Credentialing > Organizational Provider Credentialing
Organizational providers contracting with EmblemHealth must apply for credentialing. They must go through the recredentialing process in much the same way as individual practitioners.
Minimum qualification requirements for facility participation include, but are not limited to:
- Current accreditation or an acceptable site visit
- Appropriate licensure
- Current Medicare and Medicaid certification status
- Malpractice insurance coverage
- Acceptable history with regards to malpractice
Organizational providers requiring credentialing include:
- Ambulatory surgery facilities
- Clinical laboratories
- Comprehensive outpatient rehabilitation facility (CORF) providers
- Dialysis centers
- Federally qualified health centers/NYS Article 28 Certified Health and Treatment Centers
- Freestanding imaging centers
- Freestanding outpatient alcohol/drug abuse centers
- Freestanding outpatient mental health centers
- Home health agencies
- Home infusion agencies
- Outpatient diabetes self-management training (DSMT) providers
- Outpatient physical therapy and speech language pathology (OPT/SLP) providers
- Portable X-ray suppliers
- Psychiatric hospitals
- Rural health clinics
- School-based health centers (effective 1/1/21 or other official start date of the Medicaid carve-in)
- Skilled nursing facilities
- Substance abuse residential rehabilitation services
- Urgent care facilities
Site visits are completed for non-accredited entities, as applicable. Although the Centers for Medicare and Medicaid Services (CMS) or state review or certification does not serve as accreditation of an institution, a CMS or state review can be accepted in lieu of the required site visit. The actual report from the institution must be retrieved to verify that the review was performed and that the report meets acceptable standards; however, a letter from CMS which shows that the facility was reviewed and indicates that it passed inspection is acceptable in lieu of the survey report.
Following completion of the application and all applicable verifications, the CRC will consider all information gathered on the organizational provider and evaluate in light of the criteria. At that time, the CRC decides to approve or disapprove the application. The provider is advised accordingly.
The organizational provider will generally be credentialed for a three year period. However, the CRC may recommend credentialing for a period less than three years based on the results of its review. If so, the provider is advised of the decision and the reason for the shorter approval period.
If an organizational provider has been disapproved but had been providing care to plan members, the CRC will direct appropriate plan and medical group staff to develop a transition plan for identifying alternative providers or may recommend immediate cessation of referrals to the provider.
Glossary terms found on this page:
An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.
Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
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.
The government agency responsible for administering the Medicare and Medicaid programs.
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 health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
A facility or service that provides care for the terminally ill patient and support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
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.
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.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
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.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.
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 recommendation by a physician that an enrollee receive care from a specialty physician or facility.
The use of one or more drugs for purposes other than those for which they are prescribed or recommended.
Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain, such as a high fever.