Provider Panels/ Networks (#2)

Question 1

What is a Provider Panel/ Network?

Answer 1

MCOs appoint providers to a provider panel. Criteria may include:

a. Valid license
b. Unrestricted DEA
c. Relevant education, training, experience
d. Board qualified/ certified
e. Minimum 5 years work history
f. Current PL & appropriate limits
g. Agree to abide by participation contract

Question 2

NCQA on Provider Networks

Answer 2

The organization’s policies define process & criteria must include:

a. Types of practitioners to be credentialed
b. Verification sources used
c. Credentialing criteria

Question 3

URAC on Provider Networks

Answer 3

Organization must have credentialing plan to verify qualifications of participating providers. Plan must include:

• Types of practitioners credentialed
• Decison-making process
• Criteria for granting provider network participation
• Accurate accounting of the verification sources used

Question 4

ACF on Provider Networks

Answer 4

Criteria for the initial appointment/ reappointment of physicians & dentists
Must be a process to:
- Establish minimum requirements
- Review, assess & validate an individual’s qualifications
- Review & assess information received