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Credentialing

Claims Processing Contracting Credentialing Customer Service Enrollment & Eligibility Verification Quality Management Utilization Management

MedPOINT Management performs credentialing functions on every contracted IPA provider, including hospital-based physicians. Recredentialing takes place on a continual 3-year cycle. The MedPOINT Management Credentialing staff, in conjunction with the quality management department, provides information to the Credentialing Committee based on criteria that is accepted and monitored by nationally recognized regulatory agencies and health care quality organizations. MedPOINT works with a Credentialing Verification Organization (CVO) that is 10-point NCQA accredited to provide primary source verifications required for the credentialing process. Oversight of this function is provided by MedPOINT's credentialing supervisor. The Credentialing Committee meets monthly (and on an 'as-needed' basis) to review the completed files and make appropriate recommendations. The Committee is comprised of physician representatives from all of MedPOINT's managed IPA groups. The credentialing files are diligently maintained to ensure that the most up-to-date, current information is on hand for each IPA contracted provider. The credentialing/re-credentialing files include the following information: Completed IPA(s) membership application including all requested addendums Work history All currently held licenses and certifications Certificate of malpractice insurance Professional liability claims history for the past 7 years Hospital privileges/disciplinary actions taken by hospitals Results of all database queries Verification of education and training history Board of Medical Examiners status check results National Practioner Data Bank ABMS Directory of Medical Specialists (if physician is board certified) Medical Board of California MBC Hot Sheet-Monthly Disciplinary Summary Reviews for sanction activity by Medicare and Medi-Cal with the Office of the Inspector General Health and Human Services Medicare and Medi-Cal Sanctions and Reinstatement Report Physical site and medical record audit (required of all new PCP, OB/Gyn, mental health offices) as a prospective visit and in conjunction with the re-credentailing cycle Quality profile to be used for re-credentialing

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