Credentialing
The Healthcare Highways network credentialing process is designed to provide initial and ongoing assessment of the provider’s ability to deliver patient care and treatment within limits defined by licensure, liability coverage, certification and/or accreditation. Healthcare Highways is responsible for the credentialing process unless you participate through a physician organization that has been delegated credentialing by Healthcare Highways. If credentialing is not delegated and required by Healthcare Highways, applicable providers will be contacted to initiate the credentialing process.(Re-credentialing of providers occurs every three years.)
The following outlines credentialing criteria followed by Healthcare Highways or its delegates for initial credentialing of practitioners which comply with state and federal regulatory requirements and NCQA standards. Practitioner credentialing uses CAQH applications and attestations in addition to the following credentialing criteria:
- Medical or professional education and training
- Verification of Board Certification
- Current clinically unrestricted license to practice in the state(s) for which practitioner is applying for network participation
- DEA certification and/or CDS certification, if applicable
- Any sanctions levied by the Office of Inspector General (OIG) or the General Services Administration (GSA) or other disciplinary action by any federal or state entities identified by CMS
- Work History
- The practitioner must maintain unrestricted admitting privileges at a Healthcare Highways participating hospital
- The practitioner has an admitting privilege history acceptable to Healthcare Highways
- Review of sanctions and limitations on licensure
- Current malpractice coverage / malpractice history review
Efficiency
For providers in value-base care contracts with Healthcare Highways, we share a common goal of efficient and quality care to deepen the patient-to-PCP relationship help our patients enjoy healthier lives. Providers who manage their patients’ health with quality care at a lower aggregate cost than the market average (after risk adjusting for health differences) receive an annual financial bonus for each panel member.
Quality
Our key performance indicators align to our vision of improved patient health. Ten key metrics, ranging from immunization compliance to controlling diabetic and hypertension scores are also considered when determining the bonus amount for our providers in value-based care contracts with Healthcare Highways.
