Tufts Health Plan credentials affiliated practitioners when they join the plan, and again at least every three years in accordance with state and federal regulatory and accrediting agency requirements. All Tufts Medicare Preferred HMO contracting providers must be eligible for and accepting payment under Medicare.
Our credentialing process involves collecting documents from our providers and direct verification through various outside agencies, all in accordance with the standards of the National Committee for Quality Assurance (NCQA) and as required by state and federal laws.
Provider Requirements
For initial credentialing and recredentialing, each provider is required to comply with the Tufts Health Plan Credentialing Program and to submit the following information to Tufts Health Plan or its designee for review:
** Signed and completed credentialing/recredentialing application through caqh.org
** Current malpractice insurance information
** Signed Health Services Agreement (initial credentialing only) and appropriate contract documents
** Signed W-9 form (initial credentialing only)
Primary Hospital Requirements
Each physician must indicate his/her primary admitting hospital in the application. Tufts Health Plan sends a request to the primary hospital confirming that it has assessed the physician’s performance, as mandated by the Joint Commission or other accrediting agency acceptable to CMS and Tufts Health Plan. The hospital is queried again during recredentialing. Appointment verification is then sent by the primary admitting hospital for each physician. The physician must notify Tufts Health Plan in writing of changes in primary hospital affiliation.
Tufts Health Plan Requirements
In addition to verification of certain credentialing elements, Tufts Health Plan is required to obtain and review the following information prior to the final assessment of each provider:
** Board certification status
** Internal quality assurance (QA) events and member complaint reports (recredentialing only)
** Information obtained from the National Practitioner Data Bank
** Medicare/Medicaid sanctions
** State disciplinary actions.
The Quality of Care Committee (QOCC), chaired by a Tufts Health Plan medical director, meets monthly to review and discuss providers who are being credentialed or recredentialed. No provider will be authorized to provide services to Tufts Health Plan members unless the following criteria are met:
** Review of all data requirements from the provider
** Approval by a Tufts Health Plan designated medical director or by the QOCC.
Provider Rights
Federal regulations require Tufts Health Plan to maintain procedures relating to the rights of participating providers:
Provider Contracting Rights
** All participating providers must be furnished with plan participation rules and notice of material changes in participation rules.
** Participating providers may appeal adverse participation decisions. In the case of termination or suspension of a provider contract by Tufts Health Plan, the provider must be given written notice of the reasons for such action and informed of their right to appeal the action, including the process and timing for a hearing request, as required by law. There is no right of appeal on initial application.
** Providers who have not been notified of the suspension or termination of an existing contract with Tufts Health Plan may be allowed to appeal adverse participation decisions.
Provider Credentialing Rights
** There is no right of appeal for initial credentialing.
** Providers have the right to review information submitted to Tufts Health Plan for purposes of credentialing or recredentialing the practitioner, including information obtained by Tufts Health Plan from any outside primary source, such as a malpractice carrier, state license board or the National Practitioner Data Bank (NPDB). Tufts Health Plan shall notify the practitioner of the right to review such information.
Notwithstanding the foregoing, Tufts Health Plan is not required to reveal the source of information if the information was not obtained for the purpose of meeting Tufts Health Plan’s credentialing requirements.
Providers are not entitled to review references, recommendations or information that is peer-review privileged or information, which by law Tufts Health Plan is prohibited from disclosing.
** Tufts Health Plan shall notify providers in the event that credentialing information, which is obtained from sources other than the provider, varies substantially from credentialing information provided to Tufts Health Plan by the provider.
** Providers have the right to correct erroneous information submitted by another party and Tufts Health Plan shall notify providers of their right to correct erroneous information.
** If the Quality of Care Committee votes to take disciplinary action, the provider is entitled to a notice consisting of a written statement of the reasons for the action and, if applicable, has the right to appeal such action by filing a written appeal within 30 days of receipt of the statement of reasons.
** Providers have the right, upon request, to be informed of the status of their credentialing or recredentialing application.
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