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How We Select Providers

Credentialing ensures that the NHIP provider list is comprised of providers who deliver quality healthcare services in a safe and sanitary environment and use medical record practices that are consistent with the standards set forth by the NHIP.

The Operations Department is responsible for:

  • Reviewing and recommending the status (e.g., approved, pending, or denied) of applicants for credentialing or re-credentialing and inclusion in the NHIP provider list
  • Performing peer reviews of provider-specific quality of care or service issues and recommending remedial corrective action, as necessary
  • Ensuring and monitoring the impact of remedial corrective action recommendations by contracted physicians
  • Reviewing performance indicators of all NHIP contracted providers at least every six months.

How we select providers for cases

When the NHIP receives a referral for a covered and approved service, we go to work executing that referral. One of the key steps is to identify a provider who can deliver the specific service at a high quality. The National Health Insurance Ordinance limits us to a prescribed list of providers. Once the service is available from this list, then the selection of providers must be made from this list.
 
Selection is based on the Plan’s experience over the past several years, objective data collected, the availability of providers and beneficiary preference. The Plan will always try to honor the beneficiary’s preference but sometimes this may not be advisable or practical given the obligations of the plan to deliver quality care in a sustainable manner.
 
 
 

Contractual Arrangements

  • By signing a contractual agreement with the NHIP to be part of its provider list, the practitioner, provider, facility, or ancillary service agrees to
  • Abide by the policies and procedures of the NHIP when interacting with the NHIP
  • Provide the NHIP with required data as part of the initial provider enrollment process
  • Provide credentialing and re-credentialing information per NHIP standards every year
  • Provide the NHIP with updated provider information to support accurate claims payment, and provider directory information
  • Allow the NHIP to collect data and information for quality improvement purposes
  • Cooperate with the utilization management, care coordination, and disease management programs. This may involve submitting clinical data, responding to requests for information, discussing a patient’s care plan, participating in care coordination conferences, and resolving appeals, complaints, and grievances.