QUEST Integration - Provider Credentialing

Original Effective Date:

04/01/1999

Current Effective Date:

01/01/2015

DHS requires HMSA to perform credentialing activities as part of our Quality Improvement Program to ensure that members receive high-quality care from qualified providers through The HMSA Plan for QUEST Integration Members. HMSA verifies the credentials of providers such as, but not limited to, Doctor of Medicine (MDs), Doctor of Osteopathic Medicine (DOs), Doctor of Podiatric Medicine (DPMs), Psychiatrists, Psychologists, Social Workers, Advanced Practice Registered Nurses (APRNs), and diabetes educators who:

• Seek to participate with The HMSA Plan for QUEST Integration Members
• Are listed in HMSA’s QUEST Integration participating provider directory

Initial Credentialing Process

Credentialing is initiated by the provider going to the HMSA Provider Resource Center (PRC) or Hawaii Healthcare Information Network Plus (HHIN+) and completing the HMSA New Provider Application. Access to HHIN+ is not required to complete the application. Information on the completed application is verified by HMSA’s credentialing unit. HMSA’s Credentialing Committee (which includes practicing participating physicians) then reviews applications and other pertinent information to determine compliance with HMSA’s credentialing requirements. See HMSA’s Credentialing Requirements for a complete listing of compliance standards.

Providers who meet credentialing requirements will be sent an acceptance letter. Those who do not meet credentialing requirements may appeal the decision by submitting a written notice of appeal and requesting binding arbitration. The appeal must be received within 30 days of the date the provider received notification of the Credentialing Committee’s denial. HMSA’s Legal Services will manage and execute the arbitration process. An appeals process and arbitration are available for adverse re-credentialing decisions.

Providers' Right to Review Credentialing File

Providers have the right to review material contained in their credentialing file. They may submit a written request for a copy of their credentialing file to HMSA’s Credentialing Unit. Any material that is peer review-protected or client/attorney-protected will not be disclosed. To review the credentialing file, the physician may submit a written request to HMSA’s Credentialing Unit at the address below:

HMSA

Provider Operations – Credentialing Unit 7-PO
P.O. Box 860
Honolulu, HI  96808-0860

• Application Status
  Upon verbal or written request, HMSA will inform providers of the status of their credentialing application.
• When HMSA needs additional information to credential or recredential
  A provider is notified of any information obtained during the credentials verification process that differs substantially from the information provided to HMSA by the provider or other sources. A notice is sent to the provider within 10 working days of discovering the discrepancy. They are provided 10 working days to respond to the Credentialing Unit in writing to correct any erroneous information.
• Correction of information
  If a provider believes that HMSA’s credentialing file is incorrect or incomplete, they may provide the Credentialing Unit with additional information by writing to the address above.

Recredentialing Process

HMSA requires re-credentialing every three years to maintain an updated verification of credentials and to assess practitioner performance in providing quality, cost-effective healthcare services. During the recredentialing process, compliance with most professional requirements is re-verified.

In cases in which the provider believes that the correct information in their credentialing file may be perceived negatively, the provider may add a statement to the file explaining their view of the circumstance(s) in question.

Revision History