Credentialing > Practitioner Credentialing
Credentialing is an important process that ensures that health care professionals have the requisite qualifications and training needed to deliver care. The credentialing process also ensures the verification and review of individuals with adverse actions against them, such as sanctions, malpractice or fraud. When applicable, written notice will be sent to practitioners whose credentials are being reviewed.
Minimum qualification requirements for participation include, but are not limited to:
- A valid license to practice
- City of New York – non-members
- Appropriate training or board certification
- Clinical privileges in good standing (as applicable)
- Current malpractice insurance coverage
- Acceptable history with regards to malpractice
Note: Providers who are sanctioned or excluded by the New York State Department of Health's (DOH) Medicaid Program will be excluded from participation in all our benefit plans.
Also Note: All providers, professional and facility, inside and outside of New York, who treat our Medicaid, HARP and Child Health Plus members MUST be registered with the DOH for the Medicaid Program. Registration does not obligate providers to see FFS Medicaid members. The DOH offers an option for participation to be limited to Medicaid Managed Care.
During the credentialing process, practitioners maintain the following rights:
- The right to review information obtained in support of their credentialing applications, excluding references, recommendations or other peer review protected material.
- The right to correct erroneous information in written form to the credentialing department within 10 days of receipt of EmblemHealth's notification.
- The right to be informed of the status of his/her credentialing/recredentialing application. Requests may be made to EmblemHealth via written or telephone inquiry.
Per New York State law, initial applications are reviewed by the Credentialing department within 90 days of receiving a fully completed application, and the applicant is notified within that time period if credentialing has been approved or if additional time is needed. We will make our best effort to obtain any missing documentation from third parties in a timely manner.
Following completion of the application and all applicable verifications, the Credentialing/ Recredentialing Committee (CRC) will consider all information gathered on the provider and evaluate in light of the criteria. At that time, the CRC decides to approve or disapprove the provider's application. The provider is advised accordingly.
The 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 a 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 developing alternative providers or may recommend immediate cessation of referrals to the provider.
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 health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.
A process by which a physician who has been tested for proficiency in a medical specialty or subspecialty, by a medical specialty board, has passed those tests and been certified as proficient in that medical specialty.
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.
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.
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.
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
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 state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
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.