Credentialing and Contracting

We review each practitioner/provider with whom we contract. Prior to initial contracting, the practitioner/provider is reviewed to verify the following:

• Current copy of valid state license
• Current primary admitting facility or written coverage plan if no admitting privileges (if applicable)
• Current copy of valid Drug Enforcement Agency (DEA) certificate, for the state in which they are practicing, as applicable
• Board certification/education, as applicable
• Work history (most recent five years) must be in mm/yyyy format
• Current copy of adequate malpractice insurance face sheet for the contracted location(s) (also known as Professional Liability or Certificate of Liability Insurance)
• Response to professional questions (see application)
• Attestation and release by the physician or other provider.

Next, the practitioner/provider must be credentialed by us and sign our Practitioner Agreement to participate in our network. A submitted application is not a guarantee of participation. As part of the credentialing process, we contact the issuing source or a recognized source when verifying the information presented in the application. This is called “Primary Source Verification” of credentials. We do this using a variety of recognized sources such as:

• Licensure-via state licensing agency
• National Practitioner Data Bank (NPDB). Once the credentialing process is completed, we send a written notification regarding the contract status.

To maintain quality standards, we re-credential established practitioners/providers every three years.

Credentialing standards are those criteria that all participating Practitioners/Providers must meet and maintain to begin or continue to participate in our health plans. Practitioner/provider credentialing decisions are made by a Credentialing Committee.

A locum tenens practitioner is one who is temporarily working (not to exceed a time period of 90 continuous days) on behalf of a contracted practitioner. A practitioner(s) joining a group/clinic is not a locum tenens and is required to complete credentialing prior to seeing enrollees under the terms of the contract(s).

We follow national credentialing standards regarding the staff in a hospital system who must be credentialed.

I. Practitioner/providers who must be credentialed by us are those who:

• Have an independent relationship with us and provide care under our medical benefits.
• See patients outside of a facility’s inpatient setting or outside of a freestanding ambulatory facility (e.g., PT, OT).
• Are hospital-based but also see patients in their independent relationships with Premera.
• Are dentists who provide care covered by our medical benefits.

II. Practitioners who do not require credentialing by us are those who practice exclusively within the facility setting and who provide inpatient care for Premera patients. Examples include:

• Anesthesiologists
• Neonatologists
• ER physicians
• Pathologists
• Hospitalists
• Radiologists

• Hospital-based
  A physician or other practitioner who practices exclusively within the hospital or facility setting. Premera determines any exceptions based on how patients receive care.
• Physician
  A Doctor of Medicine (MD) or Doctor of Osteopathy (DO).
• Practitioner
  An individual who provides professional healthcare services and is licensed, certified, or registered by the state in which the services are performed.
• Provider
  An organization that provides healthcare services such as hospitals, home health agencies, skilled nursing facilities, surgical centers, and behavioral health facilities, and is licensed by the state in which services are performed.
• Supervision
  A physician or other practitioner acting in an oversight capacity who consistently reviews the medical care and records of a patient when services are provided by another caregiver who, in other circumstances, could practice independently of supervision by license (e.g., PT, OT) must be credentialed by us. A therapist providing outpatient services in a hospital system is considered an independent Practitioner unless supervised as described above.

Right to review credentialing file

A practitioner/provider has the right to review their credentialing file by notifying the Credentialing Department and requesting an appointment to review their file. Allow up to seven days to coordinate schedules. Contact the Premera credentialing department at Credentialing.Updates@Premera.com.

Right to correct erroneous Information

A practitioner/provider has the right to correct erroneous information. The Company will notify the practitioner/provider in writing in the event that credentialing information obtained from other sources varies from that supplied by the Practitioner/Provider. The Practitioner/Provider must explain the discrepancy, may correct any erroneous information and may provide any proof available.

Right to be informed of application status

Practitioners/Providers have the right upon request to be informed of the status of their credentialing application. Please note that after the initial credentialing process, practitioners/providers who are in the re-credentialing cycle are considered approved unless otherwise notified.

Healthcare contracting for specific lines of business discussed in this manual occurs after our credentialing process is complete. Once contracts are signed by the provider and counter-signed by us, the newly credentialed and contracted physician or other provider can then render medical services to our members and submit claims for payment. If the new physician or other provider is joining a contracted group practice, there may not be a need to sign an individual contract; however, we still require that all physicians and other providers be credentialed first.

Need a copy of your provider contract?
Send us an email request and we’ll send it to you directly as an email attachment.

Please note this email is only for requesting contract copies.

Physicians or other providers enter into an agreement with us by signing our Provider Agreement, which serves as the contract for us and our affiliates.

Our Provider Agreement contains the standard terms that pertain to all plans and products. We then attach a “Product and Compensation Addendum” for the specification of payment and any special provisions that pertain to each plan or product.

Our Health Care Delivery Systems (HCDS) department is responsible for contracting. Questions concerning contracting should be directed to your assigned Provider Network Executive (PNE) or Provider Network Associate (PNA).

We want to ensure that members are appropriately transitioned whenever a physician or other provider contract is terminated. To ensure continuity of care, the member must be notified and given the opportunity to transfer care to another physician or other provider - prior to the termination date. This process applies to all plans and whenever a physician or other provider (of any specialty) terminates our contract.

Note: Physicians or other providers are contractually required to provide us with a termination notice as set forth in their contract.

If your organization is contracted with Premera, most practitioners must be credentialed, with the exception of hospital-based practitioners. Learn more about which practitioners need to be credentialed by viewing our credentialing matrix, located as a separate PDF accompanying this document, and in our online credentialing manual, located in the password-protected section of our provider website.

Practitioners who aren’t credentialed may have their claims returned until they submit a complete credentialing application. Lack of credentialing can be grounds for termination from Premera’s network.

Member information

Confidentiality of member information is paramount to us. Our goal is to provide each member with peace of mind that his/her medical history and personal information will remain confidential. All our employees sign a confidentiality statement to that effect. State and federal regulations protect privacy. Provisions for the protection of an individual's health and financial information (protected personal information [PPI]) are included in:

• Patient Bill of Rights (PBR) - state law
• Health Insurance Portability & Accountability Act (HIPAA) - federal law
• Gramm-Leach-Bliley - federal law with state regulations about financial information

For more information about PPI, see Integrated Health Management (Chapter 8) or visit the following websites:

• hipaaadvisory.com
• healthprivacy.org
• cms.hhs.gov
• wedi.org (electronic data interchange site)

In the medical office

Confidentiality is extremely important in all healthcare offices. Federal and state laws require that all physicians or other providers maintain patient confidentiality − this obligation also extends to their office staff and any subcontracted entity that provides support services (e.g., billing services). Each physician or other provider contract includes explicit provisions that require confidentiality of a member's personal and medical information. Refer to your Provider Agreement for complete details.

New physician, provider, or clinic

New physicians, other providers, and clinics receive a W-9 form. The Internal Revenue Service requires completion of this form so we can report income. The W-9 form information must remain current at all times. If you make any change that affects the information on your W-9, you will need to complete another form immediately.

Once a physician or other provider completes the credentialing process, he/she will be set up in our payment systems.

Information/address changes

For physicians or other providers already credentialed and contracted with us, whenever there is a change in practice information (including adding a new location), please notify us in writing or complete the Contracted Provider Information Change/Update Form and return the form to Physician and Provider Relations. The form is available online.

Changes to your practice or remit address need to be reported in advance to ensure no interruption in reimbursement.