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  • Credentialing > The Credentialing/ Recredentialing Committee

    EmblemHealth's Credentialing/ Recredentialing Committee (CRC) is charged with examining the qualifications of participating clinicians and facilities against the professional standards established by our Quality Improvement Committee (QIC).

    The CRC performs the initial approval and credentialing of clinicians and facilities for participation with EmblemHealth. The CRC is assisted by the Credentialing department, which is responsible for reviewing and verifying completeness of every provider's application. Primary source verification is done of the provider's licensure and accreditation, where applicable. CMS requires primary source verification of education and training records and board certification. They reassess said clinicians and organizational providers every three years (at minimum) to assure that all credentialed clinicians and organizations remain qualified and continue to meet the established criteria.

    Members of the CRC include an EmblemHealth designee or our Medical Director (acting as the Committee Chair), at least one physician from each primary care specialty and any high volume specialists as designated by the Committee Chair. The Committee Chair ensures that the CRC has a meaningful range of participating practitioners serving on the Committee with additional specialties added on an ad-hoc basis. All practitioners in the voting membership of the Committee must maintain a current credentials file with EmblemHealth.

    The Committee Chair leads discussions concerning potential quality issues and explains and/or clarifies credentialing policy and procedure when required. The CRC is required to conduct a review of the credentialing file prior to credentialing or recredentialing an applicant.

    For Medicare Advantage health care services, the provider shall cooperate with the plan's credentialing and recredentialing process. The credentials of medical professionals covered by an agreement with one of EmblemHealth's companies will either be reviewed by EmblemHealth directly or where delegated, the credentialing process will be reviewed and approved by EmblemHealth who must audit the credentialing process on an ongoing basis.

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    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.

    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.

    The government agency responsible for administering the Medicare and Medicaid programs.

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    A person authorized by the insured to assist in obtaining access to, or payment to, the insured for health care services. If the insured has already received health care services and has no liability for payment of services, a designee will not be authorized for the purpose of requesting an external appeal.

    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 doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

    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 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. Also known as MA.

    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.

    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
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • 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.

    The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.


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