Q: What is recredentialing?
A: Recredentialing is the process of periodically verifying and reviewing practitioner and facility qualifications and performance. It ensures providers continue to meet key standards for professional competence, conduct, and delivery of high-quality care. Recredentialing generally occurs every 1-3 years after the initial credentialing process.
During recredentialing, licensure, education, training, malpractice claims, and other qualifications are re-verified. Ongoing performance indicators such as member complaints, quality metrics, and utilization data are also reviewed. Facilities may undergo additional scrutiny through site visits. The recredentialing process aims to assess continued compliance with credentialing standards and identify any emerging provider performance issues over time.
Q: How often are practitioners recredentialed?
A: Practitioners and facilities are typically recredentialed every three years unless a state or health plan has different requirements. It is important to recredential practitioners and facilities in order to verify their ability to continue providing the services for which they are contracted.
Q: What preparation is needed to begin the recredential process?
A: A provider should be notified at least sixty days prior to the recredentialing event due date, and they will have to complete an application to begin the recredentialing process.
Q: What is verified during recredentialing process, and why is it important?
A: As outlined in the table below, the Primary Source Verifications (PSV) completed during the recredentialing process are overwhelmingly identical to those completed for an initial credentialing event. This includes State Medical License, DEA License, Sanctions, and Exclusions. See the table below for an in-depth comparison of what is verified during an initial credential versus a recredential.
The recredentialing process – combined with the Quality Improvement Program, Utilization Management, and Grievance and Satisfaction Surveys – provides assurance that the practitioners remaining in the network have the ability to provide the highest level of care to the health plan members.
Q: What happens if a provider’s recredentialing application is not approved by the committee?
A: Should a provider be denied by the credentialing committee, that practitioner should be provided with a written notice covering the reasons why. The information contained in the letter must include the standards and data used to make this determination as well as inform the provider of their rights to appeal the decision.recredentila
