Credentialing and Recredentialing
Cook Children's Health Plan's (CCHP) credentialing process is designed to meet NCQA and state requirements for the evaluation of providers who apply for participation. Below is the process for initial credentialing for a provider interested in participating with CCHP:
- Providers must complete the Letter of Interest (LOI) form that is available online
- The completed forms (PDI and LOI) can be faxed to Network Development at 682-885-8403 or emailed to email@example.com for review
- Network Development will review the forms for the following:
- provider is in the Service Delivery Area (SDA)
- request for participation is a service needed by the MCO
- all information submitted is complete and correct
- Once reviewed and approved, Network Development submits the LOI and PDI to the Medical Staff Office (MSO).
- The MSO will send a link to the prospective provider with an application that will need to be completed and returned.
Incomplete applications cannot be processed until all required documentation is received.
Upon receipt of a completed application and any requested documentation, the credentialing process for a new provider will be completed within ninety (90) days.
The recredentialing process will occur at least every three (3) years.
EXPEDITED CREDENTIALING FOR PHYSICIANS IN A MEDICAL GROUP
Any physician who joins an established medical group that has a current contract in force with CCHP may apply for expedited credentialing for payment purposes pending completion of the credentialing process. If an applicant physician meets the qualifications for expedited credentialing, the physician will be treated as a participating provider for CCHP for payment purposes under the terms of the medical group's current participating provider contract.
To be eligible for expedited credentialing, a physician must:
- Be currently licensed in Texas and be in good standing with the Texas Medical Board;
- Submit all documentation and other information required by the Health Plan to begin the credentialing process; and
- Agree to comply with the terms of CCHP's current participating provider contract with the established medical group. If deemed eligible, the physician will be authorized to collect copayments from CCHP enrollees and will be paid in accordance with the terms of the medical group's current participating provider contract.
If CCHP determines that the applicant physician does not meet CCHP's credentialing criteria or is denied participation under the terms of CCHP's Credentialing Plan, the applicant physician or the medical group may retain any copayments collected or in the process of being collected as of the date that CCHP determines the applicant physician will not be credentialed.
An applicant physician will not be included in CCHP's Provider Directory or any list of participating providers, and will not be eligible for selection as a primary care provider by enrollees, unless and until the physician is credentialed as a participating provider.
In addition to verifying credentials, the health plan will consider provider performance data including Member complaints and appeals, quality of care and utilization management.