PROVIDER APPLICATION REVIEW PROCESS Sample Clauses

PROVIDER APPLICATION REVIEW PROCESS. 8 a. All credentialing and re-credentialing applications shall be reviewed by
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PROVIDER APPLICATION REVIEW PROCESS a. All credentialing and re-credentialing applications shall be reviewed by CONTRACTOR. Providers with identified adverse issues shall be asked to provide a written explanation prior to CONTRACTOR review. In addition, CONTRACTOR shall maintain P&Ps for altering the conditions of the practitioner’s participation in the network based on issues of the quality of care and service that may arise after completing the credentialing process. Such P&Ps shall be provided to ADMINISTRATOR, upon request. Decisions to alter or terminate a provider’s participation in the network shall be made by CONTRACTOR. Providers with identified quality of care or service concerns shall be presented to the Peer Review Committee established by CONTRACTOR. Providers shall be advised in advance of the identified problems and shall be invited to respond in writing to the issues to go before the Peer Review Committee. The provider’s response, along with any additional documentation supplied by CONTRACTOR, shall be reviewed by the Peer Review Committee. The Peer Review Committee may recommend that no action be taken, that the provider be issued a Corrective Action Plan, or that the provider be terminated from the network.
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PROVIDER APPLICATION REVIEW PROCESS. 20 a. All credentialing and re-credentialing applications shall be reviewed by 21 CONTRACTOR. Providers with identified adverse issues shall be asked to provide a written 22 explanation prior to CONTRACTOR review. In addition, CONTRACTOR shall maintain P&Ps for 23 altering the conditions of the practitioner’s participation in the network based on issues of the quality of 24 care and service that may arise after completing the credentialing process. Such P&Ps shall be provided 25 to ADMINISTRATOR, upon request. Decisions to alter or terminate a provider’s participation in the 26 network shall be made by CONTRACTOR. Providers with identified quality of care or service 27 concerns shall be presented to the Peer Review Committee established by CONTRACTOR. Providers 28 shall be advised in advance of the identified problems and shall be invited to respond in writing to the 29 issues to go before the Peer Review Committee. The provider’s response, along with any additional 30 documentation supplied by CONTRACTOR, shall be reviewed by the Peer Review Committee. The 31 Peer Review Committee may recommend that no action be taken, that the provider be issued a 32 Corrective Action Plan, or that the provider be terminated from the network.
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PROVIDER APPLICATION REVIEW PROCESS. 3 a. All credentialing and re-credentialing applications shall be reviewed by 4 CONTRACTOR. Providers with identified adverse issues shall be asked to provide a written explanation 5 prior to CONTRACTOR review. In addition, CONTRACTOR shall maintain P&Ps for altering the conditions of the practitioner’s participation in the network based on issues of the quality of care and 6 service that may arise after completing the credentialing process. Such P&Ps shall be provided to 7 ADMINISTRATOR, upon request. Decisions to alter or terminate a provider’s participation in the network shall be made by CONTRACTOR. Providers with identified quality of care or service concerns 8 shall be presented to the Peer Review Committee established by CONTRACTOR. Providers shall be 9 advised in advance of the identified problems and shall be invited to respond in writing to the issues to go 10 before the Peer Review Committee. The provider’s response, along with any additional documentation supplied by CONTRACTOR, shall be reviewed by the Peer Review Committee. The Peer Review 11 Committee may recommend that no action be taken, that the provider be issued a Corrective Action Plan, 12 or that the provider be terminated from the network. 13 b. CONTRACTOR shall provide notice and a fair hearing to CONTRACTOR’s Network Providers, as required under applicable state and federal law, or at the discretion of CONTRACTOR’s 14 Medical Director, in any case in which action is proposed to be taken by CONTRACTOR to restrict, 15 suspend or terminate the Network Provider’s ability to provide health care services to Beneficiaries for reasons relating to deficiencies in quality of care, professional competence, or professional conduct which 16 affects or could adversely affect the health, safety or welfare of any Beneficiaries and/or is reasonably 17 likely to be detrimental to the delivery of quality care. If CONTRACTOR takes adverse action against a 18 provider based on a quality of care issue, CONTRACTOR shall report as required by state and federal agencies and as required by the NPDB.
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