Credentialing/Re-credentialing Process

CBHA credentials and contracts with providers to deliver treatment to CBHA covered enrollees. The CBHA network includes licensed professionals who:

Psychiatrist: (MD, DO)

Licensed Clinical Psychologist: (Psychologist)

Licensed Psychological Associate: (LPA)

Licensed Clinical Social Worker: (LCSW) (LISW in South Carolina)

Clinical Specialist in Adult Psychiatry and Mental Health Nursing: (CNS)

Licensed Marriage and Family Therapist: (LMFT)

Certified Fee-Based Practicing Pastoral Counselor: (CFBPPC)

Licensed Professional Counselor: (LPC)

Licensed Clinical Addictions Specialist: (LCAS)

Certified Substance Abuse Counselor: (CSAC)

Family Nurse Practitioner: (FNP)

Physician's Assistant: (PA)

General Requirements for Credentialing/Re-Credentialing

Formal applications to CBHA's provider network shall be in writing, submitted on prescribed forms (North Carolina Department of Insurance - Uniform Application to Participate as a Health Care Practitioner) and signed by the applicant. The applicant bears the burden of producing adequate information in a timely manner for the credentialing evaluation. By applying for appointment to the CBHA network, the applicant: 1) authorizes CBHA and/or its designee to consult with others who may have information bearing on competence and qualifications; 2) authorizes those consulted to provide such information; 3) consents to inspection by CBHA or designee of all records and documents that may be material to an evaluation of professional qualifications, professional ethics, physical and mental health and emotional stability; and 4) releases from liability without malice all CBHA representatives for acts performed in connection with evaluating the applicant's qualifications.

Each application must include:

The application must also include a current and signed attestation by the applicant regarding the following:

* The exact statement or inquiry may vary depending upon applicable legal requirements such as the Americans with Disabilities Act (ADA).

Applicants are responsible to submit a complete application, including supporting documents, to the CBHA Professional Relations Department. Applications are reviewed for completeness and to ensure the applicant meets the minimal requirements for membership on the CBHA network. In instances where the application form is incomplete or there are missing supporting documents, CBHA Professional Relations staff will notify the applicant in writing within fifteen (15) days of receipt of the application. If missing information or supporting documents have not been received within sixty (60) days after the initial receipt of the application, or if date-sensitive information has expired, CBHA will close the application or delay final review pending receipt of the necessary information. The applicant will be sent written notification of this action.

In instances where the application verifies the applicant does not meet minimum requirements for membership, a letter is sent to the applicant indicating requirements have not been met and the applicant will not be considered.

Applicants for Re-Credentialing: Network providers are re-credentailed every three years. Pre-populated application forms are sent to network providers four months prior to the credentialing expiration date to ensure that information on file is no older than 180 days at the time of re-credentialing. Applicants are responsible to submit a completed application, including requested supporting documents within thirty calendar days of receipt of the application form. If an incomplete application is received, CBHA will notify the applicant in writing of all missing or incomplete information or supporting documents within fifteen (15) days of receipt of the application. The notification will include the CBHA contact for the applicant. Approximately, one month prior to the credentialing date, if the re-credentailing application has not been received, a follow-up telephone call will be placed by the Professional Relations Manager to encourage the provider to return the application. If an applicant for re-credentialing fails to return a completed application form within thirty (30) calendar days, the provider's status will be changed to "non-participating" and the effective date noted. The provider will be notified in writing that he/she has been terminated from the panel. In addition, the Enrollees being treated by the provider during the past year will also be notified of the provider's status change and will be encouraged to contact CBHA to make arrangements for treatment with another provider. After termination for failing to return a re-credentialing application, the provider may re-apply to for network status if CBHA is recruiting providers within their geographical area or if the provider has a specialty that is not being met by the current network.

Failure of Primary Sources to Respond: Applicants for credentialing or re-credentialing will be notified of any failure of others to respond to requests for credentialing information within a reasonable time frame. After such notification the applicant is responsible to obtain responses to requests for information. If information collection and verification remain incomplete for 180 days, the file will be closed and the applicant will be notified by mail.

Conflicting Data/Discrepancies: Providers will be notified by telephone or in writing of any primary source verification that varies substantially from information submitted by the provider. The provider has thirty days to address and correct any erroneous information submitted by another party.

Note: Contracted Credentialing Services: CBHA reserves the right to contract out the investigative function of the credentialing process to an accredited credentialing service. In such event, the contracted credentialing verification organization (CVO) is required to investigate each application, including primary source verification of education and licensure/certification.

Site Visit: Once information collection and verification is complete, the CBHA Professional Relations Manager may contact the applicant and arrange for a site visit, if there are issues regarding standards of quality, safety, accessibility or record keeping per CBHA credentialing policy.

Provider Profiling Data for Re-Credentialing: The following sources of information regarding providers seeking to be re-credentialed may be used to aid in the decision-making process:

The Professional Relations Manager and Quality Improvement staff are responsible for gathering relevant information for inclusion in provider files and forwards this information to the CBHA Medical Director for review whenever there is an issue identified that may warrant further investigation and response from the BQIC/Credentialing Committee.

Credentialing Committee Review

Applications for credentialing/re-credentialing are presented to the CBHA Behavioral Health Quality Improvement Committee (BQIC) on a monthly basis for review and final decision relative to inclusion on the CBHA provider network. This committee is composed of six to twelve members representing a cross-section of the provider network. All are required to sign a confidentiality statement agreeing to maintain strict confidentiality of all information and a conflict of interest statement agreeing not to participate in any decision where there may be a personal involvement or where the reviewer's judgment may be compromised.

The CBHA Medical Director presents any discrepancies and/or concerns regarding providers' responses to the committee for discussion and review. The following courses of action may be taken:

  1. Application approved;
  2. Application approved with exception(s) noted;
  3. Application on hold, pending more information;
  4. Application denied, with specific reason(s) noted.

Notice of the final decision is documented in writing in the applicant's file; the applicant is notified of the decision of the BQIC in writing.

On-Site Visits

CBHA staff will perform site visits on all providers for whom there is a serious complaint related to physical accessibility, physical appearance, adequacy of waiting room and examining room space, as well as other safety or quality reasons.

CBHA staff will conduct a site review if it receives a Level 1 or Level 2 complaint (see below for details) regarding the provider.

  1. Level 1 Complaint: A complaint concerning a situation or event that will have an immediate impact on the member's health or safety.
  2. Level 2 Complaint: A complaint concerning a situation or event that has the potential to impact the member's health or safety.
  3. Level 3 Complaint: A complaint concerning a situation or event that has no impact on the member's health or safety

Each site visit includes a review of the physical space that is designed to evaluate the following: (See attached form.)

CBHA will make the provider practice aware of the CBHA standards for record-keeping and will discuss the forms and methods that the practice uses to keep the information in a consistent manner, as well as how the practice will ensure medical record confidentiality.

CBHA will assess treatment records for orderliness of record and documentation practices, as well as look for appropriate documentation of quality of care. These standards are outlined below.

Documentation Standards: CBHA has adopted the following standards for documentation in treatment records:

General Treatment Criteria

Record includes the patient's address, employer or school, home and work telephone numbers including emergency contacts, marital or legal status, or guardianship information.

Initial Evaluation

An initial evaluation is completed and includes:

Special Situations

Special status situations, such as imminent risk of harm, suicidal ideations are prominently noted. The record reflects follow-up relative to self-harm/harm to others from one session to another. Patients who become homicidal, suicidal or unable to conduct activities of daily living are promptly referred to the appropriate level of care.

Providers Who Prescribe Medications

Each record indicates what medications have been prescribed by the provider, the dosages of each and dates of the initial prescription or refills. Allergies and or lack of known allergies and sensitivities to pharmaceuticals and other substances are prominently noted. Provider has discussed the benefits and risks of medication prescribed. Laboratory tests ordered by the provider and/or consultation reports with other providers are evident and the record reflects discussion with the patient and f/u for abnormal findings.

For Children and Adolescents

A complete developmental history

Treatment Goals and Progress Reports

A plan of treatment is developed that is consistent with diagnoses and symptoms
There is evidence of patient participation in the development of treatment goals and objectives
A progress note is in place for each treatment visit. The focus of treatment interventions, as documented in progress notes, is consistent with the goals and objectives of the plan of treatment.

Continuity of Care and Discharge

The treatment record documents referral to preventive services, when appropriate (e.g. relapse prevention, stress management, wellness programs, lifestyle changes, and referrals to community resources).

The treatment record reflects continuity and coordination of care between the primary clinician and other heath care providers, and referral sources.

The treatment record documents dates of follow-up appointments and, as appropriate, a discharge plan.

Availability of Treatment Records

Treatment records are to be stored in a secure, centralized location that is readily available to the practitioner and authorized personnel only.

Practice sites will be evaluated according to the following standards:

90 to 100 - Compliant
80 to 89 - Partial compliance - revisit in one year
0 to 79 - Non-compliant

Sites with a score of less than 90% will receive feedback with recommendations for improvements. Any site with a score of less than 80% will be reviewed by the Behavioral Health Quality Improvement Committee, which may deem that the deficiencies are such that the practice will no longer be on the CBHA provider panel. If the BQIC committee recommends retaining the practice, it will be revisited as frequently as BQIC recommends but at least annually until the 90% threshold is met.

If the practice is removed from network membership by the BQIC committee, the practice will be notified by the CBHA medical director in writing of CBHA's decision and the reason for CBHA's decision. The letter is sent via certified mail to ensure receipt by the provider/practice.

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Organizational Credentialing

CBHA enters into contracts with facilities for the provision of behavioral health services. These contracts are automatically renewed annually unless terminated by either party. CBHA ensures that network facilities are in good standing with regulatory bodies and fully accredited by appropriate accrediting bodies as part of the contract approval process:

Professional Liability Insurance: Network facilities must be able to show proof of professional liability coverage of not less than one (1) million dollars per claim and three (3) million dollars per annual aggregate.

Re-credentialing: CBHA will confirm all network facilities remain in good standing with state and federal regulatory bodies and are currently fully accredited by an appropriate accrediting body as part of the re-credentialing process. Facilities are required to complete and submit a Facility Information Form to apply for re-credentialing on a tri-annual basis. Forms will be sent to facilities for their use.

HEDIS Standards and Inpatient Discharge Follow Up

CBHA strives to meet or exceed HEDIS standards for 7-day and 30-day follow up after an inpatient stay for all members who have been hospitalized. CBHA expects that all network hospitals will work to have a member an appointment within 7 days of discharge and that the hospital will send an expedited discharge summary to the outpatient treatment providers. CBHA tracks all network facilities' compliance to HEDIS standards for discharge follow-up after hospitalization. If a hospital is having difficulty obtaining an outpatient appointment within 7 days of discharge, the facility may call a CBHA Clinical Care Manager at (800) 475-7900 to request assistance.

Delegated Credentialing

CBHA shall have a signed agreement in place prior to delegating the credentialing process; this agreement shall specifically outline responsibilities of the delegate and CBHA. CBHA Professional Relations staff periodically reviews the credentialing policies and procedures and credentialing files of each delegated entity that completes any portion of the credentialing process for provider(s) rendering care and treatment to CBHA enrollees. CBHA retains the right to approve or deny a provider from participating in the CBHA network, regardless of his/her participation with a delegated entity.

Providers must meet all criteria for the identified clinical discipline and all verifications and credentialing processes must be performed in compliance with CBHA credentialing policies and procedures.

CBHA staff shall review all credentialing policies and procedures of the delegated entity to ensure compliance.

CBHA staff shall complete an initial audit of the delegate's credentialing files and an annual audit thereafter; the lesser of 5% or 50 files shall be reviewed.

Should any deficiencies be identified during an audit, the delegated entity shall be required to submit a written corrective action plan that identifies specific steps to be taken to correct the deficiencies. If the concerns are adequately addressed in the corrective action plan, CBHA staff will conduct the next audit at the regular annual review. CBHA may exercise its discretion in requesting a re-audit prior to the annual review if the identified deficiencies raise concerns about the delegate's ability to carry out required credentialing functions. Failure to correct identified deficiencies may result in revocation of the delegation agreement.