Health Network Accreditation Standards Summary

Accreditation Overview.

The Health Network Standards apply to health networks such as preferred provider organizations (PPOs) and specialty networks. These standards encourage open-panel networks to become more integrated in their operations with a strong emphasis on quality assurance and improvement. The Health Network Standards cover three areas: network management, credentialing and consumer protection.

Please note: In addition to the specific standards described below, organizations seeking Health Network Accreditation must also comply with the Core Standards.

Scope of Services.

The organization defines the scope of its services including the type of health care services being offered, the geographic area of the provider network and populations served. The organization also establishes goals and measures performance related to access to care, availability of providers and provider selection criteria. The organization implements policies assuring access to consumers for covered services not available through participating providers and emergency care both in and out of the network.

Network Management.

The organization maintains a formal strategy for incorporating the perspectives of participating providers. The organization submits a general description of the criteria for selection to new providers and includes a provider relations program that maintains communications between the organization and the provider about network activities. The organization must have a written agreement with all providers, which details the terms between the organization and the provider. Agreements cannot include language that restricts providers from discussing health care matters with consumers or that stresses cost over quality. Upon request, the organization discloses to a provider, within 45 calendar days, a list of all payers who have access to the organization’s network. If the organization contracts with another network for access to its providers, it must ensure consistency in the contract terms. The organization also implements a policy addressing alleged violations by participating providers and a mechanism for dispute resolution and appeals. Finally, the organization implements a mechanism to immediately suspend a provider who is under investigation for criminal activities or negligence.

Provider Credentialing.

The organization develops and implements a written plan for credentialing that is approved by the organization’s executive management. The plan must address the scope of the credentialing program including the types of providers to be credentialed and must also address the governance and oversight structure of the credentialing program. This includes the formation of a credentialing committee, and a policy that states that the senior clinical staff person is responsible for the clinical aspects of the credentialing program and provider selection criteria. The plan requires that practitioners who are within the scope of the program submit a credentialing application that includes an attestation of truthfulness and accuracy signed and dated by the applicant. The plan also includes the types of credentialing information to be collected. For verification of licensure and certification, the organization must use primary sources, i.e., the issuing source of the credential.

The credentialing plan further requires that the organization implement mechanisms to review the credentialing application for completeness and accuracy before being submitted to the credentialing committee. The organization maintains the confidentiality of credentialing information, with limited access, for each provider going through the credentialing process. The organization implements mechanisms to ensure accuracy of information, to communicate with providers about their credentialing status and to accept additional information. The organization monitors providers for compliance and implements mechanisms to respond to cases of non-compliance.

The credentialing plan requires that the organization recredentials providers every three years. The organization should not submit an application older than one year or verification information older than six months to the credentialing committee. For credentialing functions it delegates to another entity, the organization retains authority to make the final determination regarding participation status, and at least every three years, conducts an on-site review of the entity.

Provider Credentialing Phase-In Period.

The organization completes its credentialing plan within a specified period. The organization completes program infrastructure design, implementation and credentialing of at least 15% of providers by the end of the first year after URAC awards initial accreditation. Fifty percent of the providers must be credentialed at the end of the second year, and 100% will be credentialed at the end of the third year, after the initial date of accreditation. The organization submits progress reports to URAC every six months, until 100% credentialing is completed.

Consumer Protection.

The organization maintains a confidentiality policy for protected information, orients the staff annually on the policy and requires staff to sign a confidentiality agreement.

The organization has mechanisms, such as a directory, to inform consumers of which providers participate in the provider network

CLICK HERE for a list of standards you must comply with in order to obtain accreditation.

Created by Matrix Group International, Inc