General Screening Criteria
Post-secondary education degree and, if applicable, post graduate training appropriate to the specialty care provided to members;
Current, unrestricted license(s) to practice the practitioner’s specialty(ies);
Current Drug Enforcement Agency certificate, if applicable;
Current certificate of insurance indicating professional liability insurance coverage (state licensure board minimum required limits);
For M.D./D.O.’s, board certification or proof of board qualification/eligibility in the orderly process of obtaining board certification by a board accredited by the American Board of Medical Specialties or the American Osteopathic Association. Physicians who are not board certified are required to achieve board certification within four (4) years of either the date of board qualification/eligibility or the date of empanelment by the Health Plan, whichever is later, to qualify for continued participation.
Surgical specialties must obtain and maintain hospital admitting/surgical privileges at a Health Plan participating hospital appropriate to their practicing specialty(ies).
Obtain and maintain hospital admitting privileges appropriate to their practicing specialty(ies) or provide a written documented coverage arrangement with another Health Plan participating physician with admitting privileges at a Health Plan participating hospital.
To quality as a primary care physician (PCP); physician must:
Practice as a PCP at least fifty percent (50%) of the time in which the physician engages in the practice of medicine; and
Be available to see members a minimum of twenty (20) hours per week; and
Have focused his/her practice of medicine in General Practice, Family Practice, General Internal Medicine and/or General Pediatrics for at least two (2) years prior to applying to the Health Plan to become a PCP. New graduates from subspecialty fellowship training programs under the aforementioned specialties are excluded from this requirement (i.e., a new graduate from a cardiology fellowship program may qualify as a PCP in Internal Medicine).
Physician Application and On-site Review
An on-site office and medical record review will be conducted prior to full participation with the Health Plan in accordance with the National Committee on Quality Assurance (NCQA) guidelines. Satisfactory completion of these requirements along with your application and participation materials will be reviewed by our Credentials Committee.
For more information on the Health Plan’s credentialing criteria, please visit thehealthplan.com or call us at (800) 876-5357
Devised: 1994
Revised: May 21, 1999
Revised: July 18, 1999
Revised: December 21, 1999
Revised: August 14, 2000
Revised: November 17, 2000
Revised: February 5, 2001
Revised: April 25, 2001
Revised: January 8, 2002
Revised: August 14, 2002
Revised: September 23, 2002
Revised: October 29, 2002
Revised: September 9, 2003
Revised: October 10, 2003
Revised: February 16, 2004
Revised: March 17, 2004
Revised: August 5, 2005
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