<p> PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/ PROCEDURE </p><p>Policy/Procedure Number: MP CR #11 Lead Department: Provider Relations Policy/Procedure Title: Delegation of Credentialing and Re- ☒External Policy credentialing Activities ☐ Internal Policy Next Review Date: 05/09/2018 Original Date: 12/01/1998 Last Review Date: 06/14/2017 Applies to: ☒ Medi-Cal ☐ Employees Reviewing ☒ IQI ☐ P & T ☐ QUAC Entities: ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT</p><p>Approving ☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☐ PAC Entities: ☐ CEO ☐ COO ☒ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER Approval Signature: Marshall Kubota, MD Approval Date: 06/14/2017</p><p>I. RELATED POLICIES: A. N/A</p><p>II. IMPACTED DEPTS: A. Provider Relations</p><p>III. DEFINITIONS: A. N/A</p><p>IV. ATTACHMENTS: A. N/A</p><p>V. PURPOSE: To ensure that delegated credentialing and re-credentialing activities meet the Credentialing and Re- credentialing Policies and Procedures of NCQA and Partnership HealthPlan of California (PHC).</p><p>VI. POLICY / PROCEDURE: </p><p>PHC Provider Relations Department, the Quality Improvement Department, and the Chief Medical Officer have responsibility to perform oversight of the delegated entity's credentialing and re- credentialing activities to ensure full compliance with Partnership HealthPlan of California's policies and to make recommendations for improvement as appropriate.</p><p>A. Potential Delegates:</p><p>A.1. Before delegation is granted the entity submits written policies and procedures related to credentialing activities of potential network providers. The written policies and procedures must meet PHC's requirements for credentialing and re-credentialing. The written protocol must document the credentialing and re-credentialing criteria, the review procedure, procedures for appeals and disciplinary actions, and the organizational structure, staffing and resources for implementing the policies and procedures. If the delegate enters into any sub-delegation agreements, PHC must be notified of this sub-delegation agreement and PHC reserves the right to approve all agreements.</p><p>To retain delegation, any revisions to the delegated entity's credentialing and re-credentialing policies and procedures must be submitted to the Credentials Committee for review and </p><p>D:\Docs\2017-07-20\0beb1f51279c4dc37d78c74fd0c72bf9.docx Page 1 of 4 recommendations for approval. A.1.a. If the delegated entity's credentialing policies and procedures are approved by PHC, a site visit to audit the delegates’ provider files is conducted.</p><p>A.1.b. PHC audit tools are used during the site visit. PHC shall review files using the NCQA 8/30 methodology.</p><p>A.1.c. Once the audit is complete and all requirements met, PHC may enter into an agreement with the entity to perform delegated activities.</p><p>A.2. The delegated entity must have an established credentials committee responsible for review of the credentials of potential providers in conjunction with quality improvement committees. Minutes of meetings of all committees involved in provider credentialing must be available to PHC for review during a site audit.</p><p>A.3. PHC Provider Relations department staff and/or the Quality Improvement Department must be permitted reasonable access to the provider credentials files for the purpose of auditing credentialing activities.</p><p>A.4. The delegated entity reports are submitted, per the individual delegation agreement to PHC those activities related to credentialing and re-credentialing, at the frequency specified in the delegation grid. The reports are reviewed by the Provider Relations Director and subsequently reported to the PHC Credentials Committee.</p><p>A.5. The delegated entity must maintain adequate staffing ratios to carry out the delegated credentialing functions.</p><p>A.6. The delegated entity is required to take appropriate action, outlined in its policies and procedures, any time an issue with an applicant's or Network Provider's credentials are identified. PHC must be notified immediately of any concerns about the practitioner's credentials. A narrative must be forwarded to PHC regarding the conclusions, recommendations, actions and follow-up of all credentialing cases in which disciplinary action, including denial, suspension, restriction, or termination of Network participation occurred.</p><p>A.7. If there is an accusation, suspension, restriction, sanction or termination of any license or privilege against a practitioner who has been credentialed by a delegated entity, the PHC Provider Relations Department will notify the delegated entity requesting complete credentialing information on the provider.</p><p>A.7.a. PHC expects a response to all requests for credentialing information within the specified time in the written inquiry. A.7.b. If the delegated entity fails to respond within the specified time frame the PHC Quality Improvement staff will work collaboratively with the delegate to set priorities and correct identified problems in order to obtain information.</p><p>A.8. PHC retains the ultimate responsibility for the approval, termination and/or suspension of providers to ensure all providers contracting with PHC meet the credentialing requirements specified in PHC Credentialing Policies and Procedures.</p><p>A.9. This delegation arrangement between the delegate and PHC includes the use of protected health information (PHI). PHI may be used for purposes of payment, treatment, and operations. The delegate must protect PHI internally and within any organization with which the delegate contracts for clinical or administrative services. Upon request, the delegate must provide individuals with access to their PHI. If the delegate identifies any inappropriate uses of PHI, the delegate must notify Policy/Procedure Number: MP CR #11 Lead Department: Provider Relations Policy/Procedure Title: Delegation of Credentialing and Re-credentialing Activities ☒ External Policy ☐ Internal Policy Original Date: 12/01/1998 Next Review Date: 05/09/2018 Last Review Date: 06/14/2017 Applies to: ☒ Medi-Cal ☐ Employees</p><p>PHC’s Privacy Officer immediately. If the delegation agreement ends or is terminated, the delegate agrees to continue to protect PHI.</p><p>A.10. If the delegated entity fails to fulfill its obligations under the delegation agreement in place, PHC retains the right to revoke delegation.</p><p>B. PHC Responsibilities:</p><p>B.1. The Provider Relations Director (or designee) and/or the Quality Improvement Department staff in consultation with the delegated entity representative(s) annually review the delegated entity's Credentialing and Re-credentialing Policies for consistency with policies and procedures of the PHC and NCQA guidelines. PHC will conduct an annual review of the delegates’ credentials files, using the NCQA audit tool.</p><p>Materials to be evaluated during the audit process include: B.1.a. Files using the NCQA 8/30 methodology of the delegates' credentialing files. B.1.b. Current delegated entity policies and procedures. B.1.c. Delegated entity Credentialing Committee minutes.</p><p>The results of this audit are reported to the PHC Credentialing Committee. The Committee makes recommendations regarding action plans addressing deficiencies. If no additional action is required the Committee makes recommendations regarding continuation of delegation agreement.</p><p>B.2. The Provider Relations Director (or designee) reports recommendations made by the PHC Credentialing Committee to the delegate and works collaboratively with the delegate to develop action plans for concern resolution as indicated.</p><p>B.3. The Provider Relations Director (or designee) and the Quality Improvement Department have responsibility to monitor the status of action plans and report ongoing progress to the PHC Credentialing Committee. The delegated entity may report the findings directly at a scheduled meeting of the PHC Credentials Committee.</p><p>B.4. Compliance with the Action Plan is considered by the PHC Credentials Committee regarding renewal or continuation, or revocation of delegation agreement. PHC retains the right to immediately revoke the delegation agreement if the delegate fails to comply with PHC standards for delegated entities.</p><p>B.5. The exception to the annual oversight requirement is that, where an entity is NCQA – certified or NCQA – accredited it is assumed that the delegate is carrying out responsibilities in accordance with NCQA standard. However, PHC will require the delegate to submit annually their policies and procedures, submit quarterly credentialing, re-credentialing activity reports and inform PHC of any actions taken against a practitioner as a result of ongoing monitoring of sanction reports.</p><p>D:\Docs\2017-07-20\0beb1f51279c4dc37d78c74fd0c72bf9.docx Page 3 of 4 VII. REFERENCES: A. - NCQA</p><p>VIII. DISTRIBUTION: A. - PHC Provider Manual</p><p>IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Credentialing Supervisor</p><p>X. REVISION DATES: 3/29/2000, 4/12/2000, 8/8/2001, 4/10/2002, 3/12/2003, 3/10/2004, 9/8/2004, 11/10/2004, 11/9/2005, 7/12/2006, 5/9/2007, 7/9/2008, 7/8/2009, 7/14/2010, 7/13/2011, 8/8/2012, 8/14/2013, 9/11/2013, 8/13/2014, 2/11/2015, 4/8/2015, 05/11/2016, 06/14/2017</p><p>PREVIOUSLY APPLIED TO: N/A</p>