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Credentialing

The recredentialing process incorporates re-verification and the identification of changes in a Practitioner's licensure, sanctions, certification, health status and/or quality and performance information (including, but not limited to, malpractice experience, sanction history, hospital privilege related or other actions) that may reflect, as applicable, on the Practitioner's professional conduct and competence.

This information is reviewed in order to assess whether Practitioners continue to meet CCHP credentialing standards. Recredentialing of Practitioners occurs every three years unless otherwise required by regulatory or accrediting bodies or a shorter term as determined by the Credentialing Committee. Credentialing terms of less than three years are not considered an action or determination that triggers appeals rights. Each Practitioner applying for continued participation in CCHP's Network must submit all required supporting documentation.

Recredentialing of Organizational Providers occurs every three (3) years unless otherwise required by regulatory or accrediting bodies. Each Organizational Provider applying for continued participation in CCHP's Network must submit all required supporting documentation.

Recredentialing Applicants must provide and/or will be primary source verified the following information:

  1.  A complete recredentialing application and required supplemental information/attachments without material omissions or misrepresentations.

  2. A signed and dated attestation, consent and release.

  3. Current, valid, unrestricted license to practice in each state in which the Practitioner provides care to Covered Persons.

  4. No current federal sanction and no new history of federal sanctions (per OIG and OPM Reports or on NPDB report)

  5. Current DEA and/or state controlled substance certification without history of or current restrictions if applicable. 

  6. Current professional liability insurance of not less than $1,000,000 per occurrence and $3,000,000 in the general aggregate with an insurer licensed to provide medical malpractice insurance in Wisconsin, or show similar financial commitments made through an appropriate Wisconsin approved alternative, as determined by CCHP and appropriate secondary coverage by the Wisconsin Injured Patients and Families Compensation Fund. The pertinent Network Agreement may require coverage that exceeds the minimum level described above

  7. No current hospital membership or privilege restrictions and no new (since prior credentialing review) history of hospital membership or privilege restrictions; OR for Practitioners in a specialty defined as requiring hospital privileges who practice solely in the outpatient setting there exists a defined referral relationship with a Network Provider of similar specialty at a Network Organizational Provider who provides inpatient care to Covered Persons needing hospitalization  

  8. No new (since previous credentialing review) history of or current use of illegal drugs or alcoholism

  9. No impairment or other condition which would negatively impact the ability to perform the essential functions in their professional field

  10. No new (since previous credentialing review) history of criminal/felony convictions, including a plea of no contest

  11. Malpractice case history reviewed since the last Credentialing Committee review; if no new cases are identified since last review, malpractice history will be reviewed as meeting criteria; if new malpractice history is present, then a minimum of last five years of malpractice history is evaluated and criteria consistent with initial credentialing is used

  12. No new (since previous credentialing review) involuntary terminations from an HMO or PPO

  13. No QA/PI data or other patient care related performance data, including complaints, above set thresholds.

Questions

If you have any questions about our credentialing process, please call our credentialing department at 844-229-2776. You may also email questions to cchp-credentialing@chw.org.

Medicaid

Children's Community Health Plan

PO Box 56099
Madison, WI 53705
1-800-482-8010

Together with CCHP

Children's Community Health Plan

PO Box 1997, MS 6280
Milwaukee, WI 53201
1-844-201-4672

 

All Rights Reserved.
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