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Prism Network, LLC

Policy/Procedure

POLICY NUMBER:

CRED 4

Title: Credentialing and Recredentialing Responsible Position: Director, Credentialing Practitioners and Providers Regulatory References: State and Federal Regulations; National Accrediting Agency Standards Reviewed/Revised:2/4/02; 4/29/02; 6/26/02; 7/29/02; 10/1/02; 11/25/02; 12/23/02; 2/24/03; 3/26/03; 6/3/03 7/25/05; 5/2/05; 3/2/06; 3/22/07; 2/19/08 Approved by/Date: Executive Quality Management and Improvement Current Revision Committee August 25, 2008 Effective: 8/14/08 Original Effective Date: 2/7/2002

I.

POLICY: Prism Network, LLC uses a uniform credentialing and recredentialing process to ensure that all practitioners and providers are screened, reviewed, selected, and contracted with in accordance with established criteria and regulatory requirements. The criteria for enrollment is: 1) established to provide objective, non-discriminatory standards to identify practitioners/providers who are appropriate for the population served, 2) established using regulatory requirements, accreditation standards, and indictors of clinical practice quality/safety as well as indicators to manage network needs, and 3) made available to potential practitioners/providers upon request. Participating practitioners and providers successfully complete the credentialing and recredentialing process, sign a participating provider agreement and actively maintain a contractual relationship in good standing with Prism. Credentialing and recredentialing decisions are not based solely on an applicant's race, ethnic/national identity, gender, age, sexual orientation or the types of procedures or types of patients that is the specialty of the practitioner or provider.

II.

PURPOSE: to establish written criteria to credential and recredential practitioners and providers to ensure that all credentialing and recredentialing applications are processed consistently. to ensure that Prism's networks consist of quality practitioners and providers who meet reasonable standards of care to ensure that health services of good quality are provided

III.

SCOPE: All participating practitioners and providers, regardless of geographic location, line of business or client relationship. This includes practitioners and providers in the States of New York, New Jersey, Vermont, Massachusetts, New Hampshire, Rhode Island, Connecticut, Pennsylvania and Maine. Types of practitioners and providers credentialed and recredentialed include: chiropractors; physical therapists; behavioral health specialists including social workers, psychologists, psychiatrists, and facilities; complementary and alternative medicine (CAM) specialists including acupuncturists, licensed massage therapists and Wellness facilities and practitioners. This criteria is applied to practitioners and providers in the following networks: Prism Health Networks, Prism Behavioral Health Network, Prism EAP Network, Prism

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Physical Medicine Network, ICM Network, CAM Network and the Wellness Network. Exception: In limited instances, a client may have no interest in accessing a provider network fully credentialed under NCQA guidelines and PHNs criteria. In this event, certain Prism and/or NCQA requirements are waived when credentialing practitioners or providers for this type of "Client Specific Network" (refer to Definitions: "Waived Credentialing Requirements") IV. 1. PROCEDURE Credentialing Committee

Prism Network Inc. utilizes a peer review process for the purpose of making credentialing and recredentialing decisions. A multidisciplinary committee comprised of administrative staff and practitioners from various specialties provide meaningful advice and expertise in making credentialing and recredentialing decisions. At a minimum, the Credentialing Committee reviews the credentials of practitioners who do not meet Prism Network Inc., established credentialing criteria. Participating providers are members of the Committee. At least one participating provider of each type of specialty credentialed under the scope of the program is a member of the Committee. This individual has no other role in the management of the corporation. If additional clinical input is required, or if a conflict of interest exists, the Committee seeks input from the appropriate discipline-specific subcommittee. Prism's Medical Director is an active member of the Credentialing Committee and is directly responsible for the credentialing and recredentialing process, including all clinical aspects of the program. As authorized by the Credentialing Committee, the Medical Director is designated to sign-off and approve clean (see Definitions), complete files. The sign-off date is the "credentialing decision" date. If a file fails to meet PHN established credentialing criteria, and/or regulatory accrediting agency standards, the file must be presented to the Credentialing Committee for review and final determination. Ultimate responsibility for compliance with this policy rests with Prism's Board of Directors. Prism's legal counsel is readily available for consultation should the need arise. Legal Counsel monitors all credentialing policies and procedures to ensure they are in compliance with all regulatory bodies and to ensure non-discriminatory activity. All Committee members sign an affirmation that Committee's decision are made in a nondiscriminatory manner. In addition, all requests denied by the Credentialing Committee are reviewed annually by the Executive Quality Management Committee to ensure no actions were taken in a discriminatory manner. The Credentialing Committee is responsible for: · establishing credentialing and recredentialing policies and procedures

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· · · · ·

annually reviewing credentialing and recredentialing policies and procedures maintaining minutes of all committee meetings and documenting all actions accessing appropriate clinical peer input when discussing standards of care for a particular type of practitioner/provider discussing whether practitioners/providers are meeting reasonable standard of care. making credentialing and recredentialing decisions

The Credentialing Committee operates within the guidelines of Prism Network, LLC's Privacy and Confidentiality Policy. The final authority to approve or disapprove a credentialing or recredentialing application belongs exclusively to the Credentialing Committee. 2. Timeframes a. Initial Credentialing I. Requests for applications to participate in Prism Network, LLC are responded to within 30 days. Applications are mailed to practitioners and providers within "Open Counties" (see Definitions of Counties). No applications are mailed to practitioners or providers within "Closed Counties". For "On Hold" Counties, Provider Inquiry Reports are prepared and reviewed by the Vice President of Network Management. If approved, an initial credentialing packet is mailed. II. Practitioners and providers are informed of the completeness of their application by telephone, letter, or fax within sixty- (60) days of receipt. Documentation of all communication is maintained in the practitioner's or provider's file. III. Credentialing staff member other than the staff who prepared the file checks all completed files prior to further review by the Medical Director and/or Credentialing Committee, within regulatory timeframes. IV. Completed clean applications are reviewed by the Medical Director no later than 90 days after the application is received. Limited exceptions to this ninety (90) day requirement are provided in cases where the credentialing process is unable to be completed in spite of Prism's best efforts, there is a failure of a third party to provide the necessary documentation, and/or unusual circumstances require additional time for review. All documentation in support of a provider's or practitioner's application must be current and submitted no greater than 180 calendar days prior to the Committee's decision. (Note: Facilities are exempt from this 180- day requirement).

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V. Completed applications are reviewed by the Credentialing Committee at its next meeting, which occurs no later than 90 days after the application is received. Limited exceptions to this ninety (90) day requirement are provided in cases where the credentialing process is unable to be completed in spite of Prism's best efforts, there is a failure of a third party to provide the necessary documentation, and/or unusual circumstances require additional time for review . All documentation in support of a provider's or practitioner's application must be current and submitted no greater than 180 calendar days prior to the Committee's decision. (Note: Facilities are exempt from this 180- day requirement). EXCEPTION - Rhode Island: Credentialing Committee must take action on a practitioner's/provider's application within 180 days of receipt of the application. VI. Practitioners and providers are notified of the Committee's decision within 60 calendar days of the approval decision. VII. If the Committee tables a decision, all credentials must be current and within the 180- day time limit when represented to the Committee for final determination. . VIII. If a practitioner's or provider's application is not approved by the Credentialing Committee ,PHN notifies practitioner of the decision immediately following the meeting. The practitioner or provider may reapply for participation after a one (1) year waiting period. Enrollment is subject to geo-access requirements at that time. b. Recredentialing I. All practitioners and providers are due for recredentialing every three (3) years. The recredentialing process must be completed within 36 months of the initial credentialing or last recredentialing month. Failure to recredential within this timeframe results in a practitioner's or provider's termination from the network for cause. II. A packet of information is mailed six months before the practitioner's or provider's recredentialing date. III. Practitioners and providers are informed of the completeness of their recredentialing application by telephone, letter, or fax within sixty (60) days of receipt. Documentation of all communication is maintained in the practitioner's or provider's file . IV. Credentialing staff make follow up phone calls every thirty (30) days to providers who have not submitted their recredentialing applications.

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V. A Notice of Proposed Action is sent to any provider who has not submitted his recredentialing application three (3) months prior to his recredentialing due date. Accommodating all appeal timeframes, this allows Prism Network, LLC to terminate a practitioner at the end of the month of his recredentialing due date if he fails to complete the recredentialing process. Practitioners who submit their recredentialing application after their due date are treated as new credentials, and approval is subject to all geo access requirements at that time. VI. Completed recredentialing applications are reviewed by the Credentialing Committee at its next meeting, which occurs no later than 90 days after application is complete. All documentation in support of a practitioner's or provider's recredentialing application must be current and submitted no greater than 180 calendar days prior to the Committee's decision. (Note: Facilities are exempt from this 180 day requirement). As part of its review process, the Committee considers quality improvement findings, member/provider complaint data, and other member/provider satisfaction information. VII. Practitioners and providers are notified of the Committee's decision within 60 calendar days of the meeting. VIII. If the Committee tables a decision, all credentials must be current and within the 180 day time limit when represented to the Committee for final determination and within the thiry-six (36) month recredentialing Timeframe. IX. If a practitioner's or provider's application is not approved by the Credentialing Committee ,PHN notifies practitioner of the decision immediately following the meeting. The practitioner or provider may reapply for participation after a one (1) year waiting period. Enrollment is subject to geo-access requirements at that time.

3. Application Status Practitioners and providers have a right, upon request, to be informed of the status of their credentialing or recredentialing application. All inquiries are directed to the Credentialing Department and are responded to within two business days. 4. Record Keeping All information gathered during the initial credentialing and recredentialing process is maintained in confidential, permanent files by Prism Network, LLC in

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accordance with current record keeping standards. Files are kept locked and access is restricted to Credentialing staff. A database is maintained containing various information on participating practitioners and providers, including but not limited to, names, addresses, credentialing and recredentialing dates, licenses, certifications or registrations, and professional liability insurance coverage. Computer access to information is limited by logins and pass codes. 5. Review

Management of the Credentialing Department reviews each credentialing or recredentialing file before presentation to the Credentialing Committee for completeness, accuracy, and conflicting information. The Committee Chairperson at a minimum, presents all files that fail to meet Prism's credentialing criteria to the Credentialing Committee, including all relevant information important to the decision making process; `clean files' may be presented to the Medical Director for review and determination or to the Committee. Committee discussion includes the practitioner's or provider's ability to meet reasonable standards of care. A motion is made and seconded; discussion transpires and then a formal vote is taken. The Chairperson documents in each file all relevant information important to the decision making process and the Committee's decision, signs each file and then all Committee members present sign each file, affirming the decision. A record of each meeting is kept in the form of minutes. 6. Verification

Practitioners and providers have the right to review information obtained to evaluate their credentialing or recredentialing application. Credentialing staff personally contact practitioners or providers by telephone within two (2) business days of receipt of any information obtained from other sources which varies substantially from information provided by the practitioner or provider. The practitioner or provider has the right to correct inaccurate, incomplete, or conflicting information. The practitioner or provider corrects information by submitting written documentation to the Credentialing Department within thirty(30) days of notification. If a practitioners or provider does not respond, information obtained from other sources is presented to the Credentialing Committee. All issues relating to a discrepancy are documented in the file and presented to the Credentialing Committee for consideration. Practitioners and providers are notified of their right to review information obtained to support their credentialing or recredentialing application and to correct erroneous information submitted by other sources through the enrollment application.

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Credentialing staff verify the following information when processing a credentialing or recredentialing application. Practitioners are informed that all claims information they provide will be verified with the National Practitioners Databank. Verification is completed no greater than 30 days prior to presentation to the Credentialing Committee. a. Verification that licenses in all States where the practitioner has worked in the past five (5) years are in good standing.* Note: State licensing boards verify a practitioner's highest level of education as part of its licensing process. On an annual basis, Credentialing staff obtains written verification from each State that it continues primary source verification as part of its licensing process. Note: New Hampshire does not have a website. Phone calls are limited to two per day; all other communication must be done by mail. b. Verification of any disciplinary actions or sanctions. Primary source verification includes, but is not limited to, the following websites: i. State Education Department, Office of Professional Discipline (issuance of license and any sanctions) Federation of Chiropractic Licensing Boards (CIN-BAD) OIG Sanction List (Office of the Inspector General) (Medicare and Medicaid sanctions) GSA Sanction List (anyone debarred from a federally funded program) National Practitioners Data Bank

ii. iii.

iv.

v. c.

Verification of Board Certification (applicable to physicians only) Website: American Board of Medical Specialties (ABMS)

Physicians: do not need to be Board certified, but if they are, it must be verified. Acupuncturists: must be certified by the National Certification Committee for Acupuncture and Oriental Medicine. Note: New York State requires individuals to successfully pass the certification exam before they can apply for licensure. Licensed Massage Therapists: must be certified by New York State Board of Massage Therapy. Note: New York State verifies this as part of its licensing process.

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d. Verification of malpractice claims history from all malpractice carriers within the past five (5) years. (This policy does not apply to facility providers). Note: Under the following circumstances, NPDB is checked rather than contacting applicable malpractice carriers. The circumstances are clearly documented in the practitioner's file and the file is complete except for malpractice history: · · · practitioner complains that no other plan request this information; or time constraints (information will expire if the file is not presented at the next Committee meeting); or the file must be expedited for other reasons

e. Verification of availability to patients after hours for all medical disciplines, which have, direct patient access. (Note: this policy does not apply to Physical Therapists or hospital Behavioral Health providers* Credentialing staff call practitioners' and providers' offices in the evening or on the weekend to determine if telephone coverage is acceptable based on established criteria (reference "24 Hour Access to Care" Policy/Procedure). f. Verification that provider has not previously been terminated from any Prism network for cause or non-renewal or has not been previously denied admission to the network.* g. Verification that State license/registration matches current office location(s) or home address. h. Verification that practitioner or provider participates in State Worker's Compensation Program, as appropriate (NOTE: applicable only to those networks where clients have contractual arrangements with Workers Comp carriers). 6. Monitoring In addition to the verification of information completed when a credentialing or recredentialing application is processed, credentialing staff also monitor the following information on a monthly basis: a) license expiration dates to ensure that all licenses remain current. b) websites to ensure that there are no current actions against participating providers: i. State Education Department, Office of Professional Discipline

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ii. iii.

Federation of Chiropractic Licensing Boards (CIN-BAD) OIG Sanction List (Office of the Inspector General (Medicare and Medicaid programs)

iv. GSA Sanction List (anyone debarred from a federally funded program State Insurance Department i. the publication "NEWS" from the State Education Department The identification of a disciplinary action or sanction is reported to the Credentialing Committee at its next meeting. The Committee reviews the information to determine if there is evidence of poor quality issues that could affect the health and safety of members. Depending on the nature of the adverse circumstances, the Committee takes appropriate action. * PHN specific criteria V. DEFINITIONS or STANDARDS Attestation ­ a practitioner or provider signs a document attesting to the following: · · · · · ·

·

active malpractice insurance reasons for any inability to perform essential functions, with or without accommodation lack of present illegal drug use history of loss of license and felony convictions history of loss or limitation of privileges or disciplinary activity the submission of a correct and complete application history of sanctions

Client Specific Network ­ a provider network not fully credentialed under Prism and/or NCQA guidelines. Closed County ­ Geo access requirements meet or exceed regulatory requirements. Prism is not accepting applications for enrollment. Inquiries are kept on file in the event enrollment is opened. (Reference "Adding New Practitioners, Providers, or Locations" Policy/Procedure for exceptions to enrollment in a "closed" county.) Dual County ­ a county that has two different statuses because two clients have membership in this area. For purposes of enrollment of new providers, the least restrictive status prevails. Example:

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County Status for Client #1 Open On Hold

County Status for Client #2 On Hold Closed

Enrollment Status for New Providers Open On Hold

File Retention ­ · New Hampshire - records and documents relating to a health care professional's credentialing verification process must be retained for 7 years.

Minimum Geo-Access Requirements ­ New York and Vermont: · City · Non City

-one provider every 10 miles - one provider every 30 miles

New Jersey: · one provider every 45 miles or one hour average driving time, whichever is less, of 90% of covered persons within each county or approved sub-county service area. Vermont (Behavioral Health): · Outpatient Mental Health or Chemical Dependency: o 30 minutes travel time · Inpatient Psychiatric and Medical Rehab: 60 minutes travel time Wellness Network: · City · Non City

-one provider every 3 miles -one provider every 30 miles

On-Hold County ­ Geo access requirements have been met in some areas. Prism is accepting some applications for enrollment. The practitioner or provider must submit a letter of interest. Requests are reviewed by the Vice President of Network Development against geo-access requirements Open County ­ Geo access requirements have not been met. Prism is accepting applications for enrollment Practitioner or Provider - a chiropractor, physical therapist, behavioral health specialist, including social workers, psychologists, psychiatrists and facilities, and complementary and alternative medicine (CAM) specialists including

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acupuncturists and licensed massage therapists, licensed, certified or authorized by law to provide professional patient health care services directly to enrollees of clients of Prism Network, LLC within the scope of the individual's or facility's license or certification. . Provider Rights - Practitioners and providers have the right to: · · · · review information obtained to evaluate their credentialing or recredentialing application correct erroneous information submitted by other sources be informed of the status of their application be informed of these rights

Waived Credentialing Requirements ­ the following Prism and/or NCQA requirements may not be pursued/applied when credentialing or recredentialing practitioners or providers for a Client Specific Network: · · · · · · · · · · signed copy of State registrations for all locations verification: State registrations for each location verification: 5 years of continuous work history verification: gaps in work history exceeding 6 months or 1 yea verification: 24 hour access to care for members attestation on site reviews 5 years malpractice claims history from carriers or NPDB enrollment of Social Workers limited to CSWRs require participation in Medicare Program

VI.

GENERAL STANDARDS OF PARTICIPATION All practitioners and providers must: A. demonstrate a willingness to abide by the policies and procedures of Prism as they currently exist or as they may be amended from time to time. B. comply with generally accepted principles of medical/clinical ethics. C. maintain qualifications that include the absence, or adequate control, of any significant physical or behavioral impairment that affects or presents a substantial probability of affecting their skill, attitude, or judgment. D. be licensed, certified, or authorized by law to provide professional patient health care services

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E. demonstrate ability to work cooperatively with colleagues, staff and other Prism participating practitioners and providers. F. comply with the provisions of Prism's Participating Provider Agreements.

VII.

SPECIFIC CRITERIA FOR CREDENTIALING OR RECREDENTIALING The following criteria is applicable to all Prism practitioners and providers. Differences in criteria specific to disciplines are reflected in the attachment to this policy. All documentation must be submitted within 180 days of credentialing/recredentialing. (Exception: Facilities are exempt from the 180 day requirement). A. accurately complete and sign Prism's application for credentialing or recredentialing B. complete and sign an Attestation (see Definitions) C. maintain professional liability insurance coverage in the amounts of $1,000,000 per occurrence, $3,000,000 aggregate D. sign a Prism and/or ICM Participating Provider Agreement Note: practitioners in a specialty where there is no existing client contract will be required to sign a Prism and/or ICM Participating Provider Agreement within 60 days of notice from Prism that a client contract has been secured. Failure to comply at that time will result in termination for cause. E. participate with Medicare (Exceptions: CAM practitioners, CSWs and MSWs (EAP Network) and any practitioner whose client base is strictly pediatric). F. sign client specific agreements or amendments, including Medicare agreements (as applicable). G. submit a signed copy of State Registration or License (Note: State license or registration must reflect current office location or home address. Chiropractors: no signature required for Maine and New Hampshire. Physical Therapists: no signature required for Rhode Island). H. submit a signed copy of any other State Registrations or Licenses (as applicable) I. sign a release allowing all malpractice carriers within the past 5 years to release claims history to Prism Network, LLC (not applicable to ICM Network)

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J. submit a current Curriculum Vitae, including 5 years of discipline specific work history (gaps of 6 months or more can be explained verbally; gaps of 1 year or more must be explained in writing) Clinical experience is required (reference attached discipline-specific criteria). (Exception: Facilities K. complete and sign a W-9 income tax form L. ensure 24 hour access to care for patients. This includes the designation of a participating backup provider in the event the practitioner is unable to offer care due to illness, vacation or any other event, which may require the need for a covering practitioner. (Note: 24 hour access is applicable to medical disciplines which have direct patient access; not applicable to New York physical therapists, behavioral health facilities providing 24 hour service, non- physician CAM practitioners and providers who only participate with the ICM Network.) New practitioners in a specialty where there is no existing client contract will be required to designate a participating backup provider within 60 days of notice from Prism that a client contract has been secured. Failure to comply at that time will result in termination for cause. M. written explanation of any malpractice claim during the past 5 years NOTE: The Credentialing Committee may exercise its discretion in making exceptions to CRITERIA L (only) to meet geo access requirements. Additional criteria for SOCIAL WORKERS participating with Prism Behavioral Health Network: · enrollment is limited to CSWRs

Additional criteria for FACILTIIES: · submit a copy of any relevant accreditation(s) within the past 3 years. Note: accreditation is not a requirement for participation

Additional criteria for PHYSICIANS: · submit copy of current DEA or CDS Certificate · list hospital affiliations or admitting privileges NOTE: Following NCQA guidelines, the following MDs are not credentialed: · those MDs who practice exclusively within the inpatient setting of a hospital

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·

those MDs who practice exclusively within facilities such as ambulatory behavioral health care facilities.

* PHN specific criteria VIII. SPECIFIC CRITERIA FOR RECREDENTIALING ONLY A. FACILITIES i. On sites are required only upon initial credentialing unless facility is not approved by an accrediting body and then an on site must be conducted every three (3) years. Verification that provider continues to be in good standing with State and Federal regulatory bodies, and if applicable, is reviewed and approved by an accrediting body

ii.

Clean File ­ is a file that meets all established credentialing requirements as defined under CRED 4 which includes but is not limited to, proof of applicable primary source verifications, no evidence of disciplinary action by licensing authorities and no evidence of a malpractice claim exceeding criteria limits as established by PHN, and meets all timeframe requirements specified within CRED 4.. PHN Medical Director has the authority to determine that the file is clean and to sign off on it as complete, clean and approved. The Medical Director's sign-off date is the "credentialing decision date."

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