NY Manual
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New York Provider Manual
I Appointment Availability and 24-Hour Access Standards | II-B Healthfirst Office Site Evaluation Form

Appendix II Credentialing

Appendix II-A — Credentialing Requirements

All providers must meet the specific core criteria listed below as a condition for their participation in any of the Healthfirst provider networks. 

1.    A valid, current, unencumbered, and registered license for the state(s) in which the applicant will provide care. A license is “unencumbered” if it has not been the subject of any adverse action, including, but not limited to, probation, suspension, revocation, imposition of conditions such as periodic reporting, restrictions on nature or scope of practice, or public or private censure.
2.    Professional liability insurance in the amount of $1 million per incident/$3 million aggregate, per annum. The practitioner must maintain continuous malpractice coverage and must have no history of denial or cancellation of professional liability insurance, or exclusion of any specific procedures from coverage or, in the case of an applicant with this history, evidence that this history does not indicate probable future substandard performance.
3.    No history of professional liability claims, including, but not limited to, lawsuits, arbitration, settlements, or judgments paid by, for, or on behalf of the practitioner or, in the case of an applicant with this history, evidence that this history does not indicate probable future substandard professional performance.
4.    Valid, current, unencumbered, and unrestricted participation in the Medicaid and Medicare programs or other government program or, in the case of a provider who does not participate in these programs, proof that such nonparticipation is entirely voluntary and not due to current or past debarment or disbarment from the programs. 
5.    No physical or mental impairment/condition, including, but not limited to, a communicable disease that makes the provider unable to perform the essential functions of a practitioner in the same area of practice or unable to perform such functions without causing a threat to the health or safety of others, except where the provider has submitted adequate evidence that a physical or mental impairment/condition does not render the provider unable to perform the essential functions of a practitioner in the same practice area or unable to perform such functions without causing a threat to the health or safety of others.
6.    No present or past chemical dependency or substance abuse problem that might adversely affect the provider’s ability to competently and safely perform the essential functions of a practitioner in the same area of practice, except where the provider has submitted adequate evidence that a chemical dependency or substance abuse problem does not adversely affect the provider’s ability to competently and safely perform the essential functions of a practitioner in the same practice area.
7.    No history of professional disciplinary actions or, in the case of an applicant with this history, evidence that this history does not indicate probable future substandard professional performance.
8.    No history of involuntary termination (including resignation to avoid dismissal) of professional employment or of a contract
9.    to provide healthcare services or, in the case of an applicant with this history, evidence that this history does not indicate probable future substandard professional performance.
10.  No history of felony criminal conviction or indictment or, in the case of an applicant with this history, evidence that this history does not indicate probable future substandard professional performance or history of felony criminal conviction or indictment or, in the case of an applicant with this history, evidence that this history does not indicate probable future substandard professional performance.
11.  No information to indicate a pattern of inappropriate utilization of medical resources. 
12.  No other information that might indicate provider is engaged in conduct unbecoming to a professional in any jurisdiction. “Conduct unbecoming” can be defined as, but not limited to, sexual misconduct (e.g., with patients), tax evasion, sexual harassment of his/her patients, fraudulent billing practices, etc.
13.  No falsification of the credentialing application, requested documents, or material omission of information requested in the application. No falsification of the credentialing application, requested documents, or material omission of information requested in the application. 
14.  No report history to the National Practitioner Data Bank.
15.  No verified adverse reports from member satisfaction surveys or, in the case of an applicant with this history, evidence that this history does not indicate probable future substandard professional performance.
16.  Absence of inclusion on the Medicare Opt-Out List.
17.  Absence of inclusion on the United States Department of the Treasury, Office of Foreign Assets Control (OFAC), Specially Designated Nationals List (SDN).
18.  Absence of inclusion on the Office of the Inspector General (OIG) Exclusions List.
19.  Absence of inclusion on the U.S. Department of Justice, Drug Enforcement Administration (DEA), Case Against Doctors Listing.
20.  Additional Requirements for MDs, DDSs, DMDs, DPMs, and Doctors of Osteopathy (DOs)
21.  Graduation from an accredited Medical School, Dental School, College of Osteopathy, or a foreign Medical School recognized by the World Health Organization, and completion of a residency program.
22.  Evidence of a minimum of five (5) years of work history. If provider does not have five (5) years of work history, the time spent after in training will be included in the five-year minimum.
23.  Valid, current DEA registration (where applicable).
24.  A review of the practitioner’s site of practice that meets Healthfirst standards for office environment assessments is required (where applicable).
25.  Additional Requirements for HIV Specialist Providers
26.  Direct clinical ambulatory care of HIV-infected persons, including management of antiretroviral therapy, in at least 20 patients during the past year AND ten (10) hours annually of continuing medical education (CME), including information on the use of antiretroviral therapy in the ambulatory care setting. Practitioners who have been accorded HIV Specialist status by the American Academy of HIV Medicine (AAHIVM) or who have met the HIV Medicine Association’s (HIVMA) definition of an HIV-experienced provider are eligible for designation as an HIV Specialist in New York State, provided that the requirements for management of antiretroviral therapy in HIV-infected patients have been fulfilled in the ambulatory care setting. 
27.  Nurse practitioners and licensed midwives who provide clinical care to HIV-infected individuals in collaboration with a physician may be considered HIV Specialists, provided that all other practice agreements are met (8 NYCRR 79-5.1; 10 NYCRR 85.36; 8 NYCRR 139-6900). Physician assistants who provide clinical care to HIV-infected individuals under the supervision of an HIV Specialist physician may also be considered HIV Specialists (10 NYCRR 94.2).
28.  A PCP must practice a minimum of 16 hours a week at each primary care site.
29.  A provider must have appropriate on-call designees (covering providers) who are in compliance with the   requirements of these credentialing criteria. 
30.  Additional Requirements for Behavioral Health/Nurse Practitioner/Nurse Midwife/Allied Health Providers.
31.  Completion of an accredited education program registered with the State Education Department or program determined by the State Education Department to be equivalent to such a registered program which is designed to prepare graduates to practice in the specialty in which the applicant will provide care.
32.  Valid, current DEA registration (where applicable).
33.  Evidence of a minimum of five (5) years of work history. If provider does not have five (5) years of work history, the time spent after in training will be included in the five-year minimum.
34.  A review of the practitioner’s site of practice that meets Healthfirst’s standards for office environment assessments is required (where applicable).
35.  Nurse Practitioners: Execution of a collaborative agreement and practice protocols with a physician, in   accordance with the requirements of the New York State Department of Education. The collaborating physician must be a member of the Healthfirst provider network.
36.  For Medicaid only, providers that are sanctioned by the NYS DOH’s Medicaid Program will be excluded from participation in the HMO’s Medicaid panel.

Nurse Midwives: A collaborative relationship with a physician in accordance with the requirements of the  New York State Department of Education. The collaborative relationship must be with an OB/GYN  provider in the Healthfirst network.