NY Manual
SHP Manual

SHP Provider Manual
4.2 Provider e-Newsletter and Notices | 4.4 Provider Rights and Responsibilities and Dual Eligible Members

4.3 Provider Credentialing and Recredentialing

There are a few steps that Senior Health Partners must complete before considering a provider as a permanent part of its network. First, the Provider must complete and return a completed provider application with the required supporting documents, e.g., copies of current Certificate of Liability, license/certification. The complete application package is reviewed by the Medical Director for approval. After all required documentation is received, the provider package is presented to the Quality Management Committee for approval. 

After the initial credentialing, all contracted providers are recredentialed biannually, which requires that providers send updated information. The Senior Health Partners recredentialing process also involves a review of provider performance indicators, which may include the following: 

     •   Member/family complaints;

     •   Information from quality improvement activities; and

     •   Member satisfaction surveys. 

If the recredentialing is denied, the provider is notified in writing of Senior Health Partners’ decision and informed of his/her right to appeal that decision. Senior Health Partners may, at its option, terminate the Provider Agreement upon sixty (60) days written notice to the Provider. 

Effective October 1, 2009, newly licensed Health Care Professionals (HCPs), or HCPs relocating from another state who are joining the group practice of in-network providers, will be allowed to participate in Senior Health Partners’ Provider Network only if they meet the participation and credentialing criteria outlined below. 

    •   Senior Health Partners will make a determination within 90 days of receipt of a completed application. If no determination is made at that time, an HCP joining a group practice will be considered “provisionally” credentialed until a final determination is made. 

    •   If the final determination is denial, the HCP will revert to non-participating status. The group practice wishing to include the newly licensed or relocated HCP must agree to refund and payments made by Senior Health Partners for in-network services delivered by the provisionally credentialed HCP that exceed any out-of-network benefit. In addition, the provider group must agree to hold the member harmless from payment of any services denied during the provisional period. 

    •   If Senior Health Partners offers a member transitional care and the transitional care is provided by a provisionally credentialed provider who was ultimately denied credentialing by Senior Health Partners, other medical group providers will assume responsibility for the member’s care. Medical groups are encouraged to provide full disclosure to members about a provider’s provisional status so that they can then determine whether to have a fully credentialed provider in charge of their care.