Credentialing Criteria and Standards

AmeriHealth Caritas VIP Care (HMO-SNP) applies credentialing and recredentialing criteria for all professional providers that, at a minimum, meet the requirements of 42 CFR 422.502 (i) (4) (iv).

AmeriHealth Caritas VIP Care (HMO-SNP)'s criteria include:

  1. Current medical licensure
  2. No revocation or suspension of the provider's state license by the Board of Medicine and Surgery
  3. Disclosure related to ownership and management (42 Code of Federal Regulations [CFR] Section 455.104), business transactions (42 CFR 455.105) and conviction of crimes (42 CFR 455.106)
  4. Proof of the provider's medical school graduation, completion of residency and other postgraduate training. Evidence of board certification is accepted in lieu of proof of medical school graduation, residency and other postgraduate training.
  5. Evidence of specialty board certification, if applicable
  6. Evidence of the provider's professional liability claims history
  7. Satisfactory review of any sanctions imposed on the provider by Medicare or Medicaid
  8. The provider's Medicare identification number, Medicaid ID number, Medicaid provider registration number or documentation of submission of the Medicaid provider registration form whenever applicable

In addition, AmeriHealth Caritas VIP Care (HMO-SNP)'s credentialing and recredentialing processes include verification of the following additional requirements for physicians:

  1. For primary care physicians and specialists — privileges in good standing at the hospital designated by the PCP as the primary admitting facility; or, if the PCP does not have admitting privileges, privileges in good standing at the hospital for another provider with whom the PCP has entered into an arrangement for hospital coverage
  2. Valid Drug Enforcement Administration (DEA) certificate, where applicable