Care Providers Who Meet Criteria
Every business day we send credentialing information on care providers who meet established criteria to one of the national Medical Directors for their review and approval.
Care Providers Who Do Not Meet Criteria
When a care providers does not meet established criteria for credentialing we give information and related documents from the care provider’s profile to the to the National Credentialing Committee. The committee may request further information from any persons or organizations, including the care provider, to assist with the evaluation process.
Determination of Approval or Denial
After it completes the review and evaluation of all of the credentialing information, the National Credentialing Committee approves or denies participation.
Care Provider Notification
For initial credentialing, we notify care providers of the National Credentialing Committee’s decision within 60 calendar days or as required by state law. For recredentialing, we notify care providers of a decision to terminate a care provider’s participation within 14 calendar days.
Right to See Members
Approved does not mean “active.” Care providers may not begin seeing our members until both they and we have signed a contract and are in our systems. We send written notice that the contract is active. We send written notice to providers in Maryland and New York for recredentialing approvals. It lists the contract participation effective date.
Listings in Care Provider Directories and Other Member Materials
Information provided in member materials, including care provider directories, is the publicly available information obtained in the credentialing process. This includes: