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Health Care Management Policy and Procedure
Credentialing .............................................................................................................................2
Credentialing, Recredentialing, Appointment, Re-Appointment ...................................... 3
Practitioner Office Site Quality ...................................................................................... 27
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
BCBSIL Provider Manual – Rev 5/13
1
Health Care Management Policy and Procedure
Credentialing
BCBSIL Provider Manual – Rev 5/13
2
Health Care Management Policy and Procedure
Policy Name:
Policy Number:
Effective Date:
Revision Date:
Credentialing, Recredentialing, Appointment, ReAppointment
Credentialing - 2
1/1/02
5/1/12
Review Date:
Signature
Approval:
Senior Medical Director
HMO, BA HMO, BlueChoice
Vice President–Network Management
Approved QI : 6/6/12
Approved P&P: 5/10/12
Policy:
Blue Cross and Blue Shield of Illinois (BCBSIL) is dedicated to facilitate the provision of, cost-effective
and accessible health care by providers in its networks. A key component of the Program is the formal
process of credentialing, recredentialing, appointment, reappointment, and departicipation of network
providers. The Credentialing/Recredentialing Program will be conducted in a manner to ensure that all
credentialing requirements are uniformly applied and shall be non-discriminatory in areas of race,
religion, ethnic/national identity, gender, age, sexual orientation or reimbursement for all applicants of
the BCBSIL Networks.
BCBSIL Networks to which this policy apply use requirements and processes derived from and in
compliance with the State of Illinois and the National Committee for Quality Assurance (NCQA)
Credentialing standards as outlined in Addendum I.
I.
Definitions:
Practitioners are physicians or other licensed individual providers of covered services who
are listed in the directories of any credentialed network.
The credentialing process reviews evidence relating to the eligibility of a practitioner for
participation in any credentialed network. In this process, information relating to
credentialing elements and requirements are reviewed by the Provider Selection Committee
(PSC) or the Medical Director, and a credentialing determination is made regarding the
practitioner i.e. eligibility for participation in a credentialed network.
Appointment is the action taken by a specific network to effect participation in that network
by a practitioner.
At the time of recredentialing, the eligibility of a practitioner for continued participation in any
credentialed network, with respect to information relating to recredentialing elements and
requirements, is reviewed by the PSC.
Reappointment is the action taken by a specific network to effect continued participation in
that network by a practitioner. The PSC reviews and makes a recommendation, coincident
with recredentialing, to the network regarding reappointment actions based on information
obtained through the practitioner’s participation in the applicable network.
Departicipation means termination of participation of a practitioner from a network.
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II. Organizational Structure
The Board of Directors of Health Care Service Corporation (HCSC) has delegated to its Illinois
Affiliate Board oversight of the Corporate Quality Improvement Program. The Illinois Affiliate Board
has delegated this function to the Managed Care Quality Improvement Committee. The Quality
Improvement Committee has delegated the process of practitioner credentialing, re-credentialing,
appointment, and reappointment to the Provider Selection Committee.
The Committee is responsible for the following and the role and participants of the Committee are
outlined in Addendum IV.
Credentialing and Recredentialing determinations;
Reviewing and providing recommendations regarding reappointment determinations which
the networks make;
Facilitating appropriate exchange of information and action with respect to departicipation;
Conducting appeal adjudication related to its actions;
Reviewing the credentials of practitioners who do not meet the organization’s established
criteria and offering advice which the organization considers;
Annually signing a non discriminatory statement Addendum VIII, Credentialing Committee
Non Discriminatory Statement.
Medical Director: In addition to the PSC, the Medical Director also has the authority to sign off on all
practitioners who meet the established credentialing criteria (i.e. clean files). The designated
Medical Director may use a handwritten signature, or electronic identifier as documentation of sign
off. The Medical Director’s sign off date is the credentialing decision date.
Procedure:
III. Credentialing
A. Elements and Requirements for Practitioners
Application
HMO, PPO and BlueChoice Select network providers must have a Council for Affordable
Quality Healthcare (CAQH) Universal Provider Datasource (UPD) Provider ID to register and
begin the credentialing process. The credentialing criteria for practitioners is detailed in
Addendum II.
BCBSIL credentials the following practitioner types for participation in the networks:
BlueChoice Select: MD, DO, DDS, DC, CNM
HMO: MD, DO, DDS, DC, DPM, Ph.D, LCSW, LCPC, LMFT.
PPO: MD, DO, DC, DPM, OD, PhD, CNM, LCSW, LCPC, LPC, LMFT, BCBA, BCaBA,
Audiologist
1. Provider not registered with CAQH:
a. Upon submission of the applicable application and service agreement for the
HMOs of Illinois or BlueChoice Select contract, BCBSIL will add the
provider’s name to its roster with CAQH.
b. CAQH will mail the practitioner a Welcome kit with registration instructions,
along with a personal CAQH Provider ID.
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c. Upon receipt of the CAQH Provider ID, the provider must log on to the CAQH
website to register.
d. After successfully authenticating key information, the provider will be able to
create a user name and unique password to begin completion of the UPD
application.
2. Provider is registered with CAQH: The provider has a CAQH Provider ID and has
completed an UPD online application; the provider must authorize BCBSIL to access
their credentialing information. This can be completed in four easy steps, as noted
below. (If the provider has chosen "global authorization", then BCBSIL will already
have access to the data).
3. To authorize BCBSIL to access data:
Go to http://www.caqh.org/cred and enter the practitioner’s username and
password
Click the Authorize tab (located under the CAQH logo)
Scroll down and check the box beside BCBSIL, or select "global
authorization".
Click Save to submit the changes.
B. Process
1. The Enterprise Credentialing (ECR) compiles the information related to the
credentialing elements (Addendum II). The ECR will contact the Independent
Physician Association (IPA) or Provider Group by phone or email, to secure any
missing elements. Missing documentation must be received within 48 hours. If the
required elements are not received within the required timeframe the incomplete
application will be returned to the sender. Once a complete application is received,
queries will be requested. Once results of the queries are returned, the ECR will
complete the credentialing process within 60 calendar days of receipt for those
complete applications.
2. A practitioner has the right to review the information compiled. A practitioner will be
notified by the ECR in the event that during the credentialing process, information
obtained varies substantially from the information provided by the practitioner. This
notification takes place prior to the review by the Medical Director or the PSC. The
practitioner has the right to submit supplemental explanatory information. The
practitioner has the right to correct erroneous information. If this occurs, the time
necessary to gather additional information from the practitioner is not included in the
60 calendar days required to complete the credentialing process.
3. The Credentialing/Recredentialing Program will be conducted in a manner to ensure
the credentialing requirements are uniformly applied to all applying practitioners and
shall be non-discriminatory in areas of race, religion, ethnic/national identity, gender,
age, sexual orientation or the type of procedure, patient, or specialty in which the
practitioner specializes. Applications are worked based on date received in the ECR
and the aging of date-sensitive documents.
4. The ECR is responsible for responding to all inquiries regarding the status of a
Credential/Recredential application. IPAs/Practitioners may contact the ECR via
phone, fax, or email, to request the status of their credentialing or recredentialing
application and ECR staff will on average respond within 48 hours.
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5. For practitioners, the ECR screens the application and query results relative to the
thresholds in Policy ECR04 Category I and Category II Matrix. When the threshold is
met, the information regarding the practitioner is reviewed by the Senior Medical
Director who makes a recommendation to the PSC. The recommendation would be
to:
a. pass the practitioner through credentialing without PHO status,
b. mark the practitioner’s file with PHO status during the credentialing process,
c. seek additional information from the practitioner, or
d. deny the practitioner credentialing.
The PSC reviews this recommendation, and may accept or alter it. If the decision is
to deny the practitioner credentialing, the practitioner is notified and may appeal the
decision using the appeals process set forth in Addendum III. If the decision is to
seek additional information, the practitioner will be notified and the Senior Medical
Director re-reviews the additional information within 30 calendar days and makes
another recommendation to the PSC. If the determination is to pass the practitioner
through credentialing, with or without PHO status, the networks are informed by their
participation in the PSC meeting.
6. For practitioners meeting credentialing requirements, a listing or electronic file of
practitioners recommended for credentialing is brought weekly to the Medical
Director by the ECR. The Medical Director reviews the listing or electronic file and
makes a determination as to whether to credential, which creates eligibility for
appointment to a credentialed network. Newly appointed practitioners will be added
to the directory, website and notified within 60 calendar days of the credentialing
decision (reference policy IL-CR-05 Practitioner Directories). If the practitioner does
not meet credentialing requirements, or is determined not to be credentialed by the
PSC, the practitioner is notified within 14 calendar days from the PSC decision date.
7. For a practitioner not meeting credentialing requirements, the management of any
network to which the practitioner is applying may review the credentialing information
and bring it to the Senior Medical Director for temporary waiver based on
considerations specific to that network. The Senior Medical Director makes a
recommendation as to whether the practitioner should be granted a waiver.
8. The PSC reviews the information and makes a determination as to whether the
practitioner is credentialed. A temporary waiver may be granted on a one-time basis
for a period of up to one year. If the determination is made not to credential a
practitioner, a letter is sent to the practitioner. The practitioner has the opportunity to
appeal this determination using the procedure set forth in Addendum III.
III. Appointment
A. Elements and Requirements
Each network sets its own elements and requirements for appointment (Addendum V),
which include having been credentialed as described in Section III. These elements and
requirements are provided to the PSC for informational purposes, and do not require
approval by the PSC.
B. Process
Practitioners seeking to participate in a credentialed network require appointment to that
network. The management staff of the network reviews the credentialing information, along
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with any additional information required for the appointment determination, and makes a
decision about appointment. A list of practitioners appointed is brought to the PSC by the
network. The PSC reviews the list but does not take action with respect to it.
IPAs/Practitioners are notified of the appointment decision within 60 calendar days. If the
network’s decision is not to appoint, the practitioner has the opportunity to appeal the
decision using the appeals policy for that network.
IV. Recredentialing
A. Elements and Requirements for Practitioners
1. The elements and requirements for recredentialing including the primary sources
used to verify the information are set forth in Addendum II and are identical to that of
initial credentialing.
2. Recredentialing will be initiated by the ECR consistent with NCQA and State of
Illinois requirements. Effective 7/1/2002, the State of Illinois requires recredentialing
to be conducted in accordance with the Health Care Professional Credentials Data
Collection Act 410 ILCS 517 which stipulates recredentialing to be completed every
three years based on the last digit of the Health Care Professional’s social security
number.
B. Process
IPAs/Practitioners will be notified in the first month of the quarter in which the practitioner is
due for recredentialing. See Addendum VI for the State of Illinois Recredentialing Single
Cycle.
V. Reappointment
A. Elements and Requirements
Each network defines its own elements and requirements for reappointment (Addendum
VIII), which include having been recredentialed as described in Addendum IV, and
acceptable performance within the network during the current period.
Reappointment elements and requirements are provided for informational purposes to the
PSC, and do not require approval by the PSC.
B. Process
Appointed practitioners seeking to continue to participate in a credentialed network require
reappointment consistent with Addendum II. The Committee reviews the information and
may request detail for further review. On that basis, the Committee either recommends
reappointment or non-reappointment. The management staff of the network has final
responsibility for making a determination as to whether the practitioner is reappointed to the
network. IPAs/Practitioners are notified via the website of the reappointment decision within
60 calendar days.
Practitioners have the opportunity to appeal a determination not to reappoint using the
appeals policy for that network.
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VI. Monitoring and Departicipation
A. Network Performance Criteria
The administration of the individual managed care networks is solely responsible for the
episodic and concurrent determination of practitioner and participation, continued
participation and departicipation. Practitioners will be continuously evaluated against
network-specific performance criteria by the network management. Those participants not
meeting performance thresholds will be placed on monitoring or required to undertake
corrective action, or both, or be departicipated from the network. The management of the
individual networks will report network-specific decisions regarding departicipation to the
PSC for informational purposes.
B. Process
When Network Management or the ECR obtains information which meets the thresholds for
PHO (ECR04 Category I and II Matrix) review or a Level 3 Quality of Care Complaint
regarding a practitioner who has previously been credentialed and is not in the process of
current recredentialing, the information is reviewed by the Senior Medical Director. The
Medical Director makes a recommendation to the PSC regarding any change in
credentialing status. The PSC may then change credentialing status or leave it unaltered.
When performance by a practitioner does not meet network standards, the network may
place the provider on monitoring and undertake corrective action. Monitoring persists until
the issues creating the action have been resolved, or the network takes other action,
including involuntary departicipation.
Practitioners may be either voluntarily or involuntarily departicipated from a network.
Departicipation is voluntary when initiated by the practitioner. Examples would be
retirement, relocation, not meeting Board Certification requirements within 24 months of the
initial credentialing decision date or failure to provide a credentialing application within 30
days of termination from a delegated entity. Involuntary departicipation is effected by the
management staff of BCBSIL Network/Quality Improvement (QI) Department under the
terms of its contract with the practitioner (or his/her agent).
Network/QI/or Special Investigations Department (SID) management report to the PSC any
practitioners placed on monitoring/corrective action or departicipated as a result of conduct
or practice that could impair the integrity of other networks or is deemed to be
unprofessional, unethical or illegal. Such conduct or practice, includes, but is not limited to:
loss, suspension, or probation of license or hospital privileges
felony charges
a quality of care or member satisfaction issue
failure to meet site visit requirements
refusal to cooperate with BCBSIL and/or contracted network policies and procedures
suspected fraud
financial insolvency
The other networks review the situation to assess the appropriateness of maintaining
participation by the practitioner. The management staff of each network subsequently reports its
determination as to continued participation by that practitioner to the PSC.
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C. Reporting
When monitoring or departicipation is occasioned by an issue of conduct or practice which is
solely or primarily related to substantial findings of professional incompetence or
professional misconduct which adversely affects, or could adversely affect the health or
welfare of a patient, the network identifies and presents the findings to the other networks
through the PSC. The ECR files a report with the appropriate authorities such as the
respective state licensing agency, State Department of Professional Regulations as
applicable, other local authorities as required by law, or the federal HealthCare Integrity and
Protection DataBank (HIPDB).
All involuntary departicipations will be evaluated by the ECR to determine if reporting to
HIPDB is required. The ECR represents the Illinois Plan on the HCSC HIPDB Certification
Committee and follows the corporate policy & procedures.
When a provider is terminated for administrative and/or performance issues related to
network performance standards and unrelated to the physician’s or professional provider’s
ability to practice, reporting is not required. In those cases that involve suspected fraud by a
physician or provider, the individual is reported to the SID. It is the responsibility of the SID
to report the situation to the appropriate authorities.
VII. Ongoing Monitoring of Sanctions, Member Complaints and Quality of Care Issues
The ECR will conduct regular reviews of the credentialed provider networks using information
regarding Medicare & Medicaid sanctions, sanctions or limitations on licensure, and member
complaints. This information will be reviewed between recredentialing cycles as follows:
A. The ECR & Corporate Compliance Department will monitor government sanctions by
reviewing the OIG, FEP, GSA, Illinois Department of Public Aid-Medicaid Sanction
Database, and the OFAC databases at the time of credentialing, as well as, monitoring the
monthly change report compiled by the Corporate Compliance Department.
B. The ECR will review sanctions or limitations on state licensure using data obtained from the
appropriate state licensing agency on a monthly basis.
C. The Senior Medical Director will review member complaints and quality of care issues as
identified by the BCBSIL Consumer Services Management area which is responsible for
resolving quality of care issues. The ECR will provide a monthly report of closed cases to
the Network Medical Directors (reference the Ongoing Monitoring of Credentialed
Practitioners policy).
VIII. Confidentiality
All information submitted and personally attested to by practitioners for the purpose of participation
determinations is confidential and is not disclosed unless reporting is determined to be required
Such information is collected and maintained electronically.
IX.
Annual Review
This policy, as well as related BCBSIL credentialing policies and procedures, is reviewed, and any
necessary revisions made, on at least an annual basis by the ECR.
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ADDENDUM I
NETWORKS INCLUDED IN THIS POLICY
Network
BlueChoice Select
HMO Illinois
BlueAdvantage
PPO
BCBSIL Provider Manual – Rev 5/13
Credentialed
Yes
Yes
Yes
Yes
Credentialing Requirements
and Process
NCQA-based credentialing
NCQA-based credentialing
NCQA-based credentialing
NCQA-based credentialing
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ADDENDUM II
CREDENTIALING and RECREDENTIALING
ELEMENTS AND REQUIREMENTS
(NCQA-BASED)
Note: Any occurrences not meeting PHO thresholds must be reviewed and accepted as consistent with
credentialing/recredentialing requirements by the PSC.
ITEM/ELEMENT
Contracting
Application/
Attestation
State Board
License
Clinical Privileges
CREDENTIALING and RECREDENTIALING
REQUIREMENTS
Practitioners must have signed a contract with a
network.
Initial Credentialing:
Practitioners must submit a State of Illinois Health
Care Professional Credentialing and Business Data
Gathering Form electronically through the Council
for Affordable Quality Healthcare (CAQH)
Recredentialing:
Practitioners must submit a State of Illinois Health
Care Professional Recredentialing and Business
Data Gathering Form electronically through the
Council for Affordable Quality Healthcare (CAQH).
Practitioners must submit:
X. Current copy of the license for the state(s) in
which the practitioner practices
Practitioners must provide clinical admitting
privileges information on the application, with the
exception of the following:
HMO/PPO/BlueChoice Select:
Practitioners only see patients in an office setting
and do not have hospital privileges will be exempt
from the hospital admitting privilege requirement.
Network Management will identify these
practitioners exempt from this requirement.
HMO/PPO:
Practitioners participating in either network, must
provide credentialing information for the practitioner
covering inpatient admissions.
BCBSIL Provider Manual – Rev 5/13
TIME FRAME
REQUIREMENTS
PRIMARY
SOURCE
VERIFICATION
REQUIREMENTS
Prior to credentialing
None
Signature date on BCBSIL
attestation to be within 365
calendar days of the
credentialing decision
Application/
Attestation
XI. Verification to occur
within 180 calendar
days of the credentialing
decision; and
XII. License to be current at
the time of the
credentialing decision
XIII. Illinois
Department of
Regulations;
XIV. Indiana State
Licensing Board;
XV. Wisconsin
Department of
Regulations and
Licensing.
Application/
Attestation
Information must be
submitted on or with
credentialing or
recredentialing application.
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ADDENDUM II
ITEM/ELEMENT
Clinical Privileges,
cont’d
Federal DEA an
State CDS
Certificate
CREDENTIALING REQUIREMENTS
TIME FRAME
REQUIREMENTS
PRIMARY SOURCE
VERIFICATION
REQUIREMENTS
HMO/PPO/BlueChoice Select:
Practitioner types exempt from this requirement
may include:
MD/DO
Allergist
Dermatologist
Ophthalmologist
HMO/BlueChoice Select: PCPs part of a
hospitalist group
PPO: Hospitalist
Other Practitioners:
Audiologist (AUD)
Chiropractor (DC)
Optometrist (OD)
Behavioral Health Practitioners:
Clinical Psychologist (PhD)
Licensed Clinical Prof’ Counselor (LCPC)
Licensed Clinical Social Worker (LCSW)
Licensed Marriage & Family Therapist ( LMFT)
Note: Additional admitting privilege information must
be obtained for any occurrence not meeting PHO
criteria.
Practitioners must fax to CAQH:
XVI. Current copy of the DEA certificate for each
state in which they practice; and
XVII.
Current copy of the state CDS certificate
for each state in which they practice.
BCBSIL Provider Manual – Rev 5/13
XVIII.
Verification to occur
within 180 calendar
days of the credentialing
decision; and
XIX. DEA and CDS to be
current at the time of
the credentialing
decision
XX. Verification obtained
from National
Technical Information
Services (NTIS); or
XXI. Verification obtained
from IDPFR website;
or
XXII.
Copy of the DEA
certificate; and
XXIII.
Copy of the CDS
certificate.
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ADDENDUM II
ITEM/ELEMENT
Education and
training
TIME FRAME
REQUIREMENTS
CREDENTIALING REQUIREMENTS
Practitioners must submit
Information relating to professional education
and training.
Initial Credentialing
Only
BCBSIL Provider Manual – Rev 5/13
XXIV.
None
PRIMARY SOURCE
VERIFICATION
REQUIREMENTS
If board certified,
verification is obtained by
proof of board certification
which fully meets this
requirement:
XXV.
American Board
Certification through
the American Board
of Medical Specialties
(ABMS)
If not board certified, the
education and training is
verified by one of the
following:
XXVI. Illinois State
Licensing Board; or
XXVII. AMA Physician
Master File; or
XXVIII. AOA Physician
Master File
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ADDENDUM II
ITEM/ELEMENT
Board Certification
HMO/BlueChoice
Select – ONLY
PPO Providers are
excluded
CREDENTIALING REQUIREMENTS
Initial Credentialing:
Board Certification is not a requirement at the time
of initial credentialing but must obtain board
certification within 24 months of initial credentialing
date. Requirement for any practitioner participating
with any of the BCBSIL Networks are as follows:
Board Certified in the specialty in which the
practitioner practices and is listed in the
directory within 2 years from completion of initial
credentialing.
Listed in the American Board of Medical
Specialties directory if applicable.
Any practitioner who does not meet this
requirement will be departed from the
network(s) after 2 years from the date of the
effective date with the product.
If a practitioner has taken the Board examination but
has not successfully passed within 2 years after the
initial credentialing, the practitioner would be
departed. The practitioner may appeal the
departicipation decision using the steps outlined in
Addendum III. The provider should include the
number of times the exam has been taken, dates for
rescheduled exam, extenuating circumstances for
added value to network.
Certified Nurse Midwives (CNM): Must have
certification through the American College of Nurse
Midwives Certification Council, Inc. at initial and
recredentialing.
TIME FRAME
REQUIREMENTS
If MD/DO/DPM are board
certified:
Verification to occur within
180 calendar days of the
credentialing decision.
PRIMARY SOURCE
VERIFICATION
REQUIREMENTS
Verification obtained from
one of the following:
XXIX. ABMS website;
or
XXX.
AOA website; or
XXXI. American Board
Podiatric Orthopedics
or American Board of
Podiatric Surgery
XXXII. Copy of
American Board
Certificate (If
applicable); or
XXXIII. Copy of
congratulation letter
from the American
Board of Medical
Specialties; or
XXXIV. Copy of letter
from American Board
of Medical Specialties
confirming the
passing of part one of
a two part exam.
Recredentialing:
Practitioner must be Board Certified within 24
months of initial credentialing date.
Exceptions:
Exceptions to the Board Certification requirement
are:
Practitioners whose specialty boards require a
period of practice as a prerequisite to board
certification; or
Practitioners appointed to the network prior to
1/1/94 are not required to seek board
certification if they were not board certified at
the time of appointment; or
Board certification of practitioners in their subspecialty is not required if appointed to the
network prior to 1/1/01.
Board Certification of practitioners is required in
each primary specialty if the practitioner desires
to participate under multiple primary specialties;
or
Network Management may exempt a
practitioner, IPA from the Board Certification
requirement due to geographical location; or
Marketing exception.
Non-board certified practitioners have no
requirement. (i.e. grandfathered providers)
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ADDENDUM II
ITEM/ELEMENT
Work History
CREDENTIALING REQUIREMENTS
Initial Credentialing Only:
Practitioners must provide via
application/curriculum vitae the last five years of
relevant work history.
Malpractice
Insurance Coverage
Malpractice History
State, Medicare
and/or Medicaid
Sanctions
Gaps greater than 30 days must be explained, in
writing and attached to the application.
Initial Credentialing/Recredentialing:
Practitioners must submit one of the following
documents in the required liability amounts:
Practitioner/Group: $1,000,000/$3,000,000
BHC Provider: $1,000,000/$1,000,000
Indiana Provider: $250,000/$750,000
XXXV. Malpractice insurance carrier/coverage
information on the application including the
period of coverage, the insurance carrier
name, and the coverage limits; or
XXXVI. Copy of malpractice insurance
certificate; or
XXXVII. Copy of federal tort letter or an
attestation from the practitioner stating that
he or she has federal tort coverage, if
applicable.
Initial Credentialing/Recredentialing:
Practitioners must complete the “Professional
History “ section of the application as well as
Form B, if applicable
Initial Credentialing/Recredentialing:
Practitioners must complete the “Professional
History “ section of the application as well as
Form A if applicable
BCBSIL Provider Manual – Rev 5/13
TIME FRAME
REQUIREMENTS
PRIMARY SOURCE
VERIFICATION
REQUIREMENTS
Information confirmed to
be complete within 365
calendar days of the
credentialing decision.
Application/Attestation
Malpractice certificate
must be in effect at the
time of the credentialing
decision.
Application/
Attestation
Copy of malpractice
insurance or federal
tort letter
Verification to occur
within 180 calendar days
of the credentialing
decision.
Verification to occur
within 180 calendar days
of the credentialing
decision
NPDB
Verification obtained
from one of the
following:
NPDB
OIG, GSA, FEP,
OFAC, Illinois Dept.
Public Aid
Medicare and
Medicaid Sanctions
and Reinstatement
Report
Chiropractic
Information
Network/Board
Action Databank
(CIN-BAD)
State Board of
Dental Exam.
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Page 14 of 24
ADDENDUM III
APPEALS PROCESS FOR CREDENTIALING/RECREDENTIALING
Practitioners appealing a credentialing or recredentialing determination must notify the ECR in writing
of the reason for appealing within 30 calendar days of receipt of the letter denying credentialing. An
appeal follows the process below:
A. The ECR passes the appeal letter, and the credentialing/recredentialing information, on to the First
Level Appeals Subcommittee of the PSC, which consists of one Medical Director from the PSC, two
Provider Affairs representatives, and one representative from Corporate Credentialing.
B. The Subcommittee reviews the information within 30 calendar days of receipt of the appeal request
and makes a determination as to whether to uphold the original decision and deny
credentialing/recredentialing, or to reverse it and credential/recredential the practitioner.
C. If the decision is to uphold the original determination, the practitioner has the opportunity, within 30
calendar days of receipt of notification, to a second level appeal. This may be requested by
submission of a written statement as to the reason for appealing further.
D. The ECR brings this letter and relevant information to a meeting of the PSC at which time the
practitioner may be present, within 30 calendar days of the appeal request.
E. The PSC reviews the matter and the Second Level Appeals Subcommittee (consisting of PSC
members not on the First Level Subcommittee) makes a final determination to either uphold the
original decision and deny credentialing/recredentialing, or to reverse it and credential/recredential
the practitioner.
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Page 15 of 24
ADDENDUM IV
Provider Selection Committee
The PSC consists of a diverse and heterogeneous membership which includes the following
responsibilities:
credentialing and recredentialing determinations,
receiving information regarding network appointment determinations,
reviewing and making recommendations regarding network reappointment determinations,
assuring appropriate exchange of information and action with respect to departicipation,
conducting appeals adjudication’s related to its actions,
adopting and overseeing compliance with the Policy which governs these activities,
reviewing the credentials of practitioners who do not meet the organization established criteria and
providing information to the practitioner related to the deficiencies,
annually signing of the non discriminatory statement (reference Addendum VIII).
Chair: Medical Director II Special Investigations
Co-Chair: Senior Medical Director, Medical Management or Medical Director II, Policy
Meeting Frequency: Meets on a monthly basis
Quorum: 50% of voting members
Voting Members:
Medical Director II, Special Investigations
Medical Director II, Policy
Senior Medical Director, Medical Management
Physician Representatives (2-5)
Manager, Professional Network Management
Senior Manager, Provider Operations
Senior Manager, Special Investigation Department
Senior Manager, Onsite Audits/Utilization Management
Non-Voting Members:
Assistant General Counsel I, Legal Department
Senior Manager, Provider Administration & Enterprise Credentialing
Senior Supervisor, Professional NM
Senior Supervisor, Professional Network Management
Senior Supervisor, Provider Operations
Administrator, Professional Network Management
Technical Support Specialist II
Three Enterprise Credentialing Coordinators
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Credentialing, Recredentialing, Appointment, Re-appointment
Page 16 of 24
ADDENDUM V
Network Management Appointment/Reappointment Requirements
Element
Defined
BlueChoice Select
Appointment/
Reappointment
Requirements
HMO
Appointment
/Reappointment
Requirements
PPO
Appointment/
Reappointment
Requirements
Appointment is the action taken by a specific network to effect participation in that network by a
practitioner. All providers, within the scope of this policy, will be credentialed and appointed before
participation in the network.
Reappointment Is the action taken by a specific network to effect continued participation in that
network by a practitioner. All providers, within the scope of this policy, are required to be
recredentialed and reappointed every 3 years.
Contracting
Provider Types: MD, DO or
CNM
Appointment/Reappointment
All BlueChoice Select
practitioners must sign a
BlueChoice Select contract
prior to credentialing.
Primary Care Physicians (PCP)
are limited to one BlueChoice
Select PCP contract. PCPs
include Family Practice,
General Practice, Internal
Medicine, Pediatrics,
Obstetrics/Gynecology and
Certified Nurse Midwife.
Participating Specialist
Physicians (PSPs) may have
multiple contract affiliations.
Physician specialties listed on
Addendum VII in the
BlueChoice Select column will
not be appointed by
BlueChoice Select.
Hospitalist physicians who see
patients only in the hospital
setting and are contracted with
BlueChoice Select will be
credentialed but will not be
listed in the BlueChoice Select
directory and will be appointed
as a specialist.
Practitioner must be contracted
with a multi-specialty group to
be considered a Hospitalist.
BCBSIL Provider Manual – Rev 5/13
Provider Types: MD, DO, DC,
DDS, DPM, PhD, LCSW, LCPC
and LMFT
Appointment/Reappointment
All HMO providers must be
participating with an IPA that is
contracted with HMO Illinois or
BlueAdvantage HMO.
Primary Care Physicians
(PCPs) are limited to
contracting with one IPA
unless “added value” is
identified by the IPA and
approved by the network. See
the PCP Affiliation with Multiple
IPA Policy.
Provider Types: MD, DO, DC,
DPM, OD, CNM, PhD, LCSW,
LCPC, LPC, LMFT, BCBA,
BCaBA and Audiologist.
All PPO practitioners must sign
a PPO contract prior to
credentialing.
Hospitalist physicians who see
patients only in the hospital
setting and are contracted with
PPO will be credentialed but
will not be listed in the PPO
directory.
Practitioner must be contracted
with a multi-specialty group to
be considered a Hospitalist.
PCPs include Family Practice,
General Practice, Internal
Medicine, Pediatrics,
Obstetrics/Gynecology and
Chiropractors.
(The PCP designation for
Chiropractors is dependent on
a request by the IPA.)
Participating Specialist
Physicians (PSPs) may have
multiple IPA affiliations.
Physician specialties not
included in Addendum VII in
the HMO column will not be
appointed by HMO.
Hospitalist physicians who see
patients only in the hospital
setting and are contracted with
HMO will be credentialed but
will not be listed in the HMO
directory.
High-volume behavioral health
care providers will be identified
by the IPA through an annual
survey.
18
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Page 17 of 24
ADDENDUM V
Element
Clinical
Privileges
Education
and
Training
Board
Certification
PPO
Excluded
BlueChoice Select
Appointment/
Reappointment
Requirements
HMO
Appointment/
Reappointment
Requirements
PPO
Appointment/
Reappointment
Requirements
Appointment/Reappointment
Practitioners must submit
clinical admitting privileges
information from a network
hospital.
Appointment/Reappointment
Practitioners must submit
clinical admitting privileges
information from a network
hospital.
Appointment/Reappointment
Practitioners must submit
clinical admitting privileges
information from a network
hospital.
Practitioners who only see
patients in an office setting
and do not have hospital
privileges will be exempt
from the hospital admitting
privilege requirement.
Practitioners who only see
patients in an office setting and
do not have hospital privileges
will be exempt from the
hospital admitting privilege
requirement.
Practitioners who only see
patients in an office setting and
do not have hospital privileges
will be exempt from the
hospital admitting privilege
requirement.
The IPA will notify HMO when
The network will identify
The network will identify these
this occurs as well as provide
these providers for the
providers for the Credentialing
credentialing information for
Credentialing department, as
department, as well as, provide
well as, provide credentialing the practitioner covering
credentialing information for
inpatient admissions.
information for the
the practitioner covering
practitioner covering
inpatient admissions.
inpatient admissions.
Appointment Only: Practitioners must submit information relating to professional education and
training.
Appointment:
Practitioners joining BCBSIL Network are not required to be Board Certified at the time of
appointment but should be in the process of attaining Board Certification. Board Certification is
required within two years after initial credentialing and will be based on the effective date with the
product.
Reappointment:
Requirements for any practitioner participating with any of the BCBSIL Networks are as follows:
Board Certified in the specialty in which the physician practices and is listed in the
directory within 2 years from completion of initial credentialing.
Listed in the American Board of Medical Specialties directory, if applicable.
Board certified MD and DO practitioners must submit copy of American Board Certificate, if
applicable or copy of congratulatory letter from the American Board of Medical Specialties.
XXXVIII. Certified Nurse Midwives must have certification through the American College of Nurse
Midwives Certification Council, Inc. to participate in BlueChoice Select.
Departicipation: Any practitioner who does not meet this requirement will be departed from the
network(s) after 2 years from the date of the effective date with the product. If a practitioner has
taken the Board examination but has not successfully passed within 2 years after the initial
credentialing, the practitioner would be departed. The practitioner may appeal the departicipation
decision using the steps outlined in this policy. The provider should include the number of times
the exam has been taken, dates for rescheduled exam, extenuating circumstances for added value
to network.
Exceptions to the Board Certification requirement are:
1. Practitioners whose specialty boards require a period of practice as a prerequisite to board
certification must submit a copy of the letter from the American Board of Medical Specialties
confirming the passing of part one of the two-part exam (i.e. OB/GYN, Neurology, Orthopedic
and Neurological Surgery).
2. Practitioners appointed to the network prior to 1/1/94 are not required to seek board
certification if they were not board certified at the time of appointment.
3. Board certification of practitioners in their sub-specialty is not required if appointed to the
network prior to 1/1/01. Board Certification of practitioners is required in each primary
specialty if the practitioner desires to participate under multiple primary specialties.
4. Network Management may exempt a practitioner, IPA from the Board Certification
requirement due to geographical location.
5. Marketing exception.
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Page 18 of 24
Appointment/Reap
pointment Requirements
ADDENDUM V
HMO
Appointment/Reappointment
Requirements
Site Visits
Site visits are not required at
initial credentialing.
Site visits are not required at
initial credentialing.
Appointment
and
Reappointm
ent
Practitioners must meet BCBSIL corporate credentialing and recredentialing requirements or
must meet the BCBSIL program requirements for delegated credentialing and recredentialing.
Element
BlueChoice Select
PPO
Appointment/Reappointment
Requirements
Site visits are not required at
initial credentialing.
Practitioners may participate as both a PCP and a PSP. (not required for PPO)
Network Management will evaluate applicants with respect to the credentialing information along
with other information including but not limited to network location, size and access criteria.
The practitioner is required to meet the appointment requirements relative to the provider type
designation.
Each practitioner is required to be appointed to the contracted network. The criteria for
appointment will be presented by Network Management to the PSC at the time of the proposed
appointment. Network management has final responsibility for making the determination as to
whether a credentialed practitioner or provider is appointed to that network.
The recommendation to approve a provider for one of the following actions is based on
credentialing/recredentialing documents, the results of primary source verification,
HMO/BLUECHOICE SELECT will take the results of performance parameters for PCP’s into
consideration and PPO, will take site visit results into consideration. Action taken includes
Initial Credentialing:
XXXIX. Appointment;
XL. Pend for further review;
XLI. Deny application.
Recredentialing:
Reappointment;
Reappointment with monitoring;
Reappointment with high-level monitoring;
Pend for further review;
Deny participation.
Notification
Appeals
Appointment/Reappointment Appointment/Reappointment
Appointment/Reappointment
A letter from the Network
A letter or report of appointed A letter from the Network Medical
Medical Director is sent to
practitioners is sent to the
Director is sent to the practitioner
the practitioner notifying
HMO Group Administrator or
notifying him/her of the decision
him/her of the decision
Credentialing Coordinator
within 60 calendar days of the
within 60 calendar days of
within 60 calendar days of the Credentialing decision. The same
the Credentialing decision.
Credentialing decision. The
information is also available on
The same information is also same information is also
the BCBSIL website.
available on the BCBSIL
available on the BCBSIL
website.
website
Appointment/Reappointment
The IPA/practitioner has the right to appeal the denial of the appointment as well as termination
decisions. The appeal must be sent in writing to the BCBSIL Network Medical Director within 30
calendar days of the notice of the decision and must state the reasons for appealing the decision.
Appeals will be reviewed by the Network Provider Affairs management team comprised of, at a
minimum, the Senior Manager of Operations, and the Medical Directors. This committee will
review the appeal within 30 calendar days of receipt of the appeal request and make a
determination to uphold the original decision or to reverse it. No additional appeal level is
available.
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Page 19 of 24
ADDENDUM VI
State of Illinois Recredentialing Single Cycle
Year
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Month
January
February
March
April
May
June
July
August
September
October
November
December
BCBSIL Provider Manual – Rev 5/13
2011
Notify
2012
Notify
2013
Notify
8
0
4
9
1
5
Open
Open
Open
Open
Open
Open
2
6
3
7
2014
Notify
2015
Notify
2016
Notify
8
0
4
9
1
5
Open
Open
Open
Open
Open
Open
2
6
3
7
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Page 20 of 24
ADDENDUM VII
BCBSIL NETWORKS Targeted Specialties
Health Plan Targeted Specialties:
American Board of Medical Specialties unless noted by **
ILLINOIS
HMOI &
BlueAdvantage
PPO
BlueChoice
Select
Allergy/Immunology
X
X
X
Colon-Rectal Surgery
X
X
X
X
X
X
Specialty - MD/DO
Subspecialty - MD/DO
Dermatology
Pediatric Dermatology
Family Medicine/Practice
X
X
Geriatric Medicine
X
Sleep Medicine
Sports Medicine
Internal Medicine
Cardiovascular Disease
X
X
X
X
X
X
X
X
X
X
X
X
X
Cardiac ElectroPhysiology**
X
Clinical Cardiac Electrophysiology
X
Critical Care Medicine
Endocrinology, Diabetes &
Metabolism
X
X
X
X
Gastroenterology
X
X
X
Geriatric Medicine
X
X
X
Hematology
X
X
X
Hematology/Oncology (2)
X
X
X
Hospice and Palliative Medicine
Infectious Diseases
X
X
Interventional Cardiology
X
X
X
Medical Oncology
X
Nephrology
X
X
X
Pulmonary Disease
X
X
X
Rheumatology
X
X
X
Sleep Medicine
X
X
X
Sports Medicine
X
X
X
Transplant Hepatology
X
X
Maxillofacial Surgery
X
X
Neurology
X
X
Neurology - Child
X
Neurological Surgery
X
Nuclear Medicine
X
X
X
X
X
Obstetrics-Gynecology
X
X
X
Gynecologic Oncology
X
X
X
Gynecology**
X
X
X
Hospice and Palliative Medicine
X
Maternal & Fetal Medicine
X
X
X
Obstetrics**
X
DO - Only
X
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Credentialing, Recredentialing, Appointment, Re-appointment
Page 21 of 24
ADDENDUM VII
BCBSIL NETWORKS Targeted Specialties
Specialty - MD/DO
Subspecialty - MD/DO
Reproductive Endocrinology &
Infertility
Ophthalmology
Orthopedic Surgery
HMOI &
BlueAdvantage
PPO
BlueChoice
Select
X
X
X
X
X
X
X
X
X
Orthopaedic Sports Medicine
Orthopedic - Surgery of the Hand
Otolaryngology
Pediatric Otolaryngology
Sleep Medicine
Pediatric
Pediatric Adolescent Medicine
Developmental-Behavioral Pediatrics
Hospice and Palliative Medicine
Pediatric Allergy & Immunology**
Neonatal-Perinatal Medicine
Neurodevelopmental Disabilities
Pediatric Cardiology
Pediatric Critical Care Medicine
Pediatric Emergency Medicine
Pediatric Endocrinology
Pediatric Gastroenterology
Pediatric Hematology-Oncology
Pediatric Infectious Disease
Pediatric Nephrology
Pediatric Neurosurgery**
Pediatric Ophthalmology**
Pediatric Orthopedics**
Pediatric Pulmonology
Pediatric Rheumatology
Pediatric Sleep Medicine
Pediatric Sports Medicine
Pediatric Transplant Hepatology
Physical Medicine & Rehabilitation
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Sports Medicine
Plastic Surgery
Surgery of the Hand
X
X
Psychiatry - Child/Adolescent
Psychiatry - Geriatric
X
X
X
Surgical Critical Care
X
X
Preventive Medicine
Psychiatry
Radiation Oncology
General Surgery
BCBSIL Provider Manual – Rev 5/13
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
23
Health Care Management Policy and Procedure
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Page 22 of 24
ADDENDUM VII
BCBSIL NETWORKS Targeted Specialties
Specialty - MD/DO
Subspecialty - MD/DO
Pediatric Surgery
HMOI &
BlueAdvantage
PPO
BlueChoice
Select
X
X
X
Vascular Surgery
X
X
X
Thoracic and Cardiac Surgery
X
X
X
Urology
X
X
X
Pediatric Urology
General Practice**
X
X
X
Surgery of the Spine**
Prothesis, Orthotics
&Pedorthists**
X
X
X
HOSPITAL BASED SPECIALTIES Following provider specialties are not credentialed.
Anesthesiology
X
Emergency Medicine
X
Pathology
Blood Banking & Transfusion Medicine
X
Radiology- Diagnostic
X
Pediatric Radiology
X
Pediatric Intensive Care**
X
Neonatal-Perinatal Medicine
X
BEHAVIORAL HEALTH: MID-LEVEL- OTHER PROVIDER TYPES
HMOI &
BlueAdvantage
PPO
Ph.D.
X
X
LCPC
X
X
Provider Type
DEGREE
BlueChoice
Select
Clinical Psychologist (Ph.D.)
(psychology (clinical))
PPO: Neuropsychology
Licensed Clinical Professional
Counselor
Licensed Professional Counselor
LPC
X
Licensed Clinical Social Worker
(LCSW)
LCSW
X
X
Licensed Marriage & Family
Therapist (LMFT)
LMFT
X
X
Board Certified Behavioral
Analyst - Doctoral
Board Certified Assistant
Behavior Analyst
BCBA
X
BCaBA
X
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Credentialing, Recredentialing, Appointment, Re-appointment
Page 23 of 24
MIDLEVEL – OTHER PROVIDER TYPES
American Board of Medical Specialties does not recognize or certify these provider types but some have their own National
Certifying Bodies. See Credentialing Criteria for name of National Certifying body.
Provider Type
Certified Nurse Midwife
Chiropractor
Podiatry
Optometrist
CNM
DC
DPM
OD
HMOI &
BlueAdvantage
PPO
BlueChoice
Select
X
X
X
X
X
X
X
X
X
Audiologist
X
Occupational Therapy (4)
OT
Physical Therapy (4)
PT
Speech Language
Therapist/Pathology (4)
SLP
**
1
2
3
4
X
Targeted
Specialty/not
credentialed
Targeted
Specialty/not
credentialed
Targeted
Specialty/not
credentialed
No corresponding American Board of Medical Specialties Certificate.
Abbreviated the ABMS Certificate name which is Endocrinology, Diabetes & Metabolism.
Combination for those providers Board Certified in both Hematology & Oncology.
Providers Board Certified in Obstetrics-Gynecology but practice only one specialty.
Targeted specialties for the BlueChoice Select Network but are not credentialed.
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Page 24 of 24
Addendum VIII
CREDENTIALING COMMITTEE NON DISCRIMINATORY STATEMENT
To:
Provider Selection Committee
From: Corporate Credentialing
Date:
RE:
Non Discriminatory Statement
Each Provider Selection Committee member affirms:
The Credentialing/Recredentialing Program is conducted in a manner to ensure that all
credentialing requirements are uniformly applied and shall be non-discriminatory in
areas of race, religion, ethnic/national identity, gender, age, sexual orientation or
reimbursement to all applicants of the BCBSIL Networks.
________________ ______
Signed
_____________________
Dated
Reviewed 5/1/12
BCBSIL Provider Manual – Rev 5/13
26
Health Care Management Policy and Procedure
Policy Name:
Practitioner Office Site Quality
Policy Number:
Effective Date:
Revision Date:
Credentialing - 8
5/1/2013
Review Date:
Approval
Signature:
Senior Medical Director
PPO, BlueChoice Select
Approved QI: 05/01/13
Approved P&P: 04/11/13
Policy:
Blue Cross and Blue Shield of Illinois (BCBSIL) has established standards for practitioner office
site quality and will monitor and investigate member complaints related to the quality of
practitioner office sites to determine whether the office site meets these standards.
Purpose:
To monitor whether members have appropriate access to health care services in a clean and
safe environment.
To define the standards and thresholds for the quality of network practitioner office sites
including:
o Physical accessibility
o Physical appearance
o Adequacy of waiting and examining room space
o Adequacy of medical/treatment record keeping
To define the methodology for investigating complaints about quality, safety and
accessibility in office sites where care is delivered.
Procedure:
Site Standards
1. Environment:
**The site should be clean and well organized to accommodate patient services.
Restrooms, doorways and hallways should be easily accessible.
The waiting room should have adequate seating for the volume of patients.
There should be an adequate number of exam rooms based on the number of
practitioners.
The site should be accessible to those with disabilities.
2. Safety Measures:
**The Practitioner and his/her staff should follow the Centers for Disease Control
and Prevention Universal Precautions guidelines when providing patient care.
**Bio-hazardous waste must be discarded according to OSHA guidelines.
**Sharp disposal containers must be available.
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Health Care Management Policy and Procedure
Practitioner Office Site Quality
Page 2 of 5
3. Medication Maintenance/Storage:
**Sample drugs, over-the-counter medications, prescription drugs, and vaccines
should be stored in restricted patient areas.*
**Controlled substances, if present, should be stored in a locked area.*
4. Medical Supply Storage:
**Sharps should be stored in restricted patient areas.*
Prescription pads should be stored in restricted patient areas.*
5. Medical Record System:
**Medical records should be handled in a confidential manner.
All patient data should be filed in the medical record, (i.e., lab, X-ray, consultation
notes, etc.)
Chart Organization: The Practitioner should maintain a uniform medical record
system of clinical recording and reporting with respect to services which includes
separate sections for progress notes and the results of diagnostic tests.
Biographical Information: Each medical record should contain the patient’s
address, employer, home and work telephone numbers including emergency
contacts, marital or legal status, appropriate consent forms and guardianship
information, if relevant.
Patient Identifiers: Patient identifiers should appear on each page of the medical
record (patient name or unique ID number).
Date and Signature: All entries are to be dated and signed/initialed by the author.
Author identification may be a handwritten signature, unique electronic identifier
or initials.
Legibility: All entries should be legible.
Allergy Status: Medication allergies should be noted in a prominent location in
the medical record. If the member has no known allergies or history of adverse
reactions, this should be prominently and consistently noted. Allergies to
environmental allergens, food, pets, etc., should also be noted.
Site Visit Performance Threshold
To pass the site visit, the practitioner office site MUST PASS all standards marked with **.
The auditor will provide feedback about any other deficiencies.
Monitoring
1. The Practitioner Office Site Quality policy is made available to all providers in the
Provider Manual.
2. Complaints related to the quality of a practitioner office site will be routed to Network
Quality and Customer Service Department for investigation. The complaint will be
reviewed.
3. If the complaint indicates a quality issue or a potential member safety issue, a site visit
will be performed within sixty days after receipt of the complaint.
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Health Care Management Policy and Procedure
Practitioner Office Site Quality
Page 3 of 5
4. When a site visit is scheduled for investigation of a complaint, the practitioner will be
provided with a copy of the Practitioner Office Site Quality policy, including the
performance thresholds.
5. Site visits will be performed to assess compliance with the site standards outlined in this
policy.
6. Identified deficiencies will be reviewed with the practitioner (or office staff, if the
practitioner is not available) at the time of the site visit.
7. The practitioner will receive a written report summarizing the site visit findings.
8. If a practitioner office site fails any of the MUST PASS standards marked with **,
BCBSIL will request that the practitioner office site develop and implement a Corrective
Action Plan (CAP) to improve the deficiencies that did not meet the requirements. The
CAP must be sent to BCBSIL within 30 days of receipt of the letter requesting of CAP.
9. BCBSIL will evaluate the effectiveness of the CAP by conducting a follow-up audit within
six months of audit failure.
10. If a site visit is performed in response to a member complaint about the quality of the
practitioner office site and the site fails to meet the standards established in this policy,
the findings will be reported to Network Management, Corporate Credentialing, and the
Provider Selection Committee (PSC).
11. Reports summarizing complaints about practitioner office site quality will be brought to
the Managed Care Quality Improvement Committee at least annually
12. Practitioners failing three or more consecutive practitioner office site audits will be
presented to PSC for further review and recommendations.
BCBSIL Provider Manual – Rev 5/13
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Health Care Management Policy and Procedure
Practitioner Office Site Quality
Page 4 of 5
Attachment I
Practitioner Office Site Quality
Audit Tool
Environment
**
The site should be clean and well organized to accommodate patient services.
Restrooms, doorways and hallways should be easily accessible.
The waiting room should have adequate seating for the volume of patients.
There should be an adequate number of exam rooms based on the number of
practitioners.
The site should be accessible to those with disabilities.
Safety Measures
**
The Practitioner and his/her staff should follow the Centers for Disease Control
and Prevention Universal Precautions guidelines when providing patient care.
**
Bio-hazardous waste must be discarded according to OSHA guidelines.
**
Sharp disposal containers must be available.
Medication Maintenance/Storage
**
Sample drugs, over-the-counter medications, prescription drugs, and vaccines
should be stored in restricted patient areas.*
Controlled substances, if present, should be stored in a locked area.*
**
Medical Supply Storage
**
Sharps should be stored in restricted patient areas.*
Prescription pads should be stored in restricted patient areas.*
Medical Record System
**
Medical records should be handled in a confidential manner.
Comments
Comments
Comments
Comments
Comments
All patient data should be filed in the medical record, (i.e., lab, X-ray, consultation
notes, etc.)
Chart Organization: The Practitioner should maintain a uniform medical record
system of clinical recording and reporting with respect to services which includes
separate sections for progress notes and the results of diagnostic tests.
Biographical Information: Each medical record should contain the patient’s
address, employer, home and work telephone numbers including emergency
contacts, marital or legal status, appropriate consent forms and guardianship
information, if relevant.
Patient Identifiers: Patient identifiers should appear on each page of the medical
record (patient name or unique ID number).
Date and Signature: All entries are to be dated and signed/initialed by the author.
Author identification may be a handwritten signature, unique electronic identifier or
initials.
Legibility: All entries should be legible.
Allergy Status: Medication allergies should be noted in a prominent location in the
medical record. If the member has no known allergies or history of adverse
reactions, this should be prominently and consistently noted. Allergies to
environmental allergens, food, pets, etc., should also be noted.
*Restricted Patient Area – a separate storage space away from the patient care area or a locked receptacle within the patient care
area
To pass the site visit, the practitioner office site MUST PASS all standards marked with **.
The auditor will provide feedback about any other deficiencies.
Reviewed: 5/1/13
BCBSIL Provider Manual – Rev 5/13
30
Health Care Management Policy and Procedure
Practitioner Office Site Quality
Page 5 of 5
Practitioner Office Site Quality Audit
Date of Audit:
Auditor:
Onsite Audit Findings:
Audit findings reviewed with:
Practitioner
Date of Review:
Reviewed: 5/1/13
BCBSIL Provider Manual – Rev 5/13
31