Care Standards and Credentialing
Read about:
Access to Care Standards and Responsibilities
Community Health Plan enrollees shall have timely access to adequate and appropriate care based on approved accessibility standards. Community Health Plan providers will meet the following access-to-care standards and other responsibilities.
All providers (PCPs, specialists, facilities) must:
- Provide an answering service (or equivalent system) available 24 hours per day, 7 days per week.
- Maintain an appointment system for enrollees’ prompt access to health care.
- Maintain continuity of care.
- Inform enrollees of their right to self-refer for certain services.
- Provide or arrange for interpretive services for enrollees who are hearing impaired or whose primary language is not English.
- Obtain informed consent from the enrollee, or from a person authorized to consent on behalf of the enrollee, prior to treatment.
- Provide adult enrollees with written information about advance directives and the right to make anatomical gifts.
- Assist enrollees in receiving health care services not covered by Community Health Plan.
- Medicare Advantage providers must not be opted out of Medicare. (Providers that have opted out of Medicare may be admitted to the network for the other lines of business.)
PCPs (including OB/GYN and Midwives) and high volume behavioral health must provide:
- Telephone response time to an after-hours urgent phone call no greater than 30 minutes.
- Routine or preventive care appointment accessibility no greater than 30 calendar days.
- Non-urgent, symptomatic office visits are available from the PCP or another provider within ten (10) calendar days.
- Urgent care appointment accessibility no greater than 24 hours. (Emergency services or urgently needed services require no referral or pre-authorization.)
- Emergency care accessibility 24 hours per day, 7 days per week.
- Routine or preventive care appointment accessibility no greater than thirty (30) calendar days.
Behavioral health providers only must provide:
- Care for a non-life threatening emergency within 6 hours.
- An appointment for a routine office visit within 10 business days.
- Urgent care within 48 hours.
Specialists only must provide:
Specialists must provide the enrollee's PCP with a written report within 14 days of the date of service regarding the proposed plan of treatment, including any proposed hospitalization or surgery. This report should also be provided to an enrollee’s PCP for self-referred services such as women’s health care services. Failure to provide the PCP with this report may result in nonpayment for services and the specialty care provider cannot bill the enrollee.
Facilities only must:
- Notify Community Health Plan of all inpatient admissions as described in Care Management.
- Have inpatient and emergency services available 24 hours a day, 7 days a week.
Compliance with these standards and responsibilities is monitored during but not limited to office site visits. Any necessary corrective action plans or follow-up are reported to the Credentialing Committee and the Quality Council on a regular basis.
Care Standards Documents:
Credentialing and Recredentialing
The Community Health Plan mission is to deliver accessible, managed care services that meet the needs and improve the health status of our communities, and make managed health care participation beneficial for underserved populations and community-responsive practitioners. In furtherance of that mission, the Community Health Plan Board of Directors has developed a Credentialing Program that meets the criteria set forth in this statement, and that meets the standards for accreditation by the National Committee for Quality Assurance (NCQA).
The Credentialing Program governs the credentialing function and sets forth the criteria, standards, and processes to select and retain qualified health care practitioners to promote quality care to enrollees. The Program also includes the structure and oversight responsibilities of Community Health Plan for any credentialing activities that may be delegated to another practitioner group or health care organization.
The Credentialing Program includes a mechanism for annual evaluation and periodic revision to the policies and procedures as adopted by the Credentialing Committee.
This program lists the credentialing criteria and standards that determine compliance for network participation.
Community Health Plan is now live with the Medversant online provider portal, ProviderSource. This is a free online portal that providers in Washington State can use for centralized collection, verification, and distribution of all provider data to be used for credentialing and privileging. This will allow for administration simplification of the application process as providers will no longer be required to complete multiple Washington Practitioner Applications or WPAs.
State Senate Bill 5346 mandates that Health Plans and Hospitals retrieve data from the centralized database and the login is hosted by OneHealthPort. Community Health Plan will now accept credentialing applications through ProviderSource as well as WPAs until further notice. For additional information and access to ProviderSource, click here.
Practitioner Rights
Right to review information to support application. Practitioners who have been or are in the process of being credentialed by Community Health Plan have the right to review credentialing information collected during credentialing, recredentialing, and ongoing review processes.
Practitioners are notified of this right to access in the cover letter that accompanies the Plan’s credentialing and recredentialing applications. The cover letter describes the intent of the process and the steps a practitioner must take to review the information collected. This notification is also made available to the practitioner as part of this Provider Manual, which is supplied either during the contracting process or after a contract has been implemented and is available on this web site.
Right to correct erroneous information. If information provided on the application is inconsistent with information obtained via primary source verification, the Community Health Plan Credentialing Specialist will send the practitioner written notification of the discrepancy and request formal written clarification. The letter to the practitioner will include a summary of the information in question and a request to have the information returned in 14 business days. Notification will be sent electronically or return receipt requested and the correspondence will be marked “Confidential” as applicable.
The practitioner does not have the right to correct an application already submitted and attested to be correct and complete. However, the practitioner has a right to submit an addendum to correct erroneous information submitted by another party. If preferred, the practitioner may add an explanation for the erroneous information on his or her application, include a signed, dated statement attesting to the accuracy of the information provided, and then return the information to the Community Health Plan Credentialing Specialist who initiated the query.
Right to be informed of application status. Practitioners may request a review of their credentials file by calling the Credentialing Assistant and scheduling an appointment with the Credentialing Staff.
All reviews must be done in person at Community Health Plan offices. A member of the credentialing staff will accompany the practitioner during the file review.
Items that may be reviewed include:
- Items submitted by the applicant
- Malpractice insurance information
- Licensing boards’ information
- American Medical Association (AMA) or American Osteopathic Association (AOA) query response
- National Practitioner Data Bank (NPDB) and Healthcare Integrity and Protection Data Bank (HIPDB) report
Peer review documents and references or other information that is peer review protected will not be shared with the applicant. Community Health Plan is not required to reveal the source of information that is not obtained to meet the primary source verification requirements or when law prohibits disclosure.
Upon request, Community Health Plan will provide the practitioner with the status of his or her application. The practitioner is notified of this right when he or she receives the cover letter that accompanies the Plan’s credentialing and recredentialing application. The practitioner may phone the credentialing specialist for this information and the credentialing specialist must explain where the credentialing is in the process. The credentialing specialist may share other information with the practitioner regarding his or her file except for any information that is peer protected.