Understanding Re-credentialing, Delegated, and Facility Credentialing for Healthcare Providers A 1199SEIU Benefit Funds Guide

Navigating the complex landscape of healthcare provider network participation requires a clear understanding of various credentialing processes. For effective provider enrollment management, it’s crucial for healthcare providers to distinguish between re-credentialing, delegated credentialing, and facility credentialing. This guide from the 1199SEIU Benefit Funds will clarify these distinct but equally vital processes, outlining their importance for compliance, patient safety, and ensuring uninterrupted reimbursement.

Table of Contents

• Re-credentialing: Maintaining Provider Network Participation
• Delegated Credentialing: Streamlining Enrollment and Oversight
• Facility and Ancillary Provider Credentialing Process
• The Critical Importance of Credentialing for Providers
• Common Challenges and Frequently Asked Questions

Re-credentialing: Maintaining Provider Network Participation

All providers participating with the 1199SEIU Benefit Funds must undergo re-credentialing every three years to continue their network participation. This process goes beyond initial enrollment; it allows us to meticulously re-evaluate a provider’s qualifications and performance, ensuring ongoing compliance with the 1199SEIU Benefit Funds
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stringent criteria. The re-evaluation entails a comprehensive review, often including:

• Verification of current professional licenses and certifications.
• Assessment of malpractice history and claims.
• Checks for sanctions, exclusions, or disciplinary actions from state and federal agencies (e.g., OIG, SAM).
• Review of current professional liability coverage.
• Validation of hospital privileges, if applicable.
• Confirmation of ongoing continuing medical education (CME).

Providers may be subject to off-cycle re-credentialing for specific triggers such as disciplinary actions, a suspended license, cancellation of professional liability coverage, loss of privileges, suspected fraudulent behavior, or quality-of-care and member dissatisfaction concerns. Any fraudulent or erroneous information submitted to the 1199SEIU Benefit Funds, including at the time of original credentialing, can lead to immediate termination of participation status.

Understanding re-credentialing requirements for private payers is key. Providers are obligated to immediately notify the 1199SEIU Benefit Funds of any changes to information submitted during initial credentialing or subsequent re-credentialing processes. This includes changes to contact information, practice locations, licensure status, or any adverse actions.

Common Re-credentialing Questions:

• How long does re-credentialing take? While the exact timeline can vary, providers should anticipate a process that typically takes 60-90 days, though it can be longer if documentation is incomplete or further investigation is required.
• What documents are needed for re-credentialing? Providers generally need to resubmit updated copies of their professional licenses, certifications, DEA certificates, malpractice insurance declarations, and attested application forms confirming current practice information and compliance.

Delegated Credentialing: Streamlining Enrollment and Oversight

In specific situations, providers may be credentialed through

delegated credentialing.

This involves an outside entity, often a hospital or large provider group, authorized by the 1199SEIU Benefit Funds, taking responsibility for the credentialing process on our behalf. While the delegate handles the primary credentialing, the provider must still sign a contract directly with the 1199SEIU Benefit Funds and successfully pass our onsite auditing process.

The 1199SEIU Benefit Funds maintain final authority to approve, terminate, or suspend a provider at our sole discretion. We may delegate credentialing to contracted facilities, organizations, or provider groups that demonstrate the ability, through a rigorous pre-delegation assessment, to meet the performance requirements of the 1199SEIU Benefit Funds. This assessment evaluates the delegate’s credentialing policies, procedures, staffing, and quality control measures. Approved delegates are then evaluated annually to monitor continued compliance with our current credentialing criteria.

Understanding what is delegated credentialing in healthcare offers benefits such as increased efficiency and faster network inclusion for providers, as the delegated entity often has streamlined processes. However, potential pitfalls include a provider
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reduced direct interaction with the health plan
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credentialing department and the need for the provider to ensure the delegated entity is maintaining up-to-date information on their behalf.

Common Delegated Credentialing Questions:

• Can delegated credentialing be revoked? Yes, the 1199SEIU Benefit Funds can revoke delegated credentialing authority if the delegate fails to meet performance requirements or comply with auditing standards. This would revert the credentialing responsibility directly back to the Benefit Funds.
• What happens if the delegated entity makes a mistake? While the delegate is responsible, the ultimate responsibility for accurate credentialing information often falls to the provider. Providers should always verify their status and information.

Facility and Ancillary Provider Credentialing Process

The 1199SEIU Benefit Funds have established comprehensive facility and ancillary criteria for evaluating and appointing providers to its network. The facility and ancillary application is designed to assess and gather appropriate certification data, verifying the extensive list of services provided by our facilities. This includes, but is not limited to, areas such as behavioral health, mental health, substance abuse, durable medical equipment (DME), orthotics and prosthetics, home health/hospice, freestanding ambulatory surgery, rehabilitation centers, dialysis clinics, imaging centers, and independent laboratories.

The facility credentialing process requires detailed documentation of the facility
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operational and clinical capabilities. Appropriate certification data includes:

• State licensure and certifications for the facility type.
• Accreditation from recognized bodies like The Joint Commission, NCQA, or URAC.
• National Provider Identifier (NPI) and Tax ID (TIN).
• Evidence of professional liability insurance for the facility.
• Detailed service line descriptions and scope of practice.
• Personnel rosters for key clinical and administrative staff.
• Quality improvement plans and outcome measures.

Common Facility Credentialing Questions:

• What documents are needed for facility credentialing? Beyond state licenses and accreditation, facilities must submit organizational charts, proof of tax-exempt status (if applicable), details on ownership, a comprehensive list of services offered, and facility-specific policies and procedures related to patient care and safety.
• Are all ancillary providers credentialed the same way? While there are general criteria, the specific requirements can vary based on the type of ancillary service (e.g., DME suppliers have different requirements than behavioral health clinics).

The Critical Importance of Credentialing for Providers

For healthcare providers, meticulous attention to credentialing

whether it’s initial credentialing, re-credentialing, delegated, or facility credentialing

is not just a bureaucratic hurdle; it’s fundamental to sustained practice viability. These processes are essential for:

• Compliance: Ensuring adherence to state and federal regulations, as well as payer-specific requirements, mitigating legal and financial risks.
• Patient Safety: Verifying that all providers meet rigorous standards of education, training, and professional conduct, thereby safeguarding patient well-being.
• Uninterrupted Reimbursement: Accurate and up-to-date credentialing is paramount for timely claim processing and receiving payments for services rendered. Any lapse can lead to denied claims and significant revenue cycle disruptions.
• Network Participation: Maintaining an active and approved status within payer networks is critical for accessing patient populations and referrals.

Common Challenges and Frequently Asked Questions

Providers often face similar challenges across all credentialing types. Some frequently asked questions include:

• How can I speed up the credentialing process? Ensuring all documentation is complete, accurate, and submitted promptly is the most effective way. Proactive communication with the credentialing department can also help.
• What are the consequences of credentialing errors? Errors can lead to delays in network participation, claim denials, payment disruptions, and, in severe cases, even loss of network privileges.
• Is there a central database for all my credentialing information? While some organizations use credentialing software, there isn’t one universal database. Providers typically manage multiple applications for different payers. CAQH ProView is a widely used system that helps streamline data collection for many health plans.

The 1199SEIU Benefit Funds are committed to protecting the confidentiality of all provider information obtained during the credentialing process.

In summary, understanding and diligently managing re-credentialing, delegated credentialing, and facility credentialing is indispensable for all healthcare providers. These processes safeguard patient care, ensure regulatory compliance, and guarantee the seamless flow of reimbursement. Providers are not only obligated to immediately notify the 1199SEIU Benefit Funds of any changes to their submitted information but also to proactively review their credentialing status regularly. For any questions regarding applying to be a participating Ancillary Provider or notifying us of new providers joining (and leaving) existing practices, please contact the Provider Relations Department. Our representatives are available to assist you in maintaining accurate and up-to-date information for your continued network participation.