Billing Manual for Community Care Network Providers

III.A.1 Practitioner Credentialing ProcessA practitioner is credentialed on the date in which the Credentialing Committee reviewsand approves the candidate's completed application.The Credentialing Committee ensures that practitioners initially meet and continue tomeet Community Care’s criteria and standards for participation in the network. TheCredentialing Committee reviews practitioner credentials and information for initialcredentialing and thereafter at least every three years.The practitioner credentialing process involves the following major steps: Each credential (degrees, certifications, licenses) must be verified with primarysources (academic institution, certifying body, licensing board or agency, etc.). Each practitioner evaluating or treating children and adolescents under the age of 18must submit a Pennsylvania State Police Criminal Background Check (Act 34),Pennsylvania Child Abuse History Clearance (Act 33), and FBI Background Checkthat are no older than 1 year from the date of submission. Each practitioner serving older (age 60 and older) or care dependent adults mustsubmit a Pennsylvania State Police Criminal Background Check that is no older than1 year from the date of submission. The completed application (all credentials verified with primary sources) must bereviewed and approved within 180 days of the date the application was signed. Ifnot, the application must be refreshed with Community Care by returning a copy ofthe original application with a new attestation to the practitioner to review for anychanges or additions. This application must be returned to Community Care with anewly signed and dated attestation.Verifying credentials with primary sources is performed by the CredentialingDepartment. This includes a review of information on sanctions or limitations withMedicare, Medicaid or state licensing agencies (NPDB, Cumulative Sanctions Report,Federal State of Medical Boards (FSMB), etc.).All criteria must be met and verified to consider the application complete forcredentialing.III.A.2 Change in Practitioner InformationAny change to information submitted by a practitioner during the credentialing andcontracting process, or at any time thereafter, including information such as streetand/or suite address and telephone and/or facsimile numbers, must be communicatedto Community Care's Network Relations Department.To prevent problems such as interruptions of referrals, failure to receiveauthorizations for services, or denial of payment for services provided toCommunity Care Provider Manual | 1-888-251-CCBH | © 2012 All Rights Reserved | Page 59