Provider Panels/ Networks (#2) Flashcards
What is a Provider Panel/ Network?
MCOs appoint providers to a provider panel. Criteria may include:
a. Valid license
b. Unrestricted DEA
c. Relevant education, training, experience
d. Board qualified/ certified
e. Minimum 5 years work history
f. Current PL & appropriate limits
g. Agree to abide by participation contract
NCQA on Provider Networks
The organization’s policies define process & criteria must include:
a. Types of practitioners to be credentialed
b. Verification sources used
c. Credentialing criteria
URAC on Provider Networks
Organization must have credentialing plan to verify qualifications of participating providers. Plan must include:
- Types of practitioners credentialed
- Decison-making process
- Criteria for granting provider network participation
- Accurate accounting of the verification sources used
ACF on Provider Networks
Criteria for the initial appointment/ reappointment of physicians & dentists
Must be a process to:
- Establish minimum requirements
- Review, assess & validate an individual’s qualifications
- Review & assess information received