Credentialing > Practitioner Recredentialing
EmblemHealth requires all practitioners to undergo recredentialing every three years.
Practitioners must maintain the same minimum qualification requirements as applicable for the initial credentialing. In addition, the recredentialing process will evaluate each practitioner on:
- Under/over utilization data
- Quality of care
- Primary and secondary prevention
- Disease management
- Member satisfaction
- Site/medical record audit scores
- Member concerns
- Peer review
- Continuity of care
Six months prior to the credential’s expiration, practitioners will receive a letter from either EmblemHealth’s Recredentialing Department or Aperture CVO (our contracted credentials verification organization). The letter will direct them to update their application on file with the Council for Affordable Quality Healthcare’s (CAQH) Universal Provider Datasource (UPD).
Practitioners should make any changes to their information on the CAQH UPD, update the malpractice claims history accordingly, and include updated copies of their curriculum vitae, State License, Drug Enforcement Agency certification and proof of malpractice insurance coverage with the application.
Practitioners with a complete application on file with CAQH UPD can advise EmblemHealth or Aperture CVO to retrieve all documentation from that source. More information on our relationship with CAQH can be found in this chapter in the section on Council for Affordable Quality Healthcare Universal Provider Database.
To ensure continued participation with EmblemHealth, it is important to return all recredentialing materials as soon as possible. Failure to respond in a timely manner may result in termination from EmblemHealth's provider networks. Reapplication to our provider networks will then be subject to network need.
The Recredentialing Department will review the updated application for completeness and present it to EmblemHealth's CRC for a determination. Occasionally, an EmblemHealth staff member may call the practitioner's office for missing or additional information. The practitioner will then be notified of continued participation or termination.
Glossary terms found on this page:
An activity of EmblemHealth or its subcontractor that results in:
- Denial or limited authorization of a service authorization request, including the type or level of service
- Reduction, suspension or termination of a previously authorized service
- Denial, in whole or in part, of payment for a service
- Failure to provide services in a timely manner
- Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals
A process in which an individual, an institution or educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies to individuals; accreditation usually applies to institutions.
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition.
An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.
A permit (or equivalent) to practice medicine or a health profession that is: 1) issued by any state or jurisdiction in the United States and 2) required for the performance of job functions.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
A set of providers contracted with a health plan to provide services to the enrollees.