Delegated credentialing provides health plans and provider networks with shorter turnaround times, reduced in-house credentialing numbers, and standardized processes. This infographic outlines the process and creates the road to success.
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1. Facility Contract
There must be an existing facility contract with the health plan or provider network, which is the basis for the relationship between the two entities, as well as an established process that outlines the eligibility criteria to enter into a delegated credentialing agreement.
2. Credentialing Policy and Procedure Audit
During the first part of the pre-delegation audit, the health plan or provider network evaluates the group’s or facility’s policies and procedures to determine compliance and gaps with regulatory and accrediting bodies.
3. Credentials File Audit
The credentials file audit, which typically encompasses 10 randomly selected initial credentialing files and 10 randomly selected recredentialing files, is the second part of the pre-delegation audit. If the files are in full compliance or have minor issues, the process moves forward.
4. Credentials Committee
The health plan or provider network presents the results to its Credentials Committee, along with a recommendation to move forward with the agreement or approve it with conditions to correct deficiencies. The contract can’t be signed until the Credentials Committee approves entering into the delegated credentialing agreement.
5. Delegated Credentialing Agreement
This is a mutually-agreed upon written document that outlines the credentialing responsibilities of each party, and contains language that the group or facility must remain in compliance with managed care standards, the termination rights of each party (with or without cause), and required reporting.
Once the delegated credentialing agreement is signed, the organization is required by the standards to conduct continual oversight, including a review of the credentialing policies and procedures and a random sample credential file audit. Results are presented to the health plan or provider network’s Credentials Committee.
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