1.    Credentialing Policies (CR 1)

• Does the plan have clearly defined and documented procedures for assessing its practitioners’ qualifications and practice history?
• Does the plan identify which types of practitioners must be credentialed?
• Does the plan have policies and procedures that define practitioner rights to review and correct credentialing information?

2.    Credentialing Committee (CR 2)

• Has the plan designated a committee to make recommendations regarding decisions about practitioners’ credentials?

3.    Initial Credentialing Verification (CR 3)

• Prior to allowing network participation, does the plan verify practitioners’ credentials, including a valid license to practice medicine; education and training, malpractice history; and work history?

4.    Application and Attestation (CR 4)

• Do practitioners applications to the plan include a current and signed attestation about why they cannot perform certain tasks; a history of loss of medical license and felony convictions; a history of limitation of privileges or disciplinary actions; and current malpractice insurance coverage?

5.    Initial Sanction Information (CR 5)

• Before making a decision on a practitioner’s qualifications, does the plan receive and review information from third parties, such as information about any disciplinary actions?

6.    Initial Credentialing Site Visits (CR 6)

• Does the plan verify through an onsite visit that primary care practitioners, obstetricians/gynecologists and high-volume behavioral health care practitioners’ offices meet its standards?
• Does the plan take necessary steps when an office does not meet its standards, and does it evaluate those steps regularly until the office improves?

7.    Recredentialing Verification (CR 7)

• Does the plan reevaluate practitioners’ qualifications every 36 months?
• Before reevaluating its decision on a practitioner’s qualifications, does the plan receive information from third parties, such as information about disciplinary actions?

8.    Recredentialing Cycle Length (CR 8)

• Does the plan reevaluate practitioners’ qualifications every 36 months?

9.    Ongoing Monitoring (CR 9)

• Between recredentialing cycles, does the plan conduct ongoing monitoring of practitioner sanctions, complaints and quality issues?
• Does the plan take appropriate action when issues are identified?

10.    Notification to Authorities and Practitioner Appeal Rights (CR 10)

• Does the plan have a process for discontinuing the contracts of practitioners who demonstrate poor performance?
• Is there a process in place by which the practitioner can appeal the plan’s decision?
• Does the plan report to appropriate authorities when it suspends or terminates practitioners?

11.    Assessment of Organizational Providers (CR 11)

• Does the plan confirm that hospitals, home health care agencies, skilled nursing facilities, nursing homes and behavioral health facilities are in good standing with state and federal agencies and accrediting organizations?
• Does the plan re-review these standings at least every three years?

12.    Delegation of Credentialing (CR 12)

• If the plan delegates to a third party decisions on evaluating or reevaluating a provider’s qualifications, is the decision-making process—including the responsibilities of the plan and delegated party—clearly documented?
• Does the plan evaluate and approve the delegated party’s plan on a regular basis?