Credentialing is a process of obtaining, verifying and evaluating the qualification of a provider. It determines whether an applicant is qualified to be a participating provider with the organization. Sun Knowledge aids provider groups as well as clients with credentialing services through a time-tested technique.
This process ensures that organizational providers are compliant with state and regulatory bodies before directing membership to these facilities. An organizational provider includes, but is not limited to the following: Hospitals, Surgical Centers, Home Health Agencies, Radiology Facilities, Long Term Care Facilities (Skilled Nursing, Inpatient Rehab, Sub-Acute Centers), and Inpatient, Residential or Behavioral Health/Substance Abuse Facilities in an ambulatory setting.
When an organizational provider has been identified as a prospective provider and contracting negotiations have begun, a completed application is submitted to the Credentialing Department.
Credentialing professionals or delegates are stringently compliant with the Ancillary Credentialing Matrix, which identifies provider types and necessary Credentialing components.
The Credentialing process of Sun Knowledge requires a Credentialing specialist to assess the application sent in, by a provider. The individual’s academic, professional and social backgrounds are thoroughly evaluated, based on researches conducted on primary and secondary resources, peer as well as expert reviews. His competency is gauged with the aid of his previous, professional records and end-user reviews on the quality of patient care, he meted out.
After assessment and verification of all the documents, an executive Provider Affairs Sub-Committee (PAS) analyzes the collected data, determining the final outcome in a ‘case by case’ manner. At the end of the process, approvals and denials are communicated to the provider. Every provider can contest a denial and appeal against it. The PAS is responsible for setting the criteria, used in the process of decision making. Initial provider acceptance is contingent upon successful completion of the Credentials review process. A provider can continue to participate upon proper completion of the re-credentialing process, every three years.
The Credentialing process verifies physicians/clinicians in terms of their:
License
Experience
Certification
Education
Training
Malpractice and Adverse Clinical Occurrence
Clinical Judgment
Technical Capability
Character in Professional Practice
Sun Knowledge boasts of a team of Credentialing veterans, who strictly abide by the standards and guidelines, set within Medicare Managed Care Manual and National Committee for Quality Assurance (NCQA).
