waive criteria at its discretion if sound rationale and documentation exist and an exception fulfills an important Member need.
Verification recency
Recency requirementPrimary source verifications must be obtained within 180 days of the Credentials Committee decision date.
Acceptable sourcesVerifications may come from the primary source, a contracted agent of the primary source, or another NCQA-accepted source listed for the credential.
License/DEA statusLicense and DEA must be current at the time of the Credentials Committee decision.
Reverification triggerIf any primary source verification becomes older than 180 days, reverification will be completed before decision.
Locum Tenens inclusion threshold
Locum Tenens thresholdLocum Tenens Providers fall within the scope of credentialing if they have practiced in the same location or on a contracted period of more than 60 consecutive days.
Scope inclusionInclusion applies when locum practice exceeds the 60-consecutive-day threshold in the same location or contracted period.
Delegation noteLocum Tenens inclusion is subject to delegation rules when applicable to rental networks or delegated credentialing arrangements.
Professional liability minimum limits
Minimum limits option 1Minimum professional liability insurance of $1,000,000 per occurrence / $3,000,000 aggregate.
Minimum limits option 2Alternatively, minimum professional liability insurance of $2,000,000 per occurrence / $2,000,000 aggregate.
DocumentationA current Certificate of Insurance or Medical Insurance Face Sheet verifying coverage limits and effective/expiration dates must be provided.
Federal tort coverageIf covered under a federal tort policy, a letter or attestation from the federal tort coverage provider will be accepted in lieu of a Certificate of Insurance.
Minimum work history — initial applications
Minimum work history (initial)For initial credentialing, a minimum of five years of relevant work history must be provided on the Application; if the Practitioner has practiced fewer than five years, relevant work history begins at initial licensure.
Time gap rulesAny time gaps exceeding six months require an explanation; gaps over one year must be explained in writing.
Documentation granularityAll work history must include month and year beginning and end dates and will be reviewed and documented by Credentialing Services personnel.
Provider Responsibilities & Actions
Documentation Required
Applicant bears the burden to provide and verify all information
The Applicant is responsible for producing and verifying all information on the credentialing Application; until Sanford Health Plan has received and primary-source verified all requested information, the Application is deemed incomplete and will not be processed.
- Applicant bears burden to provide evidence that statements and information are factual and true
- Applications become incomplete if new, additional, or clarifying information is required at any time
Documentation Required
Written notification and 10-business-day correction period
If information obtained during credentialing varies substantially from what the Practitioner provided, the Practitioner will be notified in writing and afforded ten (10) business days to correct the erroneous information; failure to respond or provide verifiable information will result in the file remaining incomplete and the Practitioner being ineligible to re-apply for one year.
- Written notification of discrepant information will identify the erroneous information
- Practitioner has one opportunity and 10 business days to provide corrected information
Billing Rule
Retrospective payment and claims release for services during credentialing
When permitted by contract with other payors or required by state law, Sanford Health Plan will hold and then release clean claims for covered services provided during the Practitioner’s credentialing period and provide retrospective payment once the Practitioner is approved.
- Practitioners are not published in the Plan Directory until after Credentials Committee approval
- Plan will hold claims during credentialing period and release them once Practitioner is approved when allowed by contracts or required by law
Documentation Required
VPMO will request additional information for pended applications (30-day response)
If the Credentials Committee pends an Application, the VPMO will send a letter requesting additional information; the Applicant is given 30 days to supply the requested information or the Application will be considered automatically withdrawn.
- Any response received will be brought to the next Credentials Committee for review
- Failure to respond within 30 days results in automatic withdrawal of the Application
Prior Authorization
VPMO sign-off of Clean Files and timely notification, including denial/Hearing rights
Sanford Credentialing Services presents Clean Files to the VPMO or designee for sign-off; the VPMO (or designee) may sign off Clean Files, and the Provider Relations Department will notify Practitioners of credentialing decisions within ten (10) business days. If an Application is denied, the VPMO will notify the Applicant of the reasons for denial and advise them of hearing/appeal rights.
- VPMO or designee signs off Clean Files; signature date is considered the Credentials Committee approval date
- Provider Relations sends notification letters within 10 business days
- VPMO notifies Applicants of denial, stated reasons, and right to a hearing
Note
Practitioner types eligible to apply for credentialing
The Plan accepts credentialing Applications for practitioners who meet inclusion/exclusion criteria and credentialing requirements, including but not limited to: Doctors of Medicine (MD), Doctors of Osteopathy (DO), Oral/Maxillofacial Surgeons, Dentists, Chiropractors, Optometrists, Podiatrists, Physician Assistants, Advanced Practice Registered Nurses (CNP, CNM, CRNA, CNS), behavioral health practitioners (psychiatrists, psychologists, licensed social workers, addiction specialists), audiologists, physical therapists, speech pathologists, occupational therapists, registered dieticians, certified diabetic educators, and acupuncturists with current NCCAOM certification and state license.
- Advanced Practice Professionals must have an agreement with a licensed physician or physician group unless state law allows independent practice
Note
Disciplines ineligible for credentialing Applications
Sanford Health Plan will not accept credentialing Applications for certain professional disciplines, including Registered Nurses, Licensed Practical Nurses, state-certified or lay midwives, Naturopathic Doctors (ND), and acupuncturists who lack NCCAOM certification or current full, active state licensure.
- Applications for these disciplines will not be accepted by SHP
Terms & Definitions
Scope of Credentialing — summary
Scope definitionScope of Credentialing defines which Practitioners and practice settings fall within Sanford Health Plan's credentialing program as detailed in Appendix A.
IncludesIncludes individual and group practices, facilities, rental networks (subject to delegation), telemedicine, and locum tenens exceeding 60 days.
ExcludesCertain exclusively inpatient practitioners and practitioners in specific free-standing facilities providing care only due to Member direction are excluded (see Appendix A for details).
Effect on eligibilityPractitioners not meeting Scope of Credentialing criteria are ineligible to apply for Sanford Health Plan participation.
Threshold Eligibility Criteria — Appendix B reference
Reference to Appendix BThreshold Eligibility Criteria are listed in Appendix B and set the minimum qualifications required for consideration as a Participating Practitioner.
Outcome for noncompliancePractitioners who do not meet Appendix B criteria are ineligible to apply and will be notified in writing if their application is withdrawn.
Exception processPractitioners may request consideration for extenuating circumstances within 30 days; the Credentials Committee may grant waivers at its discretion.
Provisional Credentialing
Provisional credentialing stanceThe Plan does not provisionally credential Practitioners; all Practitioners are fully approved.
Directory publicationPractitioners are not published in the Plan Directory until after Credentials Committee approval (see Claims Release/related sections).
ImplicationNo temporary or conditional participation status is used — applicants must complete the full approval process to be Participating Practitioners.
Clean File — definition
DefinitionA Clean File is a credentialing file with no information identified during verification that requires additional review to determine if the Practitioner is qualified for Plan participation.
ProcessingClean Files undergo a second quality review and are processed following Clean File Medical Director approval, commonly determined within 30 days (at least within 45 days) of file completion.
Appendix referenceCriteria for Clean File determination are further defined in Appendix D.
Committee File — definition and process
DefinitionA Committee File is a credentialing file that did not meet Clean File criteria or has issues/concerns requiring additional evaluation and review by the Credentials Committee.
Notification timingIf a file is not a Clean File, the Practitioner will be notified within 3 days of file completion and the file will be placed on the next Credentials Committee agenda.
Committee determination timeframeThe Credentials Committee will commonly make a determination within 30 days of file completion but may extend to 75 days if additional information is requested.
Applicant — definition
Applicant definitionAn 'Applicant' is a Practitioner who has submitted an initial or recredentialing Application to participate as a Participating Practitioner.
IncludesApplies to Practitioners seeking Sanford Health Plan participation via the formal Application process.
Distinction'Applicant' differs from 'Participating' which denotes those approved and contracted to provide services to Members.
Credentials Committee — definition
Credentials Committee definition'Credentials Committee' or 'Committee' means the Sanford Health Plan Credentials Committee responsible for reviewing Committee Files and making participation determinations.
Role and compositionCommittee reviews files, may request additional information, and makes approval/denial/alteration decisions; it is chaired by the VPMO or delegate and meets monthly.
Decision authorityThe Committee may waive threshold criteria at its discretion when justified to meet Member needs.
Participating — definition
Participating definition'Participating' means the Practitioner (or someone on the Practitioner's behalf) has signed a contract with the Plan to provide services to covered Members and has been approved by the Credentials Committee.
PrerequisitesParticipation requires meeting Scope of Credentialing and Threshold Eligibility Criteria and Committee approval.
ImplicationOnly approved, contracted Practitioners may be listed in the Plan Directory and provide services as Participating Practitioners.
VPMO — definition and role
VPMO definition'VPMO' means the Sanford Health Plan Vice President Medical Officer or the Senior Director of Medical Services; VPMO responsibilities may be delegated.
ResponsibilitiesVPMO chairs or delegates the Credentials Committee, oversees credentialing program oversight, and signs off on Clean Files as appropriate.
DelegationAny responsibilities of the VPMO may be designated to the Senior Director of Medical Services.
Resident moonlighting — criteria
Eligibility condition for residentsResident moonlighting is eligible only if the resident holds a permanent or temporary license/certification permitting unsupervised practice outside the training program in each state where they moonlight.
Minimum training levelResident must be at minimum midway through the second year (PGY2) of residency training to be eligible for credentialing.
Program director letterA letter from the Residency Program Director allowing the resident to moonlight outside the residency training must be submitted.
Credentialing cycle noteThe credentialing cycle will end 60 days after the estimated residency completion date; a re-credentialing cycle including residency verification will be completed thereafter.
Clean File Criteria — definition
Clean File criteria summaryA Clean File meets all Appendix D criteria including current unrestricted license, no exclusions/sanctions, no denied/revoked privileges, no fraud convictions, and specified malpractice limits.
Malpractice specificsMedical malpractice history must not exceed 3 paid claims in the most recent 10-year period, must have no payouts of $1,000,000 or more, and must not include claims involving unexplained death or serious injury.
Work history/gapNo concerning gaps in work history; a gap of 6 months or greater in the last five years may require further explanation if concerns arise.
Processing consequenceIf one or more Clean File criteria are not met, the file will require review by the Credentials Committee as a Committee File.
Policy Summary
Payersanford health plan
PolicyPractitioner Credentialing Program
Policy CodePolicy N/A
Change TypeNo material changes
Effective Date
Last ReviewOct 11, 2022
Next Review DateOct 11, 2022
Key ActionApplicant must provide and verify all information; incomplete applications will not be processed.
SourceLink
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