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What is doctor credentialing?
Why is doctor credentialing important to members?
What does the doctor credentialing process involve?
Please note: Innovation Health is an affiliate of Aetna, Inc. Aetna performs certain administrative services on behalf of Innovation Health.
What are the results of our commitment to credentialing?
What is doctor credentialing?
Credentialing is a process used to evaluate the qualifications and
practice history of a doctor.
This process includes a review of a doctor's completed education, training,
residency and licenses. It also includes any certifications issued by a board
in the doctor's area of specialty.
The credentialing process evaluates the qualifications of doctors who provide
care to our members. We conducts this process before the doctor is permitted to
join the network.
We also reviews doctors' credentials on a regular basis, following standards established
by states, regulatory bodies and accrediting organizations, such as the National Committee
for Quality Assurance (NCQA).
The credentialing process is not a guarantee that members will receive any level of quality
or service from participating doctors. Participants are independent doctors in private practice.
They are not agents or employees of the health plan.
Why is doctor credentialing important to members?
Credentialing plays a role in members' access to quality health care.
Our process is mature and efficient. For this reason, we are able to give members access
to doctors quickly after they sign contracts with us.
We confirm credentials for ALL medical types of health care practitioners that we have an individual
contract with. This includes psychotherapists, chiropractors, podiatrists, physical therapists and nurse
practitioners, among others.
What does the doctor credentialing process involve?
Credentialing includes (but is not limited to) the following:
-
Gathering information about a doctor's background and qualifications through a
formal application process.
- Checking the background information
- Checking the information against reliable sources, including the National
Practitioner Data Bank and the American Board of Medical Specialties
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Contacting:
- Any state where the doctor reports an active medical license and
sees our members
- Schools and hospital programs, to be sure the doctor's training
is complete and accepted by the specialty board
- The National Technical Information Service, Drug Enforcement Agency
or Controlled Substance Registration, as confirmation that the doctor is authorized to
write prescriptions
- Medicare/Medicaid, to be sure the doctor is not banned from caring
for Medicare/Medicaid patients
-
Reviewing the doctor's:
- Personal history, to determine if any disciplinary actions have
been taken
- Malpractice insurance, to confirm active coverage
- Malpractice claims history
- Hospital privileges, to determine if privileges have been
lost or limited
- Work history and employment background
- Information with our Credentialing and Performance Committee,
to determine whether or not the doctor should be included as participating in the
network
Some of the specific information gathered includes:
Provider name and office location: This information is self-reported at least every three
years or more often, according to state or federal requirements on the application, and is
accepted through a signed document from the doctor that states the information is accurate
and correct.
Provider gender: This information (male, female) is self-reported at least every three years or more
often, according to state or federal requirements on the application, and is accepted through a signed
document from the doctor that states the information is accurate and correct.
Specialty (-ies): This is the doctor's special field of practice or expertise. If the provider has contracted
with us to provide services in more than one specialty, all will be listed. This information is self-reported
at least every three years or more often, according to state or federal requirements on the application. We
check the practitioner's highest level of training in his/her specialty and checks board certification status
through primary source verification. This is the process of confirming with the certifying board and/or facility
where the doctor completed residency training.
Patient age focus: When available, DocFind will display information about whether the provider has a patient
age specialization.
Languages spoken: This information includes the languages that the practitioner speaks and is self-reported at least
every three years or more often, according to state or federal requirements on the application, and is accepted through
a signed document from the doctor that states the information is accurate and correct.
Hospital affiliation: This is a listing of the hospitals where the provider has privileges. If you require hospital care,
you may be directed to one of the hospitals listed. This information is self-reported on the application. The practitioner's
hospital affiliations are checked by contacting hospitals to verify the information at least every three years or more often,
if required by state or federal regulations.
Medical group affiliation: This is a listing of the group practice that the practitioner is part of (when applicable).
This information is self-reported at least every three years or more often, according to state or federal requirements
on the application, and is accepted through a signed document from the doctor that states the information is accurate and
correct.
Board certification: When a physician is board certified, it means that he/she has applied for and been awarded certification
from the American Board of Medical Specialties, American Osteopathic Association or other recognized boards, depending
on the specialty. To become board certified, a physician must:
- Graduate from an accredited professional school
- Complete a specific type and length of training in a specialty
- Practice for a specified amount of time in that specialty
- Pass an examination given by the professional specialty board
Board certification is a voluntary process. Most certifying boards now require physicians to be recertified at
specified intervals. The specialty board certification of the practitioner is self-reported on the application and
is checked before contracting and at least every three years or more often, according to state or federal requirements,
through one of the following primary sources:
- American Medical Association
- American Board of Medical Specialties (Access this website at www.ABMS.org. On this site,
in the Consumer section, you will find information about board certification, how to verify that your doctor
is board certified and some general tips on becoming a more educated health care consumer.)
- American Osteopathic Association Physician Profile Report
- American Board of Podiatric Surgery
- American Board of Podiatric Orthopedics and Primary Podiatric Medicine
- American Board of Lower Extremity Surgery, if applicable
- Specialty dental boards: dental specialty boards recognized by the American
Dental Association Counsel on Dental Education and Licensure (CDEL)
Office status: This indicates whether or not a provider is accepting new patients.
It is recommended that you call the provider's office to confirm. This information
is self-reported at least every three years or more often, according to state or
federal requirements on the application, and is accepted through a signed document
from the doctor that states the information is accurate and correct. Practitioners
may also notify us of updates between credentialing cycles. DocFind is updated
with new information every week.
What are the results of our commitment to credentialing?
We have a centralized credentialing verification unit that is NCQA (National Commission for
Quality Assurance) certified for 10 out of 10 verification services and URAC CVO accredited.
- We perform credentialing on about 144,000 doctors annually.
- We maintain a Customer Service unit to meet the specific needs
of the doctors.
- We have a mature and efficient process that is used consistently
for doctors in all our health plans.
Certification Expiration Date: January 29, 2015
The National Committee for Quality Assurance is an independent,
nonprofit organization that certifies credentials verification
organizations and accredits managed care organizations.
Provider Application Form
You can view the questions on the Council for Affordable Quality Health Care (CAQH) application used
by doctors when applying for participation in the Aetna network. This application form shows, in general,
the types of physician, practice information and questions asked when credentialing a provider. Please note,
this form is not applicable in all states or when providers are credentialed through third parties, such
as the hospitals with which they are affiliated,
independent practice associations (IPAs), physician medical groups (PMGs) and integrated delivery systems (IDSs).
This document is provided in Adobe Acrobat PDF format.
To view or print, the Acrobat Reader (version 4.0 or higher) is required.
View the complete Provider Application:
http://www.caqh.org/pdf/CAQH Provider Applicationv5 2006-10-31.pdf
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