Provider Panels/ Networks (#2) Flashcards

1
Q

What is a Provider Panel/ Network?

A

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

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2
Q

NCQA on Provider Networks

A

The organization’s policies define process & criteria must include:

a. Types of practitioners to be credentialed
b. Verification sources used
c. Credentialing criteria

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3
Q

URAC on Provider Networks

A

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
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4
Q

ACF on Provider Networks

A

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

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