Contracting is a separate process from credentialing. Practitioners must be part of a contracted provider business entity to proceed with being credentialed as a participating Avēsis practitioner. Credentialing is required for all licensed individual healthcare practitioners to participate in the Avēsis provider network and required prior to seeing Avēsis members. During the credentialing process Avēsis will verify practitioner qualifications, practice history, certifications, and registration to practice in a healthcare field. Credentialing standards are established by the NCQA and the Centers for Medicare & Medicaid Services (CMS).
The Council for Affordable Quality Healthcare (CAQH) is the preferred credentialing application for Avēsis. Many states require that practitioners complete a state-mandated credentialing application, CAQH offers these applications in most instances. In the event practitioners do not participate in CAQH, practitioners must submit an Avēsis provider application. The application requires information on the practitioner’s education, training, professional background, licensure, DEA certificate (if applicable), evidence of Diagnostic Pharmaceutical Agent Certification, and/or Therapeutic Pharmaceutical Agency Certification.
If you already have a CAQH Provider ID number and are registered with CAQH ProView, you can:
- Validate your account is up to date and complete
- Validate Avēsis is listed as an authorized entity to access your data
If you need to complete a CAQH application:
- Go to CAQH.org to set up an account and complete an application
Required application supplemental information
Training and Education
- Practitioner degree, post-graduate education or training
- Details of medical or professional education and training
- Completion of residency program in designated specialty
Licensing and Certification
- Current license or certification in the state(s) in which the practitioner will be practicing
- National Provider Identification (NPI) number
- Active Drug Enforcement Agency (DEA) number and/or Controlled Dangerous Substance (CDS) Certificate
- Medicare/Medicaid participation eligibility or certification (if applicable)
Work History Details
- Five-year work history, to include an explanation for gaps longer than six months
- Statement of work limitations, license history and sanctions
- Active errors and omissions (malpractice) insurance or a state-approved alternative
- Malpractice history
Primary source verification
Once Avēsis has received your complete application, we will review your application and primary source to verify your credentials.
Upon receipt of a complete application and completion of primary source verifications, practitioner applications will be presented to a peer review committee to decide on participation within the Avēsis provider network. Credentialing disposition will be sent to practitioners in writing. Approval is required for all licensed individual healthcare practitioners to participate in the Avēsis provider network and required prior to seeing Avēsis members.
Every 36 months, providers must submit an updated application, attestation, and current credentialing documents. This information can be submitted to CAQH or directly to Avēsis if the practitioner is not participating in CAQH. The practitioner’s performance will be evaluated with a review of any quality-of-care concerns. Quality of care management evaluates each practitioner by monitoring the following:
- Quality of care
- Efficiency of care
- Member satisfaction
- Fulfillment of administrative requirements
- Compliance with clinical standards
Providers have the right to be informed of the status of their credentialing or recredentialing application. If a provider requests the status of their application, Avēsis will provide a description of the status within 30 calendar days of the request. This status will specify whether the application is in the verification process or the review and decision process, or whether a credential decision has been made.
Providers have the right to review any information submitted in support of their credentialing decision, except for references, recommendations, or other peer review-protected information. The provider must submit a written request to review the information. The Plan will respond to the request via mail within 30 calendar days.
Providers have the right to correct erroneous information obtained by Avēsis during the credentialing and recredentialing process.
Credentialing Committee decisions are never based on race, gender, ethnicity, nationality, age, sexual orientation, or patient type that composes the provider’s practice. This information is excluded from the provider roster presented to the Credentialing Committee, and the Committee members are bound to a code of ethics that prohibits any such discrimination from being a factor in their decision-making process.
All credentialing and re-credentialing decisions are subject to internal audit to monitor against any discriminatory outcomes. Annually, during policy review, Compliance will evaluate a set of committee materials to ensure they do not violate our non-discrimination policy.