NY Manual
SHP Manual

New York Provider Manual
3.5 Provider Application Process | 3.7 Provider Profiling

3.6 Credentialing, Recredentialing Requirements & Provisional Credentialing

Healthfirst is committed to providing healthcare services to its members through a high quality provider network that meets the guidelines set by the NYSDOH. Providers are initially credentialed and biannually recredentialed through approved delegation agreements with participating hospitals, or every three (3) years through a rigorous credentialing review conducted by Healthfirst. Providers have the right to review their Healthfirst credentialing file (with the exception of peer review references or recommendations) and may contact Healthfirst if they wish to make arrangements to do so.

Provisional Credentialing

Newly licensed providers and providers relocating from other states can apply for provisional credentialing if Healthfirst is unable to credential providers within 90 days after the receipt of a completed application.

Providers are eligible to apply for provisional credentialing only after 90 days have passed since Healthfirst has received a completed application and the following two requirements are met:

·     Provider(s) must be newly licensed in the State of New York or relocating from other state(s)
·     Provider group has notified Healthfirst that the group and the provider will comply with the statutory requirements concerning refunds and holding members harmless

Providers who are provisionally credentialed are allowed to participate in the Healthfirst network and given provisional participation status so that claims can be processed, however, they cannot be assigned a panel. The provisional participation status for providers will continue until Healthfirst fully credentials the provider or disapproves the provider for network participation. 

Healthfirst will notify providers as soon as possible within 90 days of receipt of a completed application as to whether the provider has been credentialed, whether the application has been denied, or if additional information is needed to complete the credentialing process. 

The Credentialing Subcommittee

The Credentialing Subcommittee is a multi-disciplinary committee of clinical practitioners from Healthfirst participating hospitals, as well as the Healthfirst Chief Medical Officer, Vice President of Quality Improvement and Director of Credentialing (without vote). The Subcommittee is charged with the credentialing and recredentialing function and, through the review of credentialing and recredentialing materials, has the authority to make recommendations and decisions regarding credentialing, recredentialing and termination of providers. The Subcommittee meets quarterly and is responsible, through a peer review process, for the following functions:

·     Review and approve credentialing policies and procedures
·     Review practitioner credentials and make recommendations with respect to provider applications for membership in the Healthfirst Network
·     Review practitioner recredentialing documents and make recommendations with respect to practitioner continuation in Healthfirst Network
·     Review facility and vendor credentials and recredentials, and make recommendations with respect to participation and/or continuation in the Healthfirst Network
·     Review and approve the Standards for Delegated Credentialing
·     Review practitioner sanctions and make recommendations as to practitioners’ ability to deliver care and remain in the Healthfirst Network
·     Review and approve the Delegated Credentialing File Audit Results of each member hospital’s Level I and Level II practitioners credential files
·     Review and approve Level I and Level II practitioners in the network on a quarterly basis
·     Review Provider Quality of Care issues that meet Healthfirst’s policy and threshold for Credentialing Subcommittee Review
·     Review and approve minutes of Credentials Subcommittee Meetings
·     Review recommendations made by the Fraud, Waste and Abuse Review Committee concerning alleged improper billing practices and suspected fraud and/or abuse committed by a provider. If the Credentialing Subcommittee determines that formal termination of a provider is warranted, the Subcommittee will submit its recommendations to the Health Care Quality Council in this regard for final determination
·     Provide a summary report of findings and submit to Healthfirst Quality Improvement Committee (QIC) on a quarterly basis or more frequently as required

Please refer to Appendix II for a complete list of credentialing requirements.