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Medical credentialing

What is doctor and behavioral health practitioner credentialing?
Why is doctor and behavioral health practitioner credentialing important to Aetna members?
What does the Aetna credentialing process involve for doctors and behavioral health practitioners?

What are the results of Aetna's commitment to credentialing?

What is doctor and behavioral health practitioner credentialing?
Credentialing is a process used to evaluate the qualifications and practice history of doctors and behavioral health practitioners.

This process includes a review of each doctor and behavioral health practitioner's completed education, training, residency and licenses. It also includes any board-issued certifications in each of their specialty areas.

The Aetna credentialing process evaluates the qualifications of doctors and behavioral health practitioners who provide care to Aetna members. We conduct this process before we allow them to join our network.

We also review their credentials on a regular basis. We follow standards that states, regulatory bodies and accrediting organizations, such as the National Committee for Quality Assurance (NCQA) establish.

The credentialing process is not a guarantee that members will get any level of quality or service from these health care professionals. Participants are independent doctors or behavioral health practitioners in private practice. They are not agents or employees of Aetna.

Why is this credentialing important to Aetna members?
Credentialing plays a role in members access to quality health care.

We have used our process for many years, and it works well. After providers sign contracts with us, our goal is to credential them quickly so that members can obtain high-quality care.

We confirm credentials for all medical types of health care practitioners with whom we have an individual contract. This includes psychotherapists, chiropractors, podiatrists, physical therapists and nurse practitioners, among others.

What does the Aetna doctor and behavioral health practitioner credentialing process involve?
Our credentialing process includes (but isn’t limited to) the following:
  • Gathering information about background and qualifications through a formal application process.
    • Checking the background information
    • Checking the information against reliable sources, including the National Practitioner Data Bank and the American Board of Medical Specialties
  • Contacting:
    • Any state where the doctor or behavioral health practitioner reports an active medical license and sees our members
    • Schools and hospital programs, to be sure training is complete and accepted by the specialty board
    • The National Technical Information Service, Drug Enforcement Agency or Controlled Substance Registration, as confirmation that the doctor or behavioral health practitioner is authorized to write prescriptions
    • Medicare/Medicaid, to be sure the doctor or behavioral health practitioner is not banned from caring for Medicare/Medicaid patients.
  • Reviewing the doctor/behavioral health practitioner’s:
    • Personal history, to determine if any disciplinary actions have been taken
    • Malpractice insurance, to confirm active coverage
    • Malpractice claims history
    • Hospital privileges, to determine if privileges have been lost or limited
    • Work history and employment background
    • Information with Aetna’s Credentialing and Performance Committee, to determine whether or not the doctor or behavioral health practitioner should be included as participating in the network
Some of the specific information gathered includes:

Provider name and office location: This information is self-reported at least every three years or more often, according to state or federal requirements on the application. It is accepted through a signed document from the doctor or behavioral health practitioner that states the information is accurate and correct.

Provider gender: This information is self-reported at least every three years or more often, according to state or federal requirements on the application. It is accepted through a signed document from the doctor or behavioral health practitioner that states the information is accurate and correct.

Specialty (-ies): This is the doctor’s special field of practice or expertise. For behavioral health practitioners, it may include the practitioner’s discipline or provider type. If the provider has contracted with Aetna to provide services in more than one specialty, all will be listed. This information is self-reported at least every three years or more often, according to state or federal requirements on the application. We check the practitioner’s highest level of training in his/her specialty. We also check board certification status through primary source verification. This is the process of confirming with the certifying board and/or facility where the doctor or behavioral health practitioner completed residency training.

Patient age focus: When available, our DocFind? provider directory will show information about whether the provider has a patient age specialization.

Languages spoken: This information includes the languages that the practitioner speaks and is self-reported at least every three years or more often, according to state or federal requirements on the application. It is accepted through a signed document from the doctor or behavioral health practitioner that states the information is accurate and correct.

Hospital affiliation: This is a listing of the hospitals where the provider has privileges. If you require hospital care, you may be directed to one of the hospitals listed. This information is self-reported on the application. We check the practitioner’s hospital affiliations by contacting hospitals to verify the information at least every three years or more often, if state or federal regulations require it.

Medical group affiliation: This is a listing of the group practice that the practitioner is part of (when applicable). This information is self-reported at least every three years or more often, according to state or federal requirements on the application. It is accepted through a signed document from the doctor or behavioral health practitioner that states the information is accurate and correct.

Board certification: When a physician is board certified, it means that he/she has applied for and been awarded certification from the American Board of Medical Specialties, American Osteopathic Association or other Aetna-recognized boards, depending on the specialty. To become board certified, a physician must:

  • Graduate from an accredited professional school
  • Complete a specific type and length of training in a specialty
  • Practice for a specified amount of time in that specialty
  • Pass an examination given by the professional specialty board
Board certification is a voluntary process. Most certifying boards now require physicians to be recertified at specified intervals. The specialty board certification of the practitioner is self-reported on the application. It is checked before contracting and at least every three years or more often, according to state or federal requirements, through one of the following primary sources:
  • American Medical Association
  • American Board of Medical Specialties (Visit www.ABMS.org. On this site, in the “Consumer” section, you’ll find information about board certification, how to verify that your doctor or behavioral health practitioner is board certified, and some general tips on becoming a more educated health care consumer.
  • American Osteopathic Association Physician Profile Report
  • American Board of Podiatric Surgery
  • American Board of Podiatric Orthopedics and Primary Podiatric Medicine
  • American Board of Lower Extremity Surgery, if applicable
  • Specialty dental boards: dental specialty boards that the American
  • Dental Association Counsel on Dental Education and Licensure (CDEL) recognize
Office status: This shows whether or not a provider is accepting new patients. We recommended that you call the provider’s office to confirm. This information is self-reported at least every three years or more often, according to state or federal requirements on the application. It is accepted through a signed document from the doctor or behavioral health practitioner that states the information is accurate and correct. Practitioners may also tell Aetna of updates between credentialing cycles. We update DocFind with new information every week.

What are the results of Aetna's commitment to credentialing?

We have a centralized credentialing verification unit that is National Committee for Quality Assurance (NCQA) certified for 10 out of 10 verification services. We are also Utilization Review Accreditation Commission (URAC) Credentials Verification Organization (CVO) accredited.
  • We have a Customer Service unit to meet the specific needs of the doctors and behavioral health practitioners.
  • We have an established, well-run process. We use it consistently for doctors and behavioral health practitioners in all of our health plans.
Through our national credentialing process, we achieved the following:

  • A consistent primary source verification process for all providers, regardless of product
  • A 99.1 percent quality rating in the review of credentialing file activity, whereas the industry standard is 90 percent

Certification expiration date: January 13, 2017

The National Committee for Quality Assuranceis an independent, nonprofit organization that certifies credentials verification organizations and accredits managed care organizations.

Provider application form
You can see the questions on theCouncil for Affordable Quality Health Care (CAQH)*application that doctors or behavioral health practitioners use when applying for participation in our network. This application form shows, in general, the types of physician, practice information and questions asked when credentialing a provider. This form doesn’t apply in all states or when providers are credentialed through third parties, such as the hospitals with which they are affiliated, independent practice associations (IPAs), physician medical groups (PMGs) and integrated delivery systems (IDSs).

* This document is provided in Adobe Acrobat PDF format. To view or print, the Acrobat Reader (version 4.0 or higher) is required. To download Acrobat Reader, click here: http://get.adobe.com/reader/otherversions/