1st Medical Network

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1st Medical Network is the Healthcare Network of Georgia
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Credentialing
 
 
URAC Accredited Health Network

Home > Quality > Credentialing

Credentialing: The collection, review and verification process used to determine the current professional qualifications, such as appropriate training, licensure, certification/accreditation, and academic background, of a provider and whether the provider meets pre-established Credentialingcriteria for participation in a managed care network.

Credentialing of providers who participate in our network is an important piece of 1st Medical Network’s quality management activities. Policies have been developed and adopted to ensure oversight of our local provider partners and compliance with all appropriate local, state, and national standards and laws.

1st Medical Network is accredited as a Health Network by URAC and follows the following credentialing guidelines:

Comprehensive Credentialing Program
  • Types of providers credentialed by the network
  • Criteria for provider participation
  • Elements for collection, verification, and review
  • Review and approval structure, and appeal processes
  • Requirements for primary and secondary verification of credentialing information
  • Oversight of delegated credentialing activities


Credentialing Committee Structure

  • Responsibilities of members
  • Confidentiality of peer review
  • Oversight of Credentialing Program

Data Element Verification/Review – Individual Provider
  • Completed Application, including attestation to truthfulness of application content
  • Education/Board Certification
  • Current State Licensure
  • Current DEA (Drug Enforcement Agency) Certificate (if appropriate for provider type)
  • Malpractice Insurance Coverage
  • Malpractice History
  • Privileges in good standing at primary admitting facility (if applicable)
  • Sanction Reports
    • National Practitioner Databank
    • Medicaid/Medicare (if appropriate for provider type)
    • State Licensure
    • DEA Certificate (if applicable)

Data Element Verification/Review – Facility Provider

  • Completed Application, including attestation to truthfulness of application content
  • Accreditation (if applicable)
  • Current Licensure
  • Malpractice Insurance Coverage
  • Malpractice History
  • Sanction Reports
    • Health Integrity Protection Databank
    • Medicaid/Medicare (if appropriate for provider type)
    • Licensure

1st Medical Network uses a three-year credentialing cycle for individual and facility providers. We do continuous credentialing on all expiring data elements, such as expiring certificate, and monitor state and federal sanction databases to ensure the 1st Medical Network providers are in compliance with our Credentialing, Quality, and Contracting policies.

The Credentialing Department has NAMSS Certified Staff reviewing provider data and processing applications.

Please contact the Credentialing Department at 1st Medical Network if you have additional questions or concerns.

 

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