Overview
SHP is responsible for all aspects of the credentialing and recredentialing
process for all providers who join or participate in the SHP Network. This
process is under the QI Department and is designed to meet all regulatory and
accreditation requirements and standards. In accordance with those standards,
SHP members will not be referred or assigned to a provider until the
credentialing process has been completed.
SHP recognizes and accepts the Council for Affordable Quality Healthcare’s
(CAQH) credentialing information and application or SHP’s own practitioner
application that includes specific profile elements as required by the State of
Florida. SHP may contract with medical groups/IPA’s that have approved
credentialing function capabilities as entities with delegated credentialing
Required Information
As a practitioner requesting initial credentialing or recredentialing with SHP,
you are required to submit adequate information that will allow the Plan to
complete a thorough evaluation which includes your background, experience,
education and training; demonstrate the ability to perform
as an SHP provider without limitations, including physical and mental health
status as permitted by law.
If the application in incomplete in any way, you will receive a request from
SHP, or its delegated entity, to provide the necessary information
Site Reviews
o Site reviews are required for the following provider offices:
* All Primary Care Physicians (PCP’s), which include Family Practice, General
Practice, Pediatrics, and Internal Medicine
* Women’s Health Care Providers
* OB/GYNs
* High Volume Behavioral Health Providers
o Once SHP’s Credentialing Department receives a practitioner’s credentialing
application, a Provider Relations representative will schedule an office site
visit. The provider must have a review score of 80% or greater to pass the
review for the credentialing application process. In the event the provider
does not receive a passing score and a corrective action plan is implemented,
it is in the best interest of the provider to work with the site reviewer in
developing the corrective action plan and correcting any deficiencies so as not
to delay the credentialing process.
Credentialing Review Committee (CRC)
o All SHP providers must be credentialed and approved by the CRC prior to their
contract becoming effective
o SHP’s Credentialing Review Committee (CRC) voting members are professional
peers
o Once the requesting provider’s credentialing file is complete it is submitted
to the CRC for
review and decision
o If the CRC is unable to make a determination based on the available
information in the file and requires additional information, the Credentialing
Department will request such information on behalf of the CRC
o On occasion, the CRC may, in its sole discretion, request that an applicant
requesting credentialing appear for an interview
o SHP’s Board of Directors has delegated the authority to approve or deny
applicants who apply for credentialing through the CRC
Verification Process
The Credentialing Department is responsible for verification of the applicant’s
information such as
Recredentialing
o Once a provider is credentialed by the CRC to provide service for SHP’s
members, recredentialing will be performed every three (3) years
o The providers will receive a recredentialing application in a Provider
Profile format approximately six (6) months prior to their credentialing
expiration date. Only information that has changed since the last credentialing
needs to be updated
o Failure of the provider to return the recredentialing form to the Plan will
result in an administrative termination from SHP’s Provider Network as a
non-compliant provider
o Information will be verified and presented to the CRC for recredentialing
include:
* Basic qualifications continue to be met
* Quality performance information (i.e. medical record reviews, member
satisfaction surveys, Member Services reports)
o In the event a provider’s DEA, medical license and/or liability insurance
expires prior to a provider’s next recredentialing date, the provider will
receive a request for the updated information. Failure to provide the requested
information with the specified time frame will result in automatic suspension
and/or termination from SHP’s Provider Network
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