- New England Quality Care Alliance :: Credentialling Procedures

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Credentialing Policy & Procedure

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Policy

New England Quality Care Alliance, Inc. (“NEQCA”) is committed to contracting with physicians who provide high quality health care services. NEQCA shall have a standardized process for the credentialing of physician applicants to assess an applicant’s qualifications and professional conduct.

Procedure

Applicant should send the following initial documents to the NEQCA Credentialing Department: Pod endorsement with letter of recommendation, signed by the Pod President and another member of the Pod, copy of the applicant’s Massachusetts Board of Registration in Medicine Physician License Renewal Application, and applicant’s CV.

After review of the applicant’s initial documents, the CEO/CMO or NEQCA Quality Committee Chairman will make a decision as to whether to approve the initiation of the credentialing process and will notify the NEQCA Quality Manager accordingly.

Quality Manager will notify NEQCA Credentialing Department.

The Credentialing Department will send to applicant the application, additional required documents for completion/signature of applicant, and list of documents to be provided by applicant. This includes without limitation:

NEQCA Participating Provider Agreement (to be executed by NEQCA if applicant is accepted by NEQCA as a participating physician)

Physician Demographics Form

Disbursement of Funds Form

Integrated Massachusetts Application for Initial Credentialing/Appointment

Tufts Medical Center Medical Staff Application

Health Plan/Payor addenda/documents requiring participating physician signature

Applicant’s Authorization to Release Information form

Authorization to query the National Practitioner Database

List of documents to be provided by applicant will include:

		i.	Current CV (detailing work history and clinical training with appropriate required dates in the month/year format)

		ii.	List of work history for past ten years including names and addresses of employers

		iii.	Copy of current, unrestricted Massachusetts medical license

		iv.	Copy of most recent Massachusetts Board of Registration in Medicine license application

		v.	Copy of current Massachusetts Controlled Substance registration

		vi.	Copy of Federal DEA Controlled Substance certificate

		vii.	With respect to each hospital of which applicant is a member of the medical staff, hospital letter or verification of hospital credentialing with permission to query hospital medical staff office regarding staff membership

		viii.	A copy of current malpractice face sheet coverage statement

		ix.	Malpractice history with written explanation of any claims within the past 10 years

		x.	References from three physicians, one of which should be from the NEQCA Pod the physician plans to join, and one of which should be from a senior member of group practice the applicant is joining, if applicable. The requirement of the reference from a senior member of a group practice may be waived, at NEQCA’s discretion, for new physicians coming out of training and for physicians coming from out-of-state.

		xi.	The last two years of reports from two major Massachusetts-based health plans, based on quality and utilization data, if available. This requirement may be waived for new physicians coming out of training, if data is unavailable, and may be waived at NEQCA’s discretion for physicians coming from out-of-state, if comparable data is unavailable.

		xii.	Documentation of Board Certification. If the applicant is not Board certified, NEQCA may, in its discretion, waive this requirement upon a determination that applicant is otherwise qualified on the basis of education, training, and experience, and applicant shall be required to provide any further information the Quality Committee may reasonably request to aid in this determination.

		xiii.	Copy of ECFMG Certificate (if foreign medical school graduate)

		xiv.	Copy of photo ID, signed and dated

		xv.	Internal Revenue Service Form W9

Applicant must return completed application and all required documents to the NEQCA Credentialing Department within 60 days. The Credentialing Department will assemble the file and review the application and documents for completeness.

Completed application and supporting documentation will be presented to the NEQCA Quality Committee for approval or denial. The Quality Committee may request a meeting with the applicant as deemed necessary by the Quality Committee.

The applicant will be notified of acceptance or denial by NEQCA Quality Committee Chairman in writing. In addition, Pod will be notified of Quality Committee’s decision by the Credentialing Department.

For applicant who successfully meets the credentialing requirements: 1) NEQCA Credentialing Department will send credentialing documents to payors, and 2) a New England Medical Center Indemnity Company (“NEMCIC”) malpractice insurance application will be sent to applicant with cover letter.

Appeal Process. The applicant or Pod president, on behalf of the applicant, may appeal the decision of NEQCA in circumstances where the applicant was not accepted for membership in NEQCA.

	a.	The applicant and/or Pod president, on behalf of the applicant, must request an appeal in writing within thirty (30) days of receipt of NEQCA’s decision. The request for appeal should specify the specific basis for the reconsideration request. Failure of the applicant to request a hearing within such thirty (30) day period shall be deemed his or her waiver of the right to an appeal.

	b.	Within fifteen (15) days after receipt of a request for an appeal, the Chairman of the Quality Committee shall schedule and set a date for an appeal hearing and shall notify the applicant, who will be required to be present, of the time, place, and date so scheduled (such date to be not more than forty five (45) days from the date of receipt of the request for appeal).

	c.	The appeal will be heard by the Quality Committee or a subset thereof, at the discretion of the Chairman. If the applicant fails without good cause to appear at the hearing, the applicant shall be deemed to have waived his or her right to an appeal.

	d.	Within fifteen (15) days of the appeal hearing, the Quality Committee shall make a decision and notify the applicant and Credentialing Department in writing of the decision.

	e.	The decision of the Quality Committee shall be final.

	f.	Health Plan/Payor addenda/documents requiring participating physician signature

10.

The Quality Committee shall report its credentialing actions to the NEQCA Board of Trustees on a regular basis.

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