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
- 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.