BIBLIOGRAFÍA

We credential the following provider types:  Doctors of medicine

 Doctors of osteopathic medicine  Doctors of dental surgery  Doctors of dental medicine  Doctors of podiatric medicine  Doctors of chiropractic medicine

 Nursing facilities

 Certified nurse midwives  Physical/occupational therapists  Speech/language therapists

 Hospitals and allied services (ancillary) providers  Other applicable or appropriate mid-level providers

 ICF/MRs

 Physician assistants

 Providers of waiver services  Optometrists

 Nurse practitioners

 Providers of waiver population services as appropriate

 PRTFs

 SUD providers

 Behavioral health providers

We use a Credentialing Committee comprised of licensed practitioners to review credentialing and

recredentialing applicants, delegated groups and sanction activity related to existing network participants. The committee is also responsible for the creation and regular review of all policies and procedures relevant to the credentialing program.

We revise our credentialing policy periodically and no less frequent than annually based on input from:  Credentialing Committees

 Health plan medical director  Chief medical officer

 State and federal requirements

By signing the application, providers must attest to the accuracy of their credentials. If there are discrepancies between the application and the information obtained during the external verification process, the Amerigroup Credentialing department will investigate them. Discrepancies may be grounds for our denial of network participation or the termination of an existing contractual relationship.

Practitioners and providers will be notified by telephone or in writing if any information obtained during the process varies substantially from what was submitted.

The following elements are reviewed in the course of credentialing. Most of these elements are also included at the time of recredentialing:

1. Board Certification. Acceptable sources of verification include but are not limited to:  American Medical Association Provider Profile

 American Osteopathic Association  American Board of Medical Specialties  American Board of Podiatric Surgery

 American Board of Podiatric Orthopedics and Primary Podiatric medicine

2. Education and Training. Education and training will be verified for all practitioners at the time of initial credentialing. Acceptable sources of verification include but are not limited to:

 Board certification  State-licensing agency  Educational institution

3. Work History. A full work history, documenting at least the prior five years, must be submitted at the time of practitioner credentialing. Any gaps in work history greater than six months must be explained in written format.

4. Hospital Affiliations and Privileges. Network Practitioners must have clinical privileges, as appropriate to their scope of practice, in good standing at an Amerigroup network hospital.

5. State Licensure or Certification. Initial credentialing applicants must have a current, legal state license or certification. This information will be verified by referencing data provided to us by the state via:

 Roster  Telephone

 Written verification  Internet

6. Enforcement Administration (DEA) Number. Initial practitioner applicants must provide their current DEA numbers to Amerigroup for verification. State controlled substance certificates, when applicable, will also be queried for verification.

7. Evidence of Professional and General Liability Coverage. Amerigroup will verify practitioner and provider malpractice coverage at the time of initial credentialing. A copy of the malpractice face sheet will provide evidence of coverage. In addition, an attestation that includes the following information may be used:  Name of the carrier

 Policy number  Coverage limits

 Effective and expiration dates of such malpractice coverage

As a practitioner or a provider, you must maintain professional and general liability insurance in specified amounts in accordance with your Amerigroup contract.

8. Professional Liability Claims History. Initial credentialing applicants will be asked to provide a full professional liability claims history. This information will be assessed, along with a query of the National Practitioner’s Data Bank (NPDB).

9. CMS Sanctions. All initial credentialing practitioner and provider applicants must not have any sanctions by Medicare/Medicaid. This information is verified by accessing the NPDB or the Office of the Inspector General (OIG).

10. Disclosures — Attestation and Release of Information. All initial credentialing applicants must respond to questions, including within the application regarding the following: :

 Reasons for being unable to perform the essential functions of the position with or without accommodation

 History or current problems with chemical dependency, alcohol or substance use

 History of license revocations, suspension, voluntary relinquishment, probationary status or other licensure conditions or limitations

 History of conviction of any criminal offense other than minor traffic violations

 History of loss or limitation of privileges or disciplinary activity, including denial, suspension, limitation, termination or nonrenewal of professional privileges

 History of grievances or adverse action reports filed with a local, state or national professional society or licensing board

 History of refusal or cancellation of professional liability insurance  History of suspension or revocation of a DEA or CDS certificate  History of any Medicare/Medicaid sanctions

Applicants must also provide a/an:

 Attestation of the correctness and completeness of the application  Explanation in writing of any identified issues

 Disclosure of Ownership: The Centers for Medicare & Medicaid Services require Amerigroup to obtain certain information about the ownership and control of entities with which we contract for services for federal employees or federal health plans. This form is required for participation in the Amerigroup network. All individuals and entities included on the form must be clear of any sanctions by Medicare/Medicaid.

Indian Health Services/Tribal Providers credentialing exceptions: we do not require Disclosure of Ownership forms from these providers.

11. License History. The appropriate state-licensing board/agency is queried, along with the National Practitioner Databank (NPDB) as part of the credentialing process.