Development of a Credentialing Program
Primary Source Verification
Additional Credentialing Services
Ongoing Monitoring of Sanctions
Maintain Current Documentation
Recredentialing Services
Reporting
Office Site Visits
Medical Record Audits
Credentialing Delegation Services
Consulting Services
Imaging
Online Application

Development of a Credentialing Program

CCA can assist with the development of credentialing policies and procedures, provider applications and other documentation for compliance with NCQA requirements. CCA can also assist with establishment of a structure to support this effort.

Primary Source Verification

CCA offers comprehensive primary source verification services in accordance with NCQA, URAC, AAAHC and JCAHO standards. The elements verified differ for those organizations achieving NCQA, URAC, AAAHC and JCAHO standards, however, at a minimum the following elements may be verified:

• Current state license;
• Clinical hospital privileges;
• DEA and CDS registration (as applicable);
• Board certification;
• Medical school and residency;
• Malpractice insurance coverage and claims history;
• Medicare/Medicaid sanctions;
• State license sanctions query;
• Work history; and
• NPDB query (if designated by the client).

Additional Credentialing Services

In addition to primary source verification, CCA can provide the following services to enhance the credentialing process:

• Generate and mail pre-filled credentialing applications with provider specific data directly to the provider to initiate the credentialing process.
• Review of the application for required attached documentation.
• Review of the application and curriculum vitae for gaps in the provider's work history.
      Note: Gaps will be noted on a summary page
• Review of the application for completeness and follow-up telephone calls are made to obtain outstanding information. Any omissions of required data elements are noted on a summary sheet.
• Comparison of the verified credentials to your credentialing criteria with a notation of any discrepancies.
• Comparison of the application information to the verification information received with a notation of any discrepancies.

Ongoing Monitoring of Sanctions

To comply with NCQA requirements, CCA can provide ongoing monitoring of the following types of information:

• Medicare and Medicaid Sanctions; and
• Sanctions or limitations on licensure

Maintain Current Documentation

CCA can also maintain current provider documentation between credentialing and recredentialing dates. The documents that will be maintained are as follows:

• State Medical License
• DEA and CDS Certificate
• Malpractice Face Sheet
• Board Certification

Recredentialing Services

Managed care organizations are required to recredential providers on a periodic basis. CCA provides the following services relating to the recredentialing process:

• Generate reports listing providers who will require recredentialing in the next 120 to 180 days.
• Generate and mail pre-filled recredentialing applications directly to the provider to initiate the recredentialing process.
• Primary source verification of those elements required to be queried at recredentialing.
• Review of the reapplication for completeness, gaps in history and discrepancies.
• Revisit of provider sites, as required.

Reporting

CCA will provide monthly status reports, which will detail the provider applications received, applications in process and applications completed. CCA will also submit monthly inventory reports, which will summarize the entire previous month's activity. The report indicates those provider files that were completed and those files that have been received by CCA but are still in process. These reports provide a tool for the client to track the credentialing progress of all providers on an ongoing basis. Of course, the CCA staff is happy to answer any questions regarding a file's status at anytime.

Office Site Visits

CCA is able to conduct site visits for panel providers as required by NCQA or as determined by your credentialing standards. Our staff reviews the physical accessibility and appearance of the site, the adequacy of waiting and exam room space, the provider's procedures for medical record keeping; including confidentiality, and the availability of appointments. This process includes the review of a sample medical record and office policies and procedures.

All CCA reviewers are registered nurses with at least five years of clinical experience and are trained in generic site review techniques. They are provided with individualized instructions on each managed care organization's specific review requirements, as needed. Results reporting is individualized based upon the MCO's requirements.

Medical Record Audits

CCA is available to complete medical record audits as simple or complex as you require. Medical record audits can be as basic as a review for the presence or absence of a recommended diagnostic screening or as complex as compliance with a multifaceted standard of care. Record audits may also involve the review of generic medical record keeping practices.

In each instance, CCA works with the client to determine the extent of the review required. CCA can assist with notification of providers from whom the information is to be collected and aggregation of the data after abstracting is completed.

All CCA reviewers are registered nurses with at least five years of clinical experience. The review staff are supervised and trained by a registered nurse with over twenty years of experience in a variety of health care settings. Specialty training is conducted on a study by study basis.

Credentialing Delegation Services

CCA can provide services that will assist managed care organizations and physician organizations with the responsibilities of delegation.

Consulting

CCA is available to provide consulting services related to the provider credentialing process. These services may include a review of the client's credentialing policies and procedures, applications and other documentation for compliance with NCQA requirements.

Imaging

CCA has the capability to provide imaged documents for our clients who prefer primary source verification data be sent in a paperless format. We are also able to provide paperless back up documentation for security purposes.

Online Application

If you are a provider affiliated with one of our client's, you may complete your credentialing/ recredentialing application on-line and submit most of the information electronically (Please refer to the left: Submit Application).