Network/IPA Credentialing Overview

TPQVO offers a managed-care oriented credentialing services for networks, IPAs, PPOs and other healthcare entities outsourcing credentialing activities in a way that complies with managed care accreditation standards.  Managed care clients can delegate credentials verification services to TPQVO and be assured that TPQVO meets or exceeds NCQA credentials verification requirements.

For information about the specific verifications TPQVO provides for network credentialing, please go to this link.

Process Overview

INITIAL APPOINTMENT SYSTEM

Clients may decide whether to delegate application processing to TPQVO or maintain responsibility for distributing and collecting applications to its network member applicants.  TPQVO will work with standard managed care credentialing applications, including the CAQH Universal Application form.

When TPQVO has received a completed application from the client or its medical staff, including requested documentation, TPQVO will forward a copy of the application and materials to the client, if the client does not already have a copy.

TPQVO reviews the completeness and accuracy of the application, including whether all requested documentation is included.  If information is conflicting or missing, TPQVO will contact the applicant and request additional information or clarification.

TPQVO begins the verification process of the following information as required by the client.  Many of the verifications listed are not required by NCQA or Joint Commission and may be a matter of the client’s bylaw requirements rather than accreditation.

Licensure – all past and present licenses listed on the CV or application are verified by the appropriate state licensing board, including any disciplinary actions taken against the licensee.

Drug Enforcement Administration – TPQVO obtains a copy of the most current DEA certificate from the physician and checks expiration dates as well as addresses to which the certificate is issued.  TPQVO also verifies the certificate through the NTIS website.

Medical/Professional Education – TPQVO obtains written verification from the highest level of training (Board certification is an acceptable proxy).

Practice Affiliations –  NCQA only requires a CV or practice history listed on an application.  The applicant is required to explain any gap exceeding 30 days occurring after graduation from medical school.

Liability Insurance – NCQA only requires the applicant to attest currently having professional liability insurance. TPQVO can contact the liability insurance carrier if the client needs this information.  (See “Optional Verifications” below)

Board Certification – TPQVO verifies American Board of Medical Specialties through the certiFACTS subscription database.  All other Boards are queried in writing, fax, or Internet, where available and acceptable.

NPDB – National Practitioner Data Bank queries if the client facility is currently registered with the NPDB and has designated TPQVO as its agent for querying purposes.

Medicare/Medicaid Sanctions – TPQVO queries the Office of the Inspector General of the US Department of Health and Human Services website to determine whether the practitioner is currently excluded from participating in the Medicare or Medicaid program.  (This information is also provided through the NPDB query.)

Government Services Administration – the Excluded Parties Listing System is checked to verify whether the practitioner is debarred, suspended, proposed for debarment, or declared ineligible by agencies or by the General Accounting Office.  (This verification is not required by NCQA.)

Optional Verifications: (available for an additional charge)

Current practice affiliation: TPQVO will attempt to verify current clinical practice positions.

Claims History:  TPQVO will obtain claims history and insurance verifications for the applicant’s current carrier.

Peer References – for clients requiring peer references, TPQVO will attempt to obtain references from 3 “peers” as defined by the client.

Hospital Affiliation – active affiliations are verified from the hospitals either by letter or by current medical staff roster of practitioners in good standing.

Criminal background checks can be added at cost.  TPQVO will work with clients to identify the type and scope of background check to perform. 

TPQVO will make three attempts to obtain information from sources contacted by letter.  Clients are notified when TPQVO encounters problems receiving verifications.

When the verification process is complete, TPQVO sends (email) a certified copy of the verifications to the client’s credentialing contact.  Additionally, the completed verification profile and verifications are available for download on the TPQVO client web site for 180 days after the file is closed.

The client network will be responsible for paying for incomplete files only if the file is incomplete because of unresponsive primary sources or incomplete information from the physician applicant and if the majority of verifications were completed according to the contract and TPQVO notified the health care organization of its attempts to obtain the information.

REAPPOINTMENT/RECREDENTIALING SYSTEM 

Two Options:

The client maintains responsibility for application distribution.  In this instance, TPQVO sends the application to the client credentialing contact for distribution to the client’s professional staff or client uses its own application.  Client contact will mail, fax or email the completed application and materials to TPQVO for verification processing.

Roster or Work Order.  Client either provides either (a) quarterly rosters indicating the next date for reappointment or (b) provides TPQVO with a list of practitioners needing recredentialing in the next 120 to 180 days.  TPQVO will begin application processing and credentials verification at least 120 days before the recredentialing due date.

Upon receipt of the completed recredentialing form, TPQVO credentialing specialists review the application and documents for completeness and determine whether there is any conflicting or missing information, including requested documentation.  If information is conflicting or missing, TPQVO will contact the applicant and request additional information or clarification.

If there are any primary sources that must be queried that charge a query fee, TPQVO will invoice the applicant (or the client if paying on behalf of the applicant) for those fees.

TPQVO will verify the following information from primary sources:

Medical/Professional licenses and any disciplinary sanctions taken against the license(s) in the past 2 years will be verified by the state licensing board(s).

DEA - verification of DEA registration in the client state

Board Certification -- TPQVO verifies current board certifications through the American Board of Medical Specialties through the certiFACTS subscription database.  All other Boards are queried in writing, fax, or Internet, where available and acceptable.

NPDB – TPQVO is available to query on behalf of the health care entity if the entity designates TPQVO as its agent.

Additional/non-NCQA required verifications may include:

Medicare/Medicaid Sanctions – TPQVO queries the Office of the Inspector General of the US Department of Health and Human Services website to determine whether the practitioner is currently excluded from participating in the Medicare or Medicaid program.  (This information is also provided through the NPDB query.)

Government Services Administration – the Excluded Parties Listing System is checked to verify whether the practitioner is debarred, suspended, proposed for debarment, or declared ineligible by agencies or by the General Accounting Office.

Any new fellowships or teaching appointments listed on the application or CV.

Certificate of Insurance from the insurance carrier and claims history if provided by the insurer in response to the COI verification request.

Criminal background checks can be added at cost.  TPQVO will work with clients to identify the type and scope of background check to perform. 

TPQVO contacts unresponsive physicians and primary sources a second and third time.  If the physician or source fails to return the needed information, TPQVO will notify the client of its efforts.  Further action will be the applicant’s or client’s responsibility.