Clinical Credentialing
Consumers Life’s mission is to provide financing and management
of health benefits that improve the health and well being of our members and
the communities we serve. To support this mission, the Clinical Credentialing
Department:
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Conducts
office site and medical record reviews as part of the credentialing and
recredentialing process
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Promotes
compliance with national quality and regulatory standards by making
credentialing requirements easily accessible and allowing providers to take
advantage of onsite informational sessions
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Educates the provider community to the nationally recognized standards of documentation, confidentiality, medical record organization and accessibility, and patient appointment accessibility
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Develops and Implements
Corrective Action Plans (CAP) under the direction of the Credentialing
Committee to afford providers ample opportunity to correct credentialing
deficiencies
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Oversees
the credentialing policies and procedures of delegated entities to ensure
compliance with Consumers Life standards
Office Site and Medical Record Content and Documentation
The Clinical Credentialing Department registered nurses conduct office site and medical/treatment record reviews for providers within certain specialties as part of the Consumers Life credentialing and recredentialing process. Compliance to the standards is set at 95%.
These reviews utilize criteria that are consistent with widely accepted national quality
and regulatory standards. Consumers Life utilizes two different sets of
standards with one directed toward the Primary Care Provider (General Practice,
Family Practice, Internal Medicine, Geriatrics, Pediatrics, and OB/GYN); while
the other set is specific to the Behavioral Health Specialist (Psychiatrist,
Psychologist, Licensed Professional Counselor, and Licensed Independent Social
Worker).
All information obtained in the course of the office site and
medical record review is kept strictly confidential.
Provider Education
Clinical Credentialing registered nurses promote compliance with
these standards by offering provider education at the conclusion of each office site and medical record review.
Sample forms and policies are made available to the provider by
the Clinical Credentialing registered nurses to assist the office in moving
toward compliance with national quality and regulatory standards. The samples
are also available from this Web site.
Office Site and Medical Record Documentation Standards
Accessibility Standards